Nursing Practice III- care Of Clients With Physiologic And Psychosocial Alterations Nursing (Practice Mode)

1. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?

Chest and lower back pain

Chills, fever, night sweats, and hemoptysis

Fever of more than 104°F (40°C) and nausea

Headache and photophobia

Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn’t usual. Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C). Nausea, headache, and photophobia aren’t usual TB symptoms.

Explanation

Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn’t usual. Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C). Nausea, headache, and photophobia aren’t usual TB symptoms.

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?

Asthma attack

Respiratory arrest

Seizure

Wake up on his own

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.

Explanation

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.

3. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:

Call the physician

Place a saline-soaked sterile dressing on the wound.

Take a blood pressure and pulse.

Pull the dehiscence closed.

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.

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.

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?

Septic arthritis

Traumatic arthritis

Intermittent arthritis

Gouty arthritis

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.

Explanation

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.

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?

The client lies still.

The client asks questions.

The client hears thumping sounds.

The client wears a watch and wedding band.

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.

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.

6. 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?

Beta-adrenergic blockers

Bronchodilators

Inhaled steroids

Oral steroids

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.

Explanation

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.

7. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?

"Put on disposable gloves before bathing."

"Sterilize all plates and utensils in boiling water."

"Avoid sharing such articles as toothbrushes and razors."

"Avoid eating foods from serving dishes shared by other family members."

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.

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.

8. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

Place the client on his back remove dangerous objects, and insert a bite block.

Place the client on his side, remove dangerous objects, and insert a bite block.

Place the client o his back, remove dangerous objects, and hold down his arms.

Place the client on his side, remove dangerous objects, and protect his head.

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.

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.

9. When performing oral care on a comatose client, Nurse Krina should:

Apply lemon glycerin to the client’s lips at least every 2 hours.

Brush the teeth with client lying supine.

Place the client in a side lying position, with the head of the bed lowered.

Clean the client’s mouth with hydrogen peroxide.

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.

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.

10. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

Platelet count, prothrombin time, and partial thromboplastin time

Platelet count, blood glucose levels, and white blood cell (WBC) count

Thrombin time, calcium levels, and potassium levels

Fibrinogen level, WBC, and platelet count

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.

Explanation

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.

11. 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?

A 16-year-old female high school student

A 33-year-old day-care worker

A 43-year-old homeless man with a history of alcoholism

A 54-year-old businessman

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.

Explanation

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.

12. Which nursing intervention is most appropriate when a patient is at risk of developing pressure ulcers?

Restricting fluid intake

Keeping the patient in one position for long periods

Repositioning the patient every 2 hours

Applying cold compresses to affected areas

The most appropriate nursing intervention to prevent pressure ulcers, also known as bedsores, is repositioning the patient every 2 hours. This helps relieve pressure on vulnerable areas like the heels, hips, and back, promoting better blood circulation. Regular repositioning reduces the risk of skin breakdown. Restricting fluids can lead to dehydration, which worsens skin condition, while cold compresses do not prevent pressure ulcers. Keeping a patient in one position for extended periods increases the risk of pressure ulcers, making frequent repositioning critical.

Explanation

The most appropriate nursing intervention to prevent pressure ulcers, also known as bedsores, is repositioning the patient every 2 hours. This helps relieve pressure on vulnerable areas like the heels, hips, and back, promoting better blood circulation. Regular repositioning reduces the risk of skin breakdown. Restricting fluids can lead to dehydration, which worsens skin condition, while cold compresses do not prevent pressure ulcers. Keeping a patient in one position for extended periods increases the risk of pressure ulcers, making frequent repositioning critical.

13. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

Bone fracture

Loss of estrogen

Negative calcium balance

Dowager’s hump

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.

Explanation

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.

14. 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?

Infection of the lung.

Kinked or obstructed chest tube

Excessive water in the water-seal chamber

Excessive chest tube drainage

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.

Explanation

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.

15. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

Nights sweats, weight loss, and diarrhea

Dyspnea, tachycardia, and pallor

Nausea, vomiting, and anorexia

Itching, rash, and jaundice

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.

Explanation

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.

16. While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

Blood pressure is decreased from 160/90 to 110/70.

Pulse is increased from 87 to 95, with an occasional skipped beat.

The client is oriented when aroused from sleep, and goes back to sleep immediately.

The client refuses dinner because of anorexia.

This finding suggest that the level of consciousness is decreasing.

Explanation

This finding suggest that the level of consciousness is decreasing.

17. 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:

The attack is over.

The airways are so swollen that no air cannot get through.

The swelling has decreased.

Crackles have replaced wheezes.

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.

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.

18. 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?

Increased elastic recoil of the lungs

Increased number of functional capillaries in the alveoli

Decreased residual volume

Decreased vital capacity

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.

Explanation

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.

19. 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?

Avoid lifting objects weighing more than 5 lb (2.25 kg).

Lie on your abdomen when in bed

Keep rooms brightly lit.

Avoiding straining during bowel movement or bending at the waist.

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.

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.

20. 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:

E-rosette immunofluorescence.

Quantification of T-lymphocytes.

Enzyme-linked immunosorbent assay (ELISA).

Western blot test with ELISA.

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.

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.

21. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?

Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels

Low levels of urine constituents normally excreted in the urine

Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

Electrolyte imbalance that could affect the blood's ability to coagulate properly

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.

Explanation

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.

22. 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:

Call the physician

Document the patient’s status in his charts.

Prepare oxygen treatment

Raise the side rails

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.

Explanation

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.

23. Vic asks the nurse what PSA is. The nurse should reply that it stands for:

Prostate-specific antigen, which is used to screen for prostate cancer.

Protein serum antigen, which is used to determine protein levels.

Pneumococcal strep antigen, which is a bacteria that causes pneumonia.

Papanicolaou-specific antigen, which is used to screen for cervical cancer.

PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect.

Explanation

PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect.

24. During a breast examination, which finding most strongly suggests that the Luz has breast cancer?

Slight asymmetry of the breasts.

A fixed nodular mass with dimpling of the overlying skin

Bloody discharge from the nipple

Multiple firm, round, freely movable masses that change with the menstrual cycle

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.

Explanation

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.

25. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Infusing I.V. fluids rapidly as ordered

Encouraging increased oral intake

Restricting fluids

Administering glucose-containing I.V. fluids as ordered

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.

Explanation

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.

26. During the endorsement, which of the following clients should the on-duty nurse assess first?

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

The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin

The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)

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.

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.

27. Nurse Len should expect to administer which medication to a client with gout?

Aspirin

Furosemide (Lasix)

Colchicines

Calcium gluconate (Kalcinate)

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.

Explanation

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.

28. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

Plan care so the client can receive 8 hours of uninterrupted sleep each night.

Monitor vital signs every 2 hours.

Make sure that the client takes food and medications at prescribed intervals.

Provide milk every 2 to 3 hours.

Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate.

Explanation

Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate.

29. 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?

Stop the I.V. infusion of heparin and notify the physician.

Continue treatment as ordered.

Expect the warfarin to increase the PTT.

Increase the dosage, because the level is lower than normal.

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.

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.

30. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

On the side, to prevent obstruction of airway by tongue.

Flat on back.

On the back, with knees flexed 15 degrees.

Flat on the stomach, with the head turned to the side.

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.

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.

31. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

Laminectomy

Thoracotomy

Hemorrhoidectomy

Cystectomy.

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.

Explanation

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.

32. 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?

Acute asthma

Bronchial pneumonia

Chronic obstructive pulmonary disease (COPD)

Emphysema

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.

Explanation

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.

33. 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?

Hypocalcemia

Hyponatremia

Hyperkalemia

Hypermagnesemia

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.

Explanation

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.

34. Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator of cancer?

Acid phosphatase level

Serum calcitonin level

Alkaline phosphatase level

Carcinoembryonic antigen level

In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer.

Explanation

In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer.

35. 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:

Enzyme-linked immunosuppressant assay (ELISA) test.

Electrolyte panel and hemogram.

Stool for Clostridium difficile test.

Flat plate X-ray of the abdomen.

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.

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.

36. A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?

Encourage the client to perform pursed lip breathing.

Check the client’s temperature.

Assess the client’s potassium level.

Increase the client’s oxygen flow rate.

Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.

Explanation

Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.

37. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

Report incidents of diarrhea.

Avoid foods high in vitamin K

Use a straight razor when shaving.

Take aspirin to pain relief.

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.

Explanation

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.

38. 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?

Eversion of the right nipple and mobile mass

Nonmobile mass with irregular edges

Mobile mass that is soft and easily delineated

Nonpalpable right axillary lymph nodes

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.

Explanation

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.

39. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?

A walker is a better choice than a cane.

The cane should be used on the affected side

The cane should be used on the unaffected side

A client with osteoarthritis should be encouraged to ambulate without the cane

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.

Explanation

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.

40. 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?

Encourage the client to change positions frequently in bed.

Administer Demerol 50 mg IM q 4 hours and PRN.

Apply warmth to the abdomen with a heating pad.

Use comfort measures and pillows to position the client.

Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief.

Explanation

Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief.

41. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?

On the client’s right side

On the client’s left side

Directly in front of the client

Where the client like

The client has left visual field blindness. The client will see only from the right side.

Explanation

The client has left visual field blindness. The client will see only from the right side.

42. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

Leaving the hair intact

Shaving the area

Clipping the hair in the area

Removing the hair with a depilatory.

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.

Explanation

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.

43. George should be taught about testicular examinations during:

When sexual activity starts

After age 69

After age 40

Before age 20.

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.

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.

44. 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?

Adult respiratory distress syndrome (ARDS)

Myocardial infarction (MI)

Pneumonia

Tuberculosis

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.

Explanation

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.

45. 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?

Adrenal cortex

Pancreas

Adrenal medulla

Parathyroid

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.

Explanation

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.

46. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?

Neutrophil

Basophil

Monocyte

Lymphocyte

The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen.
Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

Explanation

The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen.
Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

47. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?

Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.

Increase in systemic blood pressure.

Presence of premature ventricular contractions (PVCs) on a cardiac monitor.

Increase in intracranial pressure (ICP).

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.

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.

48. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?

Barbiturates

Opioids

Cocaine

Benzodiazepines

Because of the client’s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbiturate overdose may trigger respiratory depression and slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion.

Explanation

Because of the client’s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbiturate overdose may trigger respiratory depression and slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion.

49. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?

"Avoid drinking liquids until the gag reflex returns."

"Avoid eating milk products for 24 hours."

"Notify a nurse if you experience blood in your urine."

"Remain supine for the time specified by the physician."

The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

Explanation

The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

50. 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?

Liver

Colon

Reproductive tract

White blood cells (WBCs)

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.

Explanation

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.

51. 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?

Pallor, bradycardia, and reduced pulse pressure

Pallor, tachycardia, and a sore tongue

Sore tongue, dyspnea, and weight gain

Angina, double vision, and anorexia

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.

Explanation

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.

52. When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?

Bread

Carrots

Orange

Strawberries

Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions.

Explanation

Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions.

53. 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?

No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis

Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

Can't assess tumor or regional lymph nodes and no evidence of metastasis

Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

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.

Explanation

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.

54. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?

Explain the risks of not having the surgery

Notifying the physician immediately

Notifying the nursing supervisor

Recording the client’s refusal in the nurses’ notes

The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and then record the client’s refusal in the nurses’ notes.

Explanation

The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and then record the client’s refusal in the nurses’ notes.

55. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

"Keep the stoma uncovered."

"Keep the stoma dry."

"Have a family member perform stoma care initially until you get used to the procedure."

"Keep the stoma moist."

The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.

Explanation

The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.

56. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:

Urine glucose level.

Fasting blood glucose level.

Serum fructosamine level.

Glycosylated hemoglobin level.

Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

Explanation

Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

57. A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

Stool Hematest

Carcinoembryonic antigen (CEA)

Sigmoidoscopy

Abdominal computed tomography (CT) scan

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.

Explanation

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.

58. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?

Ask the woman’s family to provide personal items such as photos or mementos.

Select a room with a bed by the door so the woman can look down the hall.

Suggest the woman eat her meals in the room with her roommate.

Encourage the woman to ambulate in the halls twice a day.

Photos and mementos provide visual stimulation to reduce sensory deprivation.

Explanation

Photos and mementos provide visual stimulation to reduce sensory deprivation.

59. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

Call for help and note the time.

Clear the airway

Give two sharp thumps to the precordium, and check the pulse.

Administer two quick blows.

Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure.

Explanation

Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure.

60. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

Adult respiratory distress syndrome (ARDS)

Asthma

Chronic obstructive bronchitis

Emphysema

Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema.

Explanation

Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema.

61. Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?

Osteoarthritis is gender-specific, rheumatoid arthritis isn’t

Osteoarthritis is a localized disease rheumatoid arthritis is systemic

Osteoarthritis is a systemic disease, rheumatoid arthritis is localized

Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t

Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isn’t gender-specific, but rheumatoid arthritis is. Clients have dislocations and subluxations in both disorders.

Explanation

Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isn’t gender-specific, but rheumatoid arthritis is. Clients have dislocations and subluxations in both disorders.

62. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

Weight gain.

Fine motor tremors.

Respiratory acidosis.

Bilateral hearing loss.

Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis.

Explanation

Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis.

63. 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:

A progressively deeper breaths followed by shallower breaths with apneic periods.

Rapid, deep breathing with abrupt pauses between each breath.

Rapid, deep breathing and irregular breathing without pauses.

Shallow breathing with an increased respiratory rate.

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.

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.

64. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?

Page an anesthesiologist immediately and prepare to intubate the client.

Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.

Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs.

Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.

To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

Explanation

To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

65. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:

Cancerous lumps

Areas of thickness or fullness

Changes from previous examinations.

Fibrocystic masses

Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

Explanation

Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

66. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

Avoid focusing on his weight.

Increase his activity level.

Follow a regular diet.

Continue leading a high-stress lifestyle.

The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.

Explanation

The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.

67. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?

15 ml/hour

30 ml/hour

45 ml/hour

50 ml/hour

An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.

Explanation

An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.

68. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name?

Surgery

Chemotherapy

Radiation

Immunotherapy

The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer.

Explanation

The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer.

69. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?

Hyperkalemia

Reduced blood urea nitrogen (BUN)

Hypernatremia

Hyperglycemia

In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

Explanation

In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

They contain exudate and provide a moist wound environment.

They protect the wound from mechanical trauma and promote healing.

They debride the wound and promote healing by secondary intention.

They prevent the entrance of microorganisms and minimize wound discomfort.

For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing.

Explanation

For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing.

71. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

10:00 am

Noon

4:00 pm

10:00 pm

NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.

Explanation

NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.

72. The adrenal cortex is responsible for producing which substances?

Glucocorticoids and androgens

Catecholamines and epinephrine

Mineralocorticoids and catecholamines

Norepinephrine and epinephrine

The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine.

Explanation

The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine.

73. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?

Assess for a bruit and a thrill.

Warm the dialysate solution.

Position the client on the left side.

Insert a Foley catheter

Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven.

Explanation

Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven.

74. Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.
The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?

The patient is under local anesthesia during the procedure

The aspirated bone marrow is mixed with heparin.

The aspiration site is the posterior or anterior iliac crest.

The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.

Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia.

Explanation

Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia.

75. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?

Joint pain

Joint deformity

Joint flexion of less than 50%

Joint stiffness

Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections. Joint pain may be an indication, not a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this procedure.

Explanation

Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections. Joint pain may be an indication, not a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this procedure.

76. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?

A client with hepatitis A who states, “My arms and legs are itching.”

A client with cast on the right leg who states, “I have a funny feeling in my right leg.”

A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”

A client with rheumatoid arthritis who states, “I am having trouble sleeping.”

It may indicate neurovascular compromise, requires immediate assessment.

Explanation

It may indicate neurovascular compromise, requires immediate assessment.

77. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?

Altered mental status and dehydration

Fever and chills

Hemoptysis and Dyspnea

Pleuritic chest pain and cough

Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response.

Explanation

Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response.

78. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?

To confirm the diagnosis

To determine if a repeat skin test is needed

To determine the extent of lesions

To determine if this is a primary or secondary infection

If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest X-ray can’t determine if this is a primary or secondary infection.

Explanation

If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest X-ray can’t determine if this is a primary or secondary infection.

79. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?

Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.

To avoid fractures, the client should avoid strenuous exercise.

The recommended daily allowance of calcium may be found in a wide variety of foods.

Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures.

Explanation

Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures.

80. Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity?

It appears only in men

It appears on the distal interphalangeal joint

It appears on the proximal interphalangeal joint

It appears on the dorsolateral aspect of the interphalangeal joint.

Heberden’s nodes appear on the distal interphalageal joint on both men and women. Bouchard’s node appears on the dorsolateral aspect of the proximal interphalangeal joint.

Explanation

Heberden’s nodes appear on the distal interphalageal joint on both men and women. Bouchard’s node appears on the dorsolateral aspect of the proximal interphalangeal joint.

81. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care?

General health for the last 10 years.

Current health promotion activities.

Family history of diseases.

Marital status.

Recognizing an individual’s positive health measures is very useful. General health in the previous 10 years is important, however, the current activities of an 84 year old client are most significant in planning care. Family history of disease for a client in later years is of minor significance. Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem.

Explanation

Recognizing an individual’s positive health measures is very useful. General health in the previous 10 years is important, however, the current activities of an 84 year old client are most significant in planning care. Family history of disease for a client in later years is of minor significance. Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem.

82. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:

Increasing contractility and slowing heart rate.

Increasing AV conduction and heart rate.

Decreasing contractility and oxygen consumption.

Decreasing venous return through vasodilation.

The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard.

Explanation

The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard.

83. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:

The baby can get the virus from my placenta."

"I'm planning on starting on birth control pills."

"Not everyone who has the virus gives birth to a baby who has the virus."

"I'll need to have a C-section if I become pregnant and have a baby."

The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV positive can give birth to a baby who's HIV negative.

Explanation

The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV positive can give birth to a baby who's HIV negative.

84. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:

Stand him up and perform the abdominal thrust maneuver from behind.

Lay him down, straddle him, and perform the abdominal thrust maneuver.

Leave him to get assistance

Stay with him but not intervene at this time.

If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone.

Explanation

If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone.

85. A 37-year-old client with uterine cancer asks the nurse, "Which is the most common type of cancer in women?" The nurse replies that it's breast cancer. Which type of cancer causes the most deaths in women?

Breast cancer

Lung cancer

Brain cancer

Colon and rectal cancer

Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma.

Explanation

Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma.

86. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?

The cane acts as a support and aids in weight bearing for the weaker right leg.

Explanation

The cane acts as a support and aids in weight bearing for the weaker right leg.

87. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

Tracheal

Fine crackles

Coarse crackles

Friction rubs

Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.

Explanation

Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.

88. Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.

During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:

Crowd red blood cells

Are not responsible for the anemia.

Uses nutrients from other cells

Have an abnormally short life span of cells.

The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur.

Explanation

The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur.

89. In an individual with Sjögren's syndrome, nursing care should focus on:

Moisture replacement.

Electrolyte balance.

Nutritional supplementation.

Arrhythmia management.

Sjogren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's syndrome.

Explanation

Sjogren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's syndrome.

90. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?

A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.

A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.

A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.

A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

The client is at risk for peritonitis; should be assessed for further symptoms and infection.

Explanation

The client is at risk for peritonitis; should be assessed for further symptoms and infection.

91. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?

Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.

The client supports his head and neck when turning his head to the right.

The client spontaneously flexes his wrist when the blood pressure is obtained.

The client is drowsy and complains of sore throat.

Carpal spasms indicate hypocalcemia.

Explanation

Carpal spasms indicate hypocalcemia.

92. Which of the following is part of the five rights of medication administration in nursing practice?

Right dose

Right time of day

Right patient’s family

Right reason for refusal

The five rights of medication administration are essential guidelines in nursing practice to ensure patient safety when administering medications. They include: the right patient, the right drug, the right dose, the right route, and the right time. These steps help to minimize medication errors and ensure that the patient receives the correct medication in the proper dosage, via the appropriate route, and at the right time. Other options, like the patient's family or reasons for refusal, are not part of the core "five rights" of medication administration.

Explanation

The five rights of medication administration are essential guidelines in nursing practice to ensure patient safety when administering medications. They include: the right patient, the right drug, the right dose, the right route, and the right time. These steps help to minimize medication errors and ensure that the patient receives the correct medication in the proper dosage, via the appropriate route, and at the right time. Other options, like the patient's family or reasons for refusal, are not part of the core "five rights" of medication administration.

93. Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:

Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.

Chest pain, dyspnea, cough, weight loss, and fever.

Arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.

Hoarseness and dysphagia.

Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus.

Explanation

Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus.

94. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?

Elbow contracture secondary to spasticity

Loss of muscle contraction decreasing venous return

Deep vein thrombosis (DVT) due to immobility of the ipsilateral side

Hypoalbuminemia due to protein escaping from an inflamed glomerulus

In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with a stroke, but don’t appear with swelling. DVT may develop in clients with a stroke but is more likely to occur in the lower extremities. A stroke isn’t linked to protein loss.

Explanation

In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with a stroke, but don’t appear with swelling. DVT may develop in clients with a stroke but is more likely to occur in the lower extremities. A stroke isn’t linked to protein loss.

95. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?

Check respiration, circulation, neurological response.

Align the spine, check pupils, and check for hemorrhage.

Check respirations, stabilize spine, and check circulation.

Assess level of consciousness and circulation.

Checking the airway would be priority, and a neck injury should be suspected.

Explanation

Checking the airway would be priority, and a neck injury should be suspected.

96. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).

21 U regular insulin and 9 U NPH.

10 U regular insulin and 20 U NPH.

20 U regular insulin and 10 U NPH.

A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin.

Explanation

A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin.

97. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?

The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.

The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.

The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.

A walker needs to be picked up, placed down on all legs.

Explanation

A walker needs to be picked up, placed down on all legs.

98. When caring for a female client who is being treated for hyperthyroidism, it is important to:

Provide extra blankets and clothing to keep the client warm.

Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.

Balance the client’s periods of activity and rest.

Encourage the client to be active to prevent constipation.

A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.

Explanation

A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.

99. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:

Green liquid

Solid formed

Loose, bloody

Semiformed

Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.

Explanation

Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.

100. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?

Increased sensitivity to the side effects of medications.

Decreased visual, auditory, and gustatory abilities.

Isolation from their families and familiar surroundings.

Decrease musculoskeletal function and mobility.

Gradual loss of sight, hearing, and taste interferes with normal functioning.

Explanation

Gradual loss of sight, hearing, and taste interferes with normal functioning.