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com/doc/7114903/Medical-Surgical- The portion of the cerebrum that controls speech

Exam-Part-1 and hearing is the temporal lobe. Injury to the
frontal lobe causes personality changes,
MEDICAL-SURGICAL NURSING difficulty speaking, and disturbance in memory,
Part 1 reasoning, and concentration. Injury to the
1. After a cerebrovascular accident, a 75 yr old parietal lobe causes sensory alterations and
client is admitted to the health care facility. The problems with spatial relationships. Damage to
client has left-sided weakness and an absent the occipital lobe causes vision disturbances.
gag reflex. He’s incontinent and has a tarry 6. The nurse is assessing a postcraniotomy
stool. His blood pressure is 90/50 mm Hg, and client and finds the urine output from a catheter
his hemoglobin is 10 g/dl. Which of the following is 1500 ml for the 1st hour and the same for the
is a priority for this client? 2nd hour. The nurse should suspect:
a. checking stools for occult blood a. Cushing’s syndrome
b. performing range-of-motion exercises to the b. Diabetes mellitus
left side c. Adrenal crisis
c. keeping skin clean and dry d. Diabetes insipidus
d. elevating the head of the bed to 30 degrees ANS: D
ANS: D Diabetes insipidus is an abrupt onset of extreme
Because the client’s gag reflex is absent, polyuria that commonly occurs in clients after
elevating the head of the bed to 30 degrees brain surgery. Cushing’s syndrome is excessive
helps minimize the client’s risk of aspiration. glucocorticoid secretion resulting in sodium and
Checking the stools, performing ROM exercises, water retention. Diabetes mellitus is a
and keeping the skin clean and dry are hyperglycemic state marked by polyuria,
important, but preventing aspiration through polydipsia, and polyphagia. Adrenal crisis is
positioning is the priority. undersecretion of glucocorticoids resulting in
2. The nurse is caring for a client with a profound hypoglycemia, hypovolemia, and
colostomy. The client tells the nurse that he hypotension.
makes small pin holes in the drainage bag to 7. The nurse is providing postprocedure care for
help relieve gas. The nurse should teach him a client who underwent percutaneous lithotripsy.
that this action: In this procedure, an ultrasonic probe inserted
a. destroys the odor-proof seal through a nephrostomy tube into the renal pelvis
b. wont affect the colostomy system generates ultra-high-frequency sound waves to
c. is appropriate for relieving the gas in a shatter renal calculi. The nurse should instruct
colostomy system the client to:
d. destroys the moisture barrier seal a. limit oral fluid intake for 1 to 2 weeks
ANS: A b. report the presence of fine, sandlike particles
Any hole, no matter how small, will destroy the through the nephrostomy tube.
odor-proof seal of a drainage bag. Removing the c. Notify the physician about cloudy or foulsmelling
bag or unclamping it is the only appropriate urine
method for relieving gas. d. Report bright pink urine within 24 hours after
3. When assessing the client with celiac the procedure
disease, the nurse can expect to find which of ANS: C
the following? The client should report the presence of foulsmelling
a. steatorrhea or cloudy urine. Unless contraindicated,
b. jaundiced sclerae the client should be instructed to drink large
c. clay-colored stools quantities of fluid each day to flush the kidneys.
d. widened pulse pressure Sand-like debris is normal because of residual
ANS: A stone products. Hematuria is common after
because celiac disease destroys the absorbing lithotripsy.
surface of the intestine, fat isn’t absorbed but is 8. A client with a serum glucose level of 618
passed in the stool. Steatorrhea is bulky, fatty mg/dl is admitted to the facility. He’s awake and
stools that have a foul odor. Jaundiced sclerae oriented, has hot dry skin, and has the following
result from elevated bilirubin levels. Clay-colored vital signs: temperature of 100.6º F (38.1º C),
stools are seen with biliary disease when bile heart rate of 116 beats/minute, and blood
flow is blocked. Celiac disease doesn’t cause a pressure of 108/70 mm Hg. Based on these
widened pulse pressure. assessment findings, which nursing diagnosis
4. A client is hospitalized with a diagnosis of takes the highest priority?
chronic glomerulonephritis. The client mentions a. deficient fluid volume related to osmotic
that she likes salty foods. The nurse should warn diuresis
her to avoid foods containing sodium b. decreased cardiac output related to elevated
because: heart rate
a. reducing sodium promotes urea nitrogen c. imbalanced nutrition: Less than body
excretion requirements related to insulin deficiency
b. reducing sodium improves her glomerular d. ineffective thermoregulation related to
filtration rate dehydration
c. reducing sodium increases potassium ANS: A
absorption A serum glucose level of 618 mg/dl indicates
d. reducing sodium decreases edema hyperglycemia, which causes polyuria and
ANS: D deficient fluid volume. In this client, tachycardia
Reducing sodium intake reduces fluid retention. is more likely to result from deficient fluid volume
Fluid retention increases blood volume, which than from decreased cardiac output because his
changes blood vessel permeability and allows blood pressure is normal. Although the client’s
plasma to move into interstitial tissue, causing serum glucose is elevated, food isn’t a priority
edema. Urea nitrogen excretion can be because fluids and insulin should be
increased only by improved renal function. administered to lower the serum glucose level.
Sodium intake doesn’t affect the glomerular Therefore, a diagnosis of Imbalanced Nutrition:
filtration rate. Potassium absorption is improved Less then body requirements isn’t appropriate. A
only by increasing the glomerular filtration rate; it temperature of 100.6º F isn’t life threatening,
isn’t affected by sodium intake. eliminating ineffective thermoregulation as the
5. The nurse is caring for a client with a cerebral top priority.
injury that impaired his speech and hearing. 9. Capillary glucose monitoring is being
Most likely, the client has experienced damage performed every 4 hours for a client diagnosed
to the: with diabetic ketoacidosis. Insulin is
a. frontal lobe administered using a scale of regular insulin
b. parietal lobe according to glucose results. At 2 p.m., the client
c. occipital lobe has a capillary glucose level of 250 mg/dl for
d. temporal lobe which he receives 8 U of regular insulin. The
AN:S D nurse should expect the dose’s:

a. onset to be at 2 p.m. and its peak at 3 p.m. d. before age 20
b. onset to be at 2:15 p.m. and its peak at 3 p.m. ANS: D
c. onset to be at 2:30 p.m. and its peak at 4 p.m. Testicular cancer commonly occurs in men
d. onset to be at 4 p.m. and its peak at 6 p.m. between ages 20 and 30. A male client should
ANS: C be taught how to perform testicular selfexamination
Regular insulin, which is a short-acting insulin, before age 20, preferably when he
has an onset of 15 to 30 minutes and a peak of enters his teens.
2 to 4 hours. Because the nurse gave the insulin 15. Before weaning a client from a ventilator,
at 2 p.m., the expected onset would be from which assessment parameter is most important
2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 for the nurse to review?
p.m. A. fluid intake for the last 24 hours
10. A client with a head injury is being monitored B. baseline arterial blood gas (ABG) levels
for increased intracranial pressure (ICP). His C. prior outcomes of weaning
blood pressure is 90/60 mmHG and the ICP is D. electrocardiogram (ECG) results
18 mmHg; therefore his cerebral perfusion ANS: B
pressure (CPP) is: Before weaning a client from mechanical
a. 52 mm Hg ventilation, it’s most important to have a baseline
b. 88 mm Hg ABG levels. During the weaning process, ABG
c. 48 mm Hg levels will be checked to assess how the client is
d. 68 mm Hg tolerating the procedure. Other assessment
ANS: A parameters are less critical. Measuring fluid
CPP is derived by subtracting the ICP from the volume intake and output is always important
mean arterial pressure (MAP). For adequate when a client is being mechanically ventilated.
cerebral perfusion to take place, the minimum Prior attempts at weaning and ECG results are
goal is 70 mmHg. The MAP is derived using the documented on the client’s record, and the
following formula: nurse can refer to them before the weaning
MAP = ((diastolic blood pressure x 2) + systolic process begins.
blood pressure) / 3 16. The nurse is speaking to a group of women
MAP = ((60 x2) + 90) / 3 about early detection of breast cancer. The
MAP = 70 mmHg average age of the women in the group is 47.
To find the CPP, subtract the client’s ICP from Following the American Cancer Society (ACS)
the MAP; in this case , 70 mmHg – 18 mmHg = guidelines, the nurse should recommend that
52 mmHg. the women:
11. A 52 yr-old female tells the nurse that she A. perform breast self-examination annually
has found a painless lump in her right breast B. have a mammogram annually
during her monthly self-examination. Which C. have a hormonal receptor assay annually
assessment finding would strongly suggest that D. have a physician conduct a clinical evaluation
this client’s lump is cancerous? every 2 years
a. eversion of the right nipple and a mobile mass ANS: B
b. nonmobile mass with irregular edges According to the ACS guidelines, “Women older
c. mobile mass that is oft and easily delineated than age 40 should perform breast selfexamination
d. nonpalpable right axillary lymph nodes monthly (not annually).” The
ANS: B hormonal receptor assay is done on a known
Breast cancer tumors are fixed, hard, and poorly breast tumor to determine whether the tumor is
delineated with irregular edges. Nipple retraction estrogen- or progesterone-dependent.
—not eversion—may be a sign of cancer. A 17. When caring for a client with esophageal
mobile mass that is soft and easily delineated is varices, the nurse knows that bleeding in this
most often a fluid-filled benigned cyst. Axillary disorder usually stems from:
lymph nodes may or may not be palpable on A. esophageal perforation
initial detection of a cancerous mass. B. pulmonary hypertension
12. A Client is scheduled to have a descending C. portal hypertension
colostomy. He’s very anxious and has many D. peptic ulcers
questions regarding the surgical procedure, care ANS: C
of stoma, and lifestyle changes. It would be most Increased pressure within the portal veins
appropriate for the nurse to make a referral to causes them to bulge, leading to rupture and
which member of the health care team? bleeding into the lower esophagus. Bleeding
a. Social worker associated with esophageal varices doesn’t
b. registered dietician stem from esophageal perforation, pulmonary
c. occupational therapist hypertension, or peptic ulcers.
d. enterostomal nurse therapist 18. A 49-yer-old client was admitted for surgical
ANS: D repair of a Colles’ fracture. An external fixator
An enterostomal nurse therapist is a registered was placed during surgery. The surgeon
nurse who has received advance education in explains that this method of repair:
an accredited program to care for clients with A. has very low complication rate
stomas. The enterostomal nurse therapist can B. maintains reduction and overall hand function
assist with selection of an appropriate stoma C. is less bothersome than a cast
site, teach about stoma care, and provide D. is best for older people
emotional support. ANS: B
13. Ottorrhea and rhinorrhea are most Complex intra-articular fractures are repaired
commonly seen with which type of skull with external fixators because they have a better
fracture? long-term outcome than those treated with
a. basilar casting. This is especially true in a young client.
b. temporal The incidence of complications, such as pin tract
c. occipital infections and neuritis, is 20% to 60%. Clients
d. parietal must be taught how to do pin care and assess
ANS: A for development of neurovascular complications.
Ottorrhea and rhinorrhea are classic signs of 19. A client is hospitalized with a diagnosis of
basilar skull fracture. Injury to the dura chronic renal failure. An arteriovenous fistula
commonly occurs with this fracture, resulting in was created in his left arm for hemodialysis.
cerebrospinal fluid (CSF) leaking through the When preparing the client for discharge, the
ears and nose. Any fluid suspected of being nurse should reinforce which dietary instruction?
CSF should be checked for glucose or have a A. “Be sure to eat meat at every meal.”
halo test done. B. “Monitor your fruit intake and eat plenty of
14. A male client should be taught about bananas.”
testicular examinations: C. “Restrict your salt intake.”
a. when sexual activity starts D. “Drink plenty of fluids.”
b. after age 60 ANS: C
c. after age 40 In a client with chronic renal failure, unrestricted

intake of sodium, protein, potassium, and fluids A. Avoid focusing on his weight.
may lead to a dangerous accumulation of B. Increase his activity level.
electrolytes and protein metabolic products, C. Follow a regular diet.
such as amino acids and ammonia. Therefore, D. Continue leading a high-stress lifestyle.
the client must limit his intake of sodium, meat ANS: B
(high in Protein), bananas (high in potassium), The client should be encouraged to increase his
and fluid because the kidneys can’t secrete activity level. Maintaining an ideal weight;
adequate urine. following a low-cholesterol, low-sodium diet; and
20. The nurse is caring for a client who has just avoiding stress are all important factors in
had a modified radical mastectomy with decreasing the risk of atherosclerosis.
immediate reconstruction. She’s in her 30s and 25. For a client newly diagnosed with
has tow children. Although she’s worried about radiationinduced
her future, she seems to be adjusting well to her thrombocytopenia, the nurse should
diagnosis. What should the nurse do to support include which intervention in the plan of care?
her coping? A. Administer aspirin if the temperature exceeds
A. Tell the client’s spouse or partner to be 38.8º C.
supportive while she recovers. B. Inspect the skin for petechiae once every
B. Encourage the client to proceed with the next shift.
phase of treatment. C. Provide for frequent periods of rest.
C. Recommend that the client remain cheerful D. Place the client in strict isolation.
for the sake of her children. ANS: B
D. Refer the client to the American Cancer Because thrombocytopenia impairs blood
Society’s Reach for Recovery program or clotting, the nurse should assess the client
another support program. regularly for signs of bleeding, such as
ANS: D petechiae, purpura, epistaxis, and bleeding
The client isn’t withdrawn or showing other signs gums. The nurse should avoid administering
of anxiety or depression. Therefore, the nurse aspirin because it can increase the risk of
can probably safely approach her about talking bleeding. Frequent rest periods are indicated for
with others who have had similar experiences, clients with anemia, not thrombocytopenia. Strict
either through Reach for Recovery or another isolation is indicated only for clients who have
formal support group. The nurse may educate highly contagious or virulent infections that are
the client’s spouse or partner to listen to spread by air or physical contact.
concerns, but the nurse shouldn’t tell the client’s 26. A client is chronically short of breath and yet
spouse what to do. The client must consult with has normal lung ventilation, clear lungs, and an
her physician and make her own decisions arterial oxygen saturation (SaO2) 96% or better.
about further treatment. The client needs to The client most likely has:
express her sadness, frustration, and fear. She A. poor peripheral perfusion
can’t be expected to be cheerful at all times. B. a possible Hematologic problem
21. A 21 year-old male has been seen in the C. a psychosomatic disorder
clinic for a thickening in his right testicle. The D. left-sided heart failure
physician ordered a human chorionic ANS: B
gonadotropin (HCG) level. The nurse’s SaO2 is the degree to which hemoglobin is
explanation to the client should include the fact saturated with oxygen. It doesn’t indicate the
that: client’s overall Hgb adequacy. Thus, an
A. The test will evaluate prostatic function. individual with a subnormal Hgb level could have
B. The test was ordered to identify the site of a normal SaO2 and still be short of breath. In this
possible infection. case, the nurse could assume that the client has
C. The test was ordered because clients who a Hematologic problem. Poor peripheral
have testicular cancer has elevated levels of perfusion would cause subnormal SaO2. There
HCG. isn’t enough data to assume that the client’s
D. The test was ordered to evaluate the problem is psychosomatic. If the problem were
testosterone level. left-sided heart failure, the client would exhibit
ANS: C pulmonary crackles.
HCG is one of the tumor markers for testicular 27. For a client in addisonian crisis, it would be
cancer. The HCG level won’t identify the site of very risky for a nurse to administer:
an infection or evaluate prostatic function or A. potassium chloride
testosterone level. B. normal saline solution
22. A client is receiving captopril (Capoten) for C. hydrocortisone
heart failure. The nurse should notify the D. fludrocortisone
physician that the medication therapy is ANS: A
ineffective if an assessment reveals: Addisonian crisis results in Hyperkalemia;
A. A skin rash. therefore, administering potassium chloride is
B. Peripheral edema. contraindicated. Because the client will be
C. A dry cough. hyponatremic, normal saline solution is
D. Postural hypotension. indicated. Hydrocortisone and fludrocortisone
ANS: B are both useful in replacing deficient adrenal
Peripheral edema is a sign of fluid volume cortex hormones.
overload and worsening heart failure. A skin 28. The nurse is reviewing the laboratory report
rash, dry cough, and postural hypotension are of a client who underwent a bone marrow
adverse reactions to captopril, but the don’t biopsy. The finding that would most strongly
indicate that therapy isn’t effective. support a diagnosis of acute leukemia is the
23. Which assessment finding indicates existence of a large number of immature:
dehydration? A. lymphocytes
A. Tenting of chest skin when pinched. B. thrombocytes
B. Rapid filling of hand veins. C. reticulocytes
C. A pulse that isn’t easily obliterated. D. leukocytes
D. Neck vein distention ANS: D
ANS: A Leukemia is manifested by an abnormal
Tenting of chest skin when pinched indicates overpopulation of immature leukocytes in the
decreased skin elasticity due to dehydration. bone marrow.
Hand veins fill slowly with dehydration, not 29. The nurse is performing wound care on a
rapidly. A pulse that isn’t easily obliterated and foot ulcer in a client with type 1 diabetes
neck vein distention indicate fluid overload, not mellitus. Which technique demonstrates surgical
dehydration. asepsis?
24. The nurse is teaching a client with a history A. Putting on sterile gloves then opening a
of atherosclerosis. To decrease the risk of container of sterile saline.
atherosclerosis, the nurse should encourage the B. Cleaning the wound with a circular motion,
client to: moving from outer circles toward the center.

C. Changing the sterile field after sterile water is conserve water
spilled on it. B. Imbalanced nutrition: less than body
D. Placing a sterile dressing ½” (1.3 cm) from requirements related to hypermetabolic state
the edge of the sterile field. C. Deficient fluid volume related to osmotic
ANS: C diuresis induced by hypernatremia
A sterile field is considered contaminated when it D. Imbalanced nutrition: less than body
becomes wet. Moisture can act as a wick, requirements related to catabolic effects of
allowing microorganisms to contaminate the insulin deficiency
field. The outside of containers, such as sterile ANS: A
saline bottles, aren’t sterile. The containers The client has signs and symptoms of diabetes
should be opened before sterile gloves are put insipidus, probably caused by the failure of her
on and the solution poured over the sterile renal tubules to respond to antidiuretic hormone
dressings placed in a sterile basin. Wounds as a consequence of pyelonephritis. The
should be cleaned from the most contaminated hypernatremia is secondary to her water loss.
area to the least contaminated area—for Imbalanced nutrition related to hypermetabolic
example, from the center outward. The outer state or catabolic effect of insulin deficiency is an
inch of a sterile field shouldn’t be considered inappropriate nursing diagnosis for the client.
sterile. 34. A 20 yr-old woman has just been diagnosed
30. A client with a forceful, pounding heartbeat is with Crohn’s disease. She has lost 10 lb (4.5 kg)
diagnosed with mitral valve prolapse. This client and has cramps and occasional diarrhea. The
should avoid which of the following? nurse should include which of the following
A. high volumes of fluid intake when doing a nutritional assessment?
B. aerobic exercise programs A. Let the client eat as desired during the
C. caffeine-containing products hospitalization.
D. foods rich in protein B. Weight the client daily.
ANS: C C. Ask the client to list what she eats during a
Caffeine is a stimulant, which can exacerbate typical day.
palpitations and should be avoided by a client D. Place the client on I & O status and draw
with symptomatic mitral valve prolapse. Highfluid blood for electrolyte levels.
intake helps maintain adequate preload and ANS: C
cardiac output. Aerobic exercise helps in When performing a nutritional assessment, one
increase cardiac output and decrease heart rate. of the first things the nurse should do is to
Protein-rich foods aren’t restricted but highcalorie assess what the client typically eats. The client
foods are. shouldn’t be permitted to eat as desired.
31. A client with a history of hypertension is Weighing the client daily, placing her on I & O
diagnosed with primary hyperaldosteronism. status, and drawing blood to determine
This diagnosis indicates that the client’s electrolyte level aren’t part of a nutritional
hypertension is caused by excessive hormone assessment.
secretion from which organ? 35. When instructions should be included in the
A. adrenal cortex discharge teaching plan for a client after
B. pancreas thyroidectomy for Grave’s disease?
C. adrenal medulla A. Keep an accurate record of intake and output.
D. parathyroid B. Use nasal desmopressin acetate DDAVP).
ANS: A C. Be sure to get regulate follow-up care.
Excessive of aldosterone in the adrenal cortex is D. Be sure to exercise to improve cardiovascular
responsible for the client’s hypertension. This fitness.
hormone acts on the renal tubule, where it Regular follow-up care for the client with Grave’s
promotes reabsorption of sodium and excretion disease is critical because most cases
of potassium and hydrogen ions. The pancreas eventually result in hypothyroidism. Annual
mainly secretes hormones involved in fuel thyroid-stimulating hormone tests and the
metabolism. The adrenal medulla secretes the client’s ability to recognize signs and symptoms
cathecolamines—epinephrine and of thyroid dysfunction will help detect thyroid
norepinephrine. The parathyroids secrete abnormalities early. Intake and output is
parathyroid hormone. important for clients with fluid and electrolyte
32. A client has a medical history of rheumatic imbalances but not thyroid disorders. DDAVP is
fever, type 1 (insulin dependent) diabetes used to treat diabetes insipidus. While exercise
mellitus, hypertension, pernicious anemia, and to improve cardiovascular fitness is important,
appendectomy. She’s admitted to the hospital for this client the importance of regular follow-up
and undergoes mitral valve replacement surgery. is most critical.
After discharge, the client is scheduled for a 36. A client comes to the emergency department
tooth extraction. Which history finding is a major with chest pain, dyspnea, and an irregular
risk factor for infective endocarditis? heartbeat. An electrocardiogram shows a heart
A. appendectomy rate of 110 beats/minute (sinus tachycardia) with
B. pernicious anemia frequent premature ventricular contractions.
C. diabetes mellitus Shortly after admission, the client has ventricular
D. valve replacement tachycardia and becomes unresponsive. After
ANS: D successful resuscitation, the client is taken to
A heart valve prosthesis, such as a mitral valve the intensive care unit. Which nursing diagnosis
replacement, is a major risk factor for infective is appropriate at this time?
endocarditis. Other risk factors include a history A. Deficient knowledge related to interventions
of heart disease (especially mitral valve used to treat acute illness
prolapse), chronic debilitating disease, IV drug B. Impaired physical mobility related to complete
abuse, and immunosuppression. Although bed rest
diabetes mellitus may predispose a person to C. Social isolation related to restricted visiting
cardiovascular disease, it isn’t a major risk factor hours in the intensive care unit
for infective endocarditis, nor is an D. Anxiety related to the threat of death
appendectomy or pernicious anemia. ANS: D
33. A 62 yr-old client diagnosed with Anxiety related to the threat of death is an
pyelonephritis and possible septicemia has had appropriate nursing diagnosis because the
five urinary tract infections over the past two client’s anxiety can adversely affect hear rate
years. She’s fatigued from lack of sleep; urinates and rhythm by stimulating the autonomic
frequently, even during the night; and has lost nervous system. Also, because the client
weight recently. Test reveal the following: sodium required resuscitation, the threat of death is a
level 152 mEq/L, osmolarity 340 mOsm/L, real and immediate concern. Unless anxiety is
glucose level 125 mg/dl, and potassium level 3.8 dealt with first, the client’s emotional state will
mEq/L. which of the following nursing diagnoses impede learning. Client teaching should be
is most appropriate for this client? limited to clear concise explanations that reduce
A. Deficient fluid volume related to inability to anxiety and promote cooperation. An anxious

client has difficulty learning, so the deficient tube
knowledge would continue despite attempts t ANS: B
teaching. Impaired physical mobility and social When clients are on mechanical ventilation, the
isolation are necessitated by the client’s critical artificial airway impairs the gag and cough
condition; therefore, they aren’t considered reflexes that help keep organisms out of the
problems warranting nursing diagnoses. lower respiratory tract. The artificial airway also
37. A client is admitted to the health care facility prevents the upper respiratory system from
with active tuberculosis. The nurse should humidifying and heating air to enhance
include which intervention in the plan of care? mucociliary clearance. Manipulations of the
A. Putting on a mask when entering the client’s artificial airway sometimes allow secretions into
room. the lower airways. Whit standard procedures the
B. Instructing the client to wear a mask at all other choices wouldn’t be at high risk.
times 42. The nurse is teaching a client with chronic
C. Wearing a gown and gloves when providing bronchitis about breathing exercises. Which of
direct care the following should the nurse include in the
D. Keeping the door to the client’s room open to teaching?
observe the client A. Make inhalation longer than exhalation.
ANS: A B. Exhale through an open mouth.
Because tuberculosis is transmitted by droplet C. Use diaphragmatic breathing.
nuclei from the respiratory tract, the nurse D. Use chest breathing.
should put on a mask when entering the client’s ANS: C
room. Having the client wear a mask at all the In chronic bronchitis, the diaphragmatic is flat
times would hinder sputum expectoration and and weak. Diaphragmatic breathing helps to
make the mask moist from respirations. If no strengthen the diaphragm and maximizes
contact with the client’s blood or body fluids is ventilation. Exhalation should longer than
anticipated, the nurse need not wear a gown or inhalation to prevent collapse of the bronchioles.
gloves when providing direct care. A client with The client with chronic bronchitis should exhale
tuberculosis should be in a room with laminar air through pursed lips to prolong exhalation, keep
flow, and the door should be closed at all times. the bronchioles from collapsing, and prevent air
38. The nurse is caring for a client who trapping. Diaphragmatic breathing—not chest
underwent a subtotal gastrectomy 24 hours breathing—increases lung expansion.
earlier. The client has a nasogastric (NG) tube. 43. A client is admitted to the hospital with an
The nurse should: exacerbation of her chronic systemic lupus
A. Apply suction to the NG tube every hour. erythematosus (SLE). She gets angry when her
B. Clamp the NG tube if the client complains of call bell isn’t answered immediately. The most
nausea. appropriate response to her would be:
C. Irrigate the NG tube gently with normal saline A. “You seem angry. Would you like to talk about
solution. it?”
D. Reposition the NG tube if pulled out. B. “Calm down. You know that stress will make
ANS: C your symptoms worse.”
The nurse can gently irrigate the tube but must C. “Would you like to talk about the problem with
take care not to reposition it. Repositioning can the nursing supervisor?”
cause bleeding. Suction should be applied D. “I can see you’re angry. I’ll come back when
continuously, not every hour. The NG tube you’ve calmed down.”
shouldn’t be clamped postoperatively because ANS: A
secretions and gas will accumulate, stressing Verbalizing the observed behavior is a
the suture line. therapeutic communication technique in which
39. Which statement about fluid replacement is the nurse acknowledges what the client is
accurate for a client with hyperosmolar feeling. Offering to listen to the client express
hyperglycemic nonketotic syndrome (HHNS)? her anger can help the nurse and the client
A. administer 2 to 3 L of IV fluid rapidly understand its cause and begin to deal with it.
B. administer 6 L of IV fluid over the first 24 Although stress can exacerbate the symptoms
hours of SLE, telling the client to calm down doesn’t
C. administer a dextrose solution containing acknowledge her feelings. Offering to get the
normal saline solution nursing supervisor also doesn’t acknowledge the
D. administer IV fluid slowly to prevent client’s feelings. Ignoring the client’s feelings
circulatory overload and collapse suggest that the nurse has no interest in what
ANS: A the client has said.
Regardless of the client’s medical history, rapid 44. On a routine visit to the physician, a client
fluid resuscitation is critical for maintaining with chronic arterial occlusive disease reports
cardiovascular integrity. Profound intravascular stopping smoking after 34 years. To relive
depletion requires aggressive fluid replacement. symptoms of intermittent claudication, a
A typical fluid resuscitation protocol is 6 L of fluid condition associated with chronic arterial
over the first 12 hours, with more fluid to follow occlusive disease, the nurse should recommend
over the next 24 hours. Various fluids can be which additional measure?
used, depending on the degree of hypovolemia. A. Taking daily walks.
Commonly prescribed fluids include dextran (in B. Engaging in anaerobic exercise.
case of hypovolemic shock), isotonic normal C. Reducing daily fat intake to less than 45% of
saline solution and, when the client is stabilized, total calories
hypotonic half-normal saline solution. D. Avoiding foods that increase levels of highdensity
40. Which of the following is an adverse reaction lipoproteins (HDLs)
to glipizide (Glucotrol)? ANS: A
A. headache Daily walks relieve symptoms of intermittent
B. constipation claudication, although the exact mechanism is
C. hypotension unclear. Anaerobic exercise may exacerbate
D. photosensitivity these symptoms. Clients with chronic arterial
ANS: D occlusive disease must reduce daily fat intake to
Glipizide may cause adverse skin reactions, 30% or less of total calories. The client should
such as pruritus, and photosensitivity. It doesn’t limit dietary cholesterol because hyperlipidemia
cause headache, constipation, or hypotension. is associated with atherosclerosis, a known
41. The nurse is caring for four clients on a stepdown cause of arterial occlusive disease. However,
intensive care unit. The client at the HDLs have the lowest cholesterol concentration,
highest risk for developing nosocomial so this client should eat foods that raise HDL
pneumonia is the one who: levels.
A. has a respiratory infection 45. A physician orders gastric decompression for
B. is intubated and on a ventilator a client with small bowel obstruction. The nurse
C. has pleural chest tubes should plan for the suction to be:
D. is receiving feedings through a jejunostomy A. low pressure and intermittent

B. low pressure and continuous support is usually needed. Thyroid replacement
C. high pressure and continuous will be administered IV. Although myxedema
D. high pressure and intermittent coma is associated with severe hypothermia, a
ANS: A warming blanket shouldn’t be used because it
Gastric decompression is typically low pressure may cause vasodilation and shock. Gradual
and intermittent. High pressure and continuous warming blankets would be appropriate. Intake
gastric suctioning predisposes the gastric and output are very important but aren’t critical
mucosa to injury and ulceration. interventions at this time.
46. Which nursing diagnosis is most appropriate MEDICAL-SURGICAL PART2
for an elderly client with osteoarthritis? 51. Because diet and exercise have failed to
A. Risk for injury control a 63 yr-old client’s blood glucose level,
B. Impaired urinary elimination the client is prescribed glipizide (Glucotrol). After
C. Ineffective breathing pattern oral administration, the onset of action is:A. 15
D. Imbalanced nutrition: less than body to 30 minutes
requirements B. 30 to 60 minutes
ANS: A C. 1 to 1 ½ hours
In osteoarthritis, stiffness is common in large, D. 2 to 3 hours
weight bearing joints such as the hips. This joint ANS: A
stiffness alters functional ability and range of Glipizide begins to act in 15 to 30 minutes. The
motion, placing the client at risk for falling and other options are incorrect.
injury. Therefore, client safety is in jeopardy. 52. A client with pneumonia is receiving
Osteoporosis doesn’t affect urinary elimination, supplemental oxygen, 2 L/min via nasal cannula.
breathing, or nutrition. The client’s history includes chronic obstructive
47. Parathyroid hormone (PTH) has which pulmonary disease (COPD) and coronary artery
effects on the kidney? disease. Because of these findings, the nurse
A. Stimulation of calcium reabsorption and closely monitors the oxygen flow and the client’s
phosphate excretion respiratory status. Which complication may arise
B. Stimulation of phosphate reabsorption and if the client receives a high oxygen
calcium excretion concentration?
C. Increased absorption of vit D and excretion of A. Apnea
vit E B. Anginal pain
D. Increased absorption of vit E and excretion of C. Respiratory alkalosis
Vit D D. Metabolic acidosis
PTH stimulates the kidneys to reabsorb calcium Hypoxia is the main breathing stimulus for a
and excrete phosphate and converts vit D to its client with COPD. Excessive oxygen
active form: 1 , 25 dihydroxyvitamin D. PTH administration may lead to apnea by removing
doesn’t have a role in the metabolism of Vit E. that stimulus. Anginal pain results from a
48. A visiting nurse is performing home reduced myocardial oxygen supply. A client with
assessment for a 59-yr old man recently COPD may have anginal pain from generalized
discharged after hip replacement surgery. Which vasoconstriction secondary to hypoxia; however,
home assessment finding warrants health administering oxygen at any concentration
promotion teaching from the nurse? dilates blood vessels, easing anginal pain.
A. A bathroom with grab bars for the tub and Respiratory alkalosis results from alveolar
toilet hyperventilation, not excessive oxygen
B. Items stored in the kitchen so that reaching administration. In a client with COPD, high
up and bending down aren’t necessary oxygen concentrations decrease the ventilatory
C. Many small, unsecured area rugs drive, leading to respiratory acidosis, not
D. Sufficient stairwell lighting, with switches t the alkalosis. High oxygen concentrations don’t
top and bottom of the stairs cause metabolic acidosis.
ANS: C 53. A client with type 1 diabetes mellitus has
The presence of unsecured area rugs poses a been on a regimen of multiple daily injection
hazard in all homes, particularly in one with a therapy. He’s being converted to continuous
resident at high risk for falls. subcutaneous insulin therapy. While teaching
49. A client with autoimmune thrombocytopenia the client bout continuous subcutaneous insulin
and a platelet count of 800/uL develops epistaxis therapy, the nurse would be accurate in telling
and melena. Treatment with corticosteroids and him the regimen includes the use of:
immunoglobulins has been unsuccessful, and A. intermediate and long-acting insulins
the physician recommends a splenectomy. The B. short and long-acting insulins
client states, “I don’t need surgery—this will go C. short-acting only
away on its own.” In considering her response to D. short and intermediate-acting insulins
the client, the nurse must depend on the ethical ANS: C
principle of: Continuous subcutaneous insulin regimen uses
A. beneficence a basal rate and boluses of short-acting insulin.
B. autonomy Multiple daily injection therapy uses a
C. advocacy combination of short-acting and intermediate or
D. justice long-acting insulins.
ANS: B 54. a client who recently had a cerebrovascular
Autonomy ascribes the right of the individual to accident requires a cane to ambulate. When
make his own decisions. In this case, the client teaching about cane use, the rationale for
is capable of making his own decision and the holding a cane on the uninvolved side is to:
nurse should support his autonomy. Beneficence A. prevent leaning
and justice aren’t the principles that directly B. distribute weight away from the involved side
relate to the situation. Advocacy is the nurse’s C. maintain stride length
role in supporting the principle of autonomy. D. prevent edema
50. Which of the following is t he most critical ANS: B
intervention needed for a client with myxedema Holding a cane on the uninvolved side
coma? distributes weight away from the involved side.
A. Administering and oral dose of levothyroxine Holding the cane close to the body prevents
(Synthroid) leaning. Use of a cane won’t maintain stride
B. Warming the client with a warming blanket length or prevent edema.
C. Measuring and recording accurate intake and 55. A client with a history of an anterior wall
output myocardial infarction is being transferred from
D. Maintaining a patent airway the coronary care unit (CCU) to the cardiac stepdown
ANS: D unit (CSU). While giving report to the CSU
Because respirations are depressed in nurse, the CCU nurse says, “His pulmonary
myxedema coma, maintaining a patent airway is artery wedge pressures have been in the high
the most critical nursing intervention. Ventilatory normal range.” The CSU nurse should be

especially observant for: B. Encouragement of coughing
A. hypertension C. Use of cooling blanket
B. high urine output D. Incentive spirometry
C. dry mucous membranes ANS: A
D. pulmonary crackles Endotracheal suctioning secretions as well as
ANS: D gases from the airway and lowers the arterial
High pulmonary artery wedge pressures are oxygen saturation (SaO2) level. Coughing and
diagnostic for left-sided heart failure. With leftsided incentive spirometry improve oxygenation and
heart failure, pulmonary edema can should raise or maintain oxygen saturation.
develop causing pulmonary crackles. In leftsided Because of superficial vasoconstriction, using a
heart failure, hypotension may result and cooling blanket can lower peripheral oxygen
urine output will decline. Dry mucous saturation readings, but SaO2 levels wouldn’t be
membranes aren’t directly associated with affected.
elevated pulmonary artery wedge pressures. 61. A client with a solar burn of the chest, back,
56. The nurse is caring for a client with a face, and arms is seen in urgent care. The
fractures hip. The client is combative, confused, nurse’s primary concern should be:A. fluid
and trying to get out of bed. The nurse should: resuscitation
A. leave the client and get help B. infection
B. obtain a physician’s order to restrain the client C. body image
C. read the facility’s policy on restraints D. pain management
D. order soft restraints from the storeroom ANS: D
ANS: B With a superficial partial thickness burn such as
It’s mandatory in most settings to have a a solar burn (sunburn), the nurse’s main concern
physician’s order before restraining a client. A is pain management. Fluid resuscitation and
client should never be left alone while the nurse infection become concerns if the burn extends to
summons assistance. All staff members require the dermal and subcutaneous skin layers. Body
annual instruction on the use of restraints, and image disturbance is a concern that has a lower
the nurse should be familiar with the facility’s priority than pain management.
policy. 62. Which statement is true about crackles?
57. For the first 72 hours after thyroidectomy A. They’re grating sounds.
surgery, the nurse would assess the client for B. They’re high-pitched, musical squeaks.
Chvostek’s sign and Trousseau’s sign because C. They’re low-pitched noises that sound like
they indicate which of the following?A. snoring.
hypocalcemia D. They may be fine, medium, or course.
B. hypercalcemia ANS: D
C. hypokalemia Crackles result from air moving through airways
D. Hyperkalemia that contain fluid. Heard during inspiration and
ANS: A expiration, crackles are discrete sounds that
The client who has undergone a thyroidectomy vary in pitch and intensity. They’re classified as
is t risk for developing hypocalcemia from fine, medium, or coarse. Pleural friction rubs
inadvertent removal or damage to the have a distinctive grating sound. As the name
parathyroid gland. The client with hypocalcemia indicates, these breath sounds result when
will exhibit a positive Chvostek’s sign (facial inflamed pleurae rub together. Continuous,
muscle contraction when the facial nerve in front highpitched,
of the ear is tapped) and a positive Trousseau’s musical squeaks, called wheezes, result
sign (carpal spasm when a blood pressure cuff when air moves rapidly through airways
is inflated for few minutes). These signs aren’t narrowed by asthma or infection or when an
present with hypercalcemia, hypokalemia, or airway is partially obstructed by a tumor or
Hyperkalemia. foreign body. Wheezes, like gurgles, occur on
58. In a client with enteritis and frequent expiration and sometimes on inspiration. Loud,
diarrhea, the nurse should anticipate an acidbase coarse, low-pitched sounds resembling snoring
imbalance of: are called gurgles. These sounds develop when
A. respiratory acidosis thick secretions partially obstruct airflow through
B. respiratory alkalosis the large upper airways.
C. metabolic acidosis 63. A woman whose husband was recently
D. metabolic alkalosis diagnosed with active pulmonary tuberculosis
ANS: C (TB) is a tuberculin skin test converter.
Diarrhea causes a bicarbonate deficit. With loss Management of her care would include:
of the relative alkalinity of the lower GI tract, the A. scheduling her for annual tuberculin skin
relative acidity of the upper GI tract testing
predominates leading to metabolic acidosis. B. placing her in quarantine until sputum
Diarrhea doesn’t lead to respiratory acid-base cultures are negative
imbalances, such as respiratory acidosis and C. gathering a list of persons with whom she has
respiratory alkalosis. Loss of acid, which occurs had recent contact
with severe vomiting, may lead to metabolic D. advising her to begin prophylactic therapy
alkalosis. with isoniazid (INH)
59. When caring for a client with the nursing Individuals who are tuberculin skin test
diagnosis Impaired swallowing related to converters should begin a 6-month regimen of
neuromuscular impairment, the nurse should: an antitubercular drug such as INH, and they
A. position the client in a supine position should never have another skin test. After an
B. elevate the head of the bed 90 degrees individual has a positive tuberculin skin test,
during meals subsequent skin tests will cause severe skin
C. encourage the client to remove dentures reactions but won’t provide new information
D. encourage thin liquids for dietary intake about the client’s TB status. The client doesn’t
ANS: B have active TB, so can’t transmit, or spread, the
The head of the bed must be elevated while the bacteria. Therefore, she shouldn’t be
client is eating. The client should be placed in a quarantined or asked for information about
recumbent position—not a supine position— recent contacts.
when lying down to reduce the risk of aspiration. 64. The nurse is caring for a client who ahs had
Encourage the client to wear properly fitted an above the knee amputation. The client
dentures to enhance his chewing ability. refuses to look at the stump. When the nurse
Thickened liquids, not thin liquids, decrease attempts to speak with the client about his
aspiration risk. surgery, he tells the nurse that he doesn’t wish
60. A nurse is caring for a client who has a to discuss it. The client also refuses to have his
tracheostomy and temperature of 39º C. which family visit. The nursing diagnosis that best
intervention will most likely lower the client’s describes the client’s problem is:
arterial blood oxygen saturation? A. Hopelessness
A. Endotracheal suctioning B. Powerlessness

C. Disturbed body image from cellulites. Erythema, leukocytosis, and
D. Fear swelling are present in both cellulites and
ANS: C necrotizing fasciitis.
Disturbed body image is a negative perception 69. A 28 yr-old nurse has complaints of itching
of the self that makes healthful functioning more and a rash of both hands. Contact dermatitis is
difficult. The defining characteristics for this initially suspected. The diagnosis is confirmed if
nursing diagnosis include undergoing a change the rash appears:
in body structure or function, hiding or A. erythematous with raised papules
overexposing a body part, not looking at a body B. dry and scaly with flaking skin
part, and responding verbally or nonverbally to C. inflamed with weeping and crusting lesions
the actual or perceived change in structure or D. excoriated with multiple fissures
function. This client may have any of the other ANS: A
diagnoses, but the signs and symptoms Contact dermatitis is caused by exposure to a
described in he case most closely match the physical or chemical allergen, such as cleaning
defining characteristics for disturbed body products, skin care products, and latex gloves.
image. Initial symptoms of itching, erythema, and raised
65. A client with three children who is still I the papules occur at the site of the exposure and
child bearing years is admitted for surgical repair can begin within 1 hour of exposure. Allergic
of a prolapsed bladder. The nurse would find reactions tend to be red and not scaly or flaky.
that the client understood the surgeon’s Weeping, crusting lesions are also uncommon
preoperative teaching when the client states: unless the reaction is quite severe or has been
A. “If I should become pregnant again, the child present for a long time. Excoriation is more
would be delivered by cesarean delivery.” common in skin disorders associated with a
B. “If I have another child, the procedure may moist environment.
need to be repeated.” 70. When assessing a client with partial
C. “This surgery may render me incapable of thickness burns over 60% of the body, which of
conceiving another child.” the following should the nurse report
D. “This procedure is accomplished in two immediately?
separate surgeries.” A. Complaints of intense thirst
ANS: B B. Moderate to severe pain
Because the pregnant uterus exerts a lot of C. Urine output of 70 ml the 1st hour
pressure on the urinary bladder, the bladder D. Hoarseness of the voice
repair may need to be repeated. These clients ANS: D
don’t necessarily have to have a cesarean Hoarseness indicate injury to the respiratory
delivery if they become pregnant, and this system and could indicate the need for
procedure doesn’t render them sterile. This immediate intubation. Thirst following burns is
procedure is completed in one surgery. expected because of the massive fluid shifts and
66. A client experiences problems in body resultant loss leading to dehydration. Pain,
temperature regulation associated with a skin either severe or moderate, is expected with a
impairment. Which gland is most likely involved? burn injury. The client’s output is adequate.
A. Eccrine 71. A client is admitted to the hospital following a
B. Sebaceous burn injury to the left hand and arm. The client’s
C. Apocrine burn is described as white and leathery with no
D. Endocrine blisters. Which degree of severity is this burn?
ANS: A A. first-degree burn
Eccrine glands are associated with body B. second-degree burn
temperature regulation. Sebaceous glands C. third-degree burn
lubricate the skin and hairs, and apocrine glands D. fourth-degree burn
are involved in bacteria decomposition. ANS: C
Endocrine glands secrete hormones responsible Third-degree burn may appear white, red, or
for the regulation of body processes, such as black and are dry and leathery with no blisters.
metabolism and glucose regulation. There may be little pain because nerve endings
67. A school cafeteria worker comes to the have been destroyed. First-degree burns are
physician’s office complaining of severe scalp superficial and involve the epidermis only. There
itching. On inspection, the nurse finds nail marks is local pain and redness but no blistering.
on the scalp and small light-colored round Second-degree burn appear red and moist with
specks attached to the hair shafts close to the blister formation and are painful. Fourth-degree
scalp. These findings suggest that the client burns involve underlying muscle and bone
suffers from: tissue.
A. scabies 72. The nurse is caring for client with a new
B. head lice donor site that was harvested to treat a new
C. tinea capitis burn. The nurse position the client to:
D. impetigo A. allow ventilation of the site
ANS: B B. make the site dependent
The light-colored spots attached to the hair C. avoid pressure on the site
shafts are nits, which are the eggs of head lice. D. keep the site fully covered
They can’t be brushed off the hair shaft like ANS: C
dandruff. Scabies is a contagious dermatitis A universal concern I the care of donor sites for
caused by the itch mite, Sacoptes scabiei, which burn care is to keep the site away from sources
lives just beneath the skin. Tinea capitis, or of pressure. Ventilation of the site and keeping
ringworm, causes patchy hair loss and circular the site fully covered are practices in some
lesions with healing centers. Impetigo is an institutions but aren’t hallmarks of donor site
infection caused by Staphylococcus or care. Placing the site in a position of
Sterptococcus, manifested by vesicles or dependence isn’t a justified aspect of donor site
pustules that form a thick, honey-colored crust. care.
68. Following a small-bowel resection, a client 73. a 45-yr-old auto mechanic comes to the
develops fever and anemia. The surface physician’s office because an exacerbation of
surrounding the surgical wound is warm to touch his psoriasis is making it difficult to work. He tells
and necrotizing fasciitis is suspected. Another the nurse that his finger joints are stiff and sore
manifestation that would most suggest in the morning. The nurse should respond by:
necrotizing fasciitis is: A. Inquiring further about this problem because
A. erythema psoriatic arthritis can accompany psoriasis
B. leukocytosis vulgaris
C. pressure-like pain B. Suggesting he take aspirin for relief because
D. swelling it’s probably early rheumatoid arthritis
ANS: C C. Validating his complaint but assuming it’s an
Severe pressure-like pain out of proportion to adverse effect of his vocation
visible signs distinguishes necrotizing fasciitis D. Asking him if he has been diagnosed or

treated for carpal tunnel syndrome every 1-2 hours—not every 8 hours—for clients
ANS: A who are in bed for prolonged periods. The nurse
Anyone with psoriasis vulgaris who reports joint should apply lotion to keep the skin moist but
pain should be evaluated for psoriaic arthritis. should avoid vigorous massage, which could
Approximately 15% to 20% of individuals with damage capillaries. When moving the client, the
psoriasis will also develop psoriatic arthritis, nurse should lift rather than slide the client to
which can be painful and cause deformity. It void shearing.
would be incorrect to assume that his pain is 79. Following a full-thickeness (3rd degree) burn
caused by early rheumatoid arthritis or his of his left arm, a client is treated with artificial
vocation without asking more questions or skin. The client understands postoperative care
performing diagnostic studies. Carpal tunnel of the artificial skin when he states that during
syndrome causes sensory and motor changes in the first 7 days after the procedure, he’ll restrict:
the fingers rather than localized pain in the A. range of motion
joints. B. protein intake
74. The nurse is providing home care C. going outdoors
instructions to a client who has recently had a D. fluid ingestion
skin graft. Which instruction is most important for ANS: A
the client to remember? To prevent disruption of the artificial skin’s
A. Use cosmetic camouflage techniques. adherence to the wound bed, the client should
B. Protect the graft from direct sunlight. restrict range of motion of the involved limb.
C. Continue physical therapy. Protein intake and fluid intake are important for
D. Apply lubricating lotion to the graft site. healing and regeneration and shouldn’t be
ANS: B restricted. Going outdoors is acceptable as long
To avoid burning and sloughing, the client must as the left arm is protected from direct sunlight.
protect the graft from sunlight. The other three 80. A client received burns to his entire back and
interventions are all helpful to the client and his left arm. Using the Rule of Nines, the nurse can
recovery but are less important. calculate that he has sustained burns on what
75. a 28 yr-old female nurse is seen in the percentage of his body?
employee health department for mild itching and A. 9%
rash of both hands. Which of the following could B. 18%
be causing this reaction? C. 27%
A. possible medication allergies D. 36%
B. current life stressors she may be ANS: C
experiencing According to the Rule of Nines, the posterior and
C. chemicals she may be using and use of latex anterior trunk, and legs each make up 18% of
gloves the total body surface. The head, neck, and
D. recent changes made in laundry detergent or arms each make up 9% of total body durface,
bath soap. and the perineum makes up 1%. In this case,
ANS: C the client received burns to his back (18%) and
Because the itching and rash are localized, an one arm (9%), totaling 27%.
environmental cause in the workplace should be 81. The nurse is providing care for a client who
suspected. With the advent of universal has a sacral pressure ulcer with wet-to-dry
precautions, many nurses are experiencing dressing. Which guideline is appropriate for a
allergies to latex gloves. Allergies to wet-to-dry dressing?
medications, laundry detergents, or bath soaps A. The wound should remain moist form the
or a dermatologic reaction to stress usually elicit dressing.
a more generalized or widespread rash. B. The wet-to-dry dressing should be tightly
76. The nurse assesses a client with urticaria. packed into the wound.
The nurse understands that urticaria is another C. The dressing should be allowed to dry out
name for: before removal.
A. hives D. A plastic sheet-type dressing should cover the
B. a toxin wet dressing.
C. a tubercle ANS: A
D. a virus A wet-to-dry saline dressing should always keep
ANS: A the wound moist. Tight packing or dry packing
Hives and urticaria are two names for the same can cause tissue damage and pain. A dry gauze
skin lesion. Toxin is a poison. A tubercle is a tiny —not a plastic-sheet-type dressing—should
round nodule produced by the tuberculosis cover the wet dressing.
bacillus. A virus is an infectious parasite. 82. While in skilled nursing facility, a client
77. A client with psoriasis visits the dermatology contracted scabies, which is diagnosed the day
clinic. When inspecting the affected areas, the after discharge. The client is living at her
nurse expects to see which type of secondary daughter’s home with six other persons. During
lesion? her visit to the clinic, she asks a staff nurse,
A. scale “What should my family do?” the most accurate
B. crust response from the nurse is:
C. ulcer A. “All family members will need to be treated.”
D. scar B. “If someone develops symptoms, tell him to
ANS: A see a physician right away.”
A scale is the characteristic secondary lesion C. “Just be careful not to share linens and
occurring in psoriasis. Although crusts, ulcers, towels with family members.”
and scars also are secondary lesions in skin D. “After you’re treated, family members won’t
disorders, they don’t accompany psoriasis. be at risk for contracting scabies.”
78. The nurse is caring for a bedridden, elderly ANS: A
adult. To prevent pressure ulcers, which When someone in a group of persons sharing a
intervention should the nurse include in the plan home contracts scabies, each individual in the
of care? same home needs prompt treatment whether
A. Turn and reposition the client a minimum of he’s symptomatic or not. Towels and linens
every 8 hours. should be washed in hot water. Scabies can be
B. Vigorously massage lotion into bony transmitted from one person to another before
prominences. symptoms develop
C. Post a turning schedule at the client’s 83. In an industrial accident, client who weighs
bedside. 155 lb (70.3 kg) sustained full-thickness burns
D. Slide the client, rather than lifting when over 40% of his body. He’s in the burn unit
turning. receiving fluid resuscitation. Which observation
ANS: C shows that the fluid resuscitation is benefiting
A turning schedule with a signing sheet will help the client?
ensure that the client gets turned and thus, help A. A urine output consistently above 100
prevent pressure ulcers. Turning should occur ml/hour.

B. A weight gain of 4 lb (1.8 kg) in 24 hours. B. A pressure of 70 to 200 mm H2O
C. Body temperature readings all within normal C. The presence of red blood cells (RBCs) in the
limits first specimen tube
D. An electrocardiogram (ECG) showing no D. A pressure of 00 to 250 mmH2O
arrhythmias. ANS: D
ANS: A The normal pressure is 70 to 200 mm H2O are
In a client with burns, the goal of fluid considered abnormal. The presence of glucose
resuscitation is to maintain a mean arterial blood is an expected finding in CSF, and RBCs
pressure that provides adequate perfusion of typically occur in the first specimen tube from
vital structures. If the kidneys are adequately the trauma caused by the procedure.
perfused, they will produce an acceptable urine 88. The nurse is administering eyedrops to a
output of at least 0.5 ml/kg/hour. Thus, the client with glaucoma. To achieve maximum
expected urine output of a 155-lb client is 35 absorption, the nurse should instill the eyedrop
ml/hour, and a urine output consistently above into the:
100 ml/hour is more than adequate. Weight gain A. conjunctival sac
from fluid resuscitation isn’t a goal. In fact, a 4 lb B. pupil
weight gain in 24 hours suggests third spacing. C. sclera
Body temperature readings and ECG D. vitreous humor
interpretations may demonstrate secondary ANS: A
benefits of fluid resuscitation but aren’t primary The nurse should instill the eyedrop into the
indicators. conjunctival sac where absorption can best take
84. The nurse is reviewing the laboratory results place. The pupil permits light to enter the eye.
of a client with rheumatoid arthritis. Which of the The sclera maintains the eye’s shape and size.
following laboratory results should the nurse The vitreous humor maintains the retina’s
expect to find? placement and the shape of the eye.
A. Increased platelet count 89. A 52 yr-old married man with two adolescent
B. Elevated erythrocyte sedimentation rate children is beginning rehabilitation following a
(ESR) cerebrovascular accident. As the nurse is
C. Electrolyte imbalance planning the client’s care, the nurse should
D. Altered blood urea nitrogen (BUN) and recognize that his condition will affect:
creatinine levels A. only himself
ANS: B B. only his wife and children
The ESR test is performed to detect C. him and his entire family
inflammatory processes in the body. It’s a D. no one, if he has complete recovery
nonspecific test, so the health care professional ANS: CAccording to family theory, any change in
must view results in conjunction with physical a family member, such as illness, produces role
signs and symptoms. Platelet count, changes in all family members and affects the
electrolytes, BUN, and creatinine levels aren’t entire family, even if the client eventually
usually affected by the inflammatory process. recovers completely.
85. Which nursing diagnosis takes the highest 90. Which action should take the highest priority
priority for a client with Parkinson’s crisis? when caring for a client with hemiparesis caused
A. Imbalanced nutrition: less than body by a cerebrovascular accident (CVA)?
requirements A. Perform passive range-of-motion (ROM)
B. Ineffective airway clearance exercises.
C. Impaired urinary elimination B. Place the client on the affected side.
D. Risk for injury C. Use hand rolls or pillows for support.
ANS: B D. Apply antiembolism stockings
In Parkinson’s crisis, dopamine-related ANS: B
symptoms are severely exacerbated, virtually To help prevent airway obstruction and reduce
immobilizing the client. A client who is confined the risk of aspiration, the nurse should position a
to bed during a crisis is at risk for aspiration and client with hemiparesis on the affected side.
pneumonia. Also, excessive drooling increases Although performing ROM exercises, providing
the risk of airway obstruction. Because of these pillows for support, and applying antiembolism
concerns, ineffective airway clearance is the stockings can be appropriate for a client with
priority diagnosis for this client. Although CVA, the first concern is to maintain a patent
imbalanced nutrition:less than body airway.
requirements, impaired urinary elimination and 91. The nurse is formulating a teaching plan for
risk for injury also are appropriate diagnoses for a client who has just experienced a transient
this client, they aren’t immediately lifethreatening ischemic attack (TIA). Which fact should the
and thus are less urgent. nurse include in the teaching plan?
86. A client with a spinal cord injury and A. TIA symptoms may last 24 to 48 hours.
subsequent urine retention receives intermittent B. Most clients have residual effects after having
catheterization every 4 hours. The average a TIA.
catheterized urine volume has been 550 ml. The C. TIA may be a warning that the client may
nurse should plan to: have cerebrovascular accident (CVA)
A. Increase the frequency of the D. The most common symptom of TIA is the
catheterizations. inability to speak.
B. Insert an indwelling urinary catheter ANS: C
C. Place the client on fluid restrictions TIA may be a warning that the client will
D. Use a condom catheter instead of an invasive experience a CVA, or stroke, in the near future.
one. TIA aymptoms last no longer than 24 hours and
ANS: A clients usually have complete recovery after TIA.
As a rule of practice, if intermittent The most common symptom of TIA is sudden,
catheterization for urine retention typically yields painless loss of vision lasting up to 24 hours.
500 ml or more, the frequency of catheterization 92. The nurse has just completed teaching about
should be increased. Indwelling catheterization postoperative activity to a client who is going to
is less preferred because of the risk of urinary have a cataract surgery. The nurse knows the
tract infection and the loss of bladder tone. Fluid teaching has been effective if the client:
restrictions aren’t indicated for this case; the A. coughs and deep breathes postoperatively
problem isn’t overhydration, rather it’s urine B. ties his own shoes
retention. A condom catheter doesn’t help empty C. asks his wife to pick up his shirt from the floor
the bladder of a client with urine retention. after he drops it.
87.The nurse is caring for a client who is to D. States that he doesn’t need to wear an
undergo a lumbar puncture to assess for the eyepatch or guard to bed
presence of blood in the cerebrospinal fluid ANS: C
(CSF) and to measure CSF pressure. Which Bending to pick up something from the floor
result would indicate n abnormality? would increase intraocular pressure, as would
A. The presence of glucose in the CSF. bending to tie his shoes. The client needs to

wear eye protection to bed to prevent accidental increasing ICP is a change in the level of
injury during sleep. consciousness. As neurologic deterioration
93. The least serious form of brain trauma, progresses, manifestations involving pupillary
characterized by a brief loss of consciousness symmetry, breathing patterns, and posturing will
and period of confusion, is called: occur.
A. contusion 98. Emergency medical technicians transport a
B. concussion 28 yr-old iron worker to the emergency
C. coup department. They tell the nurse, “He fell from a
D. contrecoup two-story building. He has a large contusion on
ANS: B his left chest and a hematoma in the left parietal
Concussions are considered minor with no area. He has compound fracture of his left femur
structural signs of injury. A contusion is bruising and he’s comatose. We intubated him and he’s
of the brain tissue with small hemorrhages in the maintaining an arterial oxygen saturation of 92%
tissue. Coup and contrecoup are type of injuries by pulse oximeter with a manual-resuscitation
in which the damaged area on the brain forms bag.” Which intervention by the nurse has the
directly below that site of impact (coup) or at the highest priority?
site opposite the injury (contrecoup) due to A. Assessing the left leg
movement of the brain within the skull. B. Assessing the pupils
94. When the nurse performs a neurologic C. Placing the client in Trendelenburg’s position
assessment on Anne Jones, her pupils are D. Assessing the level of consciousness
dilated and don’t respond to light. ANS: A
A. glaucoma In the scenario, airway and breathing are
B. damage to the third cranial nerve established so the nurse’s next priority should be
C. damage to the lumbar spine circulation. With a compound fracture of the
D. Bell’s palsy femur, there is a high risk of profuse bleeding;
ANS: BThe third cranial nerve (oculomotor) is therefore, the nurse should assess the site.
responsible for pupil constriction. When there is Neurologic assessment is a secondary concern
damage to the nerve, the pupils remain dilated to airway, breathing and circulation. The nurse
and don’t respond to light. Glaucoma, lumbar doesn’t have enough data to warrant putting the
spine injury, and Bell’s palsy won’t affect pupil client in Trendelenburg’s position.
constriction. 99. Alzheimer’s disease is the secondary
95. A 70 yr-old client with a diagnosis of leftsided diagnosis of a client admitted with myocardial
cerebrovascular accident is admitted to infarction. Which nursing intervention should
the facility. To prevent the development of diffuse appear on this client’s plan of care?
osteoporosis, which of the following objectives is A. Perform activities of daily living for the client
most appropriate? to decease frustration.
A. Maintaining protein levels. B. Provide a stimulating environment.
B. Maintaining vitamin levels. C. Establish and maintain a routine.
C. Promoting weight-bearing exercises D. Try to reason with the client as much as
D. Promoting range-of-motion (ROM) exercises possible.
When the mechanical stressors of weight Establishing and maintaining a routine is
bearing are absent, diffuse osteoporosis can essential to decreasing extraneous stimuli. The
occur. Therefore, if the client does weight-beari client should participate in daily care as much as
ng exercises, disuse complications can be possible. Attempting to reason with such clients
prevented. Maintaining protein and vitamins isn’t successful, because they can’t participate in
levels is important, but neither will prevent abstract thinking.
osteoporosis. ROM exercises will help prevent 100. For a client with a head injury whose neck
muscle atrophy and contractures. has been stabilized, the preferred bed position
96. A client is admitted with a diagnosis of is:
meningitis caused by Neisseria meningitides. A. Trendelenburg’s
The nurse should institute which type of isolation B. 30-degree head elevation
precautions? C. flat
A. Contact precautions D. side-lying
B. Droplet precautions ANS: B
C. Airborne precautions For clients with increased intracranial pressure
D. Standard precautions (ICP), the head of the bed is elevated to
ANS: B promote venous outflow. Trendelenburg’s
This client requires droplet precautions because position is contraindicated because it can raise
the organism can be transmitted through ICP. Flat or neutral positioning is indicated when
airborne droplets when the client coughs, elevating the head of the bed would increase the
sneezes, or doesn’t cover his mouth. Airborne risk of neck injury or airway obstruction. Sidelying
precautions would be instituted for a client isn’t specifically a therapeutic treatment for
infected with tuberculosis. Standard precautions increased ICP.
would be instituted for a client when contact with 101. In a comatose client, hearing is the last
body substances is likely. Contact precautions sense to be lost. Therefore, the nurse should
would be instituted for a client infected with an always:
organism that is transmitted through skin-to-skin A. talk loudly in case the client can hear
contact. B. speak softly before touching the client
97. A young man was running along an ocean C. tell others in the room not to talk to the client
pier, tripped on an elevated area of the decking, D. tell family members that the client probably
and struck his head on the pier railing. According can’t hear
to his friends, “He was unconscious briefly and ANS: B
then became alert and behaved as though Many clients have reported being able to hear
nothing had happened.” Shortly afterward, he when being in a comatose state. Therefore, the
began complaining of a headache and asked to nurse should converse as if the client was alert
be taken to the emergency department. If the and oriented. Talking loudly is only appropriate if
client’s intracranial pressure (ICP) is increasing, the client is hard of hearing, and family members
the nurse would expect to observe which of the should be encouraged to talk with the client
following signs first? unless contraindicated.
A. pupillary asymmetry 102. When a client experiences loss of vibratory
B. irregular breathing pattern sense on examination, this indicates:
C. involuntary posturing A. injury to the cranial nerves
D. declining level of consciousness B. injury to the peripheral nerves
ANS: D C. intact cranial nerves
With a brain injury such as an epidural D. intact peripheral nerves
hematoma (a diagnosis that is most likely based ANS: B
on this client’s symptoms), the initial sign of Appropriate perception of vibration indicates

intact dorsal column tracts and peripheral
nerves. If there’s a loss of vibratory sense, an
injury to the peripheral nerves is probable.