PREDICTOR TEST 3
- Mr. D, a 57-year-old man was admitted with acute pancreatitis in a medical-surgical unit. Suring assessment, which observation needs an immediate intervention?
- Pain described as 7/10 unrelieved by medication that radiates to the back.
- A bluish discoloration in the flank area.
- Patient is anxious and belligerent
- Serum calcium of 15 mg/dl
Rationale: B. Cullen’s sign (bluish flank discoloration) indicate seepage of bloody exudate from pancreas. Serum calcium usually declines (hypocalcemia) during pancreatitis. Pain is and anxiety is expected in the client. (Diseases: A nursing Process Approach to Excellent Care © 2006, p. 978)
- Which of the following client in the step-down unit would require the nurse to see first?
- A client attached to a balanced suspension traction with weights touching the floor.
- A client with fracture of the pelvis having petechiae on the chest.
- A client with a cast on the right leg complaining of unrelieved pain.
- A client with carpal tunnel syndrome complaining of pressure in the thumb.
Rationale: B. Petechial rashes over the chest after a pelvic fracture suggest fat embolism. Client may suffer from respiratory failure if symptoms are not treated immediately. (Saunders, p.1004)
3. Which of the following newborn delivered within 24 hours requires the nurse to assess first?
a. The newborn with episodes of apnea lasting 3-4 sec
b. The newborn with light yellow sclera
c. The newborn with pulse rate of 100 beats/minute while sleeping
d. The newborn with drooling saliva
Rationale: B. Jaundice within the 24 hours after delivery indicates pathologic jaundice and requires further follow-up. Apnea lasting to 10 sec is still considered normal. Pulse rate around 140 beats/minute may fall below 100 bpm during sleep, or reach 180 bpm with crying. (NSNA © 2007, p. 854)
- An infant is admitted for surgical repair of gastroschisis. The nurse shows appropriate knowledge on the care of the infant when she performs the following action preoperatively, except?
- Wrapping around the exposed bowel with moist saline-soaked pads
- Use overhead warming unit
- Perform nasogastric suction
- Wrapping the abdomen with plastic drapes
Rationale: A. Gastroschisis (protrusion of intraabdominal contents through a defect in the abdominal wall lateral to umbilical ring without the presence of peritoneal sac) is managed by keeping the sac or viscera moist with saline soaked-pads and wrapped around the abdomen using a plastic drape; wrapping around the exposed bowel may cause pressure and necrosis because the exposed bowel expands. Other nursing care also include using an overhead warming unit, nasogastric suction, NPO, and carrying out routine care of the IV line. (Wong’s Essentials of Pediatric Nursing 7th ed, p. 920; Saunders Comprehensive Review © 2005, p. 454)
- The nurse is playing with a 2-year-old with Tetralogy of Fallot who suddenly squats on the floor. The best initial nursing action for the nurse to take is
- Place the child in the bed and administer oxygen
- Allow the child to remain in that position and observe him
- Activate the blue code
- Bring the child inside the cool mist tent
Rationale: B. Squatting in ambulatory children is a form of compensatory mechanism. This increases systemic resistance and decreased venous return, briefly decreasing hypoxia. (NSNA © 2007, p. 626)
- When assessing a 5-year-old child with Duchenne muscular dystrophy (DMD), the nurse evaluates which of the following signs as indicatng the presence of DMD?
- One knee is lower when both legs are flexed
- Truncal asymmetry
- Mild pain in the hip and anterior thigh
- Waddling gait
Rationale: D. Duchenne muscular dystrophy (DMD), a X-linked recessive inherit disease that is common in preschooler, with an onset at 3-6 years. The disease results in a degenerative muscle wasting though to be related to the absence of the muscle protein dystropin, which leads to the degeneration of skeletal or voluntary muscles that control movement. Initial clinical manifestations (due to weakening of pelvic muscles) include waddling gait and difficulty climbing stairs, running, or riding bicycles. The seated child with DMD must use his hands to walk up the legs to achieve the standing position (Gower’s sign). Muscle atrophy leads to respiratory muscle involvement and cardiomyopathy, which leads to death in the late teens. (NSNA © 2007, p. 713)
- The nurse caring a child with Duchenne muscular dystrophy considers which of the following activities suited for the child?
- Watching video tapes
- Riding a bicycles
Rationale: A. Diversional activities such as books, tapes, and computers may be used to promote development as much as possible in the child. Avoid activities that require active muscle movement because the child suffers from a degenerative muscle wasting. (NSNA © 2007, p. 713)
- Which of the following activities will enhance the growth and development of a 6-year-old child?
a. Allow her to explore her surroundings
b. Allow ample time when toileting
c. Have her take care of his sister
d. Let her choose the clothes she wants to wear
Rationale: A sense of industry, or a stage of accomplishment, is achieved somewhere between age 6 and adolescence. Allowing the child to develop skills and participate in a meaningful work enhances their sense of industry. (Wong’s Pediatric Nursing, p. 499)
- A mother brings her baby in the primary care clinic reporting that her baby always vomits after breast feeding. Which of the following question asked by the nurse will support the diagnosis of intussusception?
a. Is the child having difficulty to pass stool regularly?
b. Does he have a jelly-like stool?
c. Is there a presence of olive-shaped mass in the child’s epigastric area?
d. Does the stool resemble a ribbon-like appearance?
Rationale: B. Intussusception is characterized by vomiting and currant jelly-like stool (bloody-mucoid stool). Constipation and ribbon-like stool are characteristics of Hirschprung’s disease. Presence of olive-shaped mass in the epigastric area is seen in pyloric stenosis. (NSNA © 2007, p. 639)
- To assure proper functioning of Bryant’s traction in a child, the nurse must assure that
- The child’s hips and legs are extended in the bed with traction applied at the foot part.
- The child’s hips rest in the bed with the legs pulled perpendicular to the body
- The child’s hips are slightly elevated in the bed with the leg suspended at the right angle with the bed.
- The child’s hips and legs are pulled by a countertraction parallel to the bed.
Rationale: C. To maintain Bryant’s traction, the legs are suspended in a right angle to the bed with the hips slightly elevated above the bed surface. (Davies NCLEX-RN, p. 575)
- An 18-month-old is hospitalized with severe dehydration. Which of the following observations would indicate an effective outcome of the hydration management?
- The child wets a diaper at least every 4 hours
- The child is consuming the prescribe IV infusion
- The child’s mother is frequently breast-feeding her
- The child has a urinary specific gravity of 1.012
Rationale: D. Urinary specific gravity is a good indicator of hydration status. Urinary output must be measured. The fact that the child is urinating in the diaper does not reveal the exact amount of each voiding. Consuming the prescribed IV and breast-feeding frequently must be supported by a proportional output to the child’s intake. (Wong’s Pediatric Nursing, p. 880).
- Which of these interventions would the nurse prioritize in a 10-year-old with vaso-occlusive sickle cell crises?
- Implementing complete bed rest
- Providing large fluid intake
- Administering the prescribed pain medication
- Administering oxygen
Rationale: B. Vaso-occlusive crisis is the most common type of crises in sickle cell disease. The crisis is caused by stasis of blood with clumping of the cells in the microcirculation. Hydration is very crucial during the crisis to prevent ischemia and infarction. (Saunders, p. 494)
- The mother of a 10-month-old baby girl makes all of these statements during a routine baby check-up. Which one definitely needs further discussion?
- “My daughter cries when she sees people she doesn’t know.”
- “My daughter pulls herself up by holding into the furniture.”
- “My daughter enjoys eating finger foods.”
- “My daughter just started to use monosyllabic babbling.”
Rationale: D. Using monosyllabic babbling occurs between 3 & 6 months of age and is the least expected in the 10-month-old child.” (Saunders © 2005, p. 377, 386)
- A child suspected of having B-Thalassemia disease is seen in a clinic with laboratory studies performed. A nurse checks the laboratory results showing that which of the following is expected in the disease?
- Reduced platelet count
- Reduced hemoglobin
- Increased WBC
- Increased RBC and hematocrit
Rationale: B. The disorder is also called Cooley’s anemia and includes a group of disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin. (Saunders, p. 496)
- The mother of a child with Thalassemia major disorder fully understands the child’s condition when she verbalizes
- “My child will need lifetime iron supplement.”
- “My child requires frequent blood transfusion.”
- “I need to contact her physician before giving any OTC medicines.”
- “I have to bring her to the clinic for monthly injection of vit. B12.”
Rationale: B. Intervention for Thalassemia focuses on the administration of blood transfusions to supply the insufficient hemoglobin and chelation therapy to reduce iron overload. (NSNA © 2007, p. 301)
- The acute nursing management of a client with heart failure includes all of the following goals, except
- Reduction in myocardial contractility
- Decreasing the afterload
- Enhancing stroke volume
- Increase renal blood perfusion
Rationale: A. Goals for clients with CHF is directd towards increasing myocardial contraction to increase cariac output and ensure perfusion to different organs of the body. Reducing myocardial contractility is a goal for MI. (Saunders Comprehensive Review © 2005, p. 796-797)
- A 50-year-old is recovering from cancer of the colon. On his 3rd post-operative day he complains that the area around the calf of his leg is warm and tender. Suspecting he may have DVT, the nurse performs thorough assessment. When assessing the common clinical manifestations for DVT, the nurse observes the client for
- Pain in the calf as the foot is sharply dorsiflexed
- Swelling of the affected extremity
- Reddened area around the clot
- Cyanosis distal to the clot
Rationale: B. in assessing for presence of DVT the nurse may detect presence of swelling and edema to the affected extremity due to obstruction of the deep veins inhibiting the outflow of venous blood. The affected extremity feels warmer and the superficial veins may appear more prominent. Tenders occurs secondary to inflammation of the vein wall. Homan’s sign (pain in the calf after the foot is sharply dorsiflexed) is not specific to DVT because it can be elicited in any painful condition of the calf. In some cases pulmonary embolus are the first indications of DVT. (MS by Brunner and Suddarths 10th ed, p. 843)
- Which of the following observations indicate an effective outcome of treatment for the client in the previous number?
- Presence of strong palpable distal pulses
- A decrease in the width of calf
- Healing of necrotic wounds distal to the extremity
- Absence of cyanosis
Rationale: B. Goals for treatment of DVT is directed towards the reduction of swelling and edema of the affected extremity to promote venous blood flow. This can be done by measuring the circumference of the extremity. (MS by Brunner and Suddarths 10th ed, p. 843)
- A client with mitral stenosis would most likely reveal a history of
- Excessive alcohol intake and smoking
- Elevated cholesterol level
- Streptococci infection
Rationale: D. Mitral stenosis is often caused by rheumatic endocarditis bring about by the invasion of group A beta-hemolytic streptococcus. (Brunner and Suddarths 10th ed, p. 767)
- An adult is admitted in the step-down unit with early left sided heart failure. Which symptoms noticed by the nurse is consistent with the clients condition?
- Frequent urination
- Muffled heart sound
Rationale: C. Pulmonary congestion result to orthopnea, dyspnea, cough, pulmonary crackles, lower than normal oxygen saturation, oliguria, tachycardia and other respiratory manifestations. (Brunner and Suddarths 10th ed, p. 794)
- The nurse assesses the vital signs of a patient immediately following total abdominal hysterectomy. Since the pre-op vital signs are normal, which of the following signs, if observed would indicate impending shock?
- Respirations of 20/min, up from 14/min
- Urine output of 30ml/hr, down from 50 ml/hr
- Pulse rate of 120/minute, up from 86/min
- Blood pressure of 100/70mmHg, down from 122/80mHg
Rationale: C. An increase in pulse rate requires continuous close monitoring because it could indicate an impending shock or hemorrhage. Other vital signs are within normal limit. (Saunders©2005, p.215)
- A client is diagnosed with a peripheral arterial vascular disease of the lower extremities. Which of the following assessment finding complements to the clients condition?
- Dilated tortuous saphenous veins of both legs
- Brownish discoloration in the ankle extending to the calf
- Loss of hair and dry scaly skin
- Edema accompanied with burning or aching pain in the distal portion of the lower extremities
Rationale: C. Loss of hair and dry scaly skin is caused by hypoxia to the distal extremities. Increase in pigmentation (brownish discoloration) is due to pooling of venous blood. Edema is absent and pain is relieved by rest. (Saunders, p. 805)
- A patient is suspected of having Abdominal Aortic Non-dissecting Aneurysm. Which of these findings will the nurse expect in this patient?
- Visible dilated blood vessels around the umbilicus
- Prominent pulsating mass in the abdomen
- Dullness during percussion above the symphysis pubis
- Hypotension and arterial ulcer in one of the toe
Rationale: B. Refer to Saunders ,p. 807 for AAA s/sx
- A client in a critical care unit is being monitored for hemodynamic complications of cardiac tamponade. Which of the following nursing care is critical for the management of cardiac tamponade?
- Maintaining adequate fluids intravenously
- Providing oxygen via nasal cannula
- Administering pain medication
- Organizing activities with rest periods
Rationale: A. Maintaining adequate hydration through IV lines is crucial in managing the decrease in cardiac output for this client. (Saunders, p. 802)
- Which of these nursing diagnoses should be given priority in the care plan of a patient who is suspected of having mitral valve disease?
- Impaired Gas Exchange
- Fluid volume Excess
- Activity Intolerance
- Decreased Cardiac Output
Rationale: D. A client with mitral valve disease is usually asymptomatic initially. Because the heart valves cannot fully open or close completely, there is inefficient blood flow through the heart. The client is at risk for decrease cardiac output and development of heart failure. (Saunders © 2005, p. 800)
- The nurse is monitoring a client in a cardiac unit after developing atrial fibrillation. Which of the following complications will the nurse expect to observe in the client?
- Distended Abdomen
Rationale: C. If the ventricular rate is consistently high such as in atrial fibrillation there will be a decrease in cardiac output decreasing perfusion to the vital organs such as the brain causing a decrease in LOC. (NSNA © 2007, p. 76)
- An elderly woman is hospitalized for the treatment of gastroenteritis complicated by dehydration and hyponatremia. The nurse expects a late symptom of hyponatremia exhibited by the client like
- Muscle twitches
Rationale: D. Late manifestations of hyponatremia involve skeletal muscle weakness leading to ineffective respiratory movement. Muscle twitches is an early sign of hypernatremia. (Saunders Comprehensive Review © 2005, p. 89)
- A client in the acute care facility is irritable but shows within normal vital signs with potassium level of 6.5mEq/L. The nurse caring the client would alert herself for possible
- Decrease in cardiac output
- Cardiac dysrhythmias
- Reduction in arterial oxygen
- Pulmonary edema
Rationale: B. Major concerns in a client with hyperkalemia are cardiac dysrhythmias, heart block, and cardiac arrest. (NSNA© 2007, p. 325)
- The charge nurse supervises a newly graduate nurse caring for a client 4 hours after transphenoidal hypophysectomy. Which of the following actions observed by the charge nurse would require her to intervene immediately?
- The newly graduate nurse moves the client to the head of the bed using a turning sheet.
- The newly graduate nurse assists the client to perform coughing and deep breathing techniques.
- The newly graduate nurse position the client’s bed in semi-fowler’s.
- The newly graduate nurse maintains the clients head in a neutral position.
Rationale: B. Coughing is discouraged in a client with head surgery because this can increase the intracranial pressure. (Kaplan © 2007, p. 261)
- A nurse formulating a nursing care plan for a client with Guillane-Barre syndrome who has an admitting diagnosis of Impaired Physical Mobility related to Paralysis would include which of the following action in the client’s care?
- Turning the client every 2 hours
- Auscultating bowel sounds
- Administering feeding through gastrostomy tube
- Limiting fluid intake
Rationale: A. Preventing the complications of immobility are key to the function and survival of client’s with GBS who experiences physical immobility. Frequent position changes prevents the client from developing pressure ulcers. (MS by Brunner and Suddarth’s 10th ed, p. 1960)
- The nurse is admitting a client who sustained an injury to the spinal cord at the level of C8 after a vehicular accident. In order to prevent the occurrence of autonomic dysreflexia, the nurse would implement which of the action?
- Regulating the clients intravenous infusion regularly
- Establishing a bowel and bladder schedule
- Monitoring the clients blood pressure
- Frequently turning the client every 2 hours
Rationale: B. Autonomic dysreflexia is usually triggered by full bladder and fecal impaction. It is characterized by severe hypertension, diaphoresis, and flushing above the level of injury, throbbing headache, blurred vision, nausea, nasal congestion, and piloerection. Inserting Foley catheter and performing digital rectal examination are some of the nursing interventions to relieve autonomic dysreflexia. (NSNA, p. 169)
- A client with Parkinson’s disease is visited by the home health nurse. Which of the following observation in the client’s environment requires further follow-up?
- The client removes the carpet in his floor
- The client has a dog house
- The client has a gas heater
- The client’s bathroom is located down the hallway
Rationale: C. The nurse must see to it that the client’s gas heater has sufficient protection such as screen to prevent him from falling into the gas heater or removed if obvious hazards are seen. Having a dog does not pose a threat to the client’s condition. Removing the carpets protects the client from accidental slipping when walking. The nurse neither the client cannot change anymore the setting of the house.
(Brunner © 2004, p. 209)
- Which of the following actions will best assist an Alzheimer’s client with nighttime voiding?
- Ask the client to void before retiring to bed
- Wake the client periodically during the night
- Withhold fluids after 6 p.m.
- Leave a night light on
Rationale: D. Providing a night light promotes safety during ambulation. Withholding fluids and asking the client to void before sleeping does not ensure that the client will not experience an urge to void at nighttime. Waking the client periodically disrupts the client and does not promote independence. (NSNA © 2007, p. 1012)
- A nurse receiving an endorsement for the care of a post lumbar puncture client would intervene when she observes
- The husband brought 3 pillows for his wife
- An LPN offers the client with water upon awaking
- The nursing assistant provides bed pan for the client
- The client lies flat in the bed
Rationale: A. Following lumbar puncture the client is must remain flat in bed for 4-8 hours to prevent spinal headache. Clients must be encouraged to take fluids and monitoring the puncture site for leakage of CSF and hematoma is also done. (NSNA © 2007, p. 156)
- Which of the following manifestations would support a diagnosis of Parkinson’s disease? Select all that applies
__b. Tremors at rest
__e. Chorea movements
Rationale: BCD. Parkinson’s disease is a neurologic disorder with three classic features: tremor, rigidity, and bradykinesia. (NSNA © 2007, p. 162)
8. What is the best bedside equipment for a client exhibiting seizure?
a. tongue depressor
b. suction equipment
c. oxygen tank
d. protective helmet
Rationale: B. Ensuring a patent airway is crucial after seizure episode. Suction helps clear secretions and prevents aspiration. (NSNA © 2007, p. 666)
9. While interviewing a client with Myasthenia Gravis, which of the following statements made by the client confirms the diagnosis?
- “I have difficulty in swallowing.”
- “I often have tremors.”
- “My visions are getting blurred.”
- “I feel numbness in my extremities.”
Rationale: A. Client with MG usually report signs of dysphagia, weakness and fatigue, ptosis, difficulty in chewing, weak hoarse voice, and respiratory paralysis & failure. Choice B, is seen in Parkinson’s disease. Choice C&D are s/sx of MS. (Saunders, p.956)
10. A client diagnosed with MS has a urinary incontinence. To achieve voiding, which nursing care should the nurse give?
- Encouraging the client to perform Kegel’s exercise
- Giving bedpan when there is an urge to void
- Providing client’s privacy during voiding
- Establishing regular voiding schedule
Rationale: D. establishing regular voiding schedule is the best way to achieve voiding in MS client. (Saunders, p.956)
11. Which of these findings would most likely indicate that a patient is developing an increased intracranial pressure?
- Rapid eye movement in reactions to light
- Lethargic reactions in response to command
- A respiratory rate of 14 breaths/ minute form 18 breaths/minute
- Narrowing of pulse pressure
Rationale: B. Changes in LOC is the most sensitive and earliest sign of increased ICP. The patient may show a declining LOC from restlessness to confusion, lethargy, and coma. (Saunders, p. 944)
12. The nurses’ plan of care for a client admitted with amyotropic lateral sclerosis (AML) would be directed towards the following measures, except
- Implementing aspiration precautions
- Promoting range of motion exercises
- Administering pain relief medications
- Detecting and preventing the development of pressure ulcers
Rationale: D. AML is a rare degenerative disorder involving the motor system characterized by the atrophy of the hands, forearms, and legs. That leads to paralysis and death. S/Sx are: muscle atrophy, fatigue, dysarthria, dysphagia and fasciculation of the face. Pressure ulcers are usually not a problem in this client because the sensory system remains intact and the client can feel when pressure on the body part is too great. (Joyce Black, p. 2186)
- Which of the following best characterizes a client manifesting with Cushing’s triad? SATA
__a. Narrowed pulse
__b. Widened pulse pressure
__e. Irregular respirations
__f. Increased systolic BP
Rationale: BDEF. Cushing’s triad is seen as a late manifestation in a client with increased ICP. (Saunders © 2005, p. 401)
- A patient with Myasthenia gravis had undergone abdominal resection. Which of the following doctors order will the nurse question?
Rationale: B. Diazepam causes respiratory depression and further aggravates MG. (Mosby’s Drug Guide, p. 305)
- A client with closed head injury will manifest which of the following in his vital signs?
a. Decrease BP
b. Increase PR
c. Decrease Temperature
d. Decrease RR
Rationale: D. Increased ICP will cause increase in BP and temperature and a decrease in heart rate and respirations. (Saunders © 2005, p. 401)
- A client is admitted for total thyroidectomy. Which observation during post-operative period would require the nurse to notify the physician immediately?
- Tremors of the hands
- Increased perspiration
- Hoarseness of voice
Rationale: A. Immediately after thyroidectomy an episode of thyroid crisis can occur caused by increased amounts of thyroid hormone released in the bloodstream during surgery. If this condition is not treated immediately, the client may die of heart failure. Antithyroid medications are usually prescribed by the physician. (Davies NCLXE-RN, p. 598-599)
- A client is admitted with a provisional diagnosis Addison’s disease. Which of the following symptoms would the nurse expect to find as she performs the client’s physical assessment?
- Puffy hands and feet
- Pendulous abdomen
- Dry skin
Rationale: C. Addison’s disease results in volume depletion, which contributes to postural hypotension and dehydration. The other symptoms are associated with myxedema. (NSNA © 2007, p. 140)
3. Arrange the following intervention according to priority in a client who develops Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) coma.
__a. Immediate intravenous infusion of Regular insulin
__b. Notify the physician
__c. Administering intravenous 0.9% sodium chloride
__d. Infusion of IV with dextrose
__e. Adding potassium to IV fluids
Rationale: CEADE. Major problem with HHNS is fluid volume depletion. Fluid treatment is started with 0.9% or 0.45% NS, depending on the client’s sodium level and severity of volume depletion. Potassium is added to IV fluids when urinary output is adequate and is guided by continuous ECG monitoring and frequent laboratory determinations of potassium. Extremely elevated blood glucose levels drop as the client is rehydrated. Insulin plays a less important role in the treatment of HHNS because it is not needed for the reversal of acidosis, as in DKA. Nonetheless insulin is administered at a continuous low rate to treat hyperglycemia, and replacement IV fluids with dextrose is administered when the glucose level is decreased to the range of 250 to 300 mg/dL.(MS by Brunners and Suddarth’s 10th ed, p. 1184)
4. Which of the following characterizes Myxedema?
- Heat intolerance
- Weight loss
Rationale: C. Myxedema is the severest form of hypothyroidism noted by nonpitting edema, puffiness of the hands and feet, profound lethargy and apathy, and slowed metabolism. (NSNA © 2007, p. 138)
5. At 8:00 AM, a patient received an injection of regular insulin. At 11:00 AM, the patient is diaphoretic and shaky. Which action should the nurse take first?
a. Give a cup of orange juice
b. Administer next dose of insulin
c. Check urine for presence of ketones
d. Perform finger-prick for glucose monitoring
Rationale: A. The patient is already exhibiting symptoms of hypoglycemia. Providing a fast acting simple carbohydrate to treat hypoglycemia like a cup of fruit juice can help prevent hypoglycemia. Administering insulin can further cause hypoglycemia. (Saunders, p. 641)
6. A nurse attending a client admitted with complaints compatible to Addison’s disease would prioritize which of the following presented nursing diagnosis?
a. Nutrition altered due to excess sodium
b. Impaired skin integrity
c. Impaired urinary elimination
d. Fluid volume deficit
Rationale: D. Client with Addison’s disease exhibit manifestations of shock and is at risk fr circulatory collapse. (Brunners, p 1283)
7. A nurse in the medical-surgical unit monitors a client with head trauma for possible development of diabetes insipidus. During a routine assessment, which of the following observation would alert the nurse for the said complication?
- Non-pitting edema
Rationale: B. Tachycardia could indicate a fluid volume deficit due to excess fluid loss. (Brunner, p. 1211)
8. It is necessary for the nurse to include which of the following instructions in a client with Cushing’s syndrome who undergo bilateral adrenalectomy?
- Taking corticosteroid regularly for the first six months
- Monitoring blood glucose for episodes of hyperglycemia
- Providing a diet rich in potassium and sodium
- Administering antacids together with steroid
Rationale: D. Steroids must be taken life-time and are irritating to the GI mucosa, thus the client is advised to take the drug with antacids and meals. Cleitn is at risk for hypoglycemia because of the removal of the source of cortisol. Diet must be high in potassium but low in sodium. (Disease: A nsg. Process Approach to Excellent Care, p. 1105)
9. To rule out the diagnosis of diabetes insipidus, a client undergoes a fluid deprivation test. The nurse conducting the procedure would be immediately terminate the procedure if she notes
- Increasing muscle weakness
- Rapid pulse rate
- Increase in the weight
- Pulmonary rales
Rationale: B. Tachycardia, hypotension, and decrease in weight indicate worsening DI and prompt to stop the procedure. (Brunner, p. 1211)
10. A 78-year-old with Alzheimer’s disease placed in a long term facility care is diagnosed with hypothyroidism. The nurse in charge of the client’s care would include which of the following in the nurses’ care plan?
- Weighing the client same every other day
- Providing a high calorie and fiber meal
- Applying eye patches at night
- Monitoring I&O
Rationale: D. Hypothyroidism leads to fluid volume excess thus fluid and salt are restricted and an accurate daily record of weight must be obtained. Clients are placed on low calories diet to decrease weight gain. Eye patches are applicable for hyperthyroidism with exopthalmos. (Disease: A nsg Process Approach to Excellent Care, p. 1087)
11. The nurse should report which of the following client assessments as consistent to the diagnosis of SIADH, except?
- Weight gain without edema
- Decrease saliva production
- Cold, clammy skin
Rationale: D. Neurologic changes including altered LOC are probably related to the cellular swelling and cerebral edema associated with hyponatremia. Edema is absent because much of the water excess is within cellular boundaries. Cold, clammy skin is associated with hypovolemia which is seen in diabetes insipidus. (NSNA, p. 136/ Saunders, p 633/ Joyce Black, p 1241/ Brunner, p.263/ Disease: An nsg Approach to Excellent Care, p. 1066)
12. A client seeking medical attention shows a history of excessive use of synthetic steroid. The nurse in charge of the client’s care would anticipate to observe
- Slender trunk with enlarged arms and legs
- Moon shaped face
- Diminished body hair growth
- Hyperpigmentation on the breast and abdomen
Rationale: B. This client will manifests s/sx that resembles to Cushing’s syndrome. Excessive steroid lead to muscle wasting causing slender extremities and enlarged trunk (truncal obesity). The excessive androgen causes virilization with increased body and facial hair. Hyperpigmentation is a result of insufficient adrenal cortex hormone (Addison’s disease). (NSNA, p. 139)
13. The nurse instructs the client with diabetes mellitus type I on ways to prevent further development of complications and to report which of the following immediately if noted?
- Increase in weight
- Numbness of the fingers
- Profuse perspiration and tremors
- Excessive urination
Rationale: B. Numbness of pain in the extremities is usually suggestive of peripheral and autonomic neuropathy. (Disease: A Nsg Process Approach to Excellent Care, p. 1111)
14. A DM type I patient asks the nurse about how he acquires the disease. The best response of the nurse would be the following, except
- Autoimmune response
- Inherited in the genes
- Insulin resistance of the body
- Exposure to viruses
Rationale: C. Resistance to biologic activity of insulin both by the liver and peripheral tissues (insulin resistance) is associated with type II DM. (NSNA, p. 141/ Black, p 1245)
15. A nurse caring for a client after hypophysectomy. The nurse monitors the client, knowing that which of the following is a common complication of the surgery?
a. Urine specific gravity of 1.005
b. Shakiness and flushing
d. Severe headache
Rationale: A. Diabetes insipidus is usually transient after hypophysectomy manifested by polyuria and low urine specific gravity readings. (MS Black © 2006, p. 1237)
1. A woman with left upper quadrant (LUQ) pain that radiates to the back has a history of biliary tract disease. She was admitted through the emergency department (ED) last night for acute pancreatitis. Which of the following laboratory findings is expected in the patient?
- 11,000 cells/ul WBC
- 151 units/L amylase
- 4.5 mg/dL phosphorus
- 7.5 mg/dl calcium
Rationale: D. during periods of acute pancreatitis, calcium is trapped by the necrotic cells leading to hypocalcemia (NV: 9-11 mg/dL) which is accompanied by the elevation of phosphorus (NV: 2.7-4.5 mg/dL). WBC and amylase are also elevated. Patient should be watched for Chvostek’s and Trousseau signs secondary to hypocalcemia. (Diseases: A nursing Process Approach to Excellent Care © 2006, p. 978)
2. Which of the following assessment findings is expected in a client with acute pancreatitis? Select all that applies
__a. Elevated WBC
__e. Cullen’s sign
__f. Murphy’s sign
Rationale: ACDE. Hypercalcemia not hypocalcemia will occur due to ininadequate insulin production secondary to destruction of pancreatic cells. Murphy’s sign (cannot take a deep breath when the examiner’s finger are passed below the hepatic margin) is seen in cholecystitis. (Diseases: A nursing Process Approach to Excellent Care © 2006, p. 978; Saunders Comprehensive Review © 2005, p. 690)
3. A client is admitted for a suspected duodenal ulcer. The nurse is interviewing her for admission history. Which description of her pain would be the most characteristic of duodenal ulcer?
- Aching in the epigastric area that awakens her from sleep
- Right upper quadrant pain that increases after meals
- Gnawing, sharp pain in the midepigastric area that radiates to the right shoulder
- Belching and heartburn after eating
Rationale: A. Duodenal ulcer pain is relieved by eating and occurs 2 to 4 hours after eating and during the night. (Saunders Comprehensive © 2005, p. 683)
4. Which of the following nursing measures in a client with percutaneous endoscopic gastrostomy (PEG) is appropriate?
- Monitoring the tubes length while feeding
- Positioning the feeding syringe at the level of client’s abdomen
- Tilting the receptacle while the liquid is instilled
- Applying continuous pressure in the syringe while feeding
Rationale: C. Tilting the receptacle allows the air to escape while the liquid is being instilled initially. Syringe is raised perpendicular not higher than 45 cm (18 in) so feeding can enter by gravity. Monitoring the tubes length should be done before feeding and the physician should be notified if the segment of the tube outside the body becomes shorter or longer. An intermittent or continuous-pressure feeding pump is already built-in for feeding requiring pump. Most feeding pumps are battery regulated that alarms when the bag is empty, battery is low, or when an occlusion id present. (Brunner and Suddarth’s 10th ed. p, 1000-1001)
- Which of the following stool characteristic would a nurse note in a client with regional ulceration (Crohn’s disease)?
- Bloody diarrhea
- Alternating episodes of diarrhea and constipation
- Mucoid diarrhea
- Coffee colored stool
Rationale: C. Crohn’s disease is characterized by diarrhea which may contain mucus and pus. Blood diarrhea is observed in ulcerative colitis. (Saunders, p. 687)
- A client with Laennec’s cirrhosis is given a lactulose (Duphalac). Which of these observations indicate that the treatment is ineffective?
- The client’s appetite improves
- The client is constipated for 2 days
- The client’s serum ammonia level decreases
- The client is more alert
Rationale: B. Lactulose is given to client with cirrhosis to prevent and treat hepatic encephalopathy by decreasing ammonia. It also promote an osmotic effect in the colon resulting to distention, promotes peristalsis, and relieving constipation. (Mosby’s Drug Guide © 2007, p. 536)
- A client with cancer of the stomach has undergone gastric resection. Which of the information should be included in the client’s post-operative teaching?
- Increasing his fat intake will help promote healing
- He will only be able to have high-carbohydrate liquids such as milk
- He can eat small frequent meals
- Provide highly fibrous foods
Rationale: C. After gastric resection, the client is prone for developing dumping syndrome. Protein must be increased to promote healing not fat. Carbohydrates and meals high in sugars, milk, chocolate, and salt must be avoided. Avoid fibrous foods such as citrus fruits because they tend to form phytobezoars (formation of gastric concretion composed of vegetable matter). After a gastric resection, the remaining gastric tissue is not able to disintegrate and digest fibrous foods. (Lippincott © 2007, p. 661)
- Which of the following client response indicates that the client clearly understands the teaching about diverticular disease?
- “I should avoid tomatoes.”
- “I should avoid fresh fruits.”
- “I need to have meticulous hygiene around my anal area.”
- “I can purchase OTC laxative when I’m constipated.”
Rationale: A. Management of uncomplicated diverticulum include high-residue diet and fiber supplements, avoiding laxatives and enema, and avoiding indigestible roughage such as nuts, popcorn, raw celery, corn, and seeds.
(Mosby Study Guide © 2007, p. 386)
- A client with suspected intestinal obstruction would present what symptoms during the early stage of the obstruction?
- Absence of bowel sounds
- Abdominal tenderness
- Hyperactive bowel sounds
Rationale: D. Bowel sounds initially may be hyperactive proximal to the obstruction and decreased or absent distal to the obstruction; eventually, all bowel sounds will be absent. (Mosby Study Guide © 2007, p. 388)
- In planning discharge teaching for the client who has undergone gastrectomy, the nurse includes what information regarding dumping syndrome?
- Drinking non-fat milk while eating delays gastric emptying
- Ambulation decreases the symptom and should be scheduled 1 hour after meals
- The syndrome is permanent and the client should eat 5-6 meals per day.
- Lying down after eating decreases the problem
Rationale: D. Dumping syndrome is caused by rapid emptying of gastric contents and can be prevented by assuming a recumbent or lying position. The client must eat 5-6 frequent small meals but not for the entire life since the syndrome is self-limiting. (Mosby Study Guide © 2007, p. 382)
- A nurse notes a bile-colored liquid containing coffee-ground material in the nasogastric tube of a client with gastric resection who is on his 3rd post-operative day. The most appropriate action for the nurse to take at this time is
- Irrigate the nasogastric tube with iced saline solution
- Continue to monitor the amount of drainage
- Reposition the nasogastric tube
- Notify the physician for possibility of bleeding
Rationale: B. Coffee-ground material is an old blood and this is considered as a normal occurrence on the third post-operative day. (Mosby Study Guide © 2007, p. 394)
- A 37-year-old is seen in the OPD for treatment of psoriasis. The nurse gathering the information would anticipate which of the following findings in this man?
- Intense pruritus that worsens at night
- Discoloration of the nails
- Erythematous papules
- Hyperpigmented skin
Rationale: B. Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic lesions. Signs and symptoms are pruritus, shedding silvery white scales; yellow discoloration, pitting, and thickening of the nails; joint inflammation (psoriatic arthritis). (Saunders Comprehensive Review © 2005, p. 540)
- The nurse caring a man about to go home who was admitted due to psoriasis directs her discharge teaching towards which measure to prevent exacerbation of the disease?
- Avoiding close personal contact with an infected person with psoriasis
- Reducing stress
- Taking full course of antibiotic during periods of infection
- Wearing long sleeved tops and long pants when going out
Rationale: B. possible causes of the disorder include stress, trauma, infection, and changes in climate. The d/o may also be exacerbated by the use of certain medication. (Saunders Comprehensive Review © 2005, p. 540)
- The nurse is caring for a man who sustained a deep full-thickness burns when his clothing was caught in fire. During the acute burn phase, the nurse explains to the client that his nursing care plan is directed towards all of the following, except?
- Inserting a Foley catheter and CVP as prescribed
- Proper hand and joint alignment
- RTC administration of SQ narcotic pain medication
- Initiating a protective isolation technique
Rationale: C. In deep full thickness burns pain is usually absent or minimal and is the least priority in the nursing care plan. SQ and IM administration of medication is not reliable due to extensive damage in the muscle tissue. Medication is usually given before painful procedures with physician’s prescription. (Saunders Comprehensive Review © 2005, p. 544-547)
- A nurse suspecting a client with scleroderma, would identify which of the following signs and symptoms of the disease? Select all that applies
__a. Raynaud’s phenomenon
__d. Taut, shinny skin
__e. Wrinkle-free, masklike appearance
__f. Contractures and joint stiffness
Rationale: ALL. Scleroderma is a diffuse connective tissue disease characterized by fibrotic, degenerative, and occasionally, inflammatory changes in skin, blood vessel, synovial membranes, skeletal muscles, and internal organs 9esp esophagus, GI, thyroid, heart, lungs, and kidney). S/sx:
- Raynaud’s phenomenon( blanching, cyanosis, and erythema of the fingers and toes)
- Frequent reflux, heartburn, dysphagia and bloating after meals
- Abdominal distention, diarrhea, constipation, malabsorption, anorexia
- Loss of normal skin folds, taut shiny skin over the hand and forearm
-Wrinkle-free, masklike appearance and a pinched mouth
- Contractures, joint pain and stiffness
-Pericardial friction rub, irregular cardiac rhythm, atrial gallop, hypertension, & renal involvement
(Diseases: A nursing Process Approach to Excellent Care © 2006, p. 462-463)
- The nurse directs her discharge teaching in a client with scleroderma in the following measures, except
- Performing routine range-of-motion exercises at home
- Placing the client in an air conditioned room
- Encouraging the client to remain upright for at least 3 hours after eating
- Providing a high calorie diet
Rationale: B. Placing the client in an air conditioned room may aggravate Raynaud’s phenomenon. Client should be warn not to take cool showers and baths and to wear gloves and mittens outside. (Diseases: A nursing Process Approach to Excellent Care © 2006, p. 462-463)
1. A client who has just received teaching following hip dislocation shows correct understanding if she verbalizes to
a. Purchase a high-seat toilet
b. Get out of bed using the affected side first
c. Sitting up straight in his bed
d. dangle legs at the side of the bed
Rationale: A. High-seat toilet and chair prevents hip flexion and displacement. Sitting up straight greater than 90 degrees must be avoided. Weigth bearing on the affected leg is not prescribed. Dangling of the leg may lead to dislocation. (Davies, p. 584/ Brunner, p. 2032)
2. A teenager sustained a basilar skull fracture after a motorcycle crash. He was brought to the nearest hospital and is now attached to a Halo traction with chest vest. The nurse attending the client would plan to implement which of the following appropriate measures for the client?
a. Maintaining the client in supine position
b. Placing pillow under the abdomen and chest when the client is turned to prone
c. Ensuring that the chest vest screws are intact and the vest is well-fitted to the clietn’s chest
d. Turning the client by the Halo vest
Rationale: B. Halo traction immobilizes the cervical spine so that client can move without the risk for further injury. Turning frequently by logrolling prevents development of pressure ulcers. Chest vest must be ensured that there is an adequate space for one finger to be inserted and can moves freely inside the vest to prevent skin breakdown. Placing pillow under the chest and abdomen prevents pressure to rest on the Halo when the client is turned to prone. (Davies, p. 580/ NSNA, p. 169)
- Which nursing intervention would be most beneficial in preparing a client after a total hip replacement?
- Pivot the affected leg when initiating a crutches
- Maintaining leg adduction by placing pillow in between legs
- Elevate affected leg with pillows
- Using overhead trapeze to lift the pelvis when using bedpan
Rationale: D. Teachings to prevent dislocation of prosthesis during total hip replacement are directed towards maintaining leg in abduction. Client must be flat on bed with 2 to 3 pillows in between the leg. Limited flexion is maintained by not raising the head of the bed more than 60 degrees. For the use of bedpan, the client can use trapeze to flex and lift the unaffected leg only. (Brunners, p. 2032)
- A carpenter who falls from the roof sustained a fracture in his femur and was brought from the surgery with a skeletal traction and Steinmann pin already attached through his lower femur. During inspection, the nurse would intervene immediately if she observes
- The client trying to reach the overhead trapeze
- The client’s heel touching the end of the bed
- The weights are suspended 18 inc from the floor
- The ropes of the traction moves freely through the pulley
Rationale: B. Heel of the affected leg must remain free of the bed to maintain accurate pull of the traction. (Davies, p. 580)
- In taking history of a client with severe painful Paget’s disease, the nurse expects the client to report all of the following except?
- Barrel shaped chest
- Waddling gait
- Tinnitus and vertigo
- Weight loss
Rationale: D. Pagets disease (osteitis deformans) is an idiopathic bone disorder characterized by abnormal and accelerated bone resorption and formation in one of more bones. An X-ray film shows increased bone expansion and density. The most common presenting complaints include one or more of the following: deep, aching bone pain; skeletal deformity, such as barrel-shaped chest, bowing of the tibia or femur, or kyphosis; changes in skin temperature; pathologic fractures through diseased bone; and manifestations related to nerve compression. Diseased bone pressing on the cranial nerves may result in vertigo, hearing loss with tinnitus, and arthritis. (MS Black © 2006, p. 605)
- Which of the following statements by the client who has recently had a total hip replacement indicates that he or she does not understand the mobility limitations?
- “I should not bend down to put on shoes or socks.”
- “I can cross my leg occasionally when sitting.”
- “I should put a pillow between my legs when lying on my side.”
- “I can’t use my recliner chair.”
Rationale: B. Clients with total hip replacement should not bring their leg across midline, which may result in prosthesis dislocation. Crossing the leg is adduction, which is contraindicated for this client. (Lippincott Manual of Nsg © 2007, p. 1006)
- A nurse formulating discharge teaching for a client with gouty arthritis should emphasize
- Increasing fluid intake to 2-3 L/day
- Avoiding alcohol intake
- Taking extra fiber
- Applying warm compress
Rationale: A. Client’s with gout should be encouraged to take high fluid to increase excretion of uric acid and to prevent the development of uric acid stones. Avoiding alcohol is also appropriate to prevent gout attacks. (Mosby Study Guide © 2007, p. 480)
- Which of the following are noted signs and symptoms in a client with chronic gout? SATA
__a. Tophi in the ear
__b. Cool extremities
__d. Bilateral pattern of inflammation
__e. Boutonniere deformity
__f. Podagra pain
Rationale: ACF. Gouty arthritis usually affects one joint—commonly the metatarsophalangeal joint (called podagra). Pain, warmth, erythema, and swelling of tissue surrounding the affected joint are observed. Fever may occur. Onset of symptoms is sudden; intensity is severe and self-limiting. Presence of tophi or uric acid crystals in the area around the large toe and outer ear develops. Bilateral pattern of inflammation and Boutonniere deformity are seen in rheumatoid arthritis. (Lippincott Manual of Nsg. Practice © 2007, p. 1024) (Mosby Study Guide © 2007, p. 480)
- A 6-year-old boy is admitted to the hospital with a diagnosis of Nephrotic Syndrome. Which of his mother’s comment is most likely related to the child’s condition?
- “My son has no appetite, yet he has gained weight.”
- “My son is still young to be hypertensive.”
- “My son had tonsillitis 2 weeks ago.”
- “My son fell from a playground slide last week.”
Rationale: A. Nephrotic Syndrome is characterized by edema with normal to below normal blood pressure. Hypertension and exposure to streptococcal infection has something to do with glomerulonephritis. Choice D is not related to the child’s condition. (Saunders, p.473)
- You are taking care with a client having an end stage renal disease managed by peritoneal dialysis. Which finding should require you to contact the physician immediately?
- A decrease in the client’s weight
- An amber color return of the dialysate fluid
- A complain of abdominal pain during inflow
- A decrease in the dialysate return compared to the amount instilled
Rationale: B. An amber or urine like return of dialysate indicates bladder perforation. Pain during inflow is common during the first few exchanges and disappears after 1 to 2 weeks of dialysis treatment. Diminished outflow can be managed by turning the client side to side to facilitate outflow. (Saunders, p. 863-864)
- The nurse providing dietary instructions to a client with oxylate renal calculi would recommend avoiding which of the following snacks?
- Cheese burger
- Chicken nuggets
Rationale: D. Calcium-oxylate stones is managed by an acid-ash diet because calcium stones have an alkaline pH. Oxalate-rich food sources include tea, peanuts, rhubarb, spinach, chocolate, almonds, cocoa, strawberries and cashews. (Saunders, p. 869)
- In assessing a patient with a diagnosis of hydronephrosis, the nurse would usually note the following observation
- Bladder distention and dull flank pain
- Development of edema to the lower extremities
- Puffiness of the external genetalia and dysuria
- Nocturia and hematuria
Rationale: A. Hydronephrosis is an abnormal dilatation of the renal pelvis and calyces of kidneys. It is caused by obstruction of urine flow in the genitourinary tract. Associated findings reveal renal or dull flank pain, bladder distention, decrease urine flow, hematuria, pyuria, dysuria, alternating oliguria and polyuria, dribbling and urinary hesistancy. (Black, p. 920/ Disease: A nsg Process Approach to excellent care: p, 901)
- A client in the outpatient clinic is being assessed for acute renal failure. The nurse would be most concern if the client made which of the following statements?
- “I am having difficulty to start the flow of my urine.”
- “I often experiences urinating in between my sleep.”
- “I observed blood streaks in my urine.”
- “I urinate once in the morning and again in the afternoon.”
Rationale: D. A decrease in urine output (anuria or oliguria) is a symptom of ARF. Normal voiding pattern is 5-6 times a day and once at night. (Saunders © 2005, p. 855)
- The nurse is caring for a client who will undergo renal biopsy. Which of the following laboratory findings will the nurse check prior to the procedure?
- Creatinine level
- Prothrombin time
- BUN level
- Hemoglobin level
Rationale: B. Prior to a renal biopsy a baseline clotting studies should be assessed because the client is at risk for bleeding at the biopsy site. (Saunders © 2005, p. 854)
- Which doctor’s order in a client with End Stage Renal Disease (ESRD) will require the nurse to intervene?
- Lactulose (Duphalac)
- Spironolactone (Aldactone)
- Proxyphene napsylate (Darvon)
- Epoetin (Procrit)
Rationale: B. Client with ESRD experiences hyperkalemia and administering spironolactone (Aldactone) reduces potassium loss. (Mosby Study Guide © 2007, p.336)
- An elderly has just returned to the nursing unit following a TURP. He has a three-way Foley catheter with CBI connected. He tells the nurse that he wants to void. The most appropriate action of the nurse is to
- Notify the physician
- Irrigate the catheter
- Allow him to void around the catheter
- Remove the catheter and assist him to the bathroom
Rationale: B. The nurse must assure the client that the urge to void results from the presence of the catheter and from bladder spasm. Irrigating the tube maintains patency and prevents obstruction . the nurse maintains an intake and output record, including the amount of fluid used. (MS by Brunner and Suddarths, 10th ed, p. 1507)
- The nurse in the medical-surgical unit is monitoring a 55-year-old man who undergoes TURP with a three-way system for bladder irrigation for possible complications. 24 hours after the surgery the client complains of pain in the surgical area. The nurse would initially perform which of the following action?
- Irrigate the tubing system with 50 ml of irrigating solution
- Check the patency of the catheter tubing
- Assess for the disconnection of the traction applied to the catheter
- Administer antispasmodic medication to relieve bladder spasm
Rationale: B. Complains of pain is usually caused by blockage or obstruction in the catheter tubing. Irrigating the drainage system with 50 ml of irrigating fluid to clear any obstruction must be done. Disconnection of catheter traction results to a dark-colored output which indicates venous bleeding. (MS by Brunner and Suddarths, 10th ed, p. 1507)
- Which of the following client complains after a removal of catheter for TURP will require immediate follow-up?
- Erectile dysfunction
- Urinary incontinence
Rationale: D. Post TURP clients are reassured that urinary incontinence, frequency, urgency, and dysuria are expected and should gradually subside. Impotence usually subsides after 6 months. Clients are caution to avoid sexual intercourse, straining at stool, heavy lifting, and long periods of sitting for 6 to 8 weeks after surgery. (Lippincott Manual of Nursing Practice © 2001, p 709)
- Which of the following instructions should be given to a client regarding testicular self-exam?
- Perform consistently in the same day of the month
- You can use a small pen light to illuminate the scrotal sac
- Palpate the testes immediately after showering
- Finding a small, pea-like lump is normal
Rationale: C. Testicular exam should be performed monthly in the same date not day. A convenient time is usually after a warm bath or shower when the scrotum is more relaxed. Using a small penlight to illuminate the scrotum is used to detect a hydrocele. Presence of a small, pea-like lump or if the testes are swollen needs to be reported to the physician. (MS by Brunner and Suddarth’s 10th ed, p. 1510)
- Who among the presented clients is at highest risk for colorectal cancer?
- Patient consuming a high-residue with diverticulosis
- Patient with rectal polyps and consuming highly refined foods
- Patient with a diet that includes excessive animal fat
- Patient working in a rubber factory for more than 20 years
Rationale: B. Greater incidence of colorectal cancer occurs in areas of higher economic development, suggesting a relationship to diet that includes excess animal fat, especially from beef and low fiber. Other factors that magnify the risk for developing colorectal cancer include diseases of the digestive tract, a history of ulcerative colitis and familial polyposis. (Disease: A nursing process approach to Excellent care, p. 350)
- Which statement, if made by a female patient who has discovered lump in her breast would indicate a highest risk factor associated with breast cancer?
- “I had my first menstrual period when I was 12.”
- “I’m taking estrogen replacement pills for about 10 years.”
- “I had my second baby when I was 40 years old.”
- “I had a history of multiple sexual partners at an early age.”
Rationale: B. Risk factor for Breast CA:
- family history of first degree relatives
- first child after the age of 35
- menarch before the age 12
- menopause after age 55
- obesity and high fat intake
- use of birth control pills and hormonal replacement
- alcohol intake and tobacco use
- radiation exposure in the chest and pre-existing fibrocystic disease
(Disease: A Nsg. Process approach to Excellent Care, p. 338)
- A male client has a tentative diagnosis of BPH. The nurses assesses the client for which of the following manifestations? Select all that apply
__b. Recurrent UTI’s
__d. Decrease force and volume of urinary stream
__e. Penile discharges
Rationale: Except A&E. (Saunders, p. 872)
8. Which of the following indicates a correct understanding in a client performing BSE?
Palpate breast on 1st day of menses
b. Inspect breast in front of the mirror
c. Compress the nipples for discharges
d. Use dominant hand in palpating both breast
Rationale: B. BSE must be done once in a month one week after the menses. Major focus is on the inspection of the breast for unilateral dimpling, prominent vein pattern, flat nipple, puckered skin, or scaly nipple by standing in front of the mirror. (NSNA © 2007, p. 264)
1. The daily weight for a client with COPD indicates that the client has gained 5lbs in less than a week, even though his oral intake has been closely monitored. The clients weight gain is associated with what complication?
a. Left ventricular failure
b. Respiratory acidosis
c. Cor pulmonale
d. Pulmonary edema
Rationale: C. Cor pulmonale is a right ventricular failure associated with COPD and other disease of the lungs. Assessment would reveal signs and symptoms related to right heart failure such as weight gain and edema. Pulmonary edema and LSHF does not cause weight gain. (Saunders Comprehensive © 2005, p. 735, 796) (NSNA © 2007, p. 57)
2. A COPD patient had undergone abdominal surgery. Baseline ABG were obtained and recorded as follows: pH = 7.35; PaO2 = 60; PaCO2 = 50; HCO3, 25. Following the surgery the nurse documented the following: pH = 7.30; PaO2 = 70; PaCO2 = 55; HCO3 = 23. Which intervention is most appropriate for the nurse to perform?
- Instructing deep breathing and coughing techniques
- Increasing O2 to 4L/m
- Placing the patient in high Fowler’s position
- Assist the patient to breath in a paper bag
Rationale: A. The patient is exhibiting respiratory acidosis. Appropriate intervention include deep breathing and coughing and purse lip breathing to eliminate excess carbon dioxide in the lungs. Increasing the oxygen is contraindicated in COPD patients. (NSNA © 54)
1. Following a left tympanoplasty, the nurse should maintain the client in which position?
a. Semi-Fowlers with the left ear facing down
b. Low trendelenburg with head in neutral position
c. Flat with the head turned to the side with the left ear facing up
d. Supine with a small neck roll to allow fro drainage
Rationale: C. Tympanoplasty is the surgical correction of a perforated tympanic membrane. Immediate post-operative instructions may include positioning the client lying with operative ear up for several hours after surgery. If necessary, the client should blow the nose gently one side at a time. The client should sneeze or cough with the mouth open. Participation in water sports or activities is prohibited. (MS Black © 2005, p. 1987)
2. The nurse collects a history from a client with suspected Menieres disease. Which of the following do not support the diagnosis?
- Episodic vertigo
- Loud tinnitus
- Severe pain at the affected area
- Fluctuating hearing loss it the affected area
Rationale: C. Menieres disease is a disorder that affects both vestibular and auditory function. It is caused by excess endolymph in the vestibular and semicircular canals. Hearing loss is fluctant and usually subtle and reversible in the early stages. Later hearing loss becomes permanent. The most prominent clinical manifestation is vertigo, tinnitus, and feeling of fullness. (MS Black © 2005, p. 1972)(NSNA © 2007, p. 25)
- A nurse is initiating the use of walker as an assistive device for ambulation in a client who needs partial weight bearing assistance. Which of the following action if performed is accurate?
- Advance the walker an arm’s length, advance the affected leg followed by the unaffected leg.
- Advance the walker an arm’s length, set all four legs on the floor and take a complete step into the walker.
- Advance the walker an arm’s length, and swing both legs between the walker.
- Advance the walker an arm’s length, move the unaffected leg followed by the affected leg.
Rationale: A. Instructions for using leg walkers for partial or non-weight bearing are the following:
- Advance the walker an arm’s length; place all four legs on the floor; advance the affected leg; push the body weight through the arms; advance the unaffected leg. Choice B is an instruction for using walker in a client who uses walker for balance and stability only. (NCLEX-CRAM, p. 188/ Delmar’s Fundamentals of Nursing, p. 1431))
- A client demonstrating the use of incentive spirometer pre-operatively best understood the teaching when he
- Keeps a loose seal between the lips and mouthpiece
- Holds breath for 10-15 sec before exhaling
- Have 2-3 intervals between each puff
- Exhales though pursed lip
Rationale: D. Rationale: Instructions for incentive spirometer:
- have patient assume a sitting position
- place mouth tightly around the mouthpiece
- inhale slowly to raise and maintain the flow rate indicator between 600 & 900 marks
- hold breath for 5 sec and exhale through pursed lip
- repeat process 10 times every hour
Choice A & C are for metered dose inhaler (Saunders, p.762)
- A nurse is caring for an 80-year-old client with anemia who is receiving a blood transfusion. Assessment findings reveal bilateral chest crackles during auscultation and distended neck veins. What is the nurses’s initial action at this point?
- Stop BT and turn on the normal saline
- Slow the rate of infusion
- Place client in an upright position
- Continue observing the client and document the findings
Rationale: B. the client is exhibiting the symptoms of fluid volume excess and slowing the rate of BT would be the proper action. Placing the client in an upright position with the feet in a dependent position should be done next. Stopping the BT is unnecessary. (Saunders, p. 167)
- The nurse has completed the client teaching about continuous ambulatory peritoneal dialysis (CAPD). The nurse determine that the client best understand the instructions given if the client states
- “I need to report to the hospital when changing the dialysate solution.”
- “I will perform self-dialysis 24 hours a day.”
- “I can remove the dialysis bag once the dwell time is accomplished.”
- “It will require me to purchase a peritoneal cycling machine at home.”
Rationale: B. CAPD does not require machine for procedure. Using CAPD, the client can perform self-dialysis 24 hours a day, 7 days a week. CAPD is ideal in promoting independence. (Saunders, p. 862)
- Immediately following retrograde pyelography, the nurse would give priority in which nursing intervention in the patient’s care plan?
- Performing perineal care
- Placing in a side lying position
- Administering stool softener
- Increasing fluid intake
Rationale: D. A retrograde pyelography involves the administration of contrast medium directly into the urinary tract to visualize abnormalities in the renal system. Post-procedure, the patient is encourage to drink at least 1L of fluid to flush the dye. (Black, p 799)
- Following endoscopic retrograde cholangiopancreatography (ERCP), the nurse would give priority in which of the following action?
- Monitoring closely for urinary output
- Assessing for return of gag reflex
- Applying pressure to the insertion site
- Placing the client flat in bed for 8 hours
Rationale: B. Post-procedure, the client must be monitored for return of gag reflex since a throat spray and sedative is administered prior to the procedure. (Saunders, p. 680)
- Which of the following client complains would alert the nurse for possible complications after ERCP?
- Profuse sweating and pallor
- Abdominal bloating
- Nausea and vomiting
- Bradycardia and indigestion
Rationale: Vomiting after ERCP may suggest ERCP-induced pancreatitis or perforation. (NSNA, p. 105)
- A client admitted with frequent UTI is scheduled for an IVP. In preparation for the procedure the nurse would carry out which action?
- Collecting a 24 hour urine specimen
- Administration of laxative
- Providing a soft, bland diet 6:00 pm the preceding evening
- Giving of radiopaque tablets in the morning before the x-ray
Rationale: B. laxatives are used prior to an IVP to evacuate the bowel and provide for better visualization of the kidney. Client is NPO after midnight and radiopaque dye is given IV not as tablets. (Black, p. 799)
- Immediately following liver biopsy, which of these measures should be included in the patient’s care plan?
- Applying an abdominal binder
- Having the patient lie on the operative side with pillow underneath
- Placing sandbag on the injection site
- Positioning patient in left lateral during procedure
Rationale: B. Placing the patient on the right side with pillow under the coastal margin decreases the risk of hemorrhage. (Saunders Comprehnsive © 2005, p. 681)
- An emaciated requires TPN to provide adequate nutrition. The nurse finds the TPN bag empty. Which fluid would the nurse hang temporarily until another bag is prepared in the pharmacy?
- Lactated Ringers solution
- 0.9% saline solution
- 10% Dextrose in water
Rationale: C. Maintaining an infusion of 10% dextrose reduces the risk of developing hypoglycemia. TPN should not be discontinued abruptly and must be tapered. D10W is a preferred solution to prevent complications of sudden lack of glucose. (Saunders © 2005, p. 141)
- A nurse planning to ambulate a visually impaired client would assist the client by
- Positioning beside the client while holding into the client’s arms
- Positioning in front of the client while holding the client’s arm
- Positioning in front of the client while the client holds the nurses’ arm
- Positioning to the side and slightly in front of the client while the client holds in the nurses’ arm
Rationale: D. The nurse can best assist a blind client with ambulation by walking slightly in front and to the side of him. Allowing the cleitn to into the nurses’ arm provides for the client to have some control. (NCLEX-CRAM, 460)
- A patient says to the nurse, “I never had a mammogram. What will be done during the procedure?” The nurse response would include which of the following statement?
- “An ultrasound sensor will be placed over your breast during the procedure.”
- “A radiopaque dye will be injected into your breast prior to the procedure.”
- “A compression plate is placed on the breast and you have to hold your breath.”
- “You have to lie flat while a radiograph view of your breast is taken.”
Rationale: C. Mammography is used as a screening test for breast cancer. During the procedure the patient stands and is asked to rest one of her breast on a table above an X-ray cassette. The compression plate is place on the breast and is told to hold her breath. (Lippincott Nsg Manual: Diagnostic © 2007, p. 284)
- Which of the following statement made by the newly hired nurse shows correct understanding about blood transfusion?
a. “I will give the BT 60 minutes after receiving the blood from laboratory.”
b. “I will infuse 50ml of blood in the 1st 30 minutes.”
c. “I will allow 6 hours for 1 unit of blood to be consumed.”
d. “I will return the blood if not administered within the day.”
Rationale: B. Upon receiving the blood it should be infused as soon as possible (within 20 to 30 minutes) after receiving it from the blood bank. To avoid the risk of septicemia, infusion (1 unit) should not exceed 4 hours. If blood is not administered within 20 to 30 minutes, return it to the blood bank. Infusing 50-1—ml of blood within 15-30 minutes will allow the nurse to evaluate transfusion reaction initially. (Saunders © 2005, p. 165) (Lippincott © 2007, p. 966)
- Patient teaching for a client undergoing EMG pre/post procedure. SATA
__b. Ice pack for hematoma
__c. Sedation if ordered
__d. Informed consent
__e. NPO before procedure
__f. Withhold skeletal muscle relaxants
__g. Alcohol prep to the insertion site
Rationale: BCDFG. Patient preparation post and pre-op for EMG:
- Tell the patient that there are no restrictions on food and fluids.
- Written informed consent must be obtained.
- Withhold medications that may interfere with the result such as cholinergics, anticholinergic, and muscle relaxants.
- Administer sedation if ordered.
- The skin is cleaned with alcohol at the site of electrode placement.
- The patient may experience residual pain.
- Assess needle site for hematomas; apply ice pack to prevent or relieve.
(Lippincott: Diagnostic test © 2007, p. 157) (Mosby Study Guide © 2007, p. 459)(NSNA © 2007, p. 705)
- A staff nurse is admitting a 36-year-old multigravida who has pregnancy-induced hypertension. Which of the following observation made by the staff nurse is consistent with the client’s admitting diagnosis?
- Weight loss
- Facial edema
- Frequent uterine contractions
- Increased respirations
Rationale: B. The three classic signs of PIH are hypertension, generalized edema and proteinuria. (Saunders, p. 285)
- A home care nurse visits a pregnant client who is being monitored for pregnancy-induced hypertension. Which client complains would require the nurse to report immediately?
- “I am experiencing frequent urination.”
- “I am experiencing an abdominal pain.”
- “I am noticing tightness in my wedding ring.”
- “I am loosing weight this past day.”
Rationale: B. Abdominal pain before the onset of labor in a client with PIH may indicate a uteroplacental insufficiency or hypoxia caused by worsening PIH. (Saunders, p. 285)
- A pregnant woman with fetal death in the utero is continuously monitored for DIC. Which of the following assessment may reveal a development of the said complication?
- Vaginal spotting
- Petechial rashes
- Fever and chills
Rationale: C. DIC is caused by a widespread damage to vascular integrity. Any bleeding, such as in the gums, petechiae and purpura is an early signs of DIC and should be reported to the health care provider immediately. (Saunders, p. 291)
- The nurse in the maternity unit is observing for a 36-year-old multigravida who has severe pregnancy-induced hypertension. Which of this action by the staff nurse would require intervention?
- Limiting the patient’s visitor to immediate family members
- Measuring accurate intake and output with each voiding
- Monitoring for fetal heart rate regularly
- Maintaining bed rest in a well-lighted room
Rationale: D. patient with PIH are prone for developing seizure episodes. Maintaingign bed rest in a quiet, dim lighted room decreases stimuli prevents triggering convulsion. (Pilliterri, p. 397)
5. A woman in the delivery room on her first stage of labor is about to receive induction of epidural anesthesia, which of the following statement indicates that the woman understands the procedure?
a. “I will have an IV infusion.”
b. “I will wait for my membranes to rupture before epidural anesthesia is given.”
c. “I have to void prior to the initiation of anesthesia.”
d. “I have to sit and flexed my head forward during catheter insertion.”
Rationale: B. There is no need for membranes to rupture before administering the epidural anesthesia because the goal of giving anesthesia is to minimize pain during contraction. (Lippincott Manual of Nursing © 2007, p. 1222)
- A woman wants to submit herself for MMR vaccination. Which client statement during history taking will require the nurse to withhold the vaccine?
- “I have allergy to penicillin and eggs.”
- “I am currently breastfeeding baby.”
- “My child was given Immunoglobulin 1 month ago.”
- “My latest pregnancy test was positive.”
Rationale: D. MMR is contraindicated to pregnancy. (Saunders © 2005, p. 520)
- In assessing a 75-year-old patient, the nurse is expecting the patient to have an increased in his
- Oral temperature
- Skin elasticity
- Bowel movement
Rationale: A. Physiological changes in older client includes increased susceptibility to hypothermia and hyperthermia, decreased skin turgor, elasticity, and subcutaneous fat, decreased lean body weight and atrophy of muscles, increased tendency towards constipation. (Saunders © 2005, p. 389)
- A nurse assessing a 72-year-old would consider which of the following as normal observation in an elderly?
Increased salt in meals
Reads very near
Decrease systolic/diastolic pressure
Increased lumbar curvature
Rationale: A. Elderly have decreased salivary flow and diminished sense of taste, which may reduce the person’s appetite and increased his consumption of sweet, salty, and spicy foods. Visual acuity changes from nearsightedness to farsightedness in elderly. They are hypertensive but prone to develop postural hypotension. Increased lumbar curvature is associated with osteoporosis. (NSNA © 2007, p. 999)
(Better Elderly Care, p. 6)
3. During a routine physical exam in a geriatric unit, which findings would concern the nurse most?
a. Rounding of thoracic rib cage
b. Increased anteroposterior chest diameter
c. Decrease urine output for 3 days
d. Brown discoloration of the legs
Rationale: D. Brawny discoloration of the legs signifies chronic venous insufficiency. Normal thoracic changes include increased anteroposterior chest diameter (barrel chest), as a result of altered calcium metabolism, and calcification of costal cartilages, which reduces mobility of the chest wall. A person’s renal function may diminish reflected by a decline in the glomerular filtration rate caused by age-related changes in renal vasculature, deceased renal blood flow from decreased cardiac output. In addition, tubular reabsorption and renal concentrating ability decline because the size and number of functioning nephrons decrease causing urine frequency, retention, dribbling, nucturia, incontinence, and dilute urine. (Better Elderly Care, p. 11, 12, 44) (NSNA © 2007, p. 997, 1001)
4. A nurse in the long term facility is formulating preventive protocols for an elderly with high risk for falls. Which of the following is best to institute to achieve the nurses’ goal?
a. Provide the client with slip-resistant shoes and slippers
b. Keep the side rails up
c. Assist the client to bathroom every 4 hours
d. Keeping beds in lowest position
Rationale: D. Keeping the bed in lowest position with the wheels locked or removed provide the least risk. Bed rails are considered environmental barriers because patients attempt to climb out of bed over the side rails. Side rails are good only for short term use and postoperative or sedated patients. (Better elderly care, p. 116)
- Which of the following statements reflects an antisocial personality?
- “I just can’t stop wanting to slash my self.”
- “I can’t get the same thoughts out of my head.”
- “I don’t care if I get others offended.”
- “I can’t live without my husband.”
Rationale: C. Antisocial personality fails to conform to social norms and disregard others. They often violate the rights of other people and are guiltless. (NSNA © 2007, p. 920)
- A nurse caring a teenager with anorexia who plans to implement intervention using behavior modification model would institute which of the following action?
- Encouraging the client to express her feelings until she gains insight about her distorted perception.
- Role playing the client’s interactions with her parents in a therapy session.
- Providing the client with frequent high calorie and protein diet.
- Restricting the client’s privileges until she gains 3 lbs.
Rationale: D. Behavior modification model is an approach that aims to bring about behavioral changes for maladaptive behavior either using negative or positive reinforcement. A stimulus attractive to the client is paired with an unpleasant event to change behavior. (Saunders Comprehensive Review © 2005, p. 1072)
- A depressed client who was admitted to the psychiatric unit for treatment and observation a week ago verbalizes, “I want to donate my organs.” Which of the following is an appropriate response of the nurse?
- “You can’t decide for yourself at the moment.”
- “Are you planning to end your life?”
- “Are there something wrong in your body?”
- “We will try to consult your physician for that matter.”
Rationale: B. Assessment for suicidal ideation, gestures, threats, and actual suicidal attempt or plan is important. Depressed clients are at risk for suicide. The nurse must develop a formal “no suicide” contract, ask if the client is thinking of suicide, and evaluate the client’s method of suicide. (Kaplan, 251)
CD & Precautions
- Which of the following client statement reflects an appropriate understanding about Hepatitis C infection?
- “I will sleep in a separate room with my wife.”
- “I will separate my eating utensils with the rest of the family member.”
- “I will not share my electrical razor with my son.”
- “I need to have a separate comfort room for myself.”
Rationale: C. Hepatitis C is a transmitted via exposure to blood of the infected person. Common modes of transmission are transfusion of contaminated blood products, hemodialysis, tattooing, sexual activity, and organ donation. (NSNA © 2007, p. 118)
- A client reveals a history of eating food contaminated with Salmonella. The nurse anticipated which kind of precaution?
- Hepatis C precaution
- Hepatitis D precaution
- Hepatitis A precaution
- Hepatitis B precaution
Rationale: C. Hepatitis B, C, D, and G are bloodborne hepatitis. Hepatitis A&E are foodborne disease acquired through ingestion of contaminated food or drink including undercooked shellfish from contaminated handler. (NSNA © 2007, p. 118)
- While caring for a child in the emergency room, the nurse notices the client to have an increasing fever, nuchal rigidity, and purpuric lesions. The nurse would immediately perform which of the following action?
a. Instituting seizure precaution
b. Placing the client in a private room and instructing the nurse to wear gown, gloves, and mask
c. Administer prophylactic antibiotic
d. Keep the client’s environment dark and quiet
Rationale: B. All the actions are appropriate and must be carried out immediately, upon suspecting meningitis the nurse must immediately institute precautionary measures and isolation to prevent spread of disease and contamination of other clients. (NSNA © 2007, p. 673)
- A school-age child develops severe neutropenia following chemotherapy for acute lymphocytic leukemia. The nurse caring the child would institute which of the following measures to prevent infection?
a. Ask the child to wear a mask when visitors enter her room.
b. Request that foods be served with disposable utensils
c. Wash IV sites with mild soap and water
d. Provide foods in a sealed single-serving packages
Rationale: D. Providing food in a sealed single-serving packages lessens the likelihood of introducing food-borne bacteria to a client with severe immunosuppression. Visitors should be instructed to wear mask and contagious visitors are advised not to visit. Washing the utensils using hot water is enough rather than using disposable one. IV sites should be cleaned with antiseptic solution. (Diseases: A nursing Process Approach to Excellent Care, p. 396-397)
- Which action demonstrate a correct understanding in the care of a child with Haemophilus influenzae infection?
a. Wear surgical mask when bathing the child
b. Wear particulate mask while feeding the child
c. Wearing gown when ambulating the child
d. Wearing gloves when changing the child’s clothes
Rationale: A. Haemophilus influenzae is an example of illness requiring Droplet Precaution. (Lippincott Manual of Nursing © 2007, p. 1036)
- A nurse caring a client with MRSA infection must implement which of the following precaution?
- Disinfecting the thermometer after using
- Wearing gown while taking the blood pressure
- Wiping the bedside table with alcohol preps
- Maintaining droplet precaution
Rationale: B. MRSA is an organism requiring contact precautions that can be transmitted by direct contact by the patient (hand or skin-to-skin contact that occurs when performing patient care activities that require touching the patient’s skin or indirect contact with environmental surfaces of patient care items in the patient’s environment. Gowns prevent contamination of clothing and the skin of personnel. (Lippincott Manual of Nursing © 2007, p. 1036)
- A client who went abdominal surgery taking several antibiotics is admitted with suspected Clostridium difficile infection. The nurse must implement which of the following precautionary measures for the client?
- Wearing gloves in handling bed pans
- Place client in a closed door room
- Maintain spatial separation of at least 3 feet between the client
- Soaking the rectal thermometer of the client in a hypochlorite solution
Rationale: A. Clostridium difficile is an infection requiring contact precaution. Wearing gloves during contact with the client and potentially contaminated environmental surfaces or items in the patient room must be implemented. (Lippincott Manual of Nsg. Practice © 2007, p. 1036)
- All of the following are appropriate infection control precaution in a client with varicella infection, except
a. Placing surgical mask when transporting the client
b. Assigning the client in a closed door private room
c. Maintaining a distance of 3 feet between the client and visitors
d. Using gloves when rendering skin care
Rationale: C. Varicella (chicken pox) is a highly contagious infection contracted via airborne transmission through dessimination of droplet nuclei. Microorganism carried in this manner can be dispersed widely by air currents and may become inhaled by or deposited on a susceptible host within the same room or over a longer distance from the source patient. (Lippincott Manual of Nursing Practice © 2007, p. 1035)
- Botulinum poisoning is ruled out in a client admitted in the intensive care unit with respiratory distress and the physician immediately orders an antitoxin for the client. Prior to the administration the nurse must see to it that
a. Endotracheal tube is inserted in the client
b. Baseline ABG is obtained
c. Epinephrine SQ is administered
d. History of any allergy are documented
Rationale: D. Before giving antitoxin accurate history of allergy especially to horses and performing skin test must be done. Afterward, watch for anaphylaxis or other hypersensitivity reaction as well as serum sickness. Keep epinephrine 1:1,000 (for SQ administration) and emergency equipment available. (Diseases A Nsg. Process Approach to Excellent Care, p. 118)
- A client with CHF is being treated with dopamine hydrochloride (Intropin). The nurse understands that the drug is primarily given to
- Increase heart rate
- Promote peripheral vasodilation
- Increase blood pressure
- Increase myocardial conductivity
Rationale: C. Dopamine acts by stimulating the alpha receptors (positive inotropic action) in the heart causing vasoconstriction thereby increasing the blood pressure, cardiac output and force of myocardial contraction. Renal and peripheral blood flows are also increased. (Saunders Comprehensive Review © 2005, 840; Nursing Drug Handbook © 2003, p. 560)
- Which of the following condition prescribed with Sudafed will require the nurse to withhold the drug?
Rationale: A. Sudafed is an adrenergic (sympathomimetics) which is highly contraindicated in clients with glaucoma, hypertension, cardiac disease, hyperthyroidism, and prostatic hyperplasia. (Nursing Drug Handbook © 2003, p. 566)
- Epidural anesthesia (morphine sulfate) was administered to a woman who undergoes cesarean section 2 hours ago. Which of the following observations will require the nurse to follow-up?
- Patient’s respirations is 13 breaths per minute
- Patient is observed scratching her face and neck
- Patient complains of not feeling anything in the lower extremity
- Patient’s blood pressure gradually declines
Rationale: B. Morphine sulfate is a narcotic analgesic used for severe pain. Patients prescribed with this medication should be watched for CNS depression causing circulatory and respiratory depression. When given epidurally, patient should be watched for pruritus and skin flushing which indicates hypersensitivity to the drug. Withhold dose and notify the physician if RR are below 12 breaths per minute.
Nursing Drug Handbook © 2003, p. 386)
- Pseudoephedrine (Sudafed) is prescribed for a client. Which of the following information noted in the clients record would alert the nurse to question the prescription?
- Pulse rate of 59 bpr
- BP of 150/100 mmHg
- Elevated BUN
- Presence of nasal congestion
Rationale: B. Sudafed is usually prescribed for nasal and Eustachian tube decongestion. This stimulates alpha receptors in the respiratory tract producing vasoconstriction to shrink swollen nasal mucus membranes and increase airway patency. It is contraindicated in clients with hypertension because it may potentiate hypertensive crisis. (Nursing Drug Handbook © 2003, p. 566)
- A nurse observes a client who is taking Prolixin restless and pacing in the hallway. The nurse suspects the client to be experiencing?
- Neuroleptic malignant syndrome
- Tardive dyskinesia
Rationale: C. Prolixin is an antipsychotic medication. Side effects include EPS symptoms like akathisia characterized by restlessness and constant moving of the client. (Saunders Comprehensive Review © 2005, p. 1133)
- A nurse is caring for a client who is taking quetiapine (Seroquel) for paranoid ideations. Which of the following adverse reactions should the nurse assess the client for?
- Dry mouth
Rationale: B. Quetiapine (Seroquel) is an antipsychotic drug that is used for psychotic disorders. Adverse reactions include orthostatic hypotension, headache, tachycardia, constipation, dry mouth, and tardive dyskinesia. (NSNA © 2007, p. 540)
- A client with MI is receiving an infusion if morphine sulfate. Which of the following observation indicates an expected side effect of the drug?
- The client becomes drowsy
- The client is euphoric
- The client experiences excessive salivation
- The client is anxious
Rationale: A. Morphine sulfate is a narcotic opioids and causes CNS manifestations such as drowsiness, to sleep to unconsciousness, decreased mental and physical activity, headache, dizziness, confusion, dysphoria, unusual dreams, hallucinations, and delirium. (NSNA © 2007, p. 1038)
- The nurse caring for a client with congestive heart failure who is just recently prescribed with furosemide (Lasix) 80 mg q 8 hrs. The nurse would be most concern if which of the following is noted?
- Potassium of 2.8 mEq/L
- Sodium of 132 mEq/L
- Calcium of 8.0 mg/dL
- Magnesium of 1.5 mEq/L
Rationale: A. Furosemide (Lasix), a loop diuretic causes hypokalemia, hyponatremia, hypocalcemia, and hypomagnesemia. Hypokalemia must be reported immediately because this predisposes the client to digoxin toxicity. (NSNA © 2007, p. 511)
- A 42-year-old woman who just returned to her room after hysterectomy. She has a PCA. To reduce anxiety regarding receiving adequate pain relief, the nurse would most likely told the client
- PCA ensures effective pain control
- Comfort will be assessed frequently
- Additional IM pain reliever will be available if pain control is inadequate
- PCA delivers the bolus dose per standing order
Rationale: B. Placing the client in PCA does not ensure that the client will be pain free, titrating upward is usually performed under physicians order to keep the client pain free. Frequent assessment of client’s comfort will help assess presence of pain which will determine the next action of the nurse. (Mosby © 2006, p. 15-18)
- The nurse would monitor which of the following electrolyte imbalances in an adult client receiving 10 mg IV infusion of dexamethasone for cerebral edema?
Rationale: Dexamethasone is a long-acting synthetic adrenocorticoid that has an anti-inflammatory and immunosuppression properties. Adverse effects include s/sx of Cushing’s syndrome and hyperglycemia. (Nurses Drug Guide © 2004, p. 454)
- A nurse understands that a client who is allergic to penicillin is contraindicated to which drug?
Rationale: A. Clients who have a known allergy to penicillins are also allergic to cephalosporins. (Nurses Drug Handbook © 2004, p.267)
- Which of the following activities is appropriate for the nurse to suggest in a client taking alendronate sodium (Fosamax)?
- Tell the patient to read newspaper 30 minutes after taking the drug
- Tell the patient to lie for 30 minutes while watching television
- Tell the patient elevate foot for 30 minutes
- Tell the patient to avoid walking for at least 30 minutes
Rationale: A. Patient should be encouraged to sit upright or ambulate for 30 minutes after taking the drug to prevent reflux that causes esophageal irritation. (Nurses Drug Handbook © 2004, p. 28-29)
- Which of the following nursing intervention is most important to perform in a client receiving magnesium sulfate?
- check deep tendon reflex
- monitor respiratory rate
- check apical pulse
- check BP
Rationale: B. Magnesium sulfate causes CNS depressant and muscle relaxation. Checking respiratory rate is very important because clients are at risk for cardiac arrest and respiratory depression. (NSNA © 2007, p.810)
- Which of the following is appropriate to instruct in a client taking Cholestyramine?
- Monitor bowel habits for episodes of diarrhea
- Increase intake of low residue foods
- Take the drug after a meal
- Encourage drinking a pulpy fruit juice
Rationale: D. Cholestyramine is an antilipemic prescribed for reducing elevated cholesterol levels. This drug can predispose to constipation, thus increasing fluids and high fiber foods must be instructed. Taking the drug with meal is the recommended instruction for achieving the desired effect. (Nursing Drug Handbook, p. 313)
- Which of the following are considered as actions of Aspirin? SATA
__f. Anti-platelet aggregator
Rationale: ABDF. Aspirin and other salicylates are thought to produce analgesia by blocking generation of pain impulses. It is thought to relieve fever by central action in the hypothalamic heat-regulating center. Exerts an anti-inflammatory effect by inhibiting prostaglandin synthesis. In lower doses, aspirin also appears to impede the clotting by blocking prostaglandin synthesis which prevents formation of the platelet aggregating substances. (Nsg. Drug Handbook, p.343)
- A home health nurse visiting a stroke client receiving coumadin (Warfarin) discovered that the client is self-medicating with herbal remedies like garlic. Which of the following observation would the nurse expect as an effect of the client’s action?
- Rebound hypertension
- Sleep disorder or insomnia
- Bleeding in the gums
- Frequent respiratory tract infection
Rationale: C. Garlic increases the risk of bleeding especially if used together with anticoagulant. (Nursing Drug Handbook, p. 1290)
- To achieve best effect of steroid therapy in a client with adrenalectomy, the nurse would recommend to
- Take the half dose in the morning and another half in the evening before sleep
- Take 2/3 of a dose in the morning and the remaining 1/3 in the early afternoon
- Take 1/3 of a dose in the morning and the remaining 2/3 in the evening
- Take the full dose once a day preferably in the morning
Rationale: B. Advising the client in this way of taking the drug mimic the diurnal adrenal secretion in a normal person. (Disease: A Nsg. Process Approach to Excellent Care: p, 1105)
- The nurse is caring for a client with bladder cancer who is receiving doxorubicin (Adriamycin) as a component of her chemotherapy. Which of the following should be reported to the physician immediately indicating the toxic effects of the drug?
- Elevated BUN and dry flacky skin
- Rales and distended neck veins
- Red discoloration of the urine and a output of 75 ml the previous hour
Rationale: C. This drug can cause cardiotoxicity exhibited by changes in ECG and CHF. Rales and distended neck veins are clinical manifestations of CHF. (Nsg. Drug Handbook, p. 939)
- A nurse reads the doctor’s order as follow, “Give ropinirole (Requip) 0.25 mg PO tid”. The nurse know that this drug is primarily given to treat
- Parkinsonian symptoms
- Rheumatic arthritis
- Paget’s disease
Rationale: A. ropinirole (Requip) is a selective agonist for dopamine D2 receptors binding at D3 receptor that contributes to antiparkinsonian effects. It decreases symptoms of Parkinsonian disease (involuntary movements). (Mosby’s Drug Guide © 2007, p. 833)
- Which of the following side effects of Oxytocin (Synthocinon / Pitocin) should be prioritized 1st”
- water intoxication
- uterine inversion
- Cardiac dysrhythmias
- Rebound hypertension
- Uterine hypertonicity
Rationale: Page 354 of Saunders 2005
- Which of the following are the Side effects of Oxytocin (synthocinon/ Pitocin):
- water intoxication
- uterine inversion
- Cardiac dysrhythmias
- Rebound hypertension
- Uterine hypertonicity
Rationale: Page 354 of Saunders 2005
- All of the following are side effects of Calcium channel blockers: EXCEPT:
- AV block
- Peripheral edema
- Reflex tachycardia
Saunders 2005 page 837-838
- All of the following are anti-consultants except:
Saunders 2005 981-982
- Which of the following side effects of Phenytoin (Dilantin) should be prioritized?
- gingival hyperplasia
- blood dyscracia
- crystallization in the IV tubings
- pinkish urine
Saunders 2005 page 981-982
- Which of the following side effects of Phenytoin Dilantin . SELECT ALL THAT APPLIES:
- gingival hyperplasia
- blood dyscracia
- crystallization in the IV tubings
- pinkish urine
- red orange urine
Saunders 2005 page 981-982