1. A client sustained a fracture 3 days ago. When the following blood studies are returned, they are all elevated. Which elevation is considered a normal finding following a fracture?
A) Alkaline phosphatase.
B) Uric acid.
C) Amylase.
D) Calcium.
Answer: A
A) Bone is rich in alkaline phosphatase and blood levels normally increase following a fracture and during fracture healing. Elevation of the other blood studies should alert the nurse to the need for further assessment of the client, because of the probable presence of an illness.
Topic: Physiological Integrity
2. A nursing care plan will include observations for possible complications associated with duodenal ulcer disease. An indication of a serious complication would be
A) Constipation of several days duration.
B) Bright-red bloody stools.
C) Tarry stools.
D) Severe diarrhea.
Answer: C
C) Bleeding is a more severe complication than either constipation or diarrhea. Bright-red stools indicate a bleeding problem low in the gastrointestinal tract. A bleeding duodenal ulcer would have tarry stools, as the blood has been digested by the action of the intestinal juices.
Topic: Physiological Integrity
3. A component of the discharge plan for a client discharged on Warfarin will be to instruct him to avoid which of the following over-the-counter products unless his doctor instructs otherwise?
A) Antihistamine.
B) Vitamin C.
C) Advil
D) Aspirin.
Answer: D
D) Aspirin or any medication that contains aspirin (such as certain cold medications) combined with the anticoagulant Warfarin could cause serious bleeding. Vitamin K should be avoided because it makes Warfarin less effective.
Topic: Physiological Integrity
4. The laboratory result that should be monitored regularly in a client who is receiving gentamycin (Garamycin) is
A) Serum calcium.
B) White blood cell count (WBC).
C) Serum creatinine.
D) Platelets.
Answer: C
C) Gentamycin, a potent aminoglycoside antibiotic, has the potential for causing nephrotoxicity. Renal function studies such as the serum creatinine and BUN should be monitored regularly to detect impaired renal function.
Topic: Physiological Integrity
5. A client, 5 months pregnant, comes to the clinic for a check-up. The nurse instructs her to immediately report any visual disturbances. The best rationale for this instruction is that visual problems
A) Mean the client needs more protein in her diet.
B) Indicate increased intracranial pressure.
C) Indicate a deficiency in iron.
D) Are a symptom of pre-eclampsia.
Answer: D
D) Visual disturbance is a symptom of pre-eclampsia and the client must immediately be put under a physician's care to prevent further development of eclampsia.
Topic: Physiological Integrity
6. The RN in the emergency room admits a 20-year-old woman who has been raped and suffered severe lacerations. Initially, the assessment should focus on the client's
A) Degree of crisis.
B) Ability to recount the incident.
C) Physical injuries.
D) Mental status.
Answer: C
C) Initially, physical injuries will take precedence over other aspects of care. They need to be assessed, treated and documented for possible legal action. Crisis treatment will be the next goal of care.
Topic: Psychosocial Integrity
7. A client fell from a horse and sustained a head injury. The nurse will consider all of the following goals; the one to receive first priority is to
A) Maintain an open airway.
B) Maintain fluid-electrolyte balance.
C) Control pain and restlessness.
D) Monitor neurological status, including vital signs.
Answer: A
A) A patent airway is always a priority need, particularly in a client with a head injury, because hypoxia and hypercapnia cause cerebral edema with increasing intracranial pressure.
Topic: Physiological Integrity
8. Following several radiation treatments, the nurse observes that a client's skin appears wet and weeping. According to protocol, the intervention is to
A) Give the treatment and instruct the client to use antibiotic lotion on the lesions.
B) Not give the treatment and explain to the client not to bathe the skin until the weeping stops.
C) Give the treatment and make a note on the record concerning the skin condition.
D) Not give the treatment and notify the physician.
Answer: D
D) During the time the reaction occurs, the protocol states that clients are taken off radiation therapy and instructed to use antibiotic lotion and steroid cream to prevent infection.
Topic: Safe, Effective Care Environment
9. A client, age 68, has an external shunt placed in preparation for hemodialysis. The nursing care plan will include
A) Observing for dark spots in the shunt that may represent clot formation.
B) Testing the shunt to determine if it is cool to the touch, like that of the forearm, which signifies patency.
C) Listening for a bruit over the shunt area; if bruit is heard, the shunt may be clotted.
D) Observing for blood going through the shunt to identify possible clotting that may occur immediately following the dialysis run.
Answer: A
A) Shunts should be inspected several times each day for presence of possible clotting. Dark spots will quickly be followed by separation of the sera and cells if clotting becomes complete. When dark spots appear, clients should be instructed to immediately seek treatment for declotting.
Topic: Physiological Integrity
10. The nurse is assigned to a male client who was admitted with flu symptoms of nausea and vomiting. He is receiving IV therapy. The lab has sent his early morning blood results which are: BUN 32, Creatinine 1.1, Hematocrit 50. The initial nursing intervention is to
A) Notify the physician immediately.
B) Decrease the IV rate and notify the physician, as lab results indicate overhydration.
C) Evaluate the urine output for amount and specific gravity.
D) Do nothing because the results are within normal limits.
Answer: C
C) These lab results indicate that the client is dehydrated. Specific gravity and urine output are indicators used to support the laboratory findings. The higher the specific gravity, the more dehydrated the client.
Topic: Physiological Integrity
11. A client who has just been admitted to the unit is in the dayroom. The nurse observes that she appears anxious and ill at ease. The nurse's most therapeutic response is to
A) Tell her that everyone feels strange at first.
B) Ask her why she is uncomfortable.
C) Offer to stay with her for a short while.
D) Leave her in the company of another client.
Answer: C
C) Remaining with a client who is anxious will assist in decreasing anxiety. Telling her everyone feels this way is false reassurance (A), and asking questions when the client is very anxious (B) is nontherapeutic. At this point, leaving the client with another person is also not therapeutic (D).
Topic: Psychosocial Integrity
12. A pregnant client arrives in the emergency room. An initial assessment indicates that she is ready to deliver and crowning is occurring. The first nursing action is to
A) Ask the client to push according to your instructions.
B) Instruct the client to take short shallow breaths to improve fetal oxygenation.
C) Apply gentle perineal pressure to prevent rapid expulsion of the head.
D) Notify the physician.
Answer: C
C) The first action is to support the perineum to prevent tears and rapid delivery. The nurse will ask the client to take short breaths (following instructions) but to prevent pushing; the nurse will also send someone for the physician.
Topic: Health Promotion and Maintenance
13. Assessing a client for hypovolemic shock, the sign that the nurse would expect to observe is
A) Oliguria.
B) Hypertension.
C) Cyanosis.
D) Tachypnea.
Answer: A
A) In shock, there is decreased blood volume through the kidneys. This is evidenced by a decrease in the amount of urine excreted. The body has numerous compensatory mechanisms that assist in keeping the blood pressure normal for a short time.
Topic: Physiological Integrity
14. Important baseline information that must be collected prior to the physician prescribing oral contraceptives for an 18-year-old female is
A) A history of thrombophlebitis or migraine headaches.
B) A complete sexual history.
C) Parental approval and written consent.
D) A report on the AIDS antibody test.
Answer: A
A) Because one of the suspected effects of the pill is thrombophlebitis, it is important to know the client's history. If the client's history indicates a predisposition, the pill would not be the contraceptive method of choice. The AIDS test is not required for contraceptive counseling; neither is parental permission.
Topic: Physiological Integrity
15. The milliliters of drug that should be used to give 0.5 gm if the label on the bottle reads 5 gm in 10 mL is
A) 5.0 mL.
B) 1.0 mL.
C) 0.5 mL.
D) 2.0 mL.
Answer: B
B) Dose on hand is in 10 mL, so to calculate the amount to give, divide the dose desired by the dose on hand and multiply by 10 mL. Example: 0.5 gm divided by 5 gm equals 0.1, then multiplying by 10 equals 1 mL.
Topic: Physiological Integrity
16. A client with congestive heart failure is placed on a mildly restricted sodium diet of 2,000 mg/day. The nurse will know this client requires more teaching if he says that he can eat
A) Instant coffee.
B) Fresh fruits.
C) Boiled eggs.
D) Canned soup.
Answer: D
D) Canned soups are high in sodium and if the client thinks that he can eat these soups, he would require further teaching. The remaining foods would be acceptable. Instant coffee is high in potassium.
Topic: Physiological Integrity
17. Following delivery, a 32-week, 5 lb. female infant demonstrates nasal flaring, intercostal retraction, expiratory grunt, and slight cyanosis. Blood gases and electrolyte studies of the baby are ordered immediately to assess the infant's
A) Antibody titer for RH.
B) Oxygen, carbon dioxide, and pH levels.
C) Leukocyte count.
D) Blood glucose level.
Answer: B
B) Blood gases are drawn to determine if the oxygen, carbon dioxide, and pH levels are within normal range. The treatment given to the infant depends to a great extent on these results. For example, if the blood PO2 level is down and the PCO2 is elevated, the concentration of oxygen the infant is receiving will be increased and the infant may be placed on CPAP or PEEP to increase residual capacity and improve oxygenation. Drugs such as sodium bicarbonate may be given to correct acidosis or a low pH. Normal values: pH 7.35-7.45; PO2 40-60; PCO2 35-45.
Topic: Health Promotion and Maintenance
18. The nurse responsible for planning an elderly, senile client's schedule knows that it is most important that the daily activities
A) Are changed each day to meet the need for variety.
B) Provide many opportunities for making choices to stimulate involvement and interest.
C) Involve physically limited activity, as the client tires easily.
D) Are highly structured to reduce anxiety.
Answer: D
D) Elderly senile clients are often anxious, especially in an unfamiliar environment. Struc-ture decreases anxiety. Making choices and constantly changing activities will increase anxiety. Their activity should not necessarily be limited.
Topic: Psychosocial Integrity
19. The nurse would assess for a cardinal sign of eclampsia during pregnancy which is
A) Hypertension.
B) Concentrated urine.
C) Weight gain of 1 to 2 pounds a week.
D) Lassitude and fatigue.
Answer: A
A) High blood pressure is one of the cardinal signs of eclampsia, along with excessive weight gain, edema and albumin in the urine.
Topic: Health Promotion and Maintenance
20. The nursing diagnosis most important for a client with a spinal cord injury at the level of cervical 3-4 (C 3-4) is
A) Altered pattern of urinary elimination.
B) High risk for disuse syndrome.
C) Ineffective breathing pattern.
D) High risk for impaired skin integrity.
Answer: C
C) Innervation to the diaphragm and intercostal muscles can be disrupted by a cervical injury; therefore, the priority nursing diagnosis is ineffective breathing pattern. The other diagnoses would be of lesser priority.
Topic: Physiological Integrity
21. A 4-year-old African-American girl lives in
A) Occlusion of small blood vessels.
B) Injury to the joints.
C) Hemarthrosis.
D) Pooling of the blood in the spleen.
Answer: A
A) Thrombic crises are the result of occlusion of small blood vessels. Sequestration crises are the result of pooling of blood in the spleen. Hemarthrosis occurs in hemophilia.
Topic: Physiological Integrity
22. Caring for a child with a basilar skull fracture, the nurse understands that the child is at risk for developing meningitis because
A) Any open fracture may become infected.
B) The blood supply is disrupted and the white blood cells cannot work against invading bacteria.
C) The fracture causes a direct tear in the meninges.
D) Of the proximity to sinuses and oronasal pharynx which may contaminate the cerebral spinal fluid.
Answer: D
D) While the fracture is not open to the environment, the upper respiratory tract harbors many organisms that could colonize in the central nervous system via the tear in the dura. Normally, the blood supply is not disrupted.
Topic: Physiological Integrity
23. Amniocentesis would not be performed on a woman if the nurse assesses that she
A) Has a family history of genetic disorders.
B) Will not consider an elective abortion.
C) Is an Ashkenazic Jew.
D) Is carrying twins.
Answer: B
B) The test is done primarily to determine fetal trisomy 21 (Down's syndrome) in pregnant women over 35 years of age. If the fetus is defective and the woman or couple do not wish to have an elective abortion, the procedure would probably not be performed due to its potential risk (though small) to the woman. Answer (C) is not correct as Ashkenazic Jews have a high incidence of Tay-Sachs disease. Although more difficult, amniocentesis may be performed on women carrying twins.
Topic: Health Promotion and Maintenance
24. A client is hospitalized following a myocardial infarction. He is receiving Digoxin and Lasix. After discharge teaching, the client should be able to tell the nurse that side effects of the drugs would include
A) Hypercalcemia.
B) Hypocalcemia.
C) Hypernatremia.
D) Hypokalemia.
Answer: D
D) Lasix is a loop diuretic which inhibits the reabsorption of sodium and chloride in the ascending loop of Henle. Potassium loss is a direct result of a large volume of urine output. The client should be taught the symptoms of hypokalemia. The client will not be hyper- or hypocalcemic or necessarily have a high sodium level because of the Lasix.
Topic: Physiological Integrity
25. An elderly female client with the diagnosis of congestive heart failure has just been admitted to the nursing unit. She is experiencing dyspnea and becomes very agitated. The priority intervention is to
A) Administer oxygen at 3 l/minute via nasal prongs per standing orders.
B) Place the client in Fowler's position.
C) Reassure the client that the nurse will stay with her.
D) Evaluate the client's breath sounds.
Answer: B
B) All four of the interventions will be carried out; however, placing her in Fowler's position is the first intervention. This position will provide better mechanics for breathing because it increases lung expansion.
Topic: Physiological Integrity
26. Which of the following statements indicates that a client with gout understands his discharge instructions?
A) "I will restrict meats and fish in my diet."
B) "I will restrict foods high in sodium."
C) "I will report any side effects of aspirin."
D) "I will increase my intake of fluids."
Answer: D
D) Clients should understand it is important to increase their fluid intake to at least 2000 ml each day. The increased fluid will assist in urate excretion and minimize urate precipitation in the urinary tract. Certain meats, such as organ meats and shellfish, are high in purine and should be restricted.
Topic: Physiological Integrity
27. The client, age 86, has a fractured hip and his physician has applied Buck's traction preoperatively. The nursing assessment is to ensure that there is adequate countertraction and will include
A) Weights hanging freely off the floor and bed.
B) Checking that the client is pulled down on the bed, using the end board as a foot rest.
C) Ropes knotted to prevent them from moving through the pulleys.
D) Checking that the foot of the bed is elevated to provide countertraction.
Answer: A
A) Weights must hang freely off floor and bed to ensure countertraction. Ropes should be securely knotted, but they must move freely through pulleys. The client should not be pulled down in bed, because this position will negate the traction. Topic: Physiological Integrity
28. The nurse is assigned to a 32-year-old male client who has just returned from surgery following above the knee amputation of his left leg. The nursing strategy that will be most helpful in assisting the client to adjust to his handicap is to
A) Ask him how he feels about the amputation.
B) Collect more information about his feelings before formulating specific goals.
C) Establish trust by anticipating all of his needs before he has to ask the nurse to do something for him.
D) Suggest that he join a group of clients who have experienced similar problems.
Answer: A
A) Assisting the client to adjust to his handicap would involve helping him express his feelings about the surgery. The more directly the nurse can assist the client to discuss and deal with these feelings, the more quickly he will be able to adjust. The more client-oriented the approach, the more it is therapeutic.
Topic: Physiological Integrity
29. Following a cardiac catheterization procedure in a child, the nurse will test the specific gravity of urine. The rationale for this test is to
A) Evaluate the child's hydration status.
B) Determine if the kidneys are functioning.
C) Identify possible complications.
D) Determine if the dye is being excreted.
Answer: A
A) Specific gravity results indicate the hydration status of the child. Children are NPO prior to the test so it is important that adequate hydration be accomplished following the procedure. Specific gravity does indicate the ability of the kidneys to concentrate or dilute urine, but in this case, the nurse would be looking for hydration status.
Topic: Physiological Integrity
30. A young client, age 14, will receive a Milwaukee Brace to correct for scoliosis, 24 degree curve. Reviewing her discharge instructions, the nurse will know she does not require more teaching when she says she will
A) Wear the brace all day and remove it only to bathe.
B) Put the brace on a minimum of 1 hour 3 times per day.
C) Wear the brace after school and at night.
D) Take off the brace if her skin gets sore or starts to break down.
Answer: A
A) It is important that the brace remain on at all times except for bathing. It will also be important to teach her to use good skin care in the area where the brace touches her skin.
Topic: Physiological Integrity
31. The physician orders a nasogastric tube to be inserted. During the insertion of the NG tube, the nurse will position the client in
A) High-Fowler's with neck hyperextended.
B) High-Fowler's with head bent forward.
C) Right side-lying with head straight up.
D) Low-Fowler's with head tilted back.
Answer: B
B) The preferred position is Fowler's with the head flexed forward to assist the tube to move into the esophagus. The nurse would never ask the client to hyperextend the neck, as this might open the airway and cause the tube to enter the trachea.
Topic: Physiological Integrity
32. The nurse is assigned to work with a client diagnosed as having pernicious anemia. The nurse will know the client requires more teaching if the client says that she should include in her diet more
A) Meat, milk, cheese.
B) Whole grains, cereals.
C) Organ meats, yellow vegetables.
D) Fruits, green leafy vegetables.
Answer: D
D) Fruits and vegetables contain vitamin C and B. Vitamin B12 comes from animal products. Clients with pernicious anemia have a B12 deficiency. Clients either need frequent B12 injections or they must drastically increase the foods (such as meat, milk and cheese) that provide B12 in sufficient quantity.
Topic: Physiological Integrity
33. A client on the psychiatric unit with the diagnosis of anorexia nervosa has lost 20 pounds and is beginning to show signs of dehydration. Which of the following nursing approaches indicates the best understanding of the situation?
A) "If you like, you can eat alone in your room."
B) "The staff wants you to eat and drink on your own; but if you won't, we'll have to tube feed you."
C) "You can't expect to get better if you don't eat and drink."
D) "Why do you want to hurt yourself like this?"
Answer: B
B) With anorexia nervosa, the danger is of starvation and death; therefore, the client should be informed of the consequences of not eating. She should not be allowed to eat alone, because there is no assurance she will actually eat the food.
Topic: Psychosocial Integrity
34. For a client with a suspected peptic ulcer, which of the following questions in an assessment history is the most relevant?
A) "Are there any changes in your bowel or bladder habits?"
B) "Have you had any changes in your stool?"
C) "Are you frequently constipated?"
D) "Do you have frequent diarrhea?"
Answer: B
B) The client is complaining of abdominal pain; therefore, the question seeking to determine gastrointestinal bleeding (tarry stools) is the most relevant.
Topic: Physiological Integrity
35. A client has otosclerosis and is scheduled for a stapedectomy. This condition chiefly involves the
A) Ossicle.
B) Auditory canal.
C) Tympanic membrane.
D) Auditory nerve.
Answer: A
A) The stapes and ossicle in the middle ear become fixed and immovable.
Topic: Physiological Integrity
36. Several chronic schizophrenic clients are assigned to a group therapy session. The best rationale for this form of treatment is that it
A) Enables clients to become aware that others have problems and that they are not alone in their suffering.
B) Is not psychoanalytically based, but deals with unconscious material.
C) Provides a social milieu similar to society in general, where the client can relate to others.
D) Is the most economicalÑone staff member can treat many clients.
Answer: C
C) Because many people's problems occur in an interpersonal framework, the group setting is a way to correct faulty perceptions as well as work on effective ways of relating to others. The remaining answers are all accurate, but they do not fit the requirement of best rationale.
Topic: Psychosocial Integrity
37. A 50-year-old client with a chronic respiratory problem comes into the emergency room with the following symptoms: fever, cough, chest pain, and tachycardia. An arterial blood gas is obtained on admission with a repeat test 1 hour later; oxygen via nasal prongs at 6 l/min. is started. Following are the ABG results:
FIO2 pH PCO2 HCO3 PO2
ABG
ABG 2: 6 liters 7.20 75 29 140
Assessing these symptoms would lead the nurse to identify the nursing diagnosis of
A) Impaired Gas Exchange.
B) Ineffective Breathing Pattern.
C) Decreased Cardiac Output.
D) Ineffective Airway Clearance.
Answer: A
A) The client's drive to breathe is hypoxia. When she was given an FIO2 to return her arterial PO2 level to above normal, the peripheral chemoreceptors no longer could respond to hypoxia.
Topic: Physiological Integrity
38. Which laboratory test result would be most important to evaluate before administering a chemotherapeutic agent?
A) Serum electrolytes.
B) Prothrombin time and APTT.
C) Complete blood count (CBC).
D) Liver function studies.
Answer: C
C) Chemotherapy commonly results in bone marrow depression. The CBC is evaluated to determine the adequacy of bone marrow function. Low WBC or platelet counts can be indicators of life-threatening toxicity.
Topic: Physiological Integrity
39. A major nursing goal in the care of a client with diabetes insipidus is
A) Watching for signs of hypokalemia.
B) Maintaining adequate fluid balance.
C) Insuring that the diabetic diet is followed.
D) Accurate administration of insulin.
Answer: B
B) Diabetes insipidus is an antidiuretic hormone deficiency condition related to posterior lobe pituitary hypofunction. Large volumes of fluids are lost through renal excretion; therefore, maintaining fluid balance is a broad, critical goal. Hyperkalemia can result from dehydration.
Topic: Physiological Integrity
40. A client on the oncology unit is in a great deal of pain but it is controlled with PCAÑpatient-controlled IV analgesia. The rationale for using this method is that it
A) Results in less pain medication used by client.
B) Programs medication to remain within acceptable limits.
C) Enables clients to administer medication when pain is experienced.
D) Allows nurses to care for more clients.
Answer: C
C) PCA works more effectively to control pain for the client with no significant difference in the amount of medication used. It is less time consuming for the nurse, but this is not the essential rationale.
Topic: Physiological Integrity
41. An infant born of a heroin addicted mother appears normal at birth. In assessing the infant, the nurse knows that withdrawal will occur
A) Within 2 days to a week.
B) At an unpredicted time because it varies with each infant.
C) Within minutes to one hour after birth.
D) Within 12-24 hours.
Answer: D
D) When the infant's mother is heroin addicted, withdrawal occurs from 12-24 hours after birth. If the mother were on methadone, answer (A) would be correct.
Topic: Health Promotion and Maintenance
42. Following a car accident, a client develops a tension pneumothorax and is admitted to the hospital. The nurse should be prepared to
A) Establish an IV.
B) Assist the physician with chest tube insertion.
C) Draw arterial blood gases for evaluation.
D) Assist the physician to perform chest decompression with a large-bore needle.
Answer: D
D) This is a medical emergency and releasing the pressure with a large-bore needle must be done immediately to preserve function of the remaining lung.
Topic: Physiological Integrity
43. A client on a psychiatric unit does not respond when the nurse stands by her bed and calls her name. The nurse's initial action would be to
A) Obtain vital signs immediately.
B) Phone the physician and bring a gastric lavage set to the bedside.
C) Shake the client and ask, "Are you all right?"
D) Attempt to sit client up and gently shake her.
Answer: C
C) When a client is unresponsive, utilize CPR principles. This action can give immediate data as to the degree of conscious awareness of the client and would be the first appropriate nursing action.
Topic: Physiological Integrity
44. A client with advanced cirrhosis of the liver will most likely be ordered a diet of
A) Fat controlled, low potassium and sodium.
B) Low protein and sodium.
C) No protein, low potassium.
D) Low protein and fat, low carbohydrate.
Answer: B
B) This diet will control the end products of protein metabolism and prevent ammonia buildup, as well as decrease fluid accumulation. A small amount of protein is needed for tissue repair.
Topic: Physiological Integrity
45. An obese man of 54 came into the emergency clinic complaining of a painful, tender big toe. The admitting diagnosis was gout. The client was put on colchicine medication. The nurse explains to the client that the primary action of this medication is to
A) Decrease uric acid level.
B) Alleviate pain.
C) Alkalinize urine.
D) Reduce inflammation.
Answer: D
D) Colchicine is an anti-inflammatory drug that is taken at the first sign of joint pain. Pain will be alleviated as a secondary factor. The drug Allopurinol decreases uric acid level, and sodium bicarbonate alkalinizes urine.
Topic: Physiological Integrity
46. A 40-year-old client is to be discharged and she wishes to walk outside. The nurse explains that the reason clients are discharged in a wheelchair is for
A) Comfort.
B) Rehabilitation.
C) Convenience.
D) Safety.
Answer: D
D) Transportation by wheelchair can prevent falls and injury; therefore, safety is the important issue.
Topic: Safe, Effective Care Environment
47. To perform the skill, "turning to the side-lying position," the nurse would lower the head of the bed, elevate the bed to working height, move the client to your side of the bed, and flex client's knees. The next intervention would be to
A) Roll the client on his side.
B) Place one hand on client's hip and other on shoulder.
C) Reposition client.
D) Reposition client's arms so they are not under his body.
Answer: B
B) Before rolling a client on his side, the nurse's hands must be in the correct position to turn. Answer (D) would be the final intervention.
Topic: Physiological Integrity
48. A client with the diagnosis of cirrhosis is being prepared for a liver biopsy. Before the procedure, it is most important that the nurse evaluate his
A) Informed consent.
B) Vital signs.
C) Psychological preparation.
D) Coagulation studies.
Answer: D
D) Because the cirrhotic client frequently has associated coagulopathy, it is essential that the coagulation profile be evaluated before performing a needle biopsy of an internal organ. A high prothrombin time may indicate a deficiency in prothrombin, fibrinogen or factors V, VII or X. The other options are also important, but not as vital.
Topic: Physiological Integrity
49. A female client with the diagnosis of acute depressive episode sits in a corner for long periods of time. She looks at the floor and does not speak. The nursing action indicated for the client is to
A) Ambulate the client every hour.
B) Allow the client to nap morning and afternoon.
C) Seat the client near a window so that she can look out.
D) Send the client to group activities.
Answer: A
A) The client needs to be mobilized and active, so interacting by walking with her is the best nursing intervention. It is too soon to send her to group activities, and she should not sleep during the day.
50. The nurse is assigned to a client who is receiving a mydriatic eye drop. Which of the following assessments indicates a systemic anticholinergic effect?
A) Respirations becoming more shallow.
B) Sweating and blurred vision.
C) Complaints of light headedness and headache.
D) Decreased pulse and blood pressure.
Answer: B
B) Sweating and blurred vision are signs of a systemic anticholinergic effect. In addition to these symptoms the client may experience loss of sight, difficulty breathing, flushing, or eye pain. If these symptoms occur, the medication must be discontinued.
Topic: Physiological Integrity
51. A client with cardiac failure and pulmonary edema has been placed on telemetry (a cardiac monitor). The purpose of this monitoring is to
A) Assess atrial ectopic beats as a result of hypoxia.
B) Identify ventricular arrhythmias resulting from hypoxia.
C) Assess ectopic beats as a result of hyperkalemia.
D) Treat ventricular arrhythmias as a result of hyperkalemia.
Answer: B
B) When the lungs are filled with fluid, oxygenation is not as efficient as it should be. Hypoxia can cause ventricular arrhythmias. These are identified easily by the use of telemetry.
Topic: Physiological Integrity
52. A client with cardiac failure and pulmonary edema has been placed on telemetry (a cardiac monitor). The purpose of this monitoring is to
A) Assess atrial ectopic beats as a result of hypoxia.
B) Identify ventricular arrhythmias resulting from hypoxia.
C) Assess ectopic beats as a result of hyperkalemia.
D) Treat ventricular arrhythmias as a result of hyperkalemia.
Answer: B
B) When the lungs are filled with fluid, oxygenation is not as efficient as it should be. Hypoxia can cause ventricular arrhythmias. These are identified easily by the use of telemetry.
Topic: Physiological Integrity
53. The signs and symptoms most often observed in clients with mitral valve stenosis are
A) Vertigo, orthopnea.
B) Palpitations, dyspnea, chest pain.
C) Angina, syncope.
D) Exertional dyspnea, fatigue.
Answer: D
D) Exertional dyspnea and fatigue are directly related to diminished cardiac output.
Topic: Physiological Integrity
54. The signs and symptoms most often observed in clients with mitral valve stenosis are
A) Vertigo, orthopnea.
B) Palpitations, dyspnea, chest pain.
C) Angina, syncope.
D) Exertional dyspnea, fatigue.
Answer: D
D) Exertional dyspnea and fatigue are directly related to diminished cardiac output.
Topic: Physiological Integrity
55. A physician orders prednisone for her client with lupus erythematosus. An important client teaching principle that the nurse would reinforce is to
A) Take medication away from food.
B) Weigh daily.
C) Limit activity.
D) Increase salt intake.
Answer: B
B) It is important to weigh daily because corticosteroid therapy may result in sudden weight gain from sodium retention. The client should reduce salt intake and take the medication with food to reduce GI irritation.
Topic: Physiological Integrity
56. A client is admitted for induction of labor. Physician's orders are to start oxytocin (Pitocin), 10 units in 100 mL D5W. After monitoring contractions, the nurse observes a contraction that lasts almost 2 minutes. The nursing intervention is to
A) Stop the infusion of oxytocin.
B) Notify the physician.
C) Continue to monitor the client.
D) Slow down the infusion of oxytocin.
Answer: A
A) If the contraction lasts over 90 seconds, the safety intervention is to stop the oxytocin and then notify the physician. Slowing down the infusion or continuing to monitor the client are not safe nursing actions.
Topic: Health Promotion and Maintenance
57. A 4-year-old child is brought to the emergency room after two days of vomiting, diarrhea and a temperature of 102 degrees F to 104 degrees F. The nurse knows that the care plan will be based on the priority nursing diagnosis of
A) Diarrhea.
B) Fluid Volume Deficit.
C) Altered Nutrition: Less than Body Requirements
D) Hyperthermia.
Answer: B
B) While all of the nursing diagnoses may be included in the care plan, the critical one is Fluid Volume Deficit, another way of saying dehydration. Because a young child has less body surface than an adult, dehydration can occur rapidly and lead to acidosis and death.
Topic: Physiological Integrity
58. A client who has a history of two abortions comes to the clinic for prenatal care. She is 8 weeks pregnant and has Rh negative blood. For a complete assessment of her status, the nurse would expect the physician to order a test for
A)
B) Hemolytic disease.
C) Rh incompatibility.
D) Direct Coomb's.
Answer: C
C) If the mother is Rh negative and has had two abortions, Rh incompatibility may be present caused by antibodies in the mother's blood. The physician would perform an indirect Coomb's test (a direct Coomb's is done on cord blood). The mother should have received
Topic: Health Promotion and Maintenance
59. A client has just returned from a bronchoscopy procedure to diagnose possible bronchogenic carcinoma. The critical nursing assessment immediately following the test is to
A) Evaluate the client's ability to deep breathe and cough.
B) Assess vital signs and compare with baseline signs.
C) Evaluate for signs of dyspnea or wheezing.
D) Assess the client's face and neck for edema.
Answer: C
C) Dyspnea and wheezing are signs of laryngeal edema or bronchospasm which may result in respiratory distress and must be reported to the physician immediately. Clients are instructed to refrain from coughing which could result in hemorrhaging. The face and neck should be assessed for subcutaneous crepitus, not just edema. Vital signs are always important to monitor, but at this time the most crucial assessment is to monitor for respiratory problems.
Topic: Physiological Integrity
60. Following surgery, a 1-day-old infant returns with a gastrostomy tube in place. On the second postoperative day, the nursing intervention would be to
A) Plug the tube.
B) Secure the tube above the level of the stomach.
C) Do nothing, leaving the tube in place.
D) Return the tube to gravity drainage.
Answer: D
D) The gastrostomy tube is returned to gravity drainage until the infant can tolerate feedings. After the second or third day, the gastrostomy tube is pinned to the infant's shirt so it is above the level of the stomach to prevent draining of stomach contents out through the tube.
61. The rationale for using transtracheal oxygen delivery is that this method will
A) Provide high levels of oxygen for clients with acute respiratory failure.
B) Provide for independent functioning for clients requiring continuous oxygen delivery.
C) Work effectively in children requiring long term oxygen therapy.
D) Promote long term oxygen delivery without frequent catheter care.
Answer: B
B) Clients can easily maintain their independence when using transtracheal oxygen catheters. This method of oxygen delivery is contraindicated in clients with acute respiratory failure. Catheter care must be provided at least twice daily with both the Heimlich Micro-Trach catheter and the SCOOP Catheter.
Topic: Physiological Integrity
62. A client has burns on the front and back of both his legs and arms. The approximate percentage of his body that has been involved is
A) 54 percent.
B) 36 percent.
C) 45 percent.
D) 27 percent.
Answer: A
A) The client's burns cover approximately 54 percent of his body surface. Each arm is 9 percent (18 percent) and each leg is 18 percent (36 percent).
Topic: Physiological Integrity
63. A client has been admitted to the hospital the day before she is scheduled for an abdominal hysterectomy. Nursing responsibilities for the preoperative period would include notifying the physician if the
A) Erythrocyte count is 6 million/cu mm.
B) Urine report indicates ketonuria.
C) Temperature is 99.6 degrees F orally.
D) Hemoglobin is 14 gm/100 ml.
Answer: B
B) All the other reports are within normal range. The ketonuria indicates a probable diabetic complication or other metabolic condition.
64. Following retinal detachment surgery, the client asks to go to the bathroom. The most appropriate response to his request is to tell him that he
A) May get up with assistance.
B) Must remain on strict bedrest.
C) May briefly get up, but he should keep the affected area dependent.
D) May get up as long as he does not bend his head down.
Answer: B
B) The client must remain on strict bedrest to prevent further damage and to keep the retina attached to the choroid until surgery. Both (C) and (D) are incorrect, because if he gets up, it would be impossible to keep the retina approximated to the choroid.
Topic: Physiological Integrity
65. If a client has an injury to the seventh cranial nerve, the nursing assessment will identify an abnormality in
A) Tongue control.
B) Hearing.
C) Trapezius muscle movement.
D) Closing the eyelid.
Answer: D
D) The seventh cranial nerve supplies both motor and sensory function. The eyelid closure is a result of the motor function.
Topic: Physiological Integrity
66. A 75-year-old client has the diagnosis of organic brain syndrome. In planning the daily schedule, it is important for the nurse to understand that the client
A) Is more likely to be able to remember current experiences than past ones.
B) May have moderate-to-severe memory impairment and short periods of concentration.
C) Can usually be trusted to be responsible for her daily care needs.
D) Will be more comfortable with a rigid daily schedule.
Answer: B
B) It is important to remember that OBS clients usually have some memory and concentration impairment. The degree depends upon the individual and is influenced by the basic personality structure and the cause of the problem.
Topic: Health Promotion and Maintenance
67. When caring for an unconscious child, the nurse's primary concern must always be
A) Maintaining range of motion and muscle tone.
B) Airway protection and adequate respiratory status.
C) Decreasing intracranial pressure.
D) Fluid balance and cardiac stability.
Answer: B
B) As neuro status deteriorates, the airway must be assured to avoid compromising oxygenation or aspiration. Hypoxia will exacerbate the brain injury. The other answers are appropriate goals after airway patency is assured.
Topic: Physiological Integrity
68. Heart rates vary according to age. In assessing the heart rate of a one year old, the nurse would expect to find a normal rate of
A) 120-130 beats per minute.
B) 110 beats per minute.
C) 140-190 beats per minute.
D) 100 beats per minute.
Answer: A
A) 120-130 beats would be the average or normal range of heart rate for the child under one year of age.
Topic: Physiological Integrity
69. A 42-year-old client is diagnosed as a chronic schizophrenic. Assessing the client, the nurse keeps in mind that a diagnosis of schizophrenia involves
A) Inability to concentrate.
B) Loss of contact with reality.
C) Feelings of worthlessness.
D) Guilt feelings.
Answer: B
B) Loss of contact with reality is a symptom of schizophrenia. All of the other symptoms are indicative of depression. While schizophrenia may be accompanied by depression, these symptoms will not usually be observed.
Topic: Psychosocial Integrity
70. As part of preoperative teaching, the nurse informs the client of postoperative measures to prevent atelectasis. The intervention that will best accomplish this goal is to
A) Apply a scultetus binder as soon as the client is fully awake to assist with deep breathing.
B) Closely observe the client's intake of fluids to liquefy secretions.
C) Have the client turn, cough and deep breathe every 2 hours.
D) Put pillows under the client's knees to decrease pressure on the incision, thereby increasing willingness to take deep breaths.
Answer: C
C) Atelectasis is the collapse of alveoli caused by mucus plugs in the small bronchioles due to inadequate ventilation. Turning, coughing and deep breathing improve ventilation and help prevent the collapse. Liquefying secretions is important but answer (1) is more critical.
Topic: Physiological Integrity
71. A female client is brought to the maternity unit by her husband. She went into labor at home and the contractions are 4 minutes apart and regular. Her membranes have ruptured spontaneously. All of the following actions are appropriate; the first nursing intervention is to
A) Notify the physician.
B) Check the fetal heart rate (FHR).
C) Assess the quantity of fluid.
D) Check the color of fluid.
Answer: B
B) The FHR needs to be checked first to determine whether the cord is prolapsed. The cord has an increased possibility of prolapsing when the membranes rupture.
Topic: Health Promotion and Maintenance
72. Observing a nursing assistant wash her hands, the nurse knows that the NA needs more instruction in handwashing technique when she observes the NA
A) Drying her hands with a paper towel.
B) Not rubbing her hands together to cause friction.
C) Not holding her hands under running water for one minute.
D) Using too much soap.
Answer: B
B) One of the most important steps in handwashing (medical asepsis) is to create friction by rubbing the two hands together. Hands should be washed for 30 seconds and paper towels are appropriate for drying.
Topic: Safe, Effective Care Environment
73. Which of the following nursing actions should appear on a client's postoperative nursing care plan following a pneumonectomy?
A) Strip chest tubes every hour.
B) Force fluids to 3500 ml/day.
C) Monitor IPPB therapy.
D) Provide range-of-motion exercises to affected arm.
Answer: D
D) Range-of-motion exercises should be initiated within four hours of surgery to prevent adhesion formation. IPPB therapy will not be used because the pressure could interrupt the suture line. Most physicians do not insert chest tubes in these clients, because the fluid is allowed to accumulate and eventually consolidate in the space. An increased fluid load of 3500 ml/day could lead to respiratory compromise.
1 comment:
Hi,
Nice post. Do you need any MCAT questions and NCLEX questions discussing answer? You can share test prep and practice questions and answers with other members of the community.
Thanks.
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