Nursing Comprehensive Exam 4
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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:
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Diabetes insipidus
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Syndrome of inappropriate antidi-uretic hormone (ADH) secretion
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End stage renal disease (ESRD)
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Chronic urinary tract infection (UTI)
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When you begin learning about something, it is important to ensure that you read what you learn over and over again so that you don’t forget it. The comprehensive test below is for beginners in nursing school, and it is perfect for ensuring that they do not go to the next step without understanding the basics. Give it a try See moreand do just that!
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- 2.
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?
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Tolerance for sips of clear liquids
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Temperature
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Hourly urine output
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Ability to turn side to side
Correct Answer
A. Hourly urine outputExplanation
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.Rate this question:
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- 3.
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:
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Impaired Physical Mobility
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Activity Intolerance
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Ineffective Breathing Pattern
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Ineffective Airway Clearance
Correct Answer
A. Activity IntoleranceExplanation
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.Rate this question:
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- 4.
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:
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Proximal end of the distal stomach is anastomosed to the duodenum
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Antrum of the stomach is removed with the remaining portion anastomosed to the duodenum
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Entire stomach is removed and the esophagus is anastomosed to the duodenum
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Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum
Correct Answer
A. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunumExplanation
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.Rate this question:
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- 5.
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?
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Mouth care
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Coughing and deep breathing
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Monitoring intake and output
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Daily weights
Correct Answer
A. Coughing and deep breathingExplanation
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.Rate this question:
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- 6.
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?
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Hoarseness
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Tingling around the mouth
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Respiratory distress
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Neck pain
Correct Answer
A. Tingling around the mouthExplanation
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 signsRate this question:
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- 7.
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?
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Extension of the extremities after a stimulus
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Flexion of the extremities after a stimulus
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Upper extremity flexion with lower extremity extension
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Upper extremity extension with lower extremity flexion
Correct Answer
A. Extension of the extremities after a stimulusExplanation
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.Rate this question:
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- 8.
A nurse is caring for a client who had a total knee replacement. Postoperatively, which of the following nursing assessments is the highest priority?
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Bladder distention
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Homans’ sign
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Extremity shortening
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Heel breakdown
Correct Answer
A. Homans’ signExplanation
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.Rate this question:
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- 9.
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?
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0.75 pack-years
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7.5 pack-years
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15 pack-years
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30 pack-years
Correct Answer
A. 7.5 pack-yearsExplanation
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.Rate this question:
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- 10.
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?
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"Have you had problems with diarrhea lately?"
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"Do you have tremors in your hands?"
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"Are you experiencing pain in your joints?"
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"Do you notice swelling in your legs at night?"
Correct Answer
A. "Are you experiencing pain in your joints?"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.Rate this question:
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- 11.
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:
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Exposure to heat
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Being in a relaxed environment
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Prolonged episodes of inactivity
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Ingestion of coffee or chocolate
Correct Answer
A. Ingestion of coffee or chocolateExplanation
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.Rate this question:
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- 12.
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?
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Chest pain that worsens on inspiration
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Pericardial friction rub
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Anterior chest pain
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Weakness and irritability
Correct Answer
A. Pericardial friction rubExplanation
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.Rate this question:
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- 13.
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?
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Purulent nasal discharge
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Chronic cough
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Headache more pronounced in the evening
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Anosmia
Correct Answer
A. Headache more pronounced in the eveningExplanation
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.Rate this question:
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- 14.
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?
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Use of hand or finger signals
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Nodding and shaking the head for yes and no
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Use of a picture board
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Use of a pencil and paper
Correct Answer
A. Nodding and shaking the head for yes and noExplanation
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.Rate this question:
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- 15.
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:
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Laryngeal cancer
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Acute Laryngitis
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Bronchogenic cancer
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Thyroid cancer
Correct Answer
A. Laryngeal cancerExplanation
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.Rate this question:
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- 16.
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:
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Tuesday or Wednesday
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Wednesday or Thursday
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Thursday or Friday
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The following Monday
Correct Answer
A. Wednesday or ThursdayExplanation
The Mantoux skin test for tuberculosis is read in 48 to 72 hours. The client should return to the clinic on Wednesday or Thursday.Rate this question:
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- 17.
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?
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Explaining each treatment in great detail
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Having the family reinforce the nurse’s directions
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Giving simple clear directions and explanations
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Speaking very little to the client until the crisis is over
Correct Answer
A. Giving simple clear directions and explanationsExplanation
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.Rate this question:
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- 18.
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?
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Encouraging the client to cough and deep breathe
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Staying with the client
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Interpreting the arterial blood gas report
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Distracting the client with television
Correct Answer
A. Staying with the clientExplanation
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.Rate this question:
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- 19.
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?
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A 50-year-old smoker with cracked asbestos lining on basement pipes in the home
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A 40-year-old smoker who works in a hospital
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A 36-year-old who works with pesticides
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A 25-year-old whose hobby is woodworking
Correct Answer
A. A 50-year-old smoker with cracked asbestos lining on basement pipes in the homeExplanation
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.Rate this question:
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- 20.
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?
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Impaired Verbal Communication related to a physical barrier
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Ineffective individual coping related to the client’s inability to handle a situational crisis
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Altered Body Image related to neurological deficit
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Knowledge deficit related to COPD
Correct Answer
A. Impaired Verbal Communication related to a physical barrierExplanation
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.Rate this question:
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- 21.
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?
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Prioritizing client needs and daily tasks
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Providing time for unexpected tasks
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Gathering supplies before beginning a task
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Documenting task completion at the end of the day
Correct Answer
A. Documenting task completion at the end of the dayExplanation
The nurse should document task completion continuously throughout the day. Options A, B, and C identify accurate components of time management.Rate this question:
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- 22.
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:
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Daily during hospitalization
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Every other day of hospitalization
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Every third day of hospitalization
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Continuously
Correct Answer
A. ContinuouslyExplanation
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.Rate this question:
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- 23.
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:
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Autocratic
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Situational
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Democratic
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Laissez-faire
Correct Answer
A. AutocraticExplanation
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.Rate this question:
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- 24.
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?
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Functional nursing
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Team nursing
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Exemplary model of nursing
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Primary nursing
Correct Answer
A. Functional nursingExplanation
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.Rate this question:
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- 25.
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?
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Put the bed in reverse Trendelenburg position
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Keep the stump flat with the client lying on the operative side
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Position the stump flat on the bed
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Elevate the foot of the bed
Correct Answer
A. Elevate the foot of the bedExplanation
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.Rate this question:
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- 26.
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?
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Plan strategies to implement the change
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Identify potential solutions and strategies for the change process
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Set goals and priorities regarding the change process
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Identify the inefficiency that needs improvement or correction
Correct Answer
A. Identify the inefficiency that needs improvement or correctionExplanation
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.Rate this question:
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- 27.
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
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Surgeon
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Clinical nurse specialist
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Social worker
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Physical therapist
Correct Answer
A. Social workerExplanation
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.Rate this question:
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- 28.
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?
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He states that he will not allow his wife to come home to die
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He immediately arranges for their three teen-aged children to live with relatives in another state
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He express his anger at God and the physicians for allowing this to happen
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He refuses to visit wife in the hospital or to discuss her illness
Correct Answer
A. He express his anger at God and the physicians for allowing this to happenExplanation
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 CRate this question:
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- 29.
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:
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To obtain a sunscreen product with an SPF of 15 or more
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That sunscreen will not be required on cloudy days
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To pack a hat, long-sleeved shirt, and long pants for the child
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To select tightly woven materials for greater protection from sun rays
Correct Answer
A. That sunscreen will not be required on cloudy daysExplanation
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.Rate this question:
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- 30.
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?
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This will be a totally painless experience. It is nothing to worry about
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I’m sure it will be a relief for you just as soon as I discontinue this IV for good. Just relax and take a deep breath
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This procedure will not take long and will be over soon. I can see that you’re anxious.
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Removal of the IV shouldn’t be painful ; however, the IV will need to be restarted in another location.
Correct Answer
A. Removal of the IV shouldn’t be painful ; however, the IV will need to be restarted in another location.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.Rate this question:
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- 31.
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:
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Femoral circulation
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Brachial circulation
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Carotid circulation
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Ulnar circulation
Correct Answer
A. Ulnar circulationExplanation
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 incorrectRate this question:
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- 32.
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:
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Provide information needed for decision making
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Assess the risk of self-harm and refer the family member to a Psychiatric Nursing professional
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Demonstrate acceptance of the family member’s feelings
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Remain with the family member without discussing funeral arrangements
Correct Answer
A. Remain with the family member without discussing funeral arrangementsExplanation
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.Rate this question:
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- 33.
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?
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Gently massage the area around the site daily
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Cleanse the site daily with alcohol
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Keep the cannula stabilized or anchored properly with tape
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Immobilize the extremity until the IV is discontinued
Correct Answer
A. Keep the cannula stabilized or anchored properly with tapeExplanation
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.Rate this question:
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- 34.
A client is diagnosed with hyperphosphatemia. The nurse encourages the client to limit intake of which of the following items that exacerbates the condition?
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Bananas
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Grapes
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Coffee
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Carbonated beverages
Correct Answer
A. Carbonated beveragesExplanation
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.Rate this question:
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- 35.
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:
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The left leg kept flat
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Elevation of the left leg
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The left leg in a dependent position
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Bathroom privileges
Correct Answer
A. Elevation of the left legExplanation
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.Rate this question:
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- 36.
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:
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Ask the client to verbalize IV site care
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Ask the client to change the IV dressing
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Review the entire discharge plan with the client again
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Demonstrate the dressing change again for the client one last time before discharge
Correct Answer
A. Ask the client to change the IV dressingExplanation
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.Rate this question:
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- 37.
A client is scheduled for an arteriogram using a radiopaque dye. A nurse assesses which most critical item before the procedure?
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Intake and output
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Vital signs
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Height and weight
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Allergy to iodine or shellfish
Correct Answer
A. Allergy to iodine or shellfishExplanation
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.Rate this question:
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- 38.
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:
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Take a blood pressure
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Stop the infusion
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Contact the nurse
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Contact the local area emergency response team
Correct Answer
A. Stop the infusionExplanation
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.Rate this question:
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- 39.
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
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Show the client various central line tubes and catheters
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Explain that an implanted port is placed under the skin and is not visible
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Notify the physician of the client’s concerns
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Explain that the client friends probably will not see the tube under the clothing
Correct Answer
A. Explain that an implanted port is placed under the skin and is not visibleExplanation
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.Rate this question:
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- 40.
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
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Liver
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Apples
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Carrots
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Milk
Correct Answer
A. LiverExplanation
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.Rate this question:
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- 41.
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?
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Increased blood pressure
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Decreased pulse
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Decreased central venous pressure (CVP)
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Bibasilar crackles
Correct Answer
A. Decreased central venous pressure (CVP)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.Rate this question:
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- 42.
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?
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Offering verbal support and reassurance
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Assisting the client to find positions of comfort
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Leaving the client alone for an extended rest period
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Providing pain medication for the client
Correct Answer
A. Leaving the client alone for an extended rest periodExplanation
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.Rate this question:
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- 43.
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?
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Metabolic acidosis
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Metabolic acidosis
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Respiratory alkalosis
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Respiratory acidosis
Correct Answer
A. Metabolic acidosisExplanation
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.Rate this question:
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- 44.
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?
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Infiltration
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Phlebitis
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Thrombosis
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Infection
Correct Answer
A. InfiltrationExplanation
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.Rate this question:
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- 45.
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:
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Reduce the chance of reinfection by limiting the number of sexual partners
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Use latex condoms to prevent disease transmission
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Return to the clinic as requested for follow-up culture in 1 week
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Antibiotics prophylactically to prevent symptoms of Chlamydia
Correct Answer
A. Antibiotics prophylactically to prevent symptoms of ChlamydiaExplanation
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.Rate this question:
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- 46.
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:
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An expected coping mechanism
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A need to notify the hospital lawyer
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An expression of guilt on the part of the client
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An ineffective coping mechanism
Correct Answer
A. An expected coping mechanismExplanation
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.Rate this question:
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- 47.
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?
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We need to avoid excessive intake of alcohol
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We need to decrease exposure to environmental hazards.
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We need to eat a nutritious diet
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I need to maintain warmth to the scrotum
Correct Answer
A. I need to maintain warmth to the scrotumExplanation
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.Rate this question:
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- 48.
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?
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Case finding in the school to identify dietary practices
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School screening programs for early detection of children with poor eating habits
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Providing educational programs, literature, and posters to promote awareness of healthy eating
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Conducting a community-wide dietary screening activity to detect community dietary trends
Correct Answer
A. Providing educational programs, literature, and posters to promote awareness of healthy eatingExplanation
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.Rate this question:
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- 49.
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?
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It is normal to miss something as basic as eating.
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I think in a few weeks you will probably be allowed to eat a little
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Tell me more about how you feel about dinner time
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You could sit with your family at dinner time anyway even if do not eat.
Correct Answer
A. Tell me more about how you feel about dinner timeExplanation
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.Rate this question:
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Current Version
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Mar 09, 2025Quiz Edited by
ProProfs Editorial Team -
Jul 14, 2012Quiz Created by
Mark Fredderick
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