Nursing Practice III- care Of Clients With Physio And Psychosocial (Exam Mode)
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A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
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Chest and lower back pain
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Chills, fever, night sweats, and hemoptysis
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Fever of more than 104°F (40°C) and nausea
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Headache and photophobia
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Mark the letter of the letter of choice then click on the next button. Score will be posted as soon as the you are done with the quiz. You got 120 minutes to finish the exam. Good luck!
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- 2.
Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might havewhich of the following reactions?
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Asthma attack
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Respiratory arrest
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Seizure
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Wake up on his own
Correct Answer
A. Respiratory arrestExplanation
Narcotics can cause respiratory arrest if given in large quantities. It’s unlikely the client will have asthma attack or a seizure or wake up on his own.Rate this question:
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- 3.
A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:
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Call the physician
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Place a saline-soaked sterile dressing on the wound.
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Take a blood pressure and pulse.
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Pull the dehiscence closed.
Correct Answer
A. Place a saline-soaked sterile dressing on the wound.Explanation
The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client’s vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.Rate this question:
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- 4.
Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
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Septic arthritis
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Traumatic arthritis
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Intermittent arthritis
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Gouty arthritis
Correct Answer
A. Gouty arthritisExplanation
Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate
deposits don't occur in septic or traumatic arthritis. Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial
lining. Traumatic arthritis results from blunt trauma to a joint or ligament. Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees.Rate this question:
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- 5.
Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
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The client lies still.
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The client asks questions.
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The client hears thumping sounds.
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The client wears a watch and wedding band.
Correct Answer
A. The client wears a watch and wedding band.Explanation
During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.Rate this question:
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- 6.
When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
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"Put on disposable gloves before bathing."
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"Sterilize all plates and utensils in boiling water."
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"Avoid sharing such articles as toothbrushes and razors."
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"Avoid eating foods from serving dishes shared by other family members."
Correct Answer
A. "Avoid sharing such articles as toothbrushes and razors."Explanation
The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.Rate this question:
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- 7.
Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?
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Beta-adrenergic blockers
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Bronchodilators
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Inhaled steroids
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Oral steroids
Correct Answer
A. BronchodilatorsExplanation
Bronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflow. Beta adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction. Inhaled oral steroids may be given to reduce the inflammation but aren’t used for emergency relief.Rate this question:
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- 8.
Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:
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Place the client on his back remove dangerous objects, and insert a bite block.
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Place the client on his side, remove dangerous objects, and insert a bite block.
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Place the client o his back, remove dangerous objects, and hold down his arms.
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Place the client on his side, remove dangerous objects, and protect his head.
Correct Answer
A. Place the client on his side, remove dangerous objects, and protect his head.Explanation
During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration.Rate this question:
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- 9.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
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Platelet count, prothrombin time, and partial thromboplastin time
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Platelet count, blood glucose levels, and white blood cell (WBC) count
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Thrombin time, calcium levels, and potassium levels
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Fibrinogen level, WBC, and platelet count
Correct Answer
A. Platelet count, prothrombin time, and partial thromboplastin timeExplanation
The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.Rate this question:
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- 10.
Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?
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A 16-year-old female high school student
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A 33-year-old day-care worker
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A 43-year-old homeless man with a history of alcoholism
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A 54-year-old businessman
Correct Answer
A. A 43-year-old homeless man with a history of alcoholismExplanation
Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB. A high school student, daycare worker, and businessman probably have a much low risk of contracting TB.Rate this question:
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- 11.
Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
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Nights sweats, weight loss, and diarrhea
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Dyspnea, tachycardia, and pallor
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Nausea, vomiting, and anorexia
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Itching, rash, and jaundice
Correct Answer
A. Dyspnea, tachycardia, and pallorExplanation
Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.Rate this question:
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- 12.
The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for thischange is that:
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The attack is over.
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The airways are so swollen that no air cannot get through.
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The swelling has decreased.
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Crackles have replaced wheezes.
Correct Answer
A. The airways are so swollen that no air cannot get through.Explanation
During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can’t get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles do not replace wheezes during an acute asthma attack.Rate this question:
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- 13.
After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
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Infection of the lung.
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Kinked or obstructed chest tube
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Excessive water in the water-seal chamber
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Excessive chest tube drainage
Correct Answer
A. Kinked or obstructed chest tubeExplanation
Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won’t cause a tension pneumothorax. Excessive water won’t affect the chest tube drainage.Rate this question:
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- 14.
When performing oral care on a comatose client, Nurse Krina should:
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Apply lemon glycerin to the client’s lips at least every 2 hours.
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Brush the teeth with client lying supine.
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Place the client in a side lying position, with the head of the bed lowered.
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Clean the client’s mouth with hydrogen peroxide.
Correct Answer
A. Place the client in a side lying position, with the head of the bed lowered.Explanation
The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and should not be used.Rate this question:
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- 15.
Vic asks the nurse what PSA is. The nurse should reply that it stands for:
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Prostate-specific antigen, which is used to screen for prostate cancer.
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Protein serum antigen, which is used to determine protein levels.
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Pneumococcal strep antigen, which is a bacteria that causes pneumonia.
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Papanicolaou-specific antigen, which is used to screen for cervical cancer.
Correct Answer
A. Prostate-specific antigen, which is used to screen for prostate cancer.Explanation
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect.Rate this question:
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- 16.
Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:
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Bone fracture
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Loss of estrogen
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Negative calcium balance
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Dowager’s hump
Correct Answer
A. Bone fractureExplanation
Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones. Estrogen deficiencies result from menopause-not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis. Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.Rate this question:
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- 17.
A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?
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Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
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Low levels of urine constituents normally excreted in the urine
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Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
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Electrolyte imbalance that could affect the blood's ability to coagulate properly
Correct Answer
A. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levelsExplanation
Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.Rate this question:
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- 18.
A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
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24 hours later, when edema has subsided.
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In the operating room.
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After the ileostomy begin to function.
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When the client is able to begin self-care procedures.
Correct Answer
A. In the operating room.Explanation
The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated.Rate this question:
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- 19.
A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
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Increased elastic recoil of the lungs
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Increased number of functional capillaries in the alveoli
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Decreased residual volume
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Decreased vital capacity
Correct Answer
A. Decreased vital capacityExplanation
Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume.Rate this question:
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- 20.
A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?
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Avoid lifting objects weighing more than 5 lb (2.25 kg).
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Lie on your abdomen when in bed
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Keep rooms brightly lit.
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Avoiding straining during bowel movement or bending at the waist.
Correct Answer
A. Avoiding straining during bowel movement or bending at the waist.Explanation
The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb. instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses.Rate this question:
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- 21.
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:
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Call the physician
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Document the patient’s status in his charts.
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Prepare oxygen treatment
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Raise the side rails
Correct Answer
A. Raise the side railsExplanation
A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety.Rate this question:
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- 22.
Nurse Len should expect to administer which medication to a client with gout?
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Aspirin
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Furosemide (Lasix)
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Colchicines
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Calcium gluconate (Kalcinate)
Correct Answer
A. ColchicinesExplanation
A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout.Rate this question:
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- 23.
A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
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E-rosette immunofluorescence.
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Quantification of T-lymphocytes.
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Enzyme-linked immunosorbent assay (ELISA).
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Western blot test with ELISA.
Correct Answer
A. Western blot test with ELISA.Explanation
HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. Erosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test.Rate this question:
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- 24.
During the endorsement, which of the following clients should the on-duty nurse assess first?
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The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
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The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
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The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin
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The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
Correct Answer
A. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)Explanation
The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don’t require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time-consuming supportive measures.Rate this question:
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- 25.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
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Infusing I.V. fluids rapidly as ordered
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Encouraging increased oral intake
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Restricting fluids
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Administering glucose-containing I.V. fluids as ordered
Correct Answer
A. Restricting fluidsExplanation
To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.Rate this question:
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- 26.
While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
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Blood pressure is decreased from 160/90 to 110/70.
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Pulse is increased from 87 to 95, with an occasional skipped beat.
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The client is oriented when aroused from sleep, and goes back to sleep immediately.
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The client refuses dinner because of anorexia.
Correct Answer
A. The client is oriented when aroused from sleep, and goes back to sleep immediately.Explanation
This finding suggest that the level of consciousness is decreasing.Rate this question:
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- 27.
On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
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Hypocalcemia
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Hyponatremia
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Hyperkalemia
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Hypermagnesemia
Correct Answer
A. HypocalcemiaExplanation
Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.Rate this question:
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- 28.
A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
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On the side, to prevent obstruction of airway by tongue.
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Flat on back.
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On the back, with knees flexed 15 degrees.
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Flat on the stomach, with the head turned to the side.
Correct Answer
A. Flat on back.Explanation
To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.Rate this question:
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- 29.
Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:
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Laminectomy
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Thoracotomy
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Hemorrhoidectomy
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Cystectomy.
Correct Answer
A. LaminectomyExplanation
The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning. Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.Rate this question:
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- 30.
During a breast examination, which finding most strongly suggests that the Luz has breast cancer?
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Slight asymmetry of the breasts.
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A fixed nodular mass with dimpling of the overlying skin
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Bloody discharge from the nipple
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Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer
A. A fixed nodular mass with dimpling of the overlying skinExplanation
A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition.Rate this question:
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- 31.
Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which of the following glands?
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Adrenal cortex
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Pancreas
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Adrenal medulla
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Parathyroid
Correct Answer
A. Adrenal cortexExplanation
Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.Rate this question:
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- 32.
Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?
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Encourage the client to change positions frequently in bed.
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Administer Demerol 50 mg IM q 4 hours and PRN.
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Apply warmth to the abdomen with a heating pad.
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Use comfort measures and pillows to position the client.
Correct Answer
A. Use comfort measures and pillows to position the client.Explanation
Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief.Rate this question:
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- 33.
A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?
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Encourage the client to perform pursed lip breathing.
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Check the client’s temperature.
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Assess the client’s potassium level.
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Increase the client’s oxygen flow rate.
Correct Answer
A. Encourage the client to perform pursed lip breathing.Explanation
Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.Rate this question:
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- 34.
Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and hasa nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?
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Acute asthma
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Bronchial pneumonia
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Chronic obstructive pulmonary disease (COPD)
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Emphysema
Correct Answer
A. Acute asthmaExplanation
Based on the client’s history and symptoms, acute asthma is the most likely diagnosis. He’s unlikely to have bronchial pneumonia without a productive cough and fever and he’s too young to have developed (COPD) and emphysema.Rate this question:
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- 35.
Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:
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Report incidents of diarrhea.
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Avoid foods high in vitamin K
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Use a straight razor when shaving.
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Take aspirin to pain relief.
Correct Answer
A. Avoid foods high in vitamin KExplanation
The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but isn’t effect of taking an anticoagulant. An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen should be used to pain relief.Rate this question:
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- 36.
A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
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Eversion of the right nipple and mobile mass
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Nonmobile mass with irregular edges
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Mobile mass that is soft and easily delineated
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Nonpalpable right axillary lymph nodes
Correct Answer
A. Nonmobile mass with irregular edgesExplanation
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.Rate this question:
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- 37.
Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
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Plan care so the client can receive 8 hours of uninterrupted sleep each night.
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Monitor vital signs every 2 hours.
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Make sure that the client takes food and medications at prescribed intervals.
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Provide milk every 2 to 3 hours.
Correct Answer
A. Make sure that the client takes food and medications at prescribed intervals.Explanation
Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate.Rate this question:
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- 38.
Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:
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A progressively deeper breaths followed by shallower breaths with apneic periods.
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Rapid, deep breathing with abrupt pauses between each breath.
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Rapid, deep breathing and irregular breathing without pauses.
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Shallow breathing with an increased respiratory rate.
Correct Answer
A. A progressively deeper breaths followed by shallower breaths with apneic periods.Explanation
Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by shallower respirations with apneas periods. Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath. Kussmaul’s respirations are rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate.Rate this question:
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- 39.
Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
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On the client’s right side
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On the client’s left side
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Directly in front of the client
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Where the client like
Correct Answer
A. On the client’s right sideExplanation
The client has left visual field blindness. The client will see only from the right side.Rate this question:
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- 40.
A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?
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Adult respiratory distress syndrome (ARDS)
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Myocardial infarction (MI)
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Pneumonia
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Tuberculosis
Correct Answer
A. PneumoniaExplanation
Fever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI. the client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions.Rate this question:
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- 41.
A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
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Stop the I.V. infusion of heparin and notify the physician.
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Continue treatment as ordered.
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Expect the warfarin to increase the PTT.
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Increase the dosage, because the level is lower than normal.
Correct Answer
A. Continue treatment as ordered.Explanation
The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.Rate this question:
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- 42.
Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?
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Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
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Increase in systemic blood pressure.
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Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
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Increase in intracranial pressure (ICP).
Correct Answer
A. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.Explanation
Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren’t as significant as PVCs in the situation.Rate this question:
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- 43.
George should be taught about testicular examinations during:
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When sexual activity starts
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After age 69
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After age 40
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Before age 20.
Correct Answer
A. Before age 20.Explanation
Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular selfexamination before age 20, preferably when he enters his teens.Rate this question:
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- 44.
Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?
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A walker is a better choice than a cane.
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The cane should be used on the affected side
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The cane should be used on the unaffected side
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A client with osteoarthritis should be encouraged to ambulate without the cane
Correct Answer
A. The cane should be used on the unaffected sideExplanation
A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints.Rate this question:
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- 45.
Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing theclient?
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Pallor, bradycardia, and reduced pulse pressure
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Pallor, tachycardia, and a sore tongue
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Sore tongue, dyspnea, and weight gain
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Angina, double vision, and anorexia
Correct Answer
A. Pallor, tachycardia, and a sore tongueExplanation
Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.Rate this question:
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- 46.
Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:
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Leaving the hair intact
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Shaving the area
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Clipping the hair in the area
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Removing the hair with a depilatory.
Correct Answer
A. Clipping the hair in the areaExplanation
Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions and depilatories can irritate the skin.Rate this question:
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- 47.
A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?
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Liver
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Colon
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Reproductive tract
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White blood cells (WBCs)
Correct Answer
A. LiverExplanation
The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.Rate this question:
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- 48.
During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order:
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Enzyme-linked immunosuppressant assay (ELISA) test.
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Electrolyte panel and hemogram.
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Stool for Clostridium difficile test.
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Flat plate X-ray of the abdomen.
Correct Answer
A. Stool for Clostridium difficile test.Explanation
Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea.Rate this question:
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- 49.
Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
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No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
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Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
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Can't assess tumor or regional lymph nodes and no evidence of metastasis
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Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
Correct Answer
A. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasisExplanation
TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.Rate this question:
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Mar 22, 2023Quiz Edited by
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Jul 07, 2010Quiz Created by
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