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because:

a. reducing sodium promotes urea nitrogen


MEDICAL-SURGICAL NURSING excretion
Part 1 b. reducing sodium improves her glomerular
filtration rate
1. After a cerebrovascular accident, a 75 yr old c. reducing sodium increases potassium
client is admitted to the health care facility. The absorption
client has left-sided weakness and an absent d. reducing sodium decreases edema
gag reflex. He’s incontinent and has a tarry
stool. His blood pressure is 90/50 mm Hg, and ANS: D
his hemoglobin is 10 g/dl. Which of the following Reducing sodium intake reduces fluid retention.
is a priority for this client? Fluid retention increases blood volume, which
a. checking stools for occult blood changes blood vessel permeability and allows
b. performing range-of-motion exercises to the plasma to move into interstitial tissue, causing
left side edema. Urea nitrogen excretion can be
c. keeping skin clean and dry increased only by improved renal function.
d. elevating the head of the bed to 30 degrees Sodium intake doesn’t affect the glomerular
filtration rate. Potassium absorption is improved
ANS: D only by increasing the glomerular filtration rate; it
Because the client’s gag reflex is absent, isn’t affected by sodium intake.
elevating the head of the bed to 30 degrees
helps minimize the client’s risk of aspiration. 5. The nurse is caring for a client with a cerebral
Checking the stools, performing ROM exercises, injury that impaired his speech and hearing.
and keeping the skin clean and dry are Most likely, the client has experienced damage
important, but preventing aspiration through to the:
positioning is the priority. a. frontal lobe
b. parietal lobe
2. The nurse is caring for a client with a c. occipital lobe
colostomy. The client tells the nurse that he d. temporal lobe
makes small pin holes in the drainage bag to
help relieve gas. The nurse should teach him AN:S D
that this action: The portion of the cerebrum that controls speech
a. destroys the odor-proof seal and hearing is the temporal lobe. Injury to the
b. wont affect the colostomy system frontal lobe causes personality changes,
c. is appropriate for relieving the gas in a difficulty speaking, and disturbance in memory,
colostomy system reasoning, and concentration. Injury to the
d. destroys the moisture barrier seal parietal lobe causes sensory alterations and
problems with spatial relationships. Damage to
ANS: A the occipital lobe causes vision disturbances.
Any hole, no matter how small, will destroy the
odor-proof seal of a drainage bag. Removing the 6. The nurse is assessing a postcraniotomy
bag or unclamping it is the only appropriate client and finds the urine output from a catheter
method for relieving gas. is 1500 ml for the 1st hour and the same for the
2nd hour. The nurse should suspect:
3. When assessing the client with celiac a. Cushing’s syndrome
disease, the nurse can expect to find which of b. Diabetes mellitus
the following? c. Adrenal crisis
a. steatorrhea d. Diabetes insipidus
b. jaundiced sclerae
c. clay-colored stools ANS: D
d. widened pulse pressure Diabetes insipidus is an abrupt onset of extreme
polyuria that commonly occurs in clients after
ANS: A brain surgery. Cushing’s syndrome is excessive
because celiac disease destroys the absorbing glucocorticoid secretion resulting in sodium and
surface of the intestine, fat isn’t absorbed but is water retention. Diabetes mellitus is a
passed in the stool. Steatorrhea is bulky, fatty hyperglycemic state marked by polyuria,
stools that have a foul odor. Jaundiced sclerae polydipsia, and polyphagia. Adrenal crisis is
result from elevated bilirubin levels. Clay-colored undersecretion of glucocorticoids resulting in
stools are seen with biliary disease when bile profound hypoglycemia, hypovolemia, and
flow is blocked. Celiac disease doesn’t cause a hypotension.
widened pulse pressure.
7. The nurse is providing postprocedure care for
4. A client is hospitalized with a diagnosis of a client who underwent percutaneous lithotripsy.
chronic glomerulonephritis. The client mentions In this procedure, an ultrasonic probe inserted
through a nephrostomy tube into the renal pelvis
that she likes salty foods. The nurse should warn generates ultra-high-frequency sound waves to
her to avoid foods containing sodium shatter renal calculi. The nurse should instruct
the client to:
a. limit oral fluid intake for 1 to 2 weeks 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6
b. report the presence of fine, sandlike particles p.m.
through the nephrostomy tube.
c. Notify the physician about cloudy or foul- 10. A client with a head injury is being monitored
smelling urine for increased intracranial pressure (ICP). His
d. Report bright pink urine within 24 hours after blood pressure is 90/60 mmHG and the ICP is
the procedure 18 mmHg; therefore his cerebral perfusion
pressure (CPP) is:
ANS: C a. 52 mm Hg
The client should report the presence of foul- b. 88 mm Hg
smelling or cloudy urine. Unless contraindicated, c. 48 mm Hg
the client should be instructed to drink large d. 68 mm Hg
quantities of fluid each day to flush the kidneys.
Sand-like debris is normal because of residual ANS: A
stone products. Hematuria is common after CPP is derived by subtracting the ICP from the
lithotripsy. mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum
8. A client with a serum glucose level of 618 goal is 70 mmHg. The MAP is derived using the
mg/dl is admitted to the facility. He’s awake and following formula:
oriented, has hot dry skin, and has the following MAP = ((diastolic blood pressure x 2) + systolic
vital signs: temperature of 100.6º F (38.1º C), blood pressure) / 3
heart rate of 116 beats/minute, and blood MAP = ((60 x2) + 90) / 3
pressure of 108/70 mm Hg. Based on these MAP = 70 mmHg
assessment findings, which nursing diagnosis To find the CPP, subtract the client’s ICP from
takes the highest priority? the MAP; in this case , 70 mmHg – 18 mmHg =
a. deficient fluid volume related to osmotic 52 mmHg.
diuresis
b. decreased cardiac output related to elevated 11. A 52 yr-old female tells the nurse that she
heart rate has found a painless lump in her right breast
c. imbalanced nutrition: Less than body during her monthly self-examination. Which
requirements related to insulin deficiency assessment finding would strongly suggest that
d. ineffective thermoregulation related to this client’s lump is cancerous?
dehydration a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
ANS: A c. mobile mass that is oft and easily delineated
A serum glucose level of 618 mg/dl indicates d. nonpalpable right axillary lymph nodes
hyperglycemia, which causes polyuria and
deficient fluid volume. In this client, tachycardia ANS: B
is more likely to result from deficient fluid volume Breast cancer tumors are fixed, hard, and poorly
than from decreased cardiac output because his delineated with irregular edges. Nipple retraction
blood pressure is normal. Although the client’s —not eversion—may be a sign of cancer. A
serum glucose is elevated, food isn’t a priority mobile mass that is soft and easily delineated is
because fluids and insulin should be most often a fluid-filled benigned cyst. Axillary
administered to lower the serum glucose level. lymph nodes may or may not be palpable on
Therefore, a diagnosis of Imbalanced Nutrition: initial detection of a cancerous mass.
Less then body requirements isn’t appropriate. A
temperature of 100.6º F isn’t life threatening, 12. A Client is scheduled to have a descending
eliminating ineffective thermoregulation as the colostomy. He’s very anxious and has many
top priority. questions regarding the surgical procedure, care
of stoma, and lifestyle changes. It would be most
9. Capillary glucose monitoring is being appropriate for the nurse to make a referral to
performed every 4 hours for a client diagnosed which member of the health care team?
with diabetic ketoacidosis. Insulin is a. Social worker
administered using a scale of regular insulin b. registered dietician
according to glucose results. At 2 p.m., the client c. occupational therapist
has a capillary glucose level of 250 mg/dl for d. enterostomal nurse therapist
which he receives 8 U of regular insulin. The
nurse should expect the dose’s: ANS: D
a. onset to be at 2 p.m. and its peak at 3 p.m. An enterostomal nurse therapist is a registered
b. onset to be at 2:15 p.m. and its peak at 3 p.m. nurse who has received advance education in
c. onset to be at 2:30 p.m. and its peak at 4 p.m. an accredited program to care for clients with
d. onset to be at 4 p.m. and its peak at 6 p.m. stomas. The enterostomal nurse therapist can
assist with selection of an appropriate stoma
ANS: C site, teach about stoma care, and provide
Regular insulin, which is a short-acting insulin, emotional support.
has an onset of 15 to 30 minutes and a peak of
2 to 4 hours. Because the nurse gave the insulin 13. Ottorrhea and rhinorrhea are most
at 2 p.m., the expected onset would be from commonly seen with which type of skull
fracture? breast tumor to determine whether the tumor is
a. basilar estrogen- or progesterone-dependent.
b. temporal
c. occipital 17. When caring for a client with esophageal
d. parietal varices, the nurse knows that bleeding in this
disorder usually stems from:
ANS: A A. esophageal perforation
Ottorrhea and rhinorrhea are classic signs of B. pulmonary hypertension
basilar skull fracture. Injury to the dura C. portal hypertension
commonly occurs with this fracture, resulting in D. peptic ulcers
cerebrospinal fluid (CSF) leaking through the
ears and nose. Any fluid suspected of being ANS: C
CSF should be checked for glucose or have a Increased pressure within the portal veins
halo test done. causes them to bulge, leading to rupture and
bleeding into the lower esophagus. Bleeding
14. A male client should be taught about associated with esophageal varices doesn’t
testicular examinations: stem from esophageal perforation, pulmonary
a. when sexual activity starts hypertension, or peptic ulcers.
b. after age 60
c. after age 40 18. A 49-yer-old client was admitted for surgical
d. before age 20 repair of a Colles’ fracture. An external fixator
was placed during surgery. The surgeon
ANS: D explains that this method of repair:
Testicular cancer commonly occurs in men A. has very low complication rate
between ages 20 and 30. A male client should B. maintains reduction and overall hand function
be taught how to perform testicular self- C. is less bothersome than a cast
examination before age 20, preferably when he D. is best for older people
enters his teens.
ANS: B
15. Before weaning a client from a ventilator, Complex intra-articular fractures are repaired
which assessment parameter is most important with external fixators because they have a better
for the nurse to review? long-term outcome than those treated with
A. fluid intake for the last 24 hours casting. This is especially true in a young client.
B. baseline arterial blood gas (ABG) levels The incidence of complications, such as pin tract
C. prior outcomes of weaning infections and neuritis, is 20% to 60%. Clients
D. electrocardiogram (ECG) results must be taught how to do pin care and assess
for development of neurovascular complications.
ANS: B
Before weaning a client from mechanical 19. A client is hospitalized with a diagnosis of
ventilation, it’s most important to have a baseline chronic renal failure. An arteriovenous fistula
ABG levels. During the weaning process, ABG was created in his left arm for hemodialysis.
levels will be checked to assess how the client is When preparing the client for discharge, the
tolerating the procedure. Other assessment nurse should reinforce which dietary instruction?
parameters are less critical. Measuring fluid A. “Be sure to eat meat at every meal.”
volume intake and output is always important B. “Monitor your fruit intake and eat plenty of
when a client is being mechanically ventilated. bananas.”
Prior attempts at weaning and ECG results are C. “Restrict your salt intake.”
documented on the client’s record, and the D. “Drink plenty of fluids.”
nurse can refer to them before the weaning
process begins. ANS: C
In a client with chronic renal failure, unrestricted
16. The nurse is speaking to a group of women intake of sodium, protein, potassium, and fluids
about early detection of breast cancer. The may lead to a dangerous accumulation of
average age of the women in the group is 47. electrolytes and protein metabolic products,
Following the American Cancer Society (ACS) such as amino acids and ammonia. Therefore,
guidelines, the nurse should recommend that the client must limit his intake of sodium, meat
the women: (high in Protein), bananas (high in potassium),
A. perform breast self-examination annually and fluid because the kidneys can’t secrete
B. have a mammogram annually adequate urine.
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation 20. The nurse is caring for a client who has just
every 2 years had a modified radical mastectomy with
immediate reconstruction. She’s in her 30s and
ANS: B has tow children. Although she’s worried about
According to the ACS guidelines, “Women older her future, she seems to be adjusting well to her
than age 40 should perform breast self- diagnosis. What should the nurse do to support
examination monthly (not annually).” The her coping?
hormonal receptor assay is done on a known A. Tell the client’s spouse or partner to be
supportive while she recovers. ANS: A
B. Encourage the client to proceed with the next Tenting of chest skin when pinched indicates
phase of treatment. decreased skin elasticity due to dehydration.
C. Recommend that the client remain cheerful Hand veins fill slowly with dehydration, not
for the sake of her children. rapidly. A pulse that isn’t easily obliterated and
D. Refer the client to the American Cancer neck vein distention indicate fluid overload, not
Society’s Reach for Recovery program or dehydration.
another support program.
24. The nurse is teaching a client with a history
ANS: D of atherosclerosis. To decrease the risk of
The client isn’t withdrawn or showing other signs atherosclerosis, the nurse should encourage the
of anxiety or depression. Therefore, the nurse client to:
can probably safely approach her about talking A. Avoid focusing on his weight.
with others who have had similar experiences, B. Increase his activity level.
either through Reach for Recovery or another C. Follow a regular diet.
formal support group. The nurse may educate D. Continue leading a high-stress lifestyle.
the client’s spouse or partner to listen to
concerns, but the nurse shouldn’t tell the client’s ANS: B
spouse what to do. The client must consult with The client should be encouraged to increase his
her physician and make her own decisions activity level. Maintaining an ideal weight;
about further treatment. The client needs to following a low-cholesterol, low-sodium diet; and
express her sadness, frustration, and fear. She avoiding stress are all important factors in
can’t be expected to be cheerful at all times. decreasing the risk of atherosclerosis.

21. A 21 year-old male has been seen in the 25. For a client newly diagnosed with radiation-
clinic for a thickening in his right testicle. The induced thrombocytopenia, the nurse should
physician ordered a human chorionic include which intervention in the plan of care?
gonadotropin (HCG) level. The nurse’s A. Administer aspirin if the temperature exceeds
explanation to the client should include the fact 38.8º C.
that: B. Inspect the skin for petechiae once every
A. The test will evaluate prostatic function. shift.
B. The test was ordered to identify the site of a C. Provide for frequent periods of rest.
possible infection. D. Place the client in strict isolation.
C. The test was ordered because clients who
have testicular cancer has elevated levels of ANS: B
HCG. Because thrombocytopenia impairs blood
D. The test was ordered to evaluate the clotting, the nurse should assess the client
testosterone level. regularly for signs of bleeding, such as
petechiae, purpura, epistaxis, and bleeding
ANS: C gums. The nurse should avoid administering
HCG is one of the tumor markers for testicular aspirin because it can increase the risk of
cancer. The HCG level won’t identify the site of bleeding. Frequent rest periods are indicated for
an infection or evaluate prostatic function or clients with anemia, not thrombocytopenia. Strict
testosterone level. isolation is indicated only for clients who have
highly contagious or virulent infections that are
22. A client is receiving captopril (Capoten) for spread by air or physical contact.
heart failure. The nurse should notify the
physician that the medication therapy is 26. A client is chronically short of breath and yet
ineffective if an assessment reveals: has normal lung ventilation, clear lungs, and an
A. A skin rash. arterial oxygen saturation (SaO2) 96% or better.
B. Peripheral edema. The client most likely has:
C. A dry cough. A. poor peripheral perfusion
D. Postural hypotension. B. a possible Hematologic problem
C. a psychosomatic disorder
ANS: B D. left-sided heart failure
Peripheral edema is a sign of fluid volume
overload and worsening heart failure. A skin ANS: B
rash, dry cough, and postural hypotension are SaO2 is the degree to which hemoglobin is
adverse reactions to captopril, but the don’t saturated with oxygen. It doesn’t indicate the
indicate that therapy isn’t effective. client’s overall Hgb adequacy. Thus, an
individual with a subnormal Hgb level could have
23. Which assessment finding indicates normal SaO2 and still be short of breath. In this
dehydration? case, the nurse could assume that the client has
A. Tenting of chest skin when pinched. a Hematologic problem. Poor peripheral
B. Rapid filling of hand veins. perfusion would cause subnormal SaO2. There
C. A pulse that isn’t easily obliterated. isn’t enough data to assume that the client’s
D. Neck vein distention problem is psychosomatic. If the problem were
left-sided heart failure, the client would exhibit
pulmonary crackles.
ANS: C
27. For a client in addisonian crisis, it would be Caffeine is a stimulant, which can exacerbate
very risky for a nurse to administer: palpitations and should be avoided by a client
A. potassium chloride with symptomatic mitral valve prolapse. High-
B. normal saline solution fluid intake helps maintain adequate preload and
C. hydrocortisone cardiac output. Aerobic exercise helps in
D. fludrocortisone increase cardiac output and decrease heart rate.
Protein-rich foods aren’t restricted but high-
ANS: A calorie foods are.
Addisonian crisis results in Hyperkalemia;
therefore, administering potassium chloride is 31. A client with a history of hypertension is
contraindicated. Because the client will be diagnosed with primary hyperaldosteronism.
hyponatremic, normal saline solution is This diagnosis indicates that the client’s
indicated. Hydrocortisone and fludrocortisone hypertension is caused by excessive hormone
are both useful in replacing deficient adrenal secretion from which organ?
cortex hormones. A. adrenal cortex
B. pancreas
28. The nurse is reviewing the laboratory report C. adrenal medulla
of a client who underwent a bone marrow D. parathyroid
biopsy. The finding that would most strongly
support a diagnosis of acute leukemia is the ANS: A
existence of a large number of immature: Excessive of aldosterone in the adrenal cortex is
A. lymphocytes responsible for the client’s hypertension. This
B. thrombocytes hormone acts on the renal tubule, where it
C. reticulocytes promotes reabsorption of sodium and excretion
D. leukocytes of potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
ANS: D metabolism. The adrenal medulla secretes the
Leukemia is manifested by an abnormal cathecolamines—epinephrine and
overpopulation of immature leukocytes in the norepinephrine. The parathyroids secrete
bone marrow. parathyroid hormone.

29. The nurse is performing wound care on a 32. A client has a medical history of rheumatic
foot ulcer in a client with type 1 diabetes fever, type 1 (insulin dependent) diabetes
mellitus. Which technique demonstrates surgical mellitus, hypertension, pernicious anemia, and
asepsis? appendectomy. She’s admitted to the hospital
A. Putting on sterile gloves then opening a and undergoes mitral valve replacement surgery.
container of sterile saline. After discharge, the client is scheduled for a
B. Cleaning the wound with a circular motion, tooth extraction. Which history finding is a major
moving from outer circles toward the center. risk factor for infective endocarditis?
C. Changing the sterile field after sterile water is A. appendectomy
spilled on it. B. pernicious anemia
D. Placing a sterile dressing ½” (1.3 cm) from C. diabetes mellitus
the edge of the sterile field. D. valve replacement

ANS: C ANS: D
A sterile field is considered contaminated when it A heart valve prosthesis, such as a mitral valve
becomes wet. Moisture can act as a wick, replacement, is a major risk factor for infective
allowing microorganisms to contaminate the endocarditis. Other risk factors include a history
field. The outside of containers, such as sterile of heart disease (especially mitral valve
saline bottles, aren’t sterile. The containers prolapse), chronic debilitating disease, IV drug
should be opened before sterile gloves are put abuse, and immunosuppression. Although
on and the solution poured over the sterile diabetes mellitus may predispose a person to
dressings placed in a sterile basin. Wounds cardiovascular disease, it isn’t a major risk factor
should be cleaned from the most contaminated for infective endocarditis, nor is an
area to the least contaminated area—for appendectomy or pernicious anemia.
example, from the center outward. The outer
inch of a sterile field shouldn’t be considered 33. A 62 yr-old client diagnosed with
sterile. pyelonephritis and possible septicemia has had
five urinary tract infections over the past two
30. A client with a forceful, pounding heartbeat is years. She’s fatigued from lack of sleep; urinates
diagnosed with mitral valve prolapse. This client frequently, even during the night; and has lost
should avoid which of the following? weight recently. Test reveal the following: sodium
A. high volumes of fluid intake level 152 mEq/L, osmolarity 340 mOsm/L,
B. aerobic exercise programs glucose level 125 mg/dl, and potassium level 3.8
C. caffeine-containing products mEq/L. which of the following nursing diagnoses
D. foods rich in protein is most appropriate for this client?
A. Deficient fluid volume related to inability to heartbeat. An electrocardiogram shows a heart
conserve water rate of 110 beats/minute (sinus tachycardia) with
B. Imbalanced nutrition: less than body frequent premature ventricular contractions.
requirements related to hypermetabolic state Shortly after admission, the client has ventricular
C. Deficient fluid volume related to osmotic tachycardia and becomes unresponsive. After
diuresis induced by hypernatremia successful resuscitation, the client is taken to
D. Imbalanced nutrition: less than body the intensive care unit. Which nursing diagnosis
requirements related to catabolic effects of is appropriate at this time?
insulin deficiency A. Deficient knowledge related to interventions
used to treat acute illness
ANS: A B. Impaired physical mobility related to complete
The client has signs and symptoms of diabetes bed rest
insipidus, probably caused by the failure of her C. Social isolation related to restricted visiting
renal tubules to respond to antidiuretic hormone hours in the intensive care unit
as a consequence of pyelonephritis. The D. Anxiety related to the threat of death
hypernatremia is secondary to her water loss.
Imbalanced nutrition related to hypermetabolic ANS: D
state or catabolic effect of insulin deficiency is an Anxiety related to the threat of death is an
inappropriate nursing diagnosis for the client. appropriate nursing diagnosis because the
client’s anxiety can adversely affect hear rate
34. A 20 yr-old woman has just been diagnosed and rhythm by stimulating the autonomic
with Crohn’s disease. She has lost 10 lb (4.5 kg) nervous system. Also, because the client
and has cramps and occasional diarrhea. The required resuscitation, the threat of death is a
nurse should include which of the following real and immediate concern. Unless anxiety is
when doing a nutritional assessment? dealt with first, the client’s emotional state will
A. Let the client eat as desired during the impede learning. Client teaching should be
hospitalization. limited to clear concise explanations that reduce
B. Weight the client daily. anxiety and promote cooperation. An anxious
C. Ask the client to list what she eats during a client has difficulty learning, so the deficient
typical day. knowledge would continue despite attempts t
D. Place the client on I & O status and draw teaching. Impaired physical mobility and social
blood for electrolyte levels. isolation are necessitated by the client’s critical
condition; therefore, they aren’t considered
ANS: C problems warranting nursing diagnoses.
When performing a nutritional assessment, one
of the first things the nurse should do is to 37. A client is admitted to the health care facility
assess what the client typically eats. The client with active tuberculosis. The nurse should
shouldn’t be permitted to eat as desired. include which intervention in the plan of care?
Weighing the client daily, placing her on I & O A. Putting on a mask when entering the client’s
status, and drawing blood to determine room.
electrolyte level aren’t part of a nutritional B. Instructing the client to wear a mask at all
assessment. times
C. Wearing a gown and gloves when providing
35. When instructions should be included in the direct care
discharge teaching plan for a client after D. Keeping the door to the client’s room open to
thyroidectomy for Grave’s disease? observe the client
A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP). ANS: A
C. Be sure to get regulate follow-up care. Because tuberculosis is transmitted by droplet
D. Be sure to exercise to improve cardiovascular nuclei from the respiratory tract, the nurse
fitness. should put on a mask when entering the client’s
room. Having the client wear a mask at all the
Regular follow-up care for the client with Grave’s times would hinder sputum expectoration and
disease is critical because most cases make the mask moist from respirations. If no
eventually result in hypothyroidism. Annual contact with the client’s blood or body fluids is
thyroid-stimulating hormone tests and the anticipated, the nurse need not wear a gown or
client’s ability to recognize signs and symptoms gloves when providing direct care. A client with
of thyroid dysfunction will help detect thyroid tuberculosis should be in a room with laminar air
abnormalities early. Intake and output is flow, and the door should be closed at all times.
important for clients with fluid and electrolyte
imbalances but not thyroid disorders. DDAVP is 38. The nurse is caring for a client who
used to treat diabetes insipidus. While exercise underwent a subtotal gastrectomy 24 hours
to improve cardiovascular fitness is important, earlier. The client has a nasogastric (NG) tube.
for this client the importance of regular follow-up The nurse should:
is most critical. A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of
36. A client comes to the emergency department nausea.
with chest pain, dyspnea, and an irregular C. Irrigate the NG tube gently with normal saline
solution. the lower airways. Whit standard procedures the
D. Reposition the NG tube if pulled out. other choices wouldn’t be at high risk.

ANS: C 42. The nurse is teaching a client with chronic


The nurse can gently irrigate the tube but must bronchitis about breathing exercises. Which of
take care not to reposition it. Repositioning can the following should the nurse include in the
cause bleeding. Suction should be applied teaching?
continuously, not every hour. The NG tube A. Make inhalation longer than exhalation.
shouldn’t be clamped postoperatively because B. Exhale through an open mouth.
secretions and gas will accumulate, stressing C. Use diaphragmatic breathing.
the suture line. D. Use chest breathing.

39. Which statement about fluid replacement is ANS: C


accurate for a client with hyperosmolar In chronic bronchitis, the diaphragmatic is flat
hyperglycemic nonketotic syndrome (HHNS)? and weak. Diaphragmatic breathing helps to
A. administer 2 to 3 L of IV fluid rapidly strengthen the diaphragm and maximizes
B. administer 6 L of IV fluid over the first 24 ventilation. Exhalation should longer than
hours inhalation to prevent collapse of the bronchioles.
C. administer a dextrose solution containing The client with chronic bronchitis should exhale
normal saline solution through pursed lips to prolong exhalation, keep
D. administer IV fluid slowly to prevent the bronchioles from collapsing, and prevent air
circulatory overload and collapse trapping. Diaphragmatic breathing—not chest
breathing—increases lung expansion.
ANS: A
Regardless of the client’s medical history, rapid 43. A client is admitted to the hospital with an
fluid resuscitation is critical for maintaining exacerbation of her chronic systemic lupus
cardiovascular integrity. Profound intravascular erythematosus (SLE). She gets angry when her
depletion requires aggressive fluid replacement. call bell isn’t answered immediately. The most
A typical fluid resuscitation protocol is 6 L of fluid appropriate response to her would be:
over the first 12 hours, with more fluid to follow A. “You seem angry. Would you like to talk about
over the next 24 hours. Various fluids can be it?”
used, depending on the degree of hypovolemia. B. “Calm down. You know that stress will make
Commonly prescribed fluids include dextran (in your symptoms worse.”
case of hypovolemic shock), isotonic normal C. “Would you like to talk about the problem with
saline solution and, when the client is stabilized, the nursing supervisor?”
hypotonic half-normal saline solution. D. “I can see you’re angry. I’ll come back when
you’ve calmed down.”
40. Which of the following is an adverse reaction
to glipizide (Glucotrol)? ANS: A
A. headache Verbalizing the observed behavior is a
B. constipation therapeutic communication technique in which
C. hypotension the nurse acknowledges what the client is
D. photosensitivity feeling. Offering to listen to the client express
her anger can help the nurse and the client
ANS: D understand its cause and begin to deal with it.
Glipizide may cause adverse skin reactions, Although stress can exacerbate the symptoms
such as pruritus, and photosensitivity. It doesn’t of SLE, telling the client to calm down doesn’t
cause headache, constipation, or hypotension. acknowledge her feelings. Offering to get the
nursing supervisor also doesn’t acknowledge the
41. The nurse is caring for four clients on a step- client’s feelings. Ignoring the client’s feelings
down intensive care unit. The client at the suggest that the nurse has no interest in what
highest risk for developing nosocomial the client has said.
pneumonia is the one who:
A. has a respiratory infection 44. On a routine visit to the physician, a client
B. is intubated and on a ventilator with chronic arterial occlusive disease reports
C. has pleural chest tubes stopping smoking after 34 years. To relive
D. is receiving feedings through a jejunostomy symptoms of intermittent claudication, a
tube condition associated with chronic arterial
occlusive disease, the nurse should recommend
ANS: B which additional measure?
When clients are on mechanical ventilation, the A. Taking daily walks.
artificial airway impairs the gag and cough B. Engaging in anaerobic exercise.
reflexes that help keep organisms out of the C. Reducing daily fat intake to less than 45% of
lower respiratory tract. The artificial airway also total calories
prevents the upper respiratory system from D. Avoiding foods that increase levels of high-
humidifying and heating air to enhance density lipoproteins (HDLs)
mucociliary clearance. Manipulations of the
artificial airway sometimes allow secretions into ANS: A
Daily walks relieve symptoms of intermittent toilet
claudication, although the exact mechanism is B. Items stored in the kitchen so that reaching
unclear. Anaerobic exercise may exacerbate up and bending down aren’t necessary
these symptoms. Clients with chronic arterial C. Many small, unsecured area rugs
occlusive disease must reduce daily fat intake to D. Sufficient stairwell lighting, with switches t the
30% or less of total calories. The client should top and bottom of the stairs
limit dietary cholesterol because hyperlipidemia
is associated with atherosclerosis, a known ANS: C
cause of arterial occlusive disease. However, The presence of unsecured area rugs poses a
HDLs have the lowest cholesterol concentration, hazard in all homes, particularly in one with a
so this client should eat foods that raise HDL resident at high risk for falls.
levels.
49. A client with autoimmune thrombocytopenia
45. A physician orders gastric decompression for and a platelet count of 800/uL develops epistaxis
a client with small bowel obstruction. The nurse and melena. Treatment with corticosteroids and
should plan for the suction to be: immunoglobulins has been unsuccessful, and
A. low pressure and intermittent the physician recommends a splenectomy. The
B. low pressure and continuous client states, “I don’t need surgery—this will go
C. high pressure and continuous away on its own.” In considering her response to
D. high pressure and intermittent the client, the nurse must depend on the ethical
principle of:
ANS: A A. beneficence
Gastric decompression is typically low pressure B. autonomy
and intermittent. High pressure and continuous C. advocacy
gastric suctioning predisposes the gastric D. justice
mucosa to injury and ulceration.
ANS: B
Autonomy ascribes the right of the individual to
46. Which nursing diagnosis is most appropriate make his own decisions. In this case, the client
for an elderly client with osteoarthritis? is capable of making his own decision and the
A. Risk for injury nurse should support his autonomy. Beneficence
B. Impaired urinary elimination and justice aren’t the principles that directly
C. Ineffective breathing pattern relate to the situation. Advocacy is the nurse’s
D. Imbalanced nutrition: less than body role in supporting the principle of autonomy.
requirements
50. Which of the following is t he most critical
ANS: A intervention needed for a client with myxedema
In osteoarthritis, stiffness is common in large, coma?
weight bearing joints such as the hips. This joint A. Administering and oral dose of levothyroxine
stiffness alters functional ability and range of (Synthroid)
motion, placing the client at risk for falling and B. Warming the client with a warming blanket
injury. Therefore, client safety is in jeopardy. C. Measuring and recording accurate intake and
Osteoporosis doesn’t affect urinary elimination, output
breathing, or nutrition. D. Maintaining a patent airway

47. Parathyroid hormone (PTH) has which ANS: D


effects on the kidney? Because respirations are depressed in
A. Stimulation of calcium reabsorption and myxedema coma, maintaining a patent airway is
phosphate excretion the most critical nursing intervention. Ventilatory
B. Stimulation of phosphate reabsorption and support is usually needed. Thyroid replacement
calcium excretion will be administered IV. Although myxedema
C. Increased absorption of vit D and excretion of coma is associated with severe hypothermia, a
vit E warming blanket shouldn’t be used because it
D. Increased absorption of vit E and excretion of may cause vasodilation and shock. Gradual
Vit D warming blankets would be appropriate. Intake
and output are very important but aren’t critical
ANS: A interventions at this time.
PTH stimulates the kidneys to reabsorb calcium
and excrete phosphate and converts vit D to its MEDICAL-SURGICAL PART2
active form: 1 , 25 dihydroxyvitamin D. PTH
doesn’t have a role in the metabolism of Vit E. 51. Because diet and exercise have failed to
control a 63 yr-old client’s blood glucose level,
48. A visiting nurse is performing home the client is prescribed glipizide (Glucotrol). After
assessment for a 59-yr old man recently oral administration, the onset of action is:A. 15
discharged after hip replacement surgery. Which to 30 minutes
home assessment finding warrants health B. 30 to 60 minutes
promotion teaching from the nurse? C. 1 to 1 ½ hours
A. A bathroom with grab bars for the tub and D. 2 to 3 hours
leaning. Use of a cane won’t maintain stride
ANS: A length or prevent edema.
Glipizide begins to act in 15 to 30 minutes. The
other options are incorrect. 55. A client with a history of an anterior wall
myocardial infarction is being transferred from
52. A client with pneumonia is receiving the coronary care unit (CCU) to the cardiac step-
supplemental oxygen, 2 L/min via nasal cannula. down unit (CSU). While giving report to the CSU
The client’s history includes chronic obstructive nurse, the CCU nurse says, “His pulmonary
pulmonary disease (COPD) and coronary artery artery wedge pressures have been in the high
disease. Because of these findings, the nurse normal range.” The CSU nurse should be
closely monitors the oxygen flow and the client’s especially observant for:
respiratory status. Which complication may arise A. hypertension
if the client receives a high oxygen B. high urine output
concentration? C. dry mucous membranes
A. Apnea D. pulmonary crackles
B. Anginal pain
C. Respiratory alkalosis ANS: D
D. Metabolic acidosis High pulmonary artery wedge pressures are
diagnostic for left-sided heart failure. With left-
ANS: A sided heart failure, pulmonary edema can
Hypoxia is the main breathing stimulus for a develop causing pulmonary crackles. In left-
client with COPD. Excessive oxygen sided heart failure, hypotension may result and
administration may lead to apnea by removing urine output will decline. Dry mucous
that stimulus. Anginal pain results from a membranes aren’t directly associated with
reduced myocardial oxygen supply. A client with elevated pulmonary artery wedge pressures.
COPD may have anginal pain from generalized 56. The nurse is caring for a client with a
vasoconstriction secondary to hypoxia; however, fractures hip. The client is combative, confused,
administering oxygen at any concentration and trying to get out of bed. The nurse should:
dilates blood vessels, easing anginal pain. A. leave the client and get help
Respiratory alkalosis results from alveolar B. obtain a physician’s order to restrain the client
hyperventilation, not excessive oxygen C. read the facility’s policy on restraints
administration. In a client with COPD, high D. order soft restraints from the storeroom
oxygen concentrations decrease the ventilatory
drive, leading to respiratory acidosis, not ANS: B
alkalosis. High oxygen concentrations don’t It’s mandatory in most settings to have a
cause metabolic acidosis. physician’s order before restraining a client. A
client should never be left alone while the nurse
53. A client with type 1 diabetes mellitus has summons assistance. All staff members require
been on a regimen of multiple daily injection annual instruction on the use of restraints, and
therapy. He’s being converted to continuous the nurse should be familiar with the facility’s
subcutaneous insulin therapy. While teaching policy.
the client bout continuous subcutaneous insulin
therapy, the nurse would be accurate in telling 57. For the first 72 hours after thyroidectomy
him the regimen includes the use of: surgery, the nurse would assess the client for
A. intermediate and long-acting insulins Chvostek’s sign and Trousseau’s sign because
B. short and long-acting insulins they indicate which of the following?A.
C. short-acting only hypocalcemia
D. short and intermediate-acting insulins B. hypercalcemia
C. hypokalemia
ANS: C D. Hyperkalemia
Continuous subcutaneous insulin regimen uses
a basal rate and boluses of short-acting insulin. ANS: A
Multiple daily injection therapy uses a The client who has undergone a thyroidectomy
combination of short-acting and intermediate or is t risk for developing hypocalcemia from
long-acting insulins. inadvertent removal or damage to the
54. a client who recently had a cerebrovascular parathyroid gland. The client with hypocalcemia
accident requires a cane to ambulate. When will exhibit a positive Chvostek’s sign (facial
teaching about cane use, the rationale for muscle contraction when the facial nerve in front
holding a cane on the uninvolved side is to: of the ear is tapped) and a positive Trousseau’s
A. prevent leaning sign (carpal spasm when a blood pressure cuff
B. distribute weight away from the involved side is inflated for few minutes). These signs aren’t
C. maintain stride length present with hypercalcemia, hypokalemia, or
D. prevent edema Hyperkalemia.

ANS: B 58. In a client with enteritis and frequent


Holding a cane on the uninvolved side diarrhea, the nurse should anticipate an acid-
distributes weight away from the involved side. base imbalance of:
Holding the cane close to the body prevents A. respiratory acidosis
B. respiratory alkalosis image disturbance is a concern that has a lower
C. metabolic acidosis priority than pain management.
D. metabolic alkalosis
62. Which statement is true about crackles?
ANS: C A. They’re grating sounds.
Diarrhea causes a bicarbonate deficit. With loss B. They’re high-pitched, musical squeaks.
of the relative alkalinity of the lower GI tract, the C. They’re low-pitched noises that sound like
relative acidity of the upper GI tract snoring.
predominates leading to metabolic acidosis. D. They may be fine, medium, or course.
Diarrhea doesn’t lead to respiratory acid-base
imbalances, such as respiratory acidosis and ANS: D
respiratory alkalosis. Loss of acid, which occurs Crackles result from air moving through airways
with severe vomiting, may lead to metabolic that contain fluid. Heard during inspiration and
alkalosis. expiration, crackles are discrete sounds that
vary in pitch and intensity. They’re classified as
59. When caring for a client with the nursing fine, medium, or coarse. Pleural friction rubs
diagnosis Impaired swallowing related to have a distinctive grating sound. As the name
neuromuscular impairment, the nurse should: indicates, these breath sounds result when
A. position the client in a supine position inflamed pleurae rub together. Continuous, high-
B. elevate the head of the bed 90 degrees pitched, musical squeaks, called wheezes, result
during meals when air moves rapidly through airways
C. encourage the client to remove dentures narrowed by asthma or infection or when an
D. encourage thin liquids for dietary intake airway is partially obstructed by a tumor or
foreign body. Wheezes, like gurgles, occur on
ANS: B expiration and sometimes on inspiration. Loud,
The head of the bed must be elevated while the coarse, low-pitched sounds resembling snoring
client is eating. The client should be placed in a are called gurgles. These sounds develop when
recumbent position—not a supine position— thick secretions partially obstruct airflow through
when lying down to reduce the risk of aspiration. the large upper airways.
Encourage the client to wear properly fitted
dentures to enhance his chewing ability. 63. A woman whose husband was recently
Thickened liquids, not thin liquids, decrease diagnosed with active pulmonary tuberculosis
aspiration risk. (TB) is a tuberculin skin test converter.
Management of her care would include:
60. A nurse is caring for a client who has a A. scheduling her for annual tuberculin skin
tracheostomy and temperature of 39º C. which testing
intervention will most likely lower the client’s B. placing her in quarantine until sputum
arterial blood oxygen saturation? cultures are negative
A. Endotracheal suctioning C. gathering a list of persons with whom she has
B. Encouragement of coughing had recent contact
C. Use of cooling blanket D. advising her to begin prophylactic therapy
D. Incentive spirometry with isoniazid (INH)

ANS: A Individuals who are tuberculin skin test


Endotracheal suctioning secretions as well as converters should begin a 6-month regimen of
gases from the airway and lowers the arterial an antitubercular drug such as INH, and they
oxygen saturation (SaO2) level. Coughing and should never have another skin test. After an
incentive spirometry improve oxygenation and individual has a positive tuberculin skin test,
should raise or maintain oxygen saturation. subsequent skin tests will cause severe skin
Because of superficial vasoconstriction, using a reactions but won’t provide new information
cooling blanket can lower peripheral oxygen about the client’s TB status. The client doesn’t
saturation readings, but SaO2 levels wouldn’t be have active TB, so can’t transmit, or spread, the
affected. bacteria. Therefore, she shouldn’t be
quarantined or asked for information about
61. A client with a solar burn of the chest, back, recent contacts.
face, and arms is seen in urgent care. The
nurse’s primary concern should be:A. fluid 64. The nurse is caring for a client who ahs had
resuscitation an above the knee amputation. The client
B. infection refuses to look at the stump. When the nurse
C. body image attempts to speak with the client about his
D. pain management surgery, he tells the nurse that he doesn’t wish
to discuss it. The client also refuses to have his
ANS: D family visit. The nursing diagnosis that best
With a superficial partial thickness burn such as describes the client’s problem is:
a solar burn (sunburn), the nurse’s main concern A. Hopelessness
is pain management. Fluid resuscitation and B. Powerlessness
infection become concerns if the burn extends to C. Disturbed body image
the dermal and subcutaneous skin layers. Body D. Fear
ANS: B
ANS: C The light-colored spots attached to the hair
Disturbed body image is a negative perception shafts are nits, which are the eggs of head lice.
of the self that makes healthful functioning more They can’t be brushed off the hair shaft like
difficult. The defining characteristics for this dandruff. Scabies is a contagious dermatitis
nursing diagnosis include undergoing a change caused by the itch mite, Sacoptes scabiei, which
in body structure or function, hiding or lives just beneath the skin. Tinea capitis, or
overexposing a body part, not looking at a body ringworm, causes patchy hair loss and circular
part, and responding verbally or nonverbally to lesions with healing centers. Impetigo is an
the actual or perceived change in structure or infection caused by Staphylococcus or
function. This client may have any of the other Sterptococcus, manifested by vesicles or
diagnoses, but the signs and symptoms pustules that form a thick, honey-colored crust.
described in he case most closely match the
defining characteristics for disturbed body 68. Following a small-bowel resection, a client
image. develops fever and anemia. The surface
surrounding the surgical wound is warm to touch
65. A client with three children who is still I the and necrotizing fasciitis is suspected. Another
child bearing years is admitted for surgical repair manifestation that would most suggest
of a prolapsed bladder. The nurse would find necrotizing fasciitis is:
that the client understood the surgeon’s A. erythema
preoperative teaching when the client states: B. leukocytosis
A. “If I should become pregnant again, the child C. pressure-like pain
would be delivered by cesarean delivery.” D. swelling
B. “If I have another child, the procedure may
need to be repeated.” ANS: C
C. “This surgery may render me incapable of Severe pressure-like pain out of proportion to
conceiving another child.” visible signs distinguishes necrotizing fasciitis
D. “This procedure is accomplished in two from cellulites. Erythema, leukocytosis, and
separate surgeries.” swelling are present in both cellulites and
necrotizing fasciitis.
ANS: B
Because the pregnant uterus exerts a lot of 69. A 28 yr-old nurse has complaints of itching
pressure on the urinary bladder, the bladder and a rash of both hands. Contact dermatitis is
repair may need to be repeated. These clients initially suspected. The diagnosis is confirmed if
don’t necessarily have to have a cesarean the rash appears:
delivery if they become pregnant, and this A. erythematous with raised papules
procedure doesn’t render them sterile. This B. dry and scaly with flaking skin
procedure is completed in one surgery. C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures
66. A client experiences problems in body
temperature regulation associated with a skin ANS: A
impairment. Which gland is most likely involved? Contact dermatitis is caused by exposure to a
A. Eccrine physical or chemical allergen, such as cleaning
B. Sebaceous products, skin care products, and latex gloves.
C. Apocrine Initial symptoms of itching, erythema, and raised
D. Endocrine papules occur at the site of the exposure and
can begin within 1 hour of exposure. Allergic
ANS: A reactions tend to be red and not scaly or flaky.
Eccrine glands are associated with body Weeping, crusting lesions are also uncommon
temperature regulation. Sebaceous glands unless the reaction is quite severe or has been
lubricate the skin and hairs, and apocrine glands present for a long time. Excoriation is more
are involved in bacteria decomposition. common in skin disorders associated with a
Endocrine glands secrete hormones responsible moist environment.
for the regulation of body processes, such as
metabolism and glucose regulation. 70. When assessing a client with partial
thickness burns over 60% of the body, which of
67. A school cafeteria worker comes to the the following should the nurse report
physician’s office complaining of severe scalp immediately?
itching. On inspection, the nurse finds nail marks A. Complaints of intense thirst
on the scalp and small light-colored round B. Moderate to severe pain
specks attached to the hair shafts close to the C. Urine output of 70 ml the 1st hour
scalp. These findings suggest that the client D. Hoarseness of the voice
suffers from:
A. scabies ANS: D
B. head lice Hoarseness indicate injury to the respiratory
C. tinea capitis system and could indicate the need for
D. impetigo immediate intubation. Thirst following burns is
expected because of the massive fluid shifts and
resultant loss leading to dehydration. Pain, syndrome causes sensory and motor changes in
either severe or moderate, is expected with a the fingers rather than localized pain in the
burn injury. The client’s output is adequate. joints.

71. A client is admitted to the hospital following a 74. The nurse is providing home care
burn injury to the left hand and arm. The client’s instructions to a client who has recently had a
burn is described as white and leathery with no skin graft. Which instruction is most important for
blisters. Which degree of severity is this burn? the client to remember?
A. first-degree burn A. Use cosmetic camouflage techniques.
B. second-degree burn B. Protect the graft from direct sunlight.
C. third-degree burn C. Continue physical therapy.
D. fourth-degree burn D. Apply lubricating lotion to the graft site.

ANS: C ANS: B
Third-degree burn may appear white, red, or To avoid burning and sloughing, the client must
black and are dry and leathery with no blisters. protect the graft from sunlight. The other three
There may be little pain because nerve endings interventions are all helpful to the client and his
have been destroyed. First-degree burns are recovery but are less important.
superficial and involve the epidermis only. There
is local pain and redness but no blistering. 75. a 28 yr-old female nurse is seen in the
Second-degree burn appear red and moist with employee health department for mild itching and
blister formation and are painful. Fourth-degree rash of both hands. Which of the following could
burns involve underlying muscle and bone be causing this reaction?
tissue. A. possible medication allergies
B. current life stressors she may be
72. The nurse is caring for client with a new experiencing
donor site that was harvested to treat a new C. chemicals she may be using and use of latex
burn. The nurse position the client to: gloves
A. allow ventilation of the site D. recent changes made in laundry detergent or
B. make the site dependent bath soap.
C. avoid pressure on the site
D. keep the site fully covered ANS: C
Because the itching and rash are localized, an
ANS: C environmental cause in the workplace should be
A universal concern I the care of donor sites for suspected. With the advent of universal
burn care is to keep the site away from sources precautions, many nurses are experiencing
of pressure. Ventilation of the site and keeping allergies to latex gloves. Allergies to
the site fully covered are practices in some medications, laundry detergents, or bath soaps
institutions but aren’t hallmarks of donor site or a dermatologic reaction to stress usually elicit
care. Placing the site in a position of a more generalized or widespread rash.
dependence isn’t a justified aspect of donor site
care. 76. The nurse assesses a client with urticaria.
The nurse understands that urticaria is another
73. a 45-yr-old auto mechanic comes to the name for:
physician’s office because an exacerbation of A. hives
his psoriasis is making it difficult to work. He tells B. a toxin
the nurse that his finger joints are stiff and sore C. a tubercle
in the morning. The nurse should respond by: D. a virus
A. Inquiring further about this problem because
psoriatic arthritis can accompany psoriasis ANS: A
vulgaris Hives and urticaria are two names for the same
B. Suggesting he take aspirin for relief because skin lesion. Toxin is a poison. A tubercle is a tiny
it’s probably early rheumatoid arthritis round nodule produced by the tuberculosis
C. Validating his complaint but assuming it’s an bacillus. A virus is an infectious parasite.
adverse effect of his vocation
D. Asking him if he has been diagnosed or 77. A client with psoriasis visits the dermatology
treated for carpal tunnel syndrome clinic. When inspecting the affected areas, the
nurse expects to see which type of secondary
ANS: A lesion?
Anyone with psoriasis vulgaris who reports joint A. scale
pain should be evaluated for psoriaic arthritis. B. crust
Approximately 15% to 20% of individuals with C. ulcer
psoriasis will also develop psoriatic arthritis, D. scar
which can be painful and cause deformity. It
would be incorrect to assume that his pain is ANS: A
caused by early rheumatoid arthritis or his A scale is the characteristic secondary lesion
vocation without asking more questions or occurring in psoriasis. Although crusts, ulcers,
performing diagnostic studies. Carpal tunnel and scars also are secondary lesions in skin
disorders, they don’t accompany psoriasis. A. The wound should remain moist form the
dressing.
78. The nurse is caring for a bedridden, elderly B. The wet-to-dry dressing should be tightly
adult. To prevent pressure ulcers, which packed into the wound.
intervention should the nurse include in the plan C. The dressing should be allowed to dry out
of care? before removal.
A. Turn and reposition the client a minimum of D. A plastic sheet-type dressing should cover the
every 8 hours. wet dressing.
B. Vigorously massage lotion into bony
prominences. ANS: A
C. Post a turning schedule at the client’s A wet-to-dry saline dressing should always keep
bedside. the wound moist. Tight packing or dry packing
D. Slide the client, rather than lifting when can cause tissue damage and pain. A dry gauze
turning. —not a plastic-sheet-type dressing—should
cover the wet dressing.
ANS: C
A turning schedule with a signing sheet will help 82. While in skilled nursing facility, a client
ensure that the client gets turned and thus, help contracted scabies, which is diagnosed the day
prevent pressure ulcers. Turning should occur after discharge. The client is living at her
every 1-2 hours—not every 8 hours—for clients daughter’s home with six other persons. During
who are in bed for prolonged periods. The nurse her visit to the clinic, she asks a staff nurse,
should apply lotion to keep the skin moist but “What should my family do?” the most accurate
should avoid vigorous massage, which could response from the nurse is:
damage capillaries. When moving the client, the A. “All family members will need to be treated.”
nurse should lift rather than slide the client to B. “If someone develops symptoms, tell him to
void shearing. see a physician right away.”
C. “Just be careful not to share linens and
79. Following a full-thickeness (3rd degree) burn towels with family members.”
of his left arm, a client is treated with artificial D. “After you’re treated, family members won’t
skin. The client understands postoperative care be at risk for contracting scabies.”
of the artificial skin when he states that during
the first 7 days after the procedure, he’ll restrict: ANS: A
A. range of motion When someone in a group of persons sharing a
B. protein intake home contracts scabies, each individual in the
C. going outdoors same home needs prompt treatment whether
D. fluid ingestion he’s symptomatic or not. Towels and linens
should be washed in hot water. Scabies can be
ANS: A transmitted from one person to another before
To prevent disruption of the artificial skin’s symptoms develop
adherence to the wound bed, the client should
restrict range of motion of the involved limb. 83. In an industrial accident, client who weighs
Protein intake and fluid intake are important for 155 lb (70.3 kg) sustained full-thickness burns
healing and regeneration and shouldn’t be over 40% of his body. He’s in the burn unit
restricted. Going outdoors is acceptable as long receiving fluid resuscitation. Which observation
as the left arm is protected from direct sunlight. shows that the fluid resuscitation is benefiting
the client?
80. A client received burns to his entire back and A. A urine output consistently above 100
left arm. Using the Rule of Nines, the nurse can ml/hour.
calculate that he has sustained burns on what B. A weight gain of 4 lb (1.8 kg) in 24 hours.
percentage of his body? C. Body temperature readings all within normal
A. 9% limits
B. 18% D. An electrocardiogram (ECG) showing no
C. 27% arrhythmias.
D. 36%
ANS: A
ANS: C In a client with burns, the goal of fluid
According to the Rule of Nines, the posterior and resuscitation is to maintain a mean arterial blood
anterior trunk, and legs each make up 18% of pressure that provides adequate perfusion of
the total body surface. The head, neck, and vital structures. If the kidneys are adequately
arms each make up 9% of total body durface, perfused, they will produce an acceptable urine
and the perineum makes up 1%. In this case, output of at least 0.5 ml/kg/hour. Thus, the
the client received burns to his back (18%) and expected urine output of a 155-lb client is 35
one arm (9%), totaling 27%. ml/hour, and a urine output consistently above
100 ml/hour is more than adequate. Weight gain
81. The nurse is providing care for a client who from fluid resuscitation isn’t a goal. In fact, a 4 lb
has a sacral pressure ulcer with wet-to-dry weight gain in 24 hours suggests third spacing.
dressing. Which guideline is appropriate for a Body temperature readings and ECG
wet-to-dry dressing? interpretations may demonstrate secondary
benefits of fluid resuscitation but aren’t primary the bladder of a client with urine retention.
indicators.
87.The nurse is caring for a client who is to
84. The nurse is reviewing the laboratory results undergo a lumbar puncture to assess for the
of a client with rheumatoid arthritis. Which of the presence of blood in the cerebrospinal fluid
following laboratory results should the nurse (CSF) and to measure CSF pressure. Which
expect to find? result would indicate n abnormality?
A. Increased platelet count A. The presence of glucose in the CSF.
B. Elevated erythrocyte sedimentation rate B. A pressure of 70 to 200 mm H2O
(ESR) C. The presence of red blood cells (RBCs) in the
C. Electrolyte imbalance first specimen tube
D. Altered blood urea nitrogen (BUN) and D. A pressure of 00 to 250 mmH2O
creatinine levels
ANS: D
ANS: B The normal pressure is 70 to 200 mm H2O are
The ESR test is performed to detect considered abnormal. The presence of glucose
inflammatory processes in the body. It’s a is an expected finding in CSF, and RBCs
nonspecific test, so the health care professional typically occur in the first specimen tube from
must view results in conjunction with physical the trauma caused by the procedure.
signs and symptoms. Platelet count,
electrolytes, BUN, and creatinine levels aren’t 88. The nurse is administering eyedrops to a
usually affected by the inflammatory process. client with glaucoma. To achieve maximum
absorption, the nurse should instill the eyedrop
85. Which nursing diagnosis takes the highest into the:
priority for a client with Parkinson’s crisis? A. conjunctival sac
A. Imbalanced nutrition: less than body B. pupil
requirements C. sclera
B. Ineffective airway clearance D. vitreous humor
C. Impaired urinary elimination
D. Risk for injury ANS: A
The nurse should instill the eyedrop into the
ANS: B conjunctival sac where absorption can best take
In Parkinson’s crisis, dopamine-related place. The pupil permits light to enter the eye.
symptoms are severely exacerbated, virtually The sclera maintains the eye’s shape and size.
immobilizing the client. A client who is confined The vitreous humor maintains the retina’s
to bed during a crisis is at risk for aspiration and placement and the shape of the eye.
pneumonia. Also, excessive drooling increases
the risk of airway obstruction. Because of these 89. A 52 yr-old married man with two adolescent
concerns, ineffective airway clearance is the children is beginning rehabilitation following a
priority diagnosis for this client. Although cerebrovascular accident. As the nurse is
imbalanced nutrition:less than body planning the client’s care, the nurse should
requirements, impaired urinary elimination and recognize that his condition will affect:
risk for injury also are appropriate diagnoses for A. only himself
this client, they aren’t immediately life- B. only his wife and children
threatening and thus are less urgent. C. him and his entire family
D. no one, if he has complete recovery
86. A client with a spinal cord injury and
subsequent urine retention receives intermittent ANS: CAccording to family theory, any change in
catheterization every 4 hours. The average a family member, such as illness, produces role
catheterized urine volume has been 550 ml. The changes in all family members and affects the
nurse should plan to: entire family, even if the client eventually
A. Increase the frequency of the recovers completely.
catheterizations.
B. Insert an indwelling urinary catheter 90. Which action should take the highest priority
C. Place the client on fluid restrictions when caring for a client with hemiparesis caused
D. Use a condom catheter instead of an invasive by a cerebrovascular accident (CVA)?
one. A. Perform passive range-of-motion (ROM)
exercises.
ANS: A B. Place the client on the affected side.
As a rule of practice, if intermittent C. Use hand rolls or pillows for support.
catheterization for urine retention typically yields D. Apply antiembolism stockings
500 ml or more, the frequency of catheterization
should be increased. Indwelling catheterization ANS: B
is less preferred because of the risk of urinary To help prevent airway obstruction and reduce
tract infection and the loss of bladder tone. Fluid the risk of aspiration, the nurse should position a
restrictions aren’t indicated for this case; the client with hemiparesis on the affected side.
problem isn’t overhydration, rather it’s urine Although performing ROM exercises, providing
retention. A condom catheter doesn’t help empty pillows for support, and applying antiembolism
stockings can be appropriate for a client with ANS: BThe third cranial nerve (oculomotor) is
CVA, the first concern is to maintain a patent responsible for pupil constriction. When there is
airway. damage to the nerve, the pupils remain dilated
and don’t respond to light. Glaucoma, lumbar
91. The nurse is formulating a teaching plan for spine injury, and Bell’s palsy won’t affect pupil
a client who has just experienced a transient constriction.
ischemic attack (TIA). Which fact should the
nurse include in the teaching plan? 95. A 70 yr-old client with a diagnosis of left-
A. TIA symptoms may last 24 to 48 hours. sided cerebrovascular accident is admitted to
B. Most clients have residual effects after having the facility. To prevent the development of diffuse
a TIA. osteoporosis, which of the following objectives is
C. TIA may be a warning that the client may most appropriate?
have cerebrovascular accident (CVA) A. Maintaining protein levels.
D. The most common symptom of TIA is the B. Maintaining vitamin levels.
inability to speak. C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises
ANS: C
TIA may be a warning that the client will ANS: C
experience a CVA, or stroke, in the near future. When the mechanical stressors of weight
TIA aymptoms last no longer than 24 hours and bearing are absent, diffuse osteoporosis can
clients usually have complete recovery after TIA. occur. Therefore, if the client does weight-beari
The most common symptom of TIA is sudden, ng exercises, disuse complications can be
painless loss of vision lasting up to 24 hours. prevented. Maintaining protein and vitamins
levels is important, but neither will prevent
92. The nurse has just completed teaching about osteoporosis. ROM exercises will help prevent
postoperative activity to a client who is going to muscle atrophy and contractures.
have a cataract surgery. The nurse knows the
teaching has been effective if the client: 96. A client is admitted with a diagnosis of
A. coughs and deep breathes postoperatively meningitis caused by Neisseria meningitides.
B. ties his own shoes The nurse should institute which type of isolation
C. asks his wife to pick up his shirt from the floor precautions?
after he drops it. A. Contact precautions
D. States that he doesn’t need to wear an B. Droplet precautions
eyepatch or guard to bed C. Airborne precautions
D. Standard precautions
ANS: C
Bending to pick up something from the floor ANS: B
would increase intraocular pressure, as would This client requires droplet precautions because
bending to tie his shoes. The client needs to the organism can be transmitted through
wear eye protection to bed to prevent accidental airborne droplets when the client coughs,
injury during sleep. sneezes, or doesn’t cover his mouth. Airborne
precautions would be instituted for a client
93. The least serious form of brain trauma, infected with tuberculosis. Standard precautions
characterized by a brief loss of consciousness would be instituted for a client when contact with
and period of confusion, is called: body substances is likely. Contact precautions
A. contusion would be instituted for a client infected with an
B. concussion organism that is transmitted through skin-to-skin
C. coup contact.
D. contrecoup
97. A young man was running along an ocean
ANS: B pier, tripped on an elevated area of the decking,
Concussions are considered minor with no and struck his head on the pier railing. According
structural signs of injury. A contusion is bruising to his friends, “He was unconscious briefly and
of the brain tissue with small hemorrhages in the then became alert and behaved as though
tissue. Coup and contrecoup are type of injuries nothing had happened.” Shortly afterward, he
in which the damaged area on the brain forms began complaining of a headache and asked to
directly below that site of impact (coup) or at the be taken to the emergency department. If the
site opposite the injury (contrecoup) due to client’s intracranial pressure (ICP) is increasing,
movement of the brain within the skull. the nurse would expect to observe which of the
following signs first?
94. When the nurse performs a neurologic A. pupillary asymmetry
assessment on Anne Jones, her pupils are B. irregular breathing pattern
dilated and don’t respond to light. C. involuntary posturing
A. glaucoma D. declining level of consciousness
B. damage to the third cranial nerve
C. damage to the lumbar spine ANS: D
D. Bell’s palsy 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 risk of neck injury or airway obstruction. Side-
increasing ICP is a change in the level of lying isn’t specifically a therapeutic treatment for
consciousness. As neurologic deterioration increased ICP.
progresses, manifestations involving pupillary
symmetry, breathing patterns, and posturing will 101. In a comatose client, hearing is the last
occur. sense to be lost. Therefore, the nurse should
always:
98. Emergency medical technicians transport a A. talk loudly in case the client can hear
28 yr-old iron worker to the emergency B. speak softly before touching the client
department. They tell the nurse, “He fell from a C. tell others in the room not to talk to the client
two-story building. He has a large contusion on D. tell family members that the client probably
his left chest and a hematoma in the left parietal can’t hear
area. He has compound fracture of his left femur
and he’s comatose. We intubated him and he’s ANS: B
maintaining an arterial oxygen saturation of 92% Many clients have reported being able to hear
by pulse oximeter with a manual-resuscitation when being in a comatose state. Therefore, the
bag.” Which intervention by the nurse has the nurse should converse as if the client was alert
highest priority? and oriented. Talking loudly is only appropriate if
A. Assessing the left leg the client is hard of hearing, and family members
B. Assessing the pupils should be encouraged to talk with the client
C. Placing the client in Trendelenburg’s position unless contraindicated.
D. Assessing the level of consciousness
102. When a client experiences loss of vibratory
ANS: A sense on examination, this indicates:
In the scenario, airway and breathing are A. injury to the cranial nerves
established so the nurse’s next priority should be B. injury to the peripheral nerves
circulation. With a compound fracture of the C. intact cranial nerves
femur, there is a high risk of profuse bleeding; D. intact peripheral nerves
therefore, the nurse should assess the site.
Neurologic assessment is a secondary concern ANS: B
to airway, breathing and circulation. The nurse Appropriate perception of vibration indicates
doesn’t have enough data to warrant putting the intact dorsal column tracts and peripheral
client in Trendelenburg’s position. nerves. If there’s a loss of vibratory sense, an
injury to the peripheral nerves is probable.
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.

ANS: 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. For a client with a head injury whose neck


has been stabilized, the preferred bed position
is:
A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying

ANS: 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

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