Part two of the comprehensive medical-surgical nursing review series! Another 100-item examination about the concepts of medical-surgical nursing.
- This is a 100-item examination about Medical-Surgical Nursing.
- Rationales and answers are given below.
- You are given 1 minute and 20 seconds each question. A total of 2 hours for this 100-item exam.
1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?
a. checking stools for occult blood
b. performing range-of-motion exercises to the left side
c. keeping skin clean and dry
d. elevating the head of the bed to 30 degrees
2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
a. destroys the odor-proof seal
b. wont affect the colostomy system
c. is appropriate for relieving the gas in a colostomy system
d. destroys the moisture barrier seal
3. When assessing the client with celiac disease, the nurse can expect to find which of the following?
b. jaundiced sclerae
c. clay-colored stools
d. widened pulse pressure
4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because:
a. reducing sodium promotes urea nitrogen excretion
b. reducing sodium improves her glomerular filtration rate
c. reducing sodium increases potassium absorption
d. reducing sodium decreases edema
5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the:
a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe
6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect:
a. Cushing’s syndrome
b. Diabetes mellitus
c. Adrenal crisis
d. Diabetes insipidus
7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
a. limit oral fluid intake for 1 to 2 weeks
b. report the presence of fine, sandlike particles through the nephrostomy tube.
c. Notify the physician about cloudy or foul smelling urine
d. Report bright pink urine within 24 hours after the procedure
8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?
a. deficient fluid volume related to osmotic diuresis
b. decreased cardiac output related to elevated heart rate
c. imbalanced nutrition: Less than body requirements related to insulin deficiency
d. ineffective thermoregulation related to dehydration
9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The
nurse should expect the dose’s:
a. onset to be at 2 p.m. and its peak at 3 p.m.
b. onset to be at 2:15 p.m. and its peak at 3 p.m.
c. onset to be at 2:30 p.m. and its peak at 4 p.m.
d. onset to be at 4 p.m. and its peak at 6 p.m.
10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:
a. 52 mm Hg
b. 88 mm Hg
c. 48 mm Hg
d. 68 mm Hg
11. A 52 yr-old female tells the nurse 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?
a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes
12. A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
a. Social worker
b. registered dietician
c. occupational therapist
d. enterostomal nurse therapist
13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?
14. A male client should be taught about testicular examinations:
a. when sexual activity starts
b. after age 60
c. after age 40
d. before age 20
15. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results
16. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women:
A. perform breast self-examination annually
B. have a mammogram annually
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation every 2 years
17. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:
A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers
18. A 49-year-old client was admitted for surgical repair of a Colles’ fracture. An external fixator was placed during surgery. The surgeon explains that this method of repair:
A. has very low complication rate
B. maintains reduction and overall hand function
C. is less bothersome than a cast
D. is best for older people
19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction?
A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake and eat plenty of bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”
20. The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has tow children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support
A. Tell the client’s spouse or partner to be supportive while she recovers.
B. Encourage the client to proceed with the next phase of treatment.
C. Recommend that the client remain cheerful for the sake of her children.
D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The nurse’s explanation to the client should include the fact that:
A. The test will evaluate prostatic function.
B. The test was ordered to identify the site of a possible infection.
C. The test was ordered because clients who have testicular cancer has elevated levels of HCG.
D. The test was ordered to evaluate the testosterone level.
22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.
23. Which assessment finding indicates dehydration?
A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention
24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.
25. For a client newly diagnosed with radiationinduced thrombocytopenia, the nurse should include which intervention in the plan of care?
A. Administer aspirin if the temperature exceeds 38.8º C.
B. Inspect the skin for petechiae once every shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.
26. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:
A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure
27. For a client in Addisionian crisis, it would be very risky for a nurse to administer:
A. potassium chloride
B. normal saline solution
28. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature:
29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
A. Putting on sterile gloves then opening a container of sterile saline.
B. Cleaning the wound with a circular motion, moving from outer circles toward the center.
C. Changing the sterile field after sterile water is spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.
30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?
A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein
31. A client 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 organ?
A. adrenal cortex
C. adrenal medulla
32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus, hypertension, pernicious anemia, and appendectomy. She’s admitted to the hospital and undergoes mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which history finding is a major risk factor for ineffective endocarditis?
B. pernicious anemia
C. diabetes mellitus
D. valve replacement
33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past two years. She’s fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most appropriate for this client?
A. Deficient fluid volume related to inability to conserve water
B. Imbalanced nutrition: less than body requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
D. Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency
34. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?
A. Let the client eat as desired during the hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats during a typical day.
D. Place the client on I & O status and draw blood for electrolyte levels.
35. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?
A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP).
C. Be sure to get regulate follow-up care.
D. Be sure to exercise to improve cardiovascular fitness.
36. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?
A. Deficient knowledge related to interventions used to treat acute illness
B. Impaired physical mobility related to complete bed rest
C. Social isolation related to restricted visiting hours in the intensive care unit
D. Anxiety related to the threat of death
37. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care?
A. Putting on a mask when entering the client’s room.
B. Instructing the client to wear a mask at all times
C. Wearing a gown and gloves when providing direct care
D. Keeping the door to the client’s room open to observe the client
38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:
A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of nausea.
C. Irrigate the NG tube gently with normal saline solution.
D. Reposition the NG tube if pulled out.
39. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
A. administer 2 to 3 L of IV fluid rapidly
B. administer 6 L of IV fluid over the first 24 hours
C. administer a dextrose solution containing normal saline solution
D. administer IV fluid slowly to prevent circulatory overload and collapse
40. Which of the following is an adverse reaction to glipizide (Glucotrol)?
41. The nurse is caring for four clients on a stepdown intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy tube
42. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.
43. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn’t answered immediately. The most appropriate response to her would be:
A. “You seem angry. Would you like to talk about it?”
B. “Calm down. You know that stress will make your symptoms worse.”
C. “Would you like to talk about the problem with the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when you’ve calmed down.”
44. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relive symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?
A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less than 45% of total calories
D. Avoiding foods that increase levels of highdensity lipoproteins (HDLs)
45. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the suction to be:
A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent
46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?
A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than body requirements
47. Parathyroid hormone (PTH) has which effects on the kidney?
A. Stimulation of calcium reabsorption and phosphate excretion
B. Stimulation of phosphate reabsorption and calcium excretion
C. Increased absorption of vit D and excretion of vit E
D. Increased absorption of vit E and excretion of Vit D
48. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip replacement surgery. Which home assessment finding warrants health promotion teaching from the nurse?
A. A bathroom with grab bars for the tub and toilet
B. Items stored in the kitchen so that reaching up and bending down aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches to the top and bottom of the stairs
49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery—this will go away on its own.” In considering her response to the client, the nurse must depend on the ethical principle of:
50. Which of the following is t he most critical intervention needed for a client with myxedema coma?
A. Administering and oral dose of levothyroxine (Synthroid)
B. Warming the client with a warming blanket
C. Measuring and recording accurate intake and output
D. Maintaining a patent airway
51. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of action is:
A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours
52. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
53. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:
A. intermediate and long-acting insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting insulins
54. a client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:
A. prevent leaning
B. distribute weight away from the involved side
C. maintain stride length
D. prevent edema
55. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:
B. high urine output
C. dry mucous membranes
D. pulmonary crackles
56. The nurse is caring for a client with a fractures hip. The client is combative, confused, and trying to get out of bed. The nurse should:
A. leave the client and get help
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints
D. order soft restraints from the storeroom
57. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?
58. In a client with enteritis and frequent diarrhea, the nurse should anticipate an acid-base imbalance of:
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis
59. When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
A. position the client in a supine position
B. elevate the head of the bed 90 degrees during meals
C. encourage the client to remove dentures
D. encourage thin liquids for dietary intake
60. A nurse is caring for a client who has a tracheostomy and temperature of 39º C. which intervention will most likely lower the client’s arterial blood oxygen saturation?
A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry
61. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:
A. fluid resuscitation
C. body image
D. pain management
62. Which statement is true about crackles?
A. They’re grating sounds.
B. They’re high-pitched, musical squeaks.
C. They’re low-pitched noises that sound like snoring.
D. They may be fine, medium, or course.
63. A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:
A. scheduling her for annual tuberculin skin testing
B. placing her in quarantine until sputum cultures are negative
C. gathering a list of persons with whom she has had recent contact
D. advising her to begin prophylactic therapy with isoniazid (INH)
64. The nurse is caring for a client who had an above the knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client’s problem is:
C. Disturbed body image
65. A client with three children who is still I the child bearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon’s preoperative teaching when the client states:
A. “If I should become pregnant again, the child would be delivered by cesarean delivery.”
B. “If I have another child, the procedure may need to be repeated.”
C. “This surgery may render me incapable of conceiving another child.”
D. “This procedure is accomplished in two separate surgeries.”
66. A client experiences problems in body temperature regulation associated with a skin impairment. Which gland is most likely involved?
67. A school cafeteria worker comes to the physician’s office complaining of severe scalp itching. On inspection, the nurse finds nail marks on the scalp and small light-colored round specks attached to the hair shafts close to the scalp. These findings suggest that the client suffers from:
B. head lice
C. tinea capitis
68. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
C. pressure-like pain
69. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:
A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures
70. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?
A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice
71. A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn is described as white and leathery with no blisters. Which degree of severity is this burn?
A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn
72. The nurse is caring for client with a new donor site that was harvested to treat a new burn. The nurse position the client to:
A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered
73. a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by:
A. Inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris
B. Suggesting he take aspirin for relief because it’s probably early rheumatoid arthritis
C. Validating his complaint but assuming it’s an adverse effect of his vocation
D. Asking him if he has been diagnosed or treated for carpal tunnel syndrome
74. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember?
A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft site.
75. A 28 yr-old female nurse is seen in the employee health department for mild itching and rash of both hands. Which of the following could be causing this reaction?
A. possible medication allergies
B. current life stressors she may be experiencing
C. chemicals she may be using and use of latex gloves
D. recent changes made in laundry detergent or bath soap.
76. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for:
B. a toxin
C. a tubercle
D. a virus
77. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
78. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?
A. Turn and reposition the client a minimum of every 8 hours.
B. Vigorously massage lotion into bony prominences.
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lifting when turning.
79. Following a full-thickness (3rd degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of the artificial skin when he states that during the first 7 days after the procedure, he’ll restrict:
A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion
80. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
81. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?
A. The wound should remain moist form the dressing.
B. The wet-to-dry dressing should be tightly packed into the wound.
C. The dressing should be allowed to dry out before removal.
D. A plastic sheet-type dressing should cover the wet dressing.
82. While in skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home with six other persons. During her visit to the clinic, she asks a staff nurse, “What should my family do?” the most accurate response from the nurse is:
A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to see a physician right away.”
C. “Just be careful not to share linens and towels with family members.”
D. “After you’re treated, family members won’t be at risk for contracting scabies.”
83. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
A. A urine output consistently above 100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours.
C. Body temperature readings all within normal limits
D. An electrocardiogram (ECG) showing no arrhythmias.
84. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis. Which of the following laboratory results should the nurse expect to find?
A. Increased platelet count
B. Elevated erythrocyte sedimentation rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and creatinine levels
85. Which nursing diagnosis takes the highest priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: less than body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
86. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
A. Increase the frequency of the catheterizations.
B. Insert an indwelling urinary catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of an invasive one.
87.The nurse is caring for a client who is to undergo a lumbar puncture to assess for the presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which result would indicate n abnormality?
A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells (RBCs) in the first specimen tube
D. A pressure of 00 to 250 mmH2O
88. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:
A. conjunctival sac
D. vitreous humor
89. A 52 yr-old married man with two adolescent children is beginning rehabilitation following a cerebrovascular accident. As the nurse is planning the client’s care, the nurse should recognize that his condition will affect:
A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete recovery
90. Which action should take the highest priority when caring for a client with hemiparesis caused by a cerebrovascular accident (CVA)?
A. Perform passive range-of-motion (ROM) exercises.
B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
D. Apply antiembolism stockings
91. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which fact should the nurse include in the teaching plan?
A. TIA symptoms may last 24 to 48 hours.
B. Most clients have residual effects after having a TIA.
C. TIA may be a warning that the client may have cerebrovascular accident (CVA)
D. The most common symptom of TIA is the inability to speak.
92. The nurse has just completed teaching about postoperative activity to a client who is going to have a cataract surgery. The nurse knows the teaching has been effective if the client:
A. coughs and deep breathes postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt from the floor after he drops it.
D. States that he doesn’t need to wear an eyepatch or guard to bed
93. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:
94. When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don’t respond to light.
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy
95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular accident is admitted to the facility. To prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?
A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises
96. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse should institute which type of isolation precautions?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
97. A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert and behaved as though nothing had happened.” Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client’s intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the following signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness
98. Emergency medical technicians transport a 28 yr-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness
99. Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client’s plan of care?
A. Perform activities of daily living for the client to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as possible.
100. For a client with a head injury whose neck has been stabilized, the preferred bed position is:
B. 30-degree head elevation
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1. Answer: D
Because the client’s gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client’s risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.
2. Answer: A
Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas.
3. Answer: A
because celiac disease destroys the absorbing surface of the intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesn’t cause a widened pulse pressure.
4. Answer: D
Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesn’t affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn’t affected by sodium intake.
5. Answer: D
The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbance in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.
6. Answer: D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing’s syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
The client should report the presence of foulsmelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal because of residual stone products. Hematuria is common after lithotripsy.
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition: Less then body requirements isn’t appropriate. A temperature of 100.6º F isn’t life threatening, eliminating ineffective thermoregulation as the top priority.
9. Answer: C
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
10. Answer: A
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the following formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from the MAP; in this case , 70 mmHg – 18 mmHg = 52 mmHg.
11. Answer: B
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple retraction —not eversion—may be a sign of cancer. A mobile mass that is soft and easily delineated is most often a fluid-filled benigned cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass.
An enterostomal nurse therapist is a registered nurse who has received advance education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support.
Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.
14. Answer: D
Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.
15. Answer: B
Before weaning a client from mechanical ventilation, it’s most important to have a baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.
16. Answer: B
According to the ACS guidelines, “Women older than age 40 should perform breast selfexamination monthly (not annually).” The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.
Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesn’t stem from esophageal perforation, pulmonary hypertension, or peptic ulcers.
18. Answer: B
Complex intra-articular fractures are repaired with external fixators because they have a better long-term outcome than those treated with casting. This is especially true in a young client. The incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must be taught how to do pin care and assess for development of neurovascular complications.
In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in Protein), bananas (high in potassium), and fluid because the kidneys can’t secrete adequate urine.
The client isn’t withdrawn or showing other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the client’s spouse or partner to listen to concerns, but the nurse shouldn’t tell the client’s spouse what to do. The client must consult with her physician and make her own decisions
about further treatment. The client needs to express her sadness, frustration, and fear. She can’t be expected to be cheerful at all times.
21. Answer: C
HCG is one of the tumor markers for testicular cancer. The HCG level won’t identify the site of an infection or evaluate prostatic function or testosterone level.
Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but the don’t indicate that therapy isn’t effective.
23. Answer: A
Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isn’t easily obliterated and neck vein distention indicate fluid overload, not dehydration.
24. Answer: B
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.
25. Answer: B
Because thrombocytopenia impairs blood clotting, the nurse should assess the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it can increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
26. Answer: B
SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesn’t indicate the client’s overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a Hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn’t enough data to assume that the client’s problem is psychosomatic. If the problem were
left-sided heart failure, the client would exhibit pulmonary crackles.
27. Answer: A
Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.
28. Answer: D
Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone marrow.
29. Answer: C
A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, aren’t sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area—for example, from the center outward. The outer inch of a sterile field shouldn’t be considered sterile.
Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps in increase cardiac output and decrease heart rate. Protein-rich foods aren’t restricted but high calorie foods are.
31. Answer: A
Excessive 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 cathecolamines—epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.
32. Answer: D
A heart valve prosthesis, such as a mitral valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, IV drug abuse, and immunosuppression. Although diabetes mellitus may predispose a person to cardiovascular disease, it isn’t a major risk factor for infective endocarditis, nor is an appendectomy or pernicious anemia.
33. Answer: A
The client has signs and symptoms of diabetes insipidus, probably caused by the failure of her renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. The hypernatremia is secondary to her water loss. Imbalanced nutrition related to hypermetabolic state or catabolic effect of insulin deficiency is an inappropriate nursing diagnosis for the client.
34. Answer: C
When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn’t be permitted to eat as desired. Weighing the client daily, placing her on I & O status, and drawing blood to determine electrolyte level aren’t part of a nutritional assessment.
35. Ans. C
Regular follow-up care for the client with Grave’s disease is critical because most cases eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client’s ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. While exercise to improve cardiovascular fitness is important, for this client the importance of regular follow-up is most critical.
36. Answer: D
Anxiety related to the threat of death is an appropriate nursing diagnosis because the client’s anxiety can adversely affect hear rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death is a real and immediate concern. Unless anxiety is dealt with first, the client’s emotional state will impede learning. Client teaching should be limited to clear concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the deficient knowledge would continue despite attempts teaching. Impaired physical mobility and social isolation are necessitated by the client’s critical condition; therefore, they aren’t considered problems warranting nursing diagnoses.
37. Answer: A
Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client’s room. Having the client wear a mask at all the times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client’s blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.
38. Answer: C
The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously, not every hour. The NG tube shouldn’t be clamped postoperatively because secretions and gas will accumulate, stressing the suture line.
39. Answer: A
Regardless of the client’s medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in case of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.
Glipizide may cause adverse skin reactions, such as pruritus, and photosensitivity. It doesn’t cause headache, constipation, or hypotension.
41. Answer: B
When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artificial airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. Whit standard procedures the other choices wouldn’t be at high risk.
42. Answer: C
In chronic bronchitis, the diaphragmatic is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing—not chest breathing—increases lung expansion.
43. Answer: A
Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn’t acknowledge her feelings. Offering to get the nursing supervisor also doesn’t acknowledge the client’s feelings. Ignoring the client’s feelings suggest that the nurse has no interest in what the client has said.
44. Answer: A
Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration,
so this client should eat foods that raise HDL levels.
45. Answer: A
Gastric decompression is typically low pressure and intermittent. High pressure and continuous gastric suctioning predisposes the gastric mucosa to injury and ulceration.
46. Answer: A
In osteoarthritis, stiffness is common in large, weight bearing joints such as the hips. This joint stiffness alters functional ability and range of motion, placing the client at risk for falling and injury. Therefore, client safety is in jeopardy. Osteoporosis doesn’t affect urinary elimination, breathing, or nutrition.
47. Answer: A
PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vit D to its active form: 1 , 25 dihydroxy vitamin D. PTH doesn’t have a role in the metabolism of Vit E.
48. Answer: C
The presence of unsecured area rugs poses a hazard in all homes, particularly in one with a resident at high risk for falls.
49. Answer: B
Autonomy ascribes the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence and justice aren’t the principles that directly relate to the situation. Advocacy is the nurse’s role in supporting the principle of autonomy.
50. Answer: D
Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Thyroid replacement will be administered IV. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn’t be used because it may cause vasodilation and shock. Gradual warming blankets would be appropriate. Intake and output are very important but aren’t critical
interventions at this time.
51. Answer: A
Glipizide begins to act in 15 to 30 minutes. The other options are incorrect.
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don’t cause metabolic acidosis.
53. Answer: C
Continuous subcutaneous insulin regimen uses a basal rate and boluses of short-acting insulin. Multiple daily injection therapy uses a combination of short-acting and intermediate or long-acting insulins.
54. Answer: B
Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane won’t maintain stride length or prevent edema.
55. Answer: D
High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With leftsided heart failure, pulmonary edema can develop causing pulmonary crackles. In leftsided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren’t directly associated with elevated pulmonary artery wedge pressures.
It’s mandatory in most settings to have a physician’s order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility’s policy.
57. Answer: A
The client who has undergone a thyroidectomy is t risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek’s sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau’s sign (carpal spasm when a blood pressure cuff is inflated for few minutes). These signs aren’t present with hypercalcemia, hypokalemia, or Hyperkalemia.
58. Answer: C
Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates leading to metabolic acidosis. Diarrhea doesn’t lead to respiratory acid-base imbalances, such as respiratory acidosis and respiratory alkalosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis.
59. Answer: B
The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position—not a supine position— when lying down to reduce the risk of aspiration. Encourage the client to wear properly fitted dentures to enhance his chewing ability. Thickened liquids, not thin liquids, decrease aspiration risk.
Endotracheal suctioning secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn’t be affected.
61. Answer: D
With a superficial partial thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has a lower priority than pain management.
62. Answer: D
Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They’re classified as fine, medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, highpitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways.
63. Ans. D
Individuals who are tuberculin skin test converters should begin a 6-month regimen of an antitubercular drug such as INH, and they should never have another skin test. After an individual has a positive tuberculin skin test, subsequent skin tests will cause severe skin reactions but won’t provide new information about the client’s TB status. The client doesn’t have active TB, so can’t transmit, or spread, the bacteria. Therefore, she shouldn’t be quarantined or asked for information about recent contacts.
64. Answer: C
Disturbed body image is a negative perception of the self that makes healthful functioning more difficult. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function, hiding or overexposing a body part, not looking at a body part, and responding verbally or nonverbally to the actual or perceived change in structure or function. This client may have any of the other diagnoses, but the signs and symptoms described in he case most closely match the defining characteristics for disturbed body image.
65. Answer: B
Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair may need to be repeated. These clients don’t necessarily have to have a cesarean delivery if they become pregnant, and this procedure doesn’t render them sterile. This procedure is completed in one surgery.
66. Answer: A
Eccrine glands are associated with body temperature regulation. Sebaceous glands lubricate the skin and hairs, and apocrine glands are involved in bacteria decomposition. Endocrine glands secrete hormones responsible for the regulation of body processes, such as metabolism and glucose regulation.
The light-colored spots attached to the hair shafts are nits, which are the eggs of head lice. They can’t be brushed off the hair shaft like dandruff. Scabies is a contagious dermatitis caused by the itch mite, Sacoptes scabiei, which lives just beneath the skin. Tinea capitis, or ringworm, causes patchy hair loss and circular lesions with healing centers. Impetigo is an infection caused by Staphylococcus or Sterptococcus, manifested by vesicles or pustules that form a thick, honey-colored crust.
68. Answer: C
Severe pressure-like pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulites. Erythema, leukocytosis, and swelling are present in both cellulites and necrotizing fasciitis.
69. Answer: A
Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of the exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red and not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment.
Hoarseness indicate injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client’s output is adequate.
71. Answer: C
Third-degree burn may appear white, red, or black and are dry and leathery with no blisters. There may be little pain because nerve endings have been destroyed. First-degree burns are superficial and involve the epidermis only. There is local pain and redness but no blistering. Second-degree burn appear red and moist with blister formation and are painful. Fourth-degree burns involve underlying muscle and bone tissue.
72. Answer: C
A universal concern I the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices in some institutions but aren’t hallmarks of donor site care. Placing the site in a position of dependence isn’t a justified aspect of donor site care.
73. Answer: A
Anyone with psoriasis vulgaris who reports joint pain should be evaluated for psoriaic arthritis. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis, which can be painful and cause deformity. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints.
74. Answer: B
To avoid burning and sloughing, the client must protect the graft from sunlight. The other three interventions are all helpful to the client and his recovery but are less important.
Because the itching and rash are localized, an environmental cause in the workplace should be suspected. With the advent of universal precautions, many nurses are experiencing allergies to latex gloves. Allergies to medications, laundry detergents, or bath soaps or a dermatologic reaction to stress usually elicit a more generalized or widespread rash.
Hives and urticaria are two names for the same skin lesion. Toxin is a poison. A tubercle is a tiny round nodule produced by the tuberculosis bacillus. A virus is an infectious parasite.
77. Answer: A
A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don’t accompany psoriasis.
78. Answer: C
A turning schedule with a signing sheet will help ensure that the client gets turned and thus, help prevent pressure ulcers. Turning should occur every 1-2 hours—not every 8 hours—for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift rather than slide the client to void shearing.
To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.
According to the Rule of Nines, the posterior and anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body durface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27%.
A wet-to-dry saline dressing should always keep the wound moist. Tight packing or dry packing can cause tissue damage and pain. A dry gauze —not a plastic-sheet-type dressing—should cover the wet dressing.
82. Answer: A
When someone in a group of persons sharing a home contracts scabies, each individual in the same home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn’t a goal. In fact, a 4 lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.
84. Answer: B
The ESR test is performed to detect inflammatory processes in the body. It’s a nonspecific test, so the health care professional must view results in conjunction with physical signs and symptoms. Platelet count, electrolytes, BUN, and creatinine levels aren’t usually affected by the inflammatory process.
In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client who is confined to bed during a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, ineffective airway clearance is the priority diagnosis for this client. Although imbalanced nutrition:less than body requirements, impaired urinary elimination and risk for injury also are appropriate diagnoses for this client, they aren’t immediately lifethreatening and thus are less urgent.
As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren’t indicated for this case; the problem isn’t overhydration, rather it’s urine retention. A condom catheter doesn’t help empty the bladder of a client with urine retention.
The normal pressure is 70 to 200 mm H2O are considered abnormal. The presence of glucose is an expected finding in CSF, and RBCs typically occur in the first specimen tube from the trauma caused by the procedure.
88. Answer: A
The nurse should instill the eyedrop into the conjunctival sac where absorption can best take place. The pupil permits light to enter the eye. The sclera maintains the eye’s shape and size. The vitreous humor maintains the retina’s placement and the shape of the eye.
According to family theory, any change in a family member, such as illness, produces role changes in all family members and affects the entire family, even if the client eventually recovers completely.
To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. Although performing ROM exercises, providing pillows for support, and applying antiembolism stockings can be appropriate for a client with CVA, the first concern is to maintain a patent airway.
91. Answer: C
TIA may be a warning that the client will experience a CVA, or stroke, in the near future. TIA aymptoms last no longer than 24 hours and clients usually have complete recovery after TIA. The most common symptom of TIA is sudden, painless loss of vision lasting up to 24 hours.
92. Answer: C
Bending to pick up something from the floor would increase intraocular pressure, as would bending to tie his shoes. The client needs to wear eye protection to bed to prevent accidental injury during sleep.
93. Answer: B
Concussions are considered minor with no structural signs of injury. A contusion is bruising of the brain tissue with small hemorrhages in the tissue. Coup and contrecoup are type of injuries in which the damaged area on the brain forms directly below that site of impact (coup) or at the
site opposite the injury (contrecoup) due to movement of the brain within the skull.
94. Answer: B
The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is damage to the nerve, the pupils remain dilated and don’t respond to light. Glaucoma, lumbar spine injury, and Bell’s palsy won’t affect pupil constriction.
When the mechanical stressors of weight bearing are absent, diffuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures.
96. Answer: B
This client requires droplet precautions because the organism can be transmitted through airborne droplets when the client coughs, sneezes, or doesn’t cover his mouth. Airborne precautions would be instituted for a client infected with tuberculosis. Standard precautions would be instituted for a client when contact with body substances is likely. Contact precautions would be instituted for a client infected with an organism that is transmitted through skin-to-skin
97. Answer: D
With a brain injury such as an epidural hematoma (a diagnosis that is most likely based on this client’s symptoms), the initial sign of increasing ICP is a change in the level of consciousness. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will
In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing and circulation. The nurse doesn’t have enough data to warrant putting the client in Trendelenburg’s position.
99. Answer: C
Establishing and maintaining a routine is essential to decreasing extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful, because they can’t participate in abstract thinking.
100. Answer: B
For clients with increased intracranial pressure (ICP), the head of the bed is elevated to promote venous outflow. Trendelenburg’s position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. Sidelying isn’t specifically a therapeutic treatment for increased ICP.