Nursing Comprehensive Exam 4

1. A nurse is assigned to care for a client who has returned to the nursing unit following left nephrectomy. The nurse places the highest priority on obtaining which of the following assessments?

Tolerance for sips of clear liquids

Temperature

Hourly urine output

Ability to turn side to side

Following nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and to detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client’s ability to reposition, cough, and deep breathe. Therefore the next most important measurements are vital signs (including temperature), pain level, and bed mobility. Clean liquids are not given until the client has bowel sounds.

Explanation

Following nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and to detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client’s ability to reposition, cough, and deep breathe. Therefore the next most important measurements are vital signs (including temperature), pain level, and bed mobility. Clean liquids are not given until the client has bowel sounds.

2. A nurse is caring for a client who has just experienced a pulmonary embolism. The client is restless and very anxious. The nurse uses which approach in communicating with this client?

Explaining each treatment in great detail

Having the family reinforce the nurse’s directions

Giving simple clear directions and explanations

Speaking very little to the client until the crisis is over

The client who has suffered pulmonary embolism is fearful and apprehensive. The nurse effectively communicates with this client by staying with the client, providing simple, clear, and accurate information, and displaying in a calm, efficient manner. Options A, B, and D will produce more anxiety for the client and family.

Explanation

The client who has suffered pulmonary embolism is fearful and apprehensive. The nurse effectively communicates with this client by staying with the client, providing simple, clear, and accurate information, and displaying in a calm, efficient manner. Options A, B, and D will produce more anxiety for the client and family.

3. A client is scheduled for an arteriogram using a radiopaque dye. A nurse assesses which most critical item before the procedure?

Intake and output

Vital signs

Height and weight

Allergy to iodine or shellfish

This procedure requires a signed informed consent, because it involves injection of a radiopaque dye into the blood vessel. Although options A, B and C are components of the preprocedure assessment, the risk of allergic reaction and possible anaphylaxis is most critical.

Explanation

This procedure requires a signed informed consent, because it involves injection of a radiopaque dye into the blood vessel. Although options A, B and C are components of the preprocedure assessment, the risk of allergic reaction and possible anaphylaxis is most critical.

4. A European-American client maintains eye contact with a nurse during conversation regarding a preoperative teaching plan. The nurse interprets this nonverbal communication as:

Rudeness

Arrogance

Indicating uneasiness

Indicating trustworthiness

In the European-American culture, eye contact is viewed as indicating trustworthiness. Eye contact is considered rude in the Asian-American culture. Arrogance and uneasiness are incorrect interpretation of this nonverbal communication in the European-American client.

Explanation

In the European-American culture, eye contact is viewed as indicating trustworthiness. Eye contact is considered rude in the Asian-American culture. Arrogance and uneasiness are incorrect interpretation of this nonverbal communication in the European-American client.

5. A client receives intralipids intravenously at home. The client's spouse manages the infusion. The community health nurse discusses potential adverse reactions and side effects of the therapy with the client and the spouse. Following the discussion, the nurse expects the spouse to verbalize, that in case of a suspected adverse reaction, the priority action is to:

Take a blood pressure

Stop the infusion

Contact the nurse

Contact the local area emergency response team

Intravenous fat emulsions (Intralipids) can cause overloading syndrome (focal seizures, fever, shock) and adverse effects including chest pain, chills, and shock. The priority action is to stop the infusion and limit the adverse response before obtaining additional assistance.

Explanation

Intravenous fat emulsions (Intralipids) can cause overloading syndrome (focal seizures, fever, shock) and adverse effects including chest pain, chills, and shock. The priority action is to stop the infusion and limit the adverse response before obtaining additional assistance.

6. A clinic nurse provides information to a married couple regarding measures to prevent infertility. Which statement made by the husband indicates a need for providing further information?

We need to avoid excessive intake of alcohol

We need to decrease exposure to environmental hazards.

We need to eat a nutritious diet

I need to maintain warmth to the scrotum

Keeping the testes cool by avoiding hot baths and tight clothing appears to improve the sperm count. Avoiding factors that depress spermatogenesis such as the use of drugs, alcohol, marijuana, and exposure to occupational or environmental hazards, and maintaining good nutrition are key components to prevent infertility.

Explanation

Keeping the testes cool by avoiding hot baths and tight clothing appears to improve the sperm count. Avoiding factors that depress spermatogenesis such as the use of drugs, alcohol, marijuana, and exposure to occupational or environmental hazards, and maintaining good nutrition are key components to prevent infertility.

7. A nurse manager employs a leadership style in which decisions regarding the management of the nursing unit are made without input from the staff. The type of leadership style that is implemented by the nurse manager is:

Autocratic

Situational

Democratic

Laissez-faire

The autocratic style of leadership is task oriented and directive. The leader used his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. Democratic styles best empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. Situational leadership style utilizes a style depending on the situation and events. Laissez-faire allows staff to work without assistance, direction or supervision.

Explanation

The autocratic style of leadership is task oriented and directive. The leader used his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. Democratic styles best empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. Situational leadership style utilizes a style depending on the situation and events. Laissez-faire allows staff to work without assistance, direction or supervision.

8. A client with newly diagnosed polycystic kidney disease has just finished speaking with the physician about the disorder. The client asks the nurse to explain again what the most serious complication of the disorder might be. In formulating a response, the nurse incorporates the understanding that the most serious complication is:

Diabetes insipidus

Syndrome of inappropriate antidi-uretic hormone (ADH) secretion

End stage renal disease (ESRD)

Chronic urinary tract infection (UTI)

The most serious complication of polycystic kidney disease is ESRD, which would be managed with dialysis or transplant. There is no reliable way to predict who will ultimately progressed to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and syndrome of inappropriate ADH secretion are unrelated disorders.

Explanation

The most serious complication of polycystic kidney disease is ESRD, which would be managed with dialysis or transplant. There is no reliable way to predict who will ultimately progressed to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and syndrome of inappropriate ADH secretion are unrelated disorders.

9. A client is diagnosed with thrombophlebitis of the left leg. A nurse documents in the nursing care plan that the client should be placed on bed test with:

The left leg kept flat

Elevation of the left leg

The left leg in a dependent position

Bathroom privileges

Elevation of the affected leg facilitates blood flow by the force of gravity and also decrease venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuation in the venous system that occur with walking. Thus, the nurse documents to elevate the left leg. Options A, B and D are inappropriate positions and will not facilitate blood flow.

Explanation

Elevation of the affected leg facilitates blood flow by the force of gravity and also decrease venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuation in the venous system that occur with walking. Thus, the nurse documents to elevate the left leg. Options A, B and D are inappropriate positions and will not facilitate blood flow.

10. A client is admitted to the hospital with a diagnosis of pericarditis. A nurse assesses the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems?

Chest pain that worsens on inspiration

Pericardial friction rub

Anterior chest pain

Weakness and irritability

A pericardial friction rub is heard when there is inflammations of the pericardial sac, during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infrction. Weakness and irritability are nonspecific complaints and could accompany a wide variety of disorders.

Explanation

A pericardial friction rub is heard when there is inflammations of the pericardial sac, during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infrction. Weakness and irritability are nonspecific complaints and could accompany a wide variety of disorders.

11. A client who had a spinal fusion with insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to the

Surgeon

Clinical nurse specialist

Social worker

Physical therapist

Following spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This individual is able to provide information about resources available to the client. The physical therapist has the best knowledge of techniques form increasing mobility and endurance. The clinical nurse specialist and surgeon would not have the necessary information to financial resources.

Explanation

Following spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This individual is able to provide information about resources available to the client. The physical therapist has the best knowledge of techniques form increasing mobility and endurance. The clinical nurse specialist and surgeon would not have the necessary information to financial resources.

12. A client with a peripheral intravenous (IV) site calls a nurse to the room and tells the nurse that the IV site is swollen. The nurse inspects the IV site and notes that it is also cool and pale and that the IV has stopped running. The nurse documents in the client's record that which of the following has probably occurred?

Infiltration

Phlebitis

Thrombosis

Infection

An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action will be to remove the catheter and have a new IV line started. The other three options are likely to be accompanied by warmth at the site, not coolness. The nurse would document that the client’s IV has infiltrated.

Explanation

An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action will be to remove the catheter and have a new IV line started. The other three options are likely to be accompanied by warmth at the site, not coolness. The nurse would document that the client’s IV has infiltrated.

13. A community health nurse visits a client who is receiving total parental nutrition (TPN) in the home. The client states, "I really miss eating with my family at dinner." Which is the best response by the nurse?

It is normal to miss something as basic as eating.

I think in a few weeks you will probably be allowed to eat a little

Tell me more about how you feel about dinner time

You could sit with your family at dinner time anyway even if do not eat.

The nurse assists the client to express feelings and deal with the aspects of illness and treatment. In option C, the nurse use clarifying and focusing to encourage the client to explore concerns. Blocks to communication such as giving opinions and changing the subject will stop the client from verbalizing feelings.

Explanation

The nurse assists the client to express feelings and deal with the aspects of illness and treatment. In option C, the nurse use clarifying and focusing to encourage the client to explore concerns. Blocks to communication such as giving opinions and changing the subject will stop the client from verbalizing feelings.

14. A client who has a history of gout is also diagnosed with urolithiasis. The stones are determined to be of the uric acid type. The nurse gives the client instructions in foods to limit, which include

Liver

Apples

Carrots

Milk

Foods containing high amount of purines should be avoided in the client with uric acid stones. This include limiting or avoiding organ meats, such as liver, brain, heart, and kidney. Other foods to avoid include sweetbreads and gravies. Food that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, coffee, tea, chocolate, and carbonated beverages.

Explanation

Foods containing high amount of purines should be avoided in the client with uric acid stones. This include limiting or avoiding organ meats, such as liver, brain, heart, and kidney. Other foods to avoid include sweetbreads and gravies. Food that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, coffee, tea, chocolate, and carbonated beverages.

15. A nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would be the best to relieve the client's anxiety?

Encouraging the client to cough and deep breathe

Staying with the client

Interpreting the arterial blood gas report

Distracting the client with television

Staying with the client has a twofold benefit. First it relieves the client’s anxiety. In addition, the nurse must stay with the client to observe respiratory status after application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax resulting in a sudden decline in respiratory status and mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Coughing and deep breathing have no immediate benefit for the client who is in distress. Option D is nontherapeutic.

Explanation

Staying with the client has a twofold benefit. First it relieves the client’s anxiety. In addition, the nurse must stay with the client to observe respiratory status after application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax resulting in a sudden decline in respiratory status and mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Coughing and deep breathing have no immediate benefit for the client who is in distress. Option D is nontherapeutic.

16. A registered nurse (RN) in charge is preparing the assignments for the day. The RN assigns a nursing assistant to make beds and bathe one of the clients on the unit and assigns another nursing assistant to fill the water pitchers and to serve juice to all the clients. Another RN is assigned to administer all medications. Based on the assignments designed by the RN in charge, which type of nursing care is implemented?

Functional nursing

Team nursing

Exemplary model of nursing

Primary nursing

The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members. Team nursing is characterized by a high degree of communication and collaboration between members. The team is generally led by a registered nurse who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client’s plan of care. In an exemplary model of nursing, each staff member works fully within the realm of his or her educational and clinical experience in an effort to provide comprehensive individualized client care. Each staff member is accountable for client care and outcomes of care. In primary nursing, the concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care.

Explanation

The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members. Team nursing is characterized by a high degree of communication and collaboration between members. The team is generally led by a registered nurse who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client’s plan of care. In an exemplary model of nursing, each staff member works fully within the realm of his or her educational and clinical experience in an effort to provide comprehensive individualized client care. Each staff member is accountable for client care and outcomes of care. In primary nursing, the concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care.

17. A client is being discharged with a peripheral intravenous (IV) site for continued home IV therapy. In planning for the discharge, the nurse teaches the client which of the following to help prevent phlebitis and infiltration?

Gently massage the area around the site daily

Cleanse the site daily with alcohol

Keep the cannula stabilized or anchored properly with tape

Immobilize the extremity until the IV is discontinued

The principles of maintaining IV therapy at home are the same as in the hospital. It is extremely important to assure that the IV site is anchored properly in order to reduce the risk of phlebitis and infiltration. Massaging the site may actually contribute to catheter movement and tissue damage. Dressing surrounding peripheral IV sites are changed and cleansed at various times (usually every 2 to 5 days) depending on facility protocols. Immobilizing the extremity is not routinely necessary for peripheral IV sites.

Explanation

The principles of maintaining IV therapy at home are the same as in the hospital. It is extremely important to assure that the IV site is anchored properly in order to reduce the risk of phlebitis and infiltration. Massaging the site may actually contribute to catheter movement and tissue damage. Dressing surrounding peripheral IV sites are changed and cleansed at various times (usually every 2 to 5 days) depending on facility protocols. Immobilizing the extremity is not routinely necessary for peripheral IV sites.

18. A nurse is conducting a health screening clinic. The nurse interprets that which of the following clients participating in the screening has the greatest need for instruction to lower the risk of developing respiratory disease?

A 50-year-old smoker with cracked asbestos lining on basement pipes in the home

A 40-year-old smoker who works in a hospital

A 36-year-old who works with pesticides

A 25-year-old whose hobby is woodworking

Smoking enhances the client’s risk of developing some form of respiratory disease. Other risk factors include exposure to harmful chemicals, airborne toxins, and dust or fumes. The client at greatest risk has two identified risk factors, one of which is smoking.

Explanation

Smoking enhances the client’s risk of developing some form of respiratory disease. Other risk factors include exposure to harmful chemicals, airborne toxins, and dust or fumes. The client at greatest risk has two identified risk factors, one of which is smoking.

19. A client scheduled for the insertion of an implanted port for intermittent chemotherapy treatment says, "I'm not sure if I can handle having a tube coming out of me all the time. What will my friends think?" Based on the client's statements, the nurse plans to do which of the following first

Show the client various central line tubes and catheters

Explain that an implanted port is placed under the skin and is not visible

Notify the physician of the client’s concerns

Explain that the client friends probably will not see the tube under the clothing

An implanted port is placed under the skin and is not visible. There is no tubing external to the body. Tubing is used only when the port is assessed intermittently and the IV line is connected. Showing the client various other tubes will not be beneficial because the client will not be using them. It is premature to notify the physician. Option D does not correct the client’s confusion regarding the implanted port.

Explanation

An implanted port is placed under the skin and is not visible. There is no tubing external to the body. Tubing is used only when the port is assessed intermittently and the IV line is connected. Showing the client various other tubes will not be beneficial because the client will not be using them. It is premature to notify the physician. Option D does not correct the client’s confusion regarding the implanted port.

20. A registered nurse (RN) is a preceptor for a new nursing graduate and is describing critical paths and variance analysis to the new graduate. The RN instructs the new nursing graduate that a variance analysis is performed on all clients:

Daily during hospitalization

Every other day of hospitalization

Every third day of hospitalization

Continuously

Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward event preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options A, B and C are incorrect.

Explanation

Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward event preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options A, B and C are incorrect.

21. A community health nurse is working with food services in a rural school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which of the following would be a primary prevention intervention that the nurse could use?

Case finding in the school to identify dietary practices

School screening programs for early detection of children with poor eating habits

Providing educational programs, literature, and posters to promote awareness of healthy eating

Conducting a community-wide dietary screening activity to detect community dietary trends

Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring therefore options C is correct. Options A, B and D are secondary prevention measures that seek to detect existing health problems or trends.

Explanation

Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring therefore options C is correct. Options A, B and D are secondary prevention measures that seek to detect existing health problems or trends.

22. A nurse is caring for a client who had a total knee replacement. Postoperatively, which of the following nursing assessments is the highest priority?

Bladder distention

Homans’ sign

Extremity shortening

Heel breakdown

Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Checking for a positive Homans’ sign assesses for this complication. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially serious complications.

Explanation

Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Checking for a positive Homans’ sign assesses for this complication. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially serious complications.

23. A client has Impaired Verbal Communication as a result of a temporary tracheostomy following a laryngectomy. In planning for communication with this client, a nurse would avoid which of the following methods because it would be the least helpful for this particular client?

Use of hand or finger signals

Nodding and shaking the head for yes and no

Use of a picture board

Use of a pencil and paper

Following laryngectomy, the client should not be asked to nod or shake the head because it is painful for the client. The use of eye blink or hand or finger signals is acceptable. Other helpful methods include the use of a pencil and paper, word or picture board, flash cards or a magic slate.

Explanation

Following laryngectomy, the client should not be asked to nod or shake the head because it is painful for the client. The use of eye blink or hand or finger signals is acceptable. Other helpful methods include the use of a pencil and paper, word or picture board, flash cards or a magic slate.

24. A client who had drainage of a pleural effusion is in pain. The nurse avoids which of the following interventions in providing support to this client?

Offering verbal support and reassurance

Assisting the client to find positions of comfort

Leaving the client alone for an extended rest period

Providing pain medication for the client

The pain associated with drainage of pleural effusion is minimized by positioning the client for comfort and administering analgesics for relief of pain. The nurse also offers verbal support reassurance. All of these measures help the client to cope with the pain and discomfort associated with this problem. It is least helpful to leave the client alone for extended periods, because the client may experience continued pain, which may be augmented by isolation.

Explanation

The pain associated with drainage of pleural effusion is minimized by positioning the client for comfort and administering analgesics for relief of pain. The nurse also offers verbal support reassurance. All of these measures help the client to cope with the pain and discomfort associated with this problem. It is least helpful to leave the client alone for extended periods, because the client may experience continued pain, which may be augmented by isolation.

25. A client seeks treatment in an ambulatory clinic for a complaint of hoarseness that has lasted for 6 weeks. Based on the symptom, the nurse interprets that the client is at risk of having:

Laryngeal cancer

Acute Laryngitis

Bronchogenic cancer

Thyroid cancer

Hoarseness is a common early sign of laryngeal cancer but not of bronchogenic or thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute problem, such as laryngitis.

Explanation

Hoarseness is a common early sign of laryngeal cancer but not of bronchogenic or thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute problem, such as laryngitis.

26. A nurse in an ambulatory clinic administers a Mantoux skin test to a client on a Monday. The nurse plans to have the client return to the clinic to have results read on:

Tuesday or Wednesday

Wednesday or Thursday

Thursday or Friday

The following Monday

The Mantoux skin test for tuberculosis is read in 48 to 72 hours. The client should return to the clinic on Wednesday or Thursday.

Explanation

The Mantoux skin test for tuberculosis is read in 48 to 72 hours. The client should return to the clinic on Wednesday or Thursday.

27. A nurse is receiving a client in transfer from the postanesthesia care unit following a left above-the-knee amputation. The nurse should take which of the following most important actions when positioning the client at this time?

Put the bed in reverse Trendelenburg position

Keep the stump flat with the client lying on the operative side

Position the stump flat on the bed

Elevate the foot of the bed

Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. Following the first 24 hours, the stump is placed flat on the bed to prevent hip contracture. Edema is also controlled by stump wrapping techniques.

Explanation

Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. Following the first 24 hours, the stump is placed flat on the bed to prevent hip contracture. Edema is also controlled by stump wrapping techniques.

28. A client with a history of self-managed peptic ulcer disease has frequently used excessive amount of oral antacids. A nurse interprets that this client is at most risk for which acid-base disturbance?

Metabolic acidosis

Respiratory alkalosis

Respiratory acidosis

Oral antacids commonly contain bicarbonate or other alkaline components. These bind into the hydrochloric acid in the stomach to neutralize the acid. Excessive used of oral antacid containing bicarbonate can cause a metabolic alkalosis over time. Options A, C and D are incorrect.

Explanation

Oral antacids commonly contain bicarbonate or other alkaline components. These bind into the hydrochloric acid in the stomach to neutralize the acid. Excessive used of oral antacid containing bicarbonate can cause a metabolic alkalosis over time. Options A, C and D are incorrect.

29. A nurse prepares a postoperative plan of care for a client scheduled for hypophysectomy. The nurse avoids including which of the following in the plan?

Mouth care

Coughing and deep breathing

Monitoring intake and output

Daily weights

Toothbrushing, sneezing, coughing, nose blowing and bending are activities that should be avoided postoperatively in the client that underwent a hypophysectomy. These activities interfere with the healing of the incision and can disrupt the graft. Options A, C, and D are appropriate postoperative interventions.

Explanation

Toothbrushing, sneezing, coughing, nose blowing and bending are activities that should be avoided postoperatively in the client that underwent a hypophysectomy. These activities interfere with the healing of the incision and can disrupt the graft. Options A, C, and D are appropriate postoperative interventions.

30. A nurse is assessing a client's smoking habit. The client admits smoking ¾ pack per day for the last 10 years. The nurse calculates that the client has a smoking history of how many pack-years?

0.75 pack-years

7.5 pack-years

15 pack-years

30 pack-years

The standard method for quantifying smoking history is to multiply the number of packs smoked per day by the number pack-years of smoking. The number is recorded as the number of pack-years. The calculation for the number of pack-years for the client who has smoked ¾ pack a day for 10 day for 10 years is: 0.75 (3/4) packs x 10 years = 7.5 pack-years.

Explanation

The standard method for quantifying smoking history is to multiply the number of packs smoked per day by the number pack-years of smoking. The number is recorded as the number of pack-years. The calculation for the number of pack-years for the client who has smoked ¾ pack a day for 10 day for 10 years is: 0.75 (3/4) packs x 10 years = 7.5 pack-years.

31. A client with gastric tumor is scheduled for subtotal gastrectomy (Billroth II procedure). The nurse explains the procedure to the client and tells the client that the:

Proximal end of the distal stomach is anastomosed to the duodenum

Antrum of the stomach is removed with the remaining portion anastomosed to the duodenum

Entire stomach is removed and the esophagus is anastomosed to the duodenum

Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum

In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options A, B, and C are incorrect descriptions.

Explanation

In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options A, B, and C are incorrect descriptions.

32. A client goes into respiratory distress, and an arterial blood gas (ABG) specimen is drawn from the radial artery. The nurse performs the Allen's test prior to the ABG to determine the adequacy of the:

Femoral circulation

Brachial circulation

Carotid circulation

Ulnar circulation

Before radial puncture for obtaining an arterial specimen for ABGs, an Allen test should be performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result is severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. The other options are incorrect

Explanation

Before radial puncture for obtaining an arterial specimen for ABGs, an Allen test should be performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result is severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. The other options are incorrect

33. A client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued due to an infiltration. The nurse makes which appropriate statement to the client?

This will be a totally painless experience. It is nothing to worry about

This procedure will not take long and will be over soon. I can see that you’re anxious.

Removal of the IV shouldn’t be painful ; however, the IV will need to be restarted in another location.

While discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option B does not acknowledge the client’s feelings and does not tell the client that an infiltrated IV may need to be restarted. Option C does not address the client’s feelings. Option D addresses the client’s anxiety and honestly informs the client that the IV will need to be restarted. This option uses the therapeutic technique of giving information as well as acknowledging the client’s feelings.

Explanation

While discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option B does not acknowledge the client’s feelings and does not tell the client that an infiltrated IV may need to be restarted. Option C does not address the client’s feelings. Option D addresses the client’s anxiety and honestly informs the client that the IV will need to be restarted. This option uses the therapeutic technique of giving information as well as acknowledging the client’s feelings.

34. A client with a history or respiratory disease is ambulating with the nurse to the doorway of the hospital room. The client becomes pale and dyspneic. The nurse made the client sit down and takes the client's vital signs. The respiratory rate is 32 breaths/min, oxygen saturation is 90%, and the heart rate has increased from 76 to 98 beats/min. The nurse interprets that this client is experiencing:

Impaired Physical Mobility

Activity Intolerance

Ineffective Breathing Pattern

Ineffective Airway Clearance

Activity Intolerance is characterized by exertional dyspnea, adverse changes in blood pressure or heart rate with activity, and fatigue. Ineffective Breathing Pattern occurs when the rate, timing, depth, or rhythm of breathing is insufficient to maintain optimal ventilation. Ineffective Airway Clearance occurs when the client is unable to clear own secretions from the airway. Impaired Physical Mobility occurs when the client is limited in physical movement and has limited muscle strength, rage of motion, or coordination.

Explanation

Activity Intolerance is characterized by exertional dyspnea, adverse changes in blood pressure or heart rate with activity, and fatigue. Ineffective Breathing Pattern occurs when the rate, timing, depth, or rhythm of breathing is insufficient to maintain optimal ventilation. Ineffective Airway Clearance occurs when the client is unable to clear own secretions from the airway. Impaired Physical Mobility occurs when the client is limited in physical movement and has limited muscle strength, rage of motion, or coordination.

35. A nurse manager is planning to implement a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system and the nurse manager determines that a change is required. The initial step in the process of change for the nurse manager is which of the following?

Plan strategies to implement the change

Identify potential solutions and strategies for the change process

Set goals and priorities regarding the change process

Identify the inefficiency that needs improvement or correction

When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems, because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.

Explanation

When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems, because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.

36. A camp nurse provides instructions regarding skin protection from the sun to the parents who are preparing their children for a camping adventure. The nurse avoid telling the parents:

To obtain a sunscreen product with an SPF of 15 or more

That sunscreen will not be required on cloudy days

To pack a hat, long-sleeved shirt, and long pants for the child

To select tightly woven materials for greater protection from sun rays

The sun’s rays are as damaging to the skin on cloudy hazy days as they are on sunny days. Sunscreens with an SPF of 15 or more are recommended and should be applied before exposure to the sun and reapplied frequently and liberally at least every 2 hours. A hat, long sleeved shirt, and long pants should be worn when out in the sun. Tightly woven materials provide greater protection from the sun’s rays.

Explanation

The sun’s rays are as damaging to the skin on cloudy hazy days as they are on sunny days. Sunscreens with an SPF of 15 or more are recommended and should be applied before exposure to the sun and reapplied frequently and liberally at least every 2 hours. A hat, long sleeved shirt, and long pants should be worn when out in the sun. Tightly woven materials provide greater protection from the sun’s rays.

37. A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. A nurse would assess for which sign or symptom that correlates with this fluid imbalance?

Increased blood pressure

Decreased pulse

Decreased central venous pressure (CVP)

Bibasilar crackles

A client dehydration has a low CVP. The normal CVP is between 4 and 11 mm H2O. Other assessment finding with fluid volume deficit are increased pulse and respiration, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit and altered level of consciousness. The assessment signs in options A, B and D occur with fluid volume excess.

Explanation

A client dehydration has a low CVP. The normal CVP is between 4 and 11 mm H2O. Other assessment finding with fluid volume deficit are increased pulse and respiration, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit and altered level of consciousness. The assessment signs in options A, B and D occur with fluid volume excess.

38. A nurse is caring for a client who is comatose. The nurse notes in the chart that the client is exhibiting decerebrate posturing. Based on this documented finding, the nurse expects to note which of the following?

Extension of the extremities after a stimulus

Flexion of the extremities after a stimulus

Upper extremity flexion with lower extremity extension

Upper extremity extension with lower extremity flexion

Decerebrate posturing, which can occur with the upper brainstem injury, is the extension of the extremities after a stimulus. Options B, C, and D are incorrect descriptions of this type of posturing.

Explanation

Decerebrate posturing, which can occur with the upper brainstem injury, is the extension of the extremities after a stimulus. Options B, C, and D are incorrect descriptions of this type of posturing.

39. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and says to a nurse. "This is all the doctor's fault! I have done everything that the doctor has asked me to do!" The nurse interprets the client's statement as:

An expected coping mechanism

A need to notify the hospital lawyer

An expression of guilt on the part of the client

An ineffective coping mechanism

The expression is known to be a normal response to impending loss, and the anger may be directed toward oneself, God or other spiritual being, or the caregivers. The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client’s feelings, and the data in the question do not provide an indication that guilt is present.

Explanation

The expression is known to be a normal response to impending loss, and the anger may be directed toward oneself, God or other spiritual being, or the caregivers. The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client’s feelings, and the data in the question do not provide an indication that guilt is present.

40. A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse's most appropriate action is to:

Provide information needed for decision making

Assess the risk of self-harm and refer the family member to a Psychiatric Nursing professional

Demonstrate acceptance of the family member’s feelings

Remain with the family member without discussing funeral arrangements

The family member is exhibiting the first stage of grief, denial. Option A may be an appropriate intervention for the bargaining stage. Option B may be an appropriate intervention for the depression stage. Option C is an appropriate intervention for the acceptance or reorganization and restitution stage.

Explanation

The family member is exhibiting the first stage of grief, denial. Option A may be an appropriate intervention for the bargaining stage. Option B may be an appropriate intervention for the depression stage. Option C is an appropriate intervention for the acceptance or reorganization and restitution stage.

41. A client is diagnosed with hyperphosphatemia. The nurse encourages the client to limit intake of which of the following items that exacerbates the condition?

Bananas

Grapes

Coffee

Carbonated beverages

Food items and liquids that are naturally high in phosphate should be avoided by the client with hyperphosphatemia. These include fish, egg, milk products, vegetables, whole grains, and carbonated beverages.

Explanation

Food items and liquids that are naturally high in phosphate should be avoided by the client with hyperphosphatemia. These include fish, egg, milk products, vegetables, whole grains, and carbonated beverages.

42. A client undergoes a thyroidectomy. The nurse monitors the client for signs of damage to the parathyroid glands postoperatively. Which of the following findings would indicate damage to the parathyroid glands?

Hoarseness

Tingling around the mouth

Respiratory distress

Neck pain

The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers, and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek’s and Trousseau’s signs

Explanation

The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers, and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek’s and Trousseau’s signs

43. A nurse is interviewing a client with chronic obstructive pulmonary disease (COPD), who has a respiratory rate of 35 breaths/min and is experiencing extreme dyspnea. Which if the following nursing diagnoses would be most appropriate for this client?

Impaired Verbal Communication related to a physical barrier

Ineffective individual coping related to the client’s inability to handle a situational crisis

Altered Body Image related to neurological deficit

Knowledge deficit related to COPD

A client may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration affecting speech. There are no data in the question that support options B, C, and D.

Explanation

A client may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration affecting speech. There are no data in the question that support options B, C, and D.

44. A nurse has received a client assignment for the day and is organizing the required tasks. Which of the following will not be a component of the plan for time management?

Prioritizing client needs and daily tasks

Providing time for unexpected tasks

Gathering supplies before beginning a task

Documenting task completion at the end of the day

The nurse should document task completion continuously throughout the day. Options A, B, and C identify accurate components of time management.

Explanation

The nurse should document task completion continuously throughout the day. Options A, B, and C identify accurate components of time management.

45. A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. A nurse explores the client's feelings and identifies which of these responses by the husband as indicative of effective individual coping?

He states that he will not allow his wife to come home to die

He immediately arranges for their three teen-aged children to live with relatives in another state

He express his anger at God and the physicians for allowing this to happen

He refuses to visit wife in the hospital or to discuss her illness

The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward oneself, the dying person, God or other spiritual being, or the caregivers. Option A and B indicate possibly rash and unilateral decisions made by the husband, without taking into consideration anyone else’s feelings. There is evidence of denial in option D, as he refuses to visit his wife or discuss her illness. The only response that indicates effective individual coping by the husband is option C

Explanation

The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward oneself, the dying person, God or other spiritual being, or the caregivers. Option A and B indicate possibly rash and unilateral decisions made by the husband, without taking into consideration anyone else’s feelings. There is evidence of denial in option D, as he refuses to visit his wife or discuss her illness. The only response that indicates effective individual coping by the husband is option C

46. A client is ready to be discharged to home health care for continued intravenous (IV) therapy at home. Home care instructions regarding care of the IV have been given to the client. The best way to evaluate the client ability to care for the IV site is to:

Ask the client to verbalize IV site care

Ask the client to change the IV dressing

Review the entire discharge plan with the client again

Demonstrate the dressing change again for the client one last time before discharge

Acquisition of psychomotor skills is best evaluated by observing how a client can carry out a procedure. The client may be able to verbalize how to do the procedure, but may not be able to actually perform the psychomotor function. Reviewing the entire plan again, and demonstrating it again will not evaluate the client’s ability. Actively demonstrating is always the best method of evaluating a psychomotor skill.

Explanation

Acquisition of psychomotor skills is best evaluated by observing how a client can carry out a procedure. The client may be able to verbalize how to do the procedure, but may not be able to actually perform the psychomotor function. Reviewing the entire plan again, and demonstrating it again will not evaluate the client’s ability. Actively demonstrating is always the best method of evaluating a psychomotor skill.

47. An 18 year-old client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb, followed by redness and swelling and throbbing, achy pain. Raynaud's disease is suspected. The nurse further assesses the client to see if these episodes occur with:

Exposure to heat

Being in a relaxed environment

Prolonged episodes of inactivity

Ingestion of coffee or chocolate

Raynaud’s disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity is unrelated to these episodes.

Explanation

Raynaud’s disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity is unrelated to these episodes.

48. A nurse is conducting a health history of a client with hyperparathyroidsm. Which of the following questions made to the client would elicit information about this condition?

"Have you had problems with diarrhea lately?"

"Do you have tremors in your hands?"

"Are you experiencing pain in your joints?"

"Do you notice swelling in your legs at night?"

Hyperparathyroidism causes and oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options A and B relate to assessment of hypoparathyroidism. Option D is unrelated to hyperparathyroidism.

Explanation

Hyperparathyroidism causes and oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options A and B relate to assessment of hypoparathyroidism. Option D is unrelated to hyperparathyroidism.

49. An ambulatory care nurse is assessing client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem?

Purulent nasal discharge

Chronic cough

Headache more pronounced in the evening

Anosmia

Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse upon arising after sleep.

Explanation

Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse upon arising after sleep.

50. A client with Chlamydia infection has received instructions on self-care and prevention of further infection. The nurse evaluates that the client needs further reinforcement if the client states to:

Reduce the chance of reinfection by limiting the number of sexual partners

Use latex condoms to prevent disease transmission

Return to the clinic as requested for follow-up culture in 1 week

Antibiotics prophylactically to prevent symptoms of Chlamydia

Antibiotics are not taken prophylactically to prevent Chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners, and by the use of condoms. In some instances, follow-up culture is requested in 4 to 7 days to confirm a cure.

Explanation

Antibiotics are not taken prophylactically to prevent Chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners, and by the use of condoms. In some instances, follow-up culture is requested in 4 to 7 days to confirm a cure.