General Nursing Board 101 Medical Surgical Nursing Pre-test 1 http://nsgbrd101.proboards.com/index.cgi?

i?board=answers&action=display&thread=11 Medical Surgical Nursing Pre-test 1 Post by admin on Aug 18, 2010, 1:19pm 1. If parents or legal guardians aren't available to give consent for treatment of a life-threatening situation in a minor child, which of the following statements is most accurate? a.)Consent may be obtained from a neighbor or close friend of the family. b.)Consent may not be needed in a life-threatening situation. c.)Consent must be in the form of a signed document; therefore, parents or guardians must be contacted. d.)Consent may be given by the family physician. B. RATIONALE: In emergencies, including danger to life or possibility of permanent injury, consent may be implied, according to the law. Parents have full responsibility for the minor child and are required to give informed consent whenever possible. Verbal consent may be obtained. 2. You're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which room arrangements would be best for this client? a.)In isolation off a side hallway b.)A private room near the nurses' station c.)A room with another child who also has meningitis d.)A room with two toddlers who have croup B. RATIONALE: With meningitis, the child should be isolated for the first day but be close to where he can be observed frequently. In isolation off a side hallway is too far away for frequent observation. Putting the client in a room with another child who has meningitis or with two toddlers who have croup present an infectious hazard to the other children. 3. Which of the following points should a team leader consider when delegating work to team members in order to conserve time? a.)Assign unfinished work to other team members. b.)Explain to each team member what needs to be done. c.)Relinquish responsibility for the outcome of the work. d.)Assign each team member the responsibility to obtain dietary trays. B. RATIONALE: When all team members know what needs to be done, they can work together on the most efficient plan for accomplishing necessary tasks. Delegation can be flexible, ranging from telling a staff member exactly what needs to be done and how to do it to allowing team members some freedom to decide how best to carry out the tasks. Assigning unfinished work to other team members and assigning each team member the responsibility to obtain dietary trays don't allow for input from team members. It's the team leader's job to maintain responsibility for the outcome of a task. 4. The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless: a.)the client is mentally ill. b.)the client refuses to give informed consent. c.)the client is in an emergency situation. d.)the client asks the nurse to give substituted consent. C. RATIONALE: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. Even though a client who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent. 5. The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as: a.)a quality improvement issue. b.)an ethical dilemma.

c.)an informed consent problem. d.)a risk-management incident. D. RATIONALE: The nurse should treat this episode as a risk-management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident. 6. The nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What's the appropriate action for the nurse to take? a.)Speak to the manager and document in writing all concerns related to the assignment. b.)Refuse the assignment. c.)Ignore the assignment and leave the unit. d.)Trade assignments with another nurse. A. RATIONALE: When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice. 7. The nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves aren't necessary unless the client is known to have tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse to take? a.)Ignore it because it isn't directly the nurse's problem b.)Document the problem in writing for the manager. c.)Talk to other staff members to ascertain their practices. d.)Instruct the clients to remind this colleague to wear gloves. B. RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards. 8. An adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney stating that the nurse has committed an intentional tort. Which intentional tort has this nurse committed? a.)Fraud b.)Defamation of character c.)Assault and battery d.)Breach of confidentiality D. RATIONALE: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment. 9. A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should: a.)call the facility's attorney. b.)inform the client's family. c.)complete an incident report. d.)do nothing because the client's condition is stable.

C. RATIONALE: The nurse should file an incident report. Incident reports highlight areas of potential liability. It's then the risk manager's responsibility to notify the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option. 10. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: a.)encourage the client to ask questions about personal sexuality. b.)provide time for privacy. c.)provide support for the spouse or significant other. d.)suggest referral to a sex counselor or other appropriate professional. D. RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling. 11. The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation? a.)The nurse may assign the two nonprofessionals to work independently with a client assignment. b.)The nurse is responsible to supervise assistive personnel. c.)Nonprofessionals aren't responsible for their own actions. d.)Nonprofessionals don't require training before they work with clients. B. RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform. 12. Each state has guidelines that regulate the different levels of nursing & licensed practical or vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of practice for nurses are known as: a.)consent to treatment. b.)client's bill of rights. c.)nurse practice acts. d.)licensure requirements. C. RATIONALE: Each state has a nurse practice act that defines the scope of nursing practice within the state. Consent to treatment refers to informed consent for a treatment or procedure. The client's bill of rights defines the rights of clients. Licensure requirements are constructed by the state board of nursing to set standards for receiving a nursing license. 13. A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to: a.)detain him until he signs the paperwork. b.)detain him until his physician arrives. c.)call security for assistance. d.)let him leave. D. RATIONALE: The nurse is obligated to let him leave. Detaining him in any form is a violation of the patient's bill of rights. 14. A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn't: a.)properly educated this client about safety measures. b.)restrained the client. c.)documented that she left the client. d.)arranged for continual care of the client. D. RATIONALE: By leaving the client, the nurse is at fault for abandonment. The better course of action is to

turn on the call bell or elicit help on the way to the client's room. Educating the client about safety measures doesn't alleviate the nurse from responsibility for ensuring the client's safety. The nurse can't restrain the client without a physician's order and restraints won't ensure the client's safety. Documenting that she left the client doesn't excuse the nurse from her responsibility for ensuring the client's safety. 15. When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be: a.)allowing the family to see a newly admitted client. b.)ambulating the client in the hallway. c.)administering pain medication. d.)placing wrist restraints on the client. C. RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity is on the second layer. Safety is on the third layer. Love and belonging are on the fourth layer. 16. When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship: a.)at discharge. b.)during the first meeting. c.)at the midpoint of the relationship. d.)when the client demonstrates the ability to function independently. B. RATIONALE: When initiating a therapeutic relationship with a client, preparation for termination of the relationship should begin during the first meeting. For example, the nurse should introduce herself to the client and tell him exactly when she'll be involved in his care. This sets the boundaries of the relationship. In the middle and at discharge of care, the relationship may be too involved to end abruptly without warning. The client's ability to function independently isn't the deciding factor in preparing the client for the termination of the therapeutic relationship. 17. To be effective, a clinical nurse-manager in a managed care environment must: a.)expect all staff to accept change. b.)go along with a proposed change. c.)be a catalyst for change. d.)document staff nurses' reactions to change. C. RATIONALE: The clinical nurse-manager is responsible for making things happen, not just letting things happen. She must be more than a role model who goes along with change & she must also encourage change and support staff during change. Documentation of the nurses' reactions to change can be threatening and serves no purpose in helping change to occur. 18. In community-based nursing, primary responsibility for decisions related to health care belongs to the: a.)nurse. b.)client. c.)health care team. d.)physician. B. RATIONALE: The client is primarily responsible for health care decisions in community-based nursing. The nurse assists with monitoring of health treatment and teaching and intervenes only as needed after assessing the client's ability to follow a regimen. The health care team collaborates on decisions related to treatment. The physician dictates medical orders related to treatment and medication. 19. A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is most likely to be held liable? a.)No one because it was an accident b.)The hospital c.)The nurse d.)The nurse and the hospital D. RATIONALE: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, both the nurse and the hospital are liable. Although the mistake wasn't intentional, standard procedure wasn't followed.

20. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to: a.)change his own dressing. b.)walk in the hallway. c.)walk from his room to the end of the hall and back before discharge. d.)eat a special diet. C. RATIONALE: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case. 21. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client? a.)Tell him that it's a legal question beyond the scope of nursing practice. b.)Give him a copy of the client's bill of rights. c.)Provide information on active euthanasia. d.)Discuss documenting his wishes in an advance directive. D. RATIONALE: Advance directives give a competent client control over his situation and a legal forum in which to express his wishes about his care. Discussion of advance directives isn't outside the scope of nursing practice. The client's bill of rights involves multiple client rights and doesn't provide detailed information about advance directives. Active euthanasia is illegal. 22. While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to: a.)document findings thoroughly. b.)question the client about the bruising. c.)inform appropriate local authorities. d.)tell the client's physician. C. RATIONALE: This client may be experiencing elder abuse based on her history and symptoms. Authorities to be notified may include local social service or law enforcement agencies. The nurse should also document findings and include illustrations to support the assessment. The client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the physician may not be sufficient for fulfilling the nurse's legal responsibility. 23. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource can best help the client adapt to the disease? a.)The client's family b.)Pastoral care c.)Support group .)Hospice care C. RATIONALE: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease-related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life. 24. A client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time? a.)Approach the client's family about organ donation. b.)Make the decision to withdraw life support. c.)Sedate the client. d.)Talk to the staff about their feelings. A. RATIONALE: The most appropriate nursing intervention is to discuss organ donation with the family. The decision to withdraw life isn't within a nurse's scope of practice. Because the client is brain-dead, he doesn't need sedation. Although talking to the staff is a viable strategy for staff decompression, it isn't the first action to take.

25. A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? a.)Social worker b.)Registered dietitian c.)Occupational therapist d.)Enterostomal nurse therapist D. RATIONALE: An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence with activities of daily living. 26. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which intervention should the nursing care plan include? a.)Check on the client once per shift. b.)Provide mouth and skin care only if the family requests it. c.)Turn the client only if he's uncomfortable. d.)Provide emotional support and pain relief. D. RATIONALE: When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers. 27. The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the registered nurse understands that the unlicensed assistant: a.)interprets clinical data. b.)collects clinical data. c.)is trained in the nursing process. d.)can function independently. B. RATIONALE: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. The registered nurse has learned critical thinking skills and is able to interpret the clinical findings. Unlicensed assistants are trained to perform skills & they don't learn the nursing process. Unlicensed assistants don't function independently & they're assigned tasks by a registered nurse who retains overall responsibility for the client. Other nursing responsibilities when delegating tasks to unlicensed assistants include knowing the institutions policies regarding delegation, knowing the assistant's training, knowing the client's needs, receiving frequent updates from the assistant, asking specific questions, and making frequent rounds of clients. 28. A nurse on a medical-surgical floor is making assignments for an 8-hour shift. Which of the following considerations has the highest priority? a.)Complexity of care required b.)Age of the clients c.)Skills of the assigned personnel d.)The number of clients C. RATIONALE: The nurse is legally responsible for assigning personnel according to skill level. All of the other factors are important but don't take priority. 29. The nurse is caring for a homeless client with active tuberculosis. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which intervention will best ensure that the client complies with treatment? a.)Referring the client to a social worker for discharge planning b.)Providing individualized client education

c.)Having the client attend a formal education session d.)Attempting to contact a member of the client's family to provide assistance A. RATIONALE: Referring the client to a health care professional with knowledge of community resources is the best intervention to ensure compliance in a homeless client. Educating the client about his condition may help, but basic needs for shelter, food, and clothing must be met first. Providing formal education and attempting to contact family members are inappropriate when seeking to help a homeless client. 30. The nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What's a critical pathway? a.)A nursing care plan that helps the nurse to decide which intervention to perform first b.)A multidisciplinary care plan that helps the nurse to use a variety of critical interventions c.)A standardized care plan that lists basic interventions for the nurse to use with every client d.)A clinical management tool that organizes the major interventions for a multidisciplinary health care team D. RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions. They set forth expectations for interventions, outcomes, and client progression. Elements of the nursing care plan are commonly folded into the critical pathway. The descriptions of standardized and multidisciplinary plans of care don't adequately describe the critical pathway. Because the critical pathway is standardized and multidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client.

General Nursing Board 101 Medical Surgical Nursing Pre-test 2 http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=12 Medical Surgical Nursing Pre-test 2 Post by admin on Aug 18, 2010, 1:20pm 1. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride a. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. b. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. c. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. d. Is an angiotensin-converting enzyme (ACE) inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II. Ans: A propranolol is b-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction. 2. The nurse understands that a priority nursing diagnosis for the client with hypertension would be a. Pain. b. Deficient Fluid Volume. c. Impaired skin integrity. d. Ineffective health maintenance. Ans: D managing hypertension is a priority for the client with hypertension. Clients with hypertension frequently do not experience other signs and symptoms such as pain, deficient fluid volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat, because clients may not recognize they are hypertensive or may not perceive the need for aggressive management of the disease. 3. The most important long-term goal for a client with hypertension would be to a. Learn how to avoid stress. b. Explore a job change or early retirement. c. Make a commitment to long-term therapy. d. Control high blood pressure.

Ans: C compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without during therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance. 4. The client with hypertension is prone to long-term complications of the disease. Which of the following is a long-term complication of hypertension? a. Renal insufficiency and failure. b. Valvular heart disease. c. Endocarditis d. Peptic ulcer disease. Ans: A renal disease, including renal insufficiency and failure is a complication of hypertension. effective treatment of hypertension assists in preventing this compliance valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension. 5. Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of a. Cerebrovascular accidents (CVAs) b. Liver disease. c. Myocardial infarction. d. Pulmonary disease. Ans: A hypertension is referred to as the silent killer for adults, because until the adult has significant damage to others systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infraction is generally related to coronary artery disease. 6. During the past few months, a 56-year old woman has felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friends apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? a. Visit her friend b. Rest for at least an hour before climbing the stairs c. Take a nitroglycerin tablet before climbing the stairs. d. Lie down once she reaches the friends apartment. Ans: C nitroglycerin may be used prophylactically before stressful physical activities such as stair-climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode. 7. The client who experiences angina pectoris has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low cholesterol diet? a. Hamburger, salad, and milkshake. b. Baked liver, green beans, and coffee. c. Spaghetti with tomato sauce, salad, and coffee d. Fried chicken, green beans, and skim milk Ans: C pasta, tomato sauce, salad, and coffee would be the best selection for the client following a lowcholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol. 8. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? a. A change in the pattern of her pain b. Pain during sexual activity c. Pain during an argument with her husband d. Pain during or after an activity such as lawn mowing Ans: A the client should report a change in the pattern of chest pain. It may help increasing severity of coronary artery disease. Pain occurring during stress or sexuality activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent

this pain or may be restricted from doing such activities. 9. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: a. Open and dilate blocked coronary arteries b. Assess the extent of arterial blockage c. Bypass obstructed vessels d. Assess the functional adequacy of the valves and heart muscle Ans: B cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage. 10. The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA would include: a. Minimizing dyspnea b. Maintaining adequate blood pressure control c. Decreasing myocardial contractility d. Preventing fluid volume deficit Ans: D because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility. 11. Which of the following is not generally considered to be a risk factor for the development of atheroclerosis? a. Family history of early heart attack b. Late onset of puberty c. Total blood cholesterol level greater than 220 mg/dL d. Elevated fasting blood sugar concentration Ans: B late onset of puberty is not generally considered to be a risk factor of the development of atherosclerosis. Risk factors for atherosclerosis include cigarette smoking, hypertension, high blood cholesterol level, male gender, family history of atherosclerosis, diabetes mellitus, obesity, and physical inactivity. 12. Many more men than women younger than 50 years of age have coronary artery disease as a result of atherosclerosis. The leading cause of death in women is: a. Acquired immunodeficiency syndrome b. Breast cancer c. Coronary artery disease d. Chronic obstructive pulmonary disease Ans: C coronary artery disease is the leading cause of dearth in women as well as men. Although it is generally agreed that estrogen helps protect women from atherosclerotic changes before menopause, women are still at risk for coronary artery disease. Much attention has been focused on the lack of research studies dealing with cardiac disease in women and minorities, and work is under way to gain a better understanding of cardiac disease in these populations. 13. A client angina asks the nurse, What information does an ECG provide? The nurse would respond that an electrocardiogram (ECG) primarily gives information about the: a. Electrical conduction of the myocardium b. Oxygenation and perfusion of the heart c. Contractile status of the ventricles d. Physical integrity of the heart muscle Ans: A an ECG directly reflects the transmission of electrical cardiac impulses through the heart. This information makes it possible to evaluate indirectly the functional status of the heart muscle and the contractile response of the ventricles. However, these elements are not measured directly. The ECG does not give information about the oxygenation and perfusion of the heart. 14. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg

given sublingually. This drugs principal effects are produced by: a. Antispasmodic effects on the pericardium b. Causing an increased myocardial oxygen demand c. Vasodilation of peripheral vasculature d. Improved conductivity in the myocardium Ans: C nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium. 15. The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: a. Headache b. High blood pressure c. Shortness of breath d. Stomach cramps Ans: A because of its widespread vasodilating effects, nitroglycerin often produces such as side effects as headache, hypotension, and dizziness. The client should sit or lie down to avoid fainting. Nitroglycerin does not cause shortness of breath or stomach cramps. 16. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? a. Take one tablet every 2 to 5 minutes until the pain stops b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes c. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after these tablets d. Take one tablet. If pain still persists 5 minutes later, call the physician Ans: C the correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. 17. A client with angina has been taking nifedipine. The client should be taught to: a. Monitor blood pressure monthly b. Perform daily weights c. Inspect gums daily d. Limit intake of green leafy vegetables Ans: C the client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon side effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables. The Client With A Permanent Pacemaker 18. A 74-year-old woman is admitted to the telemetry unit for placement of a permanent pacemaker would be to: a. Maintain skin integrity b. Maintain cardiac conduction stability c. Decrease cardiac output d. Increase activity level Ans: B maintaining cardiac conduction stability to prevent dysrythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic (ECG) monitoring until proper pacemaker functioning is verified. 19. The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. Outcome criteria include that the client: a. Selects a low-cholesterol diet to control coronary artery disease b. States a need for bed rest for 1 week after discharge c. Verbalizes safety precautions needed to prevent pacemaker malfunction d. Explain sign and symptoms of myocardial infraction Ans: C education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions necessary to maintain proper pacemaker function.

The Client Requiring Cardiopulmonary Resuscitation 20. A rescuer is called to a neighbors home after a 56-year-old man collapses. After quickly assessing the victim, the rescuer determines that the victim is unresponsive. To determine unresponsiveness, the rescuer can: a. Call the victims name and gently shake the victim b. Perform the chin-tilt to open the victims airway c. Feel for any air movement from the victims nose or mouth d. Watch the victims chest for respirations Ans: A calling the victims name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victims airway. Feeling for any air movement from the victims nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victims chest for respirations to see if the victim is breathing. 21. Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which of the following complications? a. Gastrointestinal bleeding b. Myocardial infraction c. Emesis d. Rib fracture Ans: D proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach. 22. The American Heart Association guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for: a. Early defibrillation in cases of atrial fibrillation b. Cardioversion in cases of atrial fibrillation c. Pacemaker placement d. Early defibrillation in cases of ventricular fibrillation Ans: D AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association places major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a toll to increase sudden cardiac arrest survival rates. 23. A client who has been given CPR is transported by ambulance to the hospitals emergency department, where the admitting nurse quickly assesses the clients condition. Of the following observations, the one most often recommended for determining the effectiveness of CPR is noting whether the: a. Pulse rate is normal b. Pupils are reacting to light c. Mucous membranes are pink d. Systolic blood pressure is at least 80 mmHg Ans: B Pupillary reaction is the best indication of whether oxygenated blood has been reaching the clients brain. Pupils that remain widely dilated and do not react to light probably indicate that serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be pink, and systolic blood pressure may be 80 mmHg or higher, and serious brain damage may still have occurred. 24. The client receives epinephrine during resuscitation in the emergency department. This drug is administered primarily because of its ability to: a. Dilate bronchioles b. Constrict arterioles c. Free glycogen from the liver d. Enhance myocardial contractility Ans: D. Epinephrine is administered during resuscitation efforts primarily for its ability to improve cardiac activity. Epinephrine has great affinity for adrenergic receptors in cardiac tissue and acts to strengthen and speed the heart rate as well as to increase impulses conduction from atria to ventricles. Epinephrine dilates bronchioles and constricts arterioles, but these are not the primary reasons for administering it during resuscitation. Epinephrine is not associated with freeing glycogen from the liver. 25. The rescuer understands that the compression-to-ventilation ratio for one-rescuer adult CPR is: a. 5:1

b. 15:1 c. 5:2 d. 15:2 Ans: D With one-rescuer CPR, the compression to ventilation ratio is 15:2. 26. During CPR, the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for laceration by forceful compressions over the xiphoid process? a. Lung b. Liver c. Stomach d. Diaphragm Ans: B Because of its location near the xiphoid process, the liver is the organ most easily damaged from pressure exerted over the xiphoid process during CPR. The pressure on the victims chest wall should be sufficient to compress the heart but not so great as to damage internal organs. Injury may result, however, even when CPR is performed properly. 27. When performing external chest compressions on an adult during CPR, the rescuer should depress the sternum. a. 0.5 to 1 inch b. 1 to 1.5 inches c. 1.5 to 2 inches d. 2 to 2.5 inches Ans: C an adults sternum must be depressed 1.5 to 2 inches with each compression to ensure adequate heart compression. 28. The American Heart Association guidelines for Basic Cardiac Life Support recommend that the rescuer after first establishing unresponsiveness, should: a. Perform CPR for 2 minutes on the adult victim then place a call for emergency assistance b. Place a call for emergency assistance immediately c. Begin rescue breathing for the victim d. Begin CPR on the adult victim and wait until help comes on the scene Ans: B the American Heart Association guidelines for Basic Cardiac Life Support now recommends that the rescuer call for emergency assistance immediately after establishing unresponsiveness in the adult victim. A call for emergency assistance takes places precedence over initiating CPR in the adult victim, in an effort to get emergency personnel and an AED to the scene. Early defibrillation and prompt bystander CPR have increased sudden cardiac arrest survival rates. 29. If the victims chest wall fails to rise with each inflammation when rescue breathing is administered during CPR, the most likely reason is that the: a. Airway is not opened properly b. Victim is beyond resuscitation c. Inflations are being given at too rapid a rate d. Rescuer is using inadequate force for cardiac compression Ans: A if the airway is not opened properly, it is impossible to inflate the lungs during CPR. A common signs of airway obstruction is failure of the victims chest wall to rise with each inflation. The victim should not be considered beyond resuscitation; rather the airway should be opened properly. Inflations may be being given too rapidly. However, this is not the usual cause of not being able to adequately ventilate the victim. If the rescuer is using inadequate force for cardiac compression, it should not interfere with how ventilations are delivered. 30. During rescue breathing in CPR, the victim with exhale by: a. Normal relaxation of the chest b. Gentle pressure of the rescuers hand on the upper chest c. The presence of cardiac compressions d. Turning the head to the side Ans: A the exhalation phase of ventilation is a passive activity that occurs during CPR as part of the normal relaxation of the victims chest. No action by the rescuer is necessary.

General Nursing Board 101 Medical Surgical Nursing Comprehensive http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=13 Medical Surgical Nursing Comprehensive Post by admin on Aug 18, 2010, 1:23pm 1. A 60-year-old male client comes into the emergency department with complaints of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infraction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given intravenously. The nurse should first: a. Administer the morphine b. Obtain a 12-lead ECG c. Obtain the blood work d. Order the chest radiograph Ans: A although obtaining the ECG, chest radiograph, and blood work are all important, the nurses priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is priority action. 2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of the drug is to: a. Help keep him well hydrated b. Dissolve clots that he may have c. Prevent kidney failure d. Treat potential cardiac dysrhythmias Ans: B thrombolytic drugs are administered within the first 6 hours after of myocardial infarction to lyse clots and reduce the extent of myocardial damage. 3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs should the nurse expect to observe? a. Oliguria b. Bradycardia c. Elevated blood pressure d. Fever Ans: A oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typically signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. 4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI. essential nursing action include which of the following? a. Obtaining an infusion pump for the medication b. Monitoring blood pressure every 4 hours c. Monitoring urine output hourly d. Obtaining serum potassium levels daily Ans: A intravenous nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion. 5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused by: a. Left ventricular overload b. Impending circulatory collapse c. Extracellular electrolyte imbalances d. Insufficient oxygen reaching the heart muscle Ans: D an MI interferes with or blocks circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina. 6. Aspirin is administered to the client experiencing an MI because of its:

a. Antipyretic action b. Antithrombotic action c. Antiplatelet action d. Analgesic action Ans: B aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason aspirin is administered to the client experiencing an MI is its antithrombotic action. In clinical trials, the antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI. 7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and oxygen at 2 L/minute. The nurses first course of action should be to: a. Increase the intravenous infusion rate b. Notify the physician promptly c. Increase the oxygen concentration d. Administer a prescribed analgesic Ans: B PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the intravenous infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurses first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability. 8. Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? The client: a. Has minimal chest pain b. Can identify risk factors for MI c. Agrees to participate in a cardiac rehabilitation program d. Can perform personal self-care activities without pain Ans: D by day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to be able to agree to participate in a cardiac rehabilitation program. 9. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased PVCs Ans: B furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease dysrhythmias. 10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This type of exercise is recommended primarily to help: a. Prepare the client for ambulation b. Promote urinary and intestinal elimination c. Prevent thrombophlebitis and blood clot formation d. Decrease the likelihood of decubitus ulcer formation Ans: C although this type of exercise may decrease the likelihood of heel decubitus ulcer form formation, it is taught to the MI client to prevent thrombophlebitis and blood clot formation. Movement of the lower extremities provides muscular action and aids venous return. As a result, the activity helps prevent stasis of blood, which predisposes the client to thrombophlebitis and blood clot formation. This type of exercise is not associated with promoting urinary and intestinal elimination. 11. Which of the following reflects the principle on which a clients diet will most likely be based during the acute phase of MI? a. Liquids as desired b. Small, easily digested meals c. Three regular meals per day d. Nothing by mouth Ans: B recommended dietary principles in the acute phase of MI include avoiding large meals because

small, easily digested foods are better tolerated. Fluids are given according to the clients needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable. 12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely linked to the development of the disease? a. Age b. Medication usage c. High cholesterol levels d. Gender Ans: C high cholesterol levels are considered a controllable risk factor for CAD and appear most clearly linked to the development of the disease. High cholesterol levels can be modified through diet, exercise, and medication. Age and gender are uncontrollable risk factors for CAD. Medication usage is not considered a risk factor for CAD. 13. Which of the following is an uncontrollable risk factor that has been linked to the development of CAD? a. Exercise b. Obesity c. Stress d. Heredity Ans: D heredity has been linked to CAD and is an uncontrollable risk factor. Exercise, obesity, and stress are controllable risk factor for CAD. 14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, technique of behavior modification may be used to help the client change behavior. The nurse can best reinforce new adaptive behaviors by: a. Explaining how the old behavior leads to poor health b. Withholding praise until the new behavior is well established c. Rewarding the client whenever the acceptable behavior is performed d. Instilling mild fear into the client to extinguish the behavior Ans: C a basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward. 15. Alteplase recombinant. Or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of MI to: a. Control chest pain b. Reduce coronary artery vasospasm c. Control the dysrhythmias associated with MI d. Revascularize the blocked coronary artery Ans: D the thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset. 16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to: a. Observe the client for chest pain b. Monitor for fever c. Monitor the 12-lead ECG every 4 hours d. Monitor breath sounds Ans: A although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority, because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever. 17. When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor vital signs and have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? a. Cardiac dysrhythmias b. Hypertension c. Seizure d. Hypothermia Ans: A cardiac dysrhythmias are commonly observed with administration of t-PA. Cardiac dysrhythmias

associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue. 18. Contraindication to the administration of t-PA include which of the following? a. Age greater than 60 years b. History of cerebral hemorrhage c. History of heart failure d. Cigarette smoking Ans: B a past history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications. 19. A client has driven himself into the emergency room. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurses next action would be to: a. Call for the doctor b. Start an intravenous line c. Obtain a portable chest radiograph d. Draw blood for laboratory studies Ans: B advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the intravenous line. 20. Crackles heard on lung auscultation indicate which of the following? a. Cyanosis b. Bronchospasm c. Airway narrowing d. Fluid-filled alveoli Ans: D crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds. 21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness. The first nursing action should be to: a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness b. Administer oxygen via nasal cannula c. Offer pain medication for the chest heaviness d. Inform the physician of the chest heaviness Ans: A further assessments is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician. 22. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? a. Cancer b. Hypertension c. Liver disease d. Myocardial damage Ans: D detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after physician. 23. An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: a. Left ventricular atrophy b. Irregular heart beats c. Peripheral vascular occlusion d. Pacemaker placement Ans: A in older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden able to respond to the increased demands on the myocardial muscle. Decreased cardiac output,

cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adults lifestyle. Peripheral vascular occlusion of pacemaker placement should not affect response to stress. The Client With Heart Failure 24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should be assessed first? a. Blood pressure b. Skin breakdown c. Serum potassium d. Urine output Ans: A it is a priority to assess the blood pressure first, because people with pulmonary edema typically experience severe hypertension that requires early intervention. 25. In which of the following should the nurse place a client with suspected heart failure? a. Semi-sitting (Low Fowlers position) b. Lying on the right side (Sims position) c. Sitting almost upright (High Fowlers position) d. Lying on the back with the head lowered (Trendelenburg position) Ans: C sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowlers position would be used if the client could not tolerate high Fowlers position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg position. 26. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? a. Risk for infection related to line placements b. Impaired skin integrity related to pressure c. Activity intolerance related to imbalance between oxygen supply and demand d. Constipation related to immobility Ans: C activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to line placements or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with heart failure and pulmonary edema, nor is constipation related to immobility. 27. The major goal of therapy for a client with heart failure and pulmonary edema would be to: a. Increase cardiac output b. Improve respiratory edema c. Decrease peripheral edema d. Enhance comfort Ans: A increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema. 28. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to: a. Dilate coronary arteries b. Increase myocardial contractility c. Decrease cardiac dysrhythmias d. Decrease electrical conductivity in the heart Ans: B digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias and does decrease the electrical conductivity of the myocardium, this is not the primary reason for its use in clients with heart failure and pulmonary edema. 29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with

heart failure because it acts as a: a. Vasopressor b. Volume expander c. Vasodilator d. Potassium-sparing diuretic Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure. 30. Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drugs desired effect? a. 5 to 10 minutes b. 30 to 60 minutes c. 2 to 4 hours d. 6 to 8 hours Ans: A after intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously. 31. The nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary reason for this is to help: a. Prevent electrolyte imbalances b. Retard rapid drug absorption c. Excrete excessive fluids accumulated during the night d. Prevent sleep disturbances during the night Ans: D when diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the clients sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night. 32. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse would suspect atrial fibrillation when palpation of the radial pulse reveals: a. Two regular beats followed by one irregular b. An irregular pulse rhythm c. Pulse rate below 60 bpm d. A weak, thready pulse Ans: B characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock. 33. When teaching the client about complications of atrial fibrillation, the nurse understands that the complications can be caused by: a. Stasis of blood in the atria b. Increased cardiac output c. Decreased pulse rate d. Elevated blood pressure Ans: A atrial fibrillation occurs when the sinoatrial node no longer functions as the hearts pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate. 34. The nurse should teach the client that signs of digitalis toxicity include which of the following? a. Skin rash over the chest and back b. Increased appetite c. Visual disturbances such as seeing yellow spots d. Elevated blood pressure Ans: C colored vision and seeing yellow spots are symptoms of digitalis toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digitalis toxicity. Additional signs of toxicity include dysrhythmias, such as atrial fibrillation or bradycardia. Skin rash, increased appetite, and elevated blood

pressure are not associated with digitalis toxicity. 35. The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels indicate that the client has a: a. Low sodium level b. High glucose level c. High calcium level d. Low potassium level Ans: D a low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. 36. Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-g sodium diet? a. Apples b. Tomato juice c. Whole wheat bread d. Beef tenderloin Ans: B canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet, canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice. 37. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic should be encouraged to eat such foods as bananas, orange juice, and, a. Spinach b. Skimmed milk c. Baked chicken d. Brown rice Ans: A foods rich in potassium include bananas, orange juice, and green leafy vegetables such as spinach. Honeydew melon, cantaloupe, and watermelons are also rich in potassium. Other good sources of potassium are grapefruit juice, nectarines, potatoes, dried prunes, raisins, and figs. Skimmed milk, baked chicken, and brown rice are not considered high in potassium. 38. The nurse finds the apical impulses below the fifth intercostals space. The nurse suspects a. Left atrial enlargement b. Left ventricular enlargement c. Right atrial enlargement d. Right ventricular enlargement Ans: B - a normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostals space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostals space or lateral to the midclavicular line may indicate left ventricular enlargement. 39. The nurse is admitting a 69-year old man to the clinical unit. The client has a history of left ventricular enlargement. During the assessment the nurse notes +3 pitting edema of the ankles bilaterally. The client does not have chest pain. The nurse observes that the client does have dyspnea at rest. The nurse infers that the client may have a. Arteriosclerosis b. Congestive heart failure c. Chronic bronchitis d. Acute myocardial infarction Ans: B peripheral edema is a symptom of congestive heart failure. Congestive heart failure results when the heart chronically pumps against increased resistance or is unable to contract forcefully to pump the blood out into the systemic circulation. As a result, the ventricles become overfilled and there is an accumulation of volume within the closed system. The clients symptoms do not indicate arteriosclerosis, chronic bronchitis, or acute MI. 40. The nurses discharge teaching plan for the client with congestive heart failure would stress the significance of which of the following? a. Maintaining a high-fiber diet b. Walking 2 miles every day c. Obtaining daily weights at the same time each day

d. Remaining sedentary for most of the day Ans: C Congestive heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 pounds or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet id beneficial, but it is not relevant to the teaching needs of the client with congestive heart failure. Prescribing an exercise program for the client, such as walking 2 miles everyday, would not be appropriate at discharge. The clients exercise program would need to be planned in consultation with the physician and based on his history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not pre-lifestyle should not be recommended. 41. A 70-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the clients childhood health history included: a. Chicken pox b. Poliomyelitis c. Rheumatic fever d. Meningitis Ans: C Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chicken pox, poliomyelitis, and meningitis are not associated with mitral stenosis. 42. A client experiences some initial signs of excitation after having an intravenous infusion of lidocaine hydrochloride started. The nurse would assess that the client is demonstrating a typical adverse reaction to lidocaine hydrochloride when the client complains of: a. Palpitations b. Tinnitus c. Urinary frequency d. Lethargy Ans: B Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, convulsions, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine hydrochloride. 43. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary capillary wedge pressures. The purpose of this is to help assess the: a. Degree of coronary artery stenosis b. Peripheral arterial pressure c. Pressure from fluid within the left ventricle d. Oxygen and carbon dioxide concentrations in the blood Ans: C the pulmonary artery pressures are used to assess the hearts ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricular end-diastolic pressure and guides the physician in determining fluid management for the client. The degree of coronary artery stenosis is assessed during a cardiac catheterization. The peripheral arterial pressure is assessed with an arterial line. The oxygen and carbon dioxide concentrations in the arterial blood can be measured by an arterial blood gas determination. 44. Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? a. Exertional dyspnea b. Confusion c. Elevated creatine phosphokinase concentration d. Chest pain Ans: A weight gain due to fluid retention and worsening heart failure cause exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward to the pulmonary veins, capillaries, and arterioles and eventually to he right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow. Confusion, elevated creatine phosphokinase concentration, and chest pain are not typically associated with mitral regurgitation. 45. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with

congestion in the: a. Aorta b. Right atrium c. Superior vena cava d. Pulmonary circulation Ans: D when mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure. functioning of the aorta, right atrium, and superior vena cava is not immediately influenced by mitral stenosis. 46. Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the clients past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client? a. Medication therapy b. Diet modification c. Activity restrictions d. Dental care Ans: A preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does. 47. In preparing the client and the family for a postoperative stay in the intensive care unit after open heart surgery, the nurse should explain that: a. The client will remain in the intensive care unit for 5 days b. The client will sleep most of the time while in the intensive care unit c. Noise and activity within the intensive care unit are minimal d. The client will receive medication to relieve pain Ans: D management of postoperative pain is priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the intensive care unit as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery. 48. A client who has undergone a mitral valve replacement experiences persistent bleeding from the surgical incision during the early postoperative period. Which of the following pharmaceutical agents should the nurse be prepared to administer to this client? a. Vitamin C b. Protamine sulfate c. Quinidine sulfate d. Warfarin sodium (Coumadin) Ans: B protamine sulfate is used to help combat persistent bleeding in a client who has had open heart surgery. Vitamin C and quinidine sulfate do not influence blood clotting. Warfarin sodium is an anticoagulant, as is heparin, and these two agents would tend to cause the client to bleed even more. 49. The most effective measure the nurse can use to prevent wound infection when changing a clients dressing after coronary artery bypass surgery is to: a. Observe careful handwashing procedures b. Cleanse the incisional area with an antiseptic c. Use prepackaged sterile dressings to cover the incision d. Place soiled dressings in a waterproof bag before disposing of them Ans: A many factors help prevent wound infections, including washing hands carefully, using the sterile prepackaged supplies and equipment, cleansing the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful handwashing is also important in helping reduce other infections often acquired in hospitals, such as urinary tract and respiratory system infections.

50. For a client who excretes excessive amounts of calcium during the postoperative period after open surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? a. Ensure a liberal fluid intake b. Provide an alkaline-ash diet c. Prevent constipation d. Enrich the clients diet with dairy products Ans: A in an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi. 51. The nurse teaches the client who is receiving warfarin sodium that: a. Partial thromboplastin time values determine the dosage of warfarin sodium b. Protamine sulfate is used to reverse the effects of warfarin sodium c. The international normalized ration (INR) is used to assess effectiveness d. Warfarin sodium will facilitate clotting of the blood Ans: C - the INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodiums anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots. 52. Good dental care is an important measure in reducing risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: a. A manual toothbrush b. An electric toothbrush c. An irrigation device d. Dental floss Ans: A daily dental care and frequent checkups by a dentist who is informed about the clients condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis. 53. Before a clients disease discharge after mitral valve replacement surgery, the nurse should evaluate the clients understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month-old postdischarge appointment with the surgeon? a. Showering b. Lifting anything heavier than 10 pounds c. A program of gradually progressive walking d. Light housework Ans: B most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge. 54. Three days after mitral valve surgery, a 45-year-old woman comments that she hears a clicking noise coming from her chest and her rather large chest incision. The nurses response should reflect the understanding that the client may be experiencing which of the following? a. Anxiety related to altered body image b. Anxiety related to altered health status c. Altered tissue perfusion d. Lack of knowledge regarding the postoperative course Ans: A verbalized concerns from the client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the

changes in her body image. The client is not concerned about altered tissue perfusion. The Client With Hypertension 55. An industrial health nurse at a large printing plant finds a male employees blood pressure to be elevated on two occasions 1 month apart and refers him to his provide physician. The employee is about 25 pounds overweight and has smoked a pack of cigarettes daily for more than 20 years. The clients physician prescribes atenolol for the hypertension. The nurse should instruct the client to: a. Avoid sudden discontinuation of the drug b. Monitor the blood pressure annually c. Follow a 2-g sodium diet d. Discontinue the medication if severe headaches develop Ans: A atenolol is b-adrenergic antagonists indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a doctors order. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension. 56. The nurse teaches her client, who has recently been diagnosed with hypertension, about his dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the clients? a. Mixed green salad with blue cheese dressing, crackers, and cold cuts b. Ham sandwich on rye bread and an orange c. Baked chicken, an apple, and a slice of white bread d. Hot dogs, baked beans, and celery and carrot sticks Ans: C processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both and fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement\ with clients who are basically asymptomatic. 57. A clients job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following? a. Muscle aches b. Thirst c. Lethargy d. Postural hypotension Ans: D possible dizziness from postural hypotension when rising a crouched or bent position increases the clients risk of being injured by the equipment. The nurse should assess the clients blood pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle aches, or thirst from working in a warm, dry room, but these are not as potentially dangerous as postural hypotension. The client should not be experiencing lethargy. 58. An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program? a. Giving the client a written exercise program. b. Explaining the exercise program to the clients spouse. c. Reassuring the client that he or she can do the exercise program. d. Tailoring a program to the clients needs and abilities. Ans: D tailoring or individualizing a program to the clients lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the clients spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program. 59. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? a. Review the negative effects of smoking on the body. b. Discuss the effects of passive smoking on environmental pollution. c. Established the clients smoking pattern. d. Explain how smoking worsens high blood pressure. Ans: C - a plan to reduce or stop smoking begins with establishing the clients personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risk, but this knowledge has not been shown to help clients change their smoking

behavior. 60. Essential Hypertension would be diagnosed in a 40-year-old man whose blood pressure readings were consistently at or above which of the following? a. 120/90 mmHg b. 130/85 mmHg c. 140/90 mmHg d. 160/80 mmHg Ans: C Heart Center of the Philippines standards define hypertension as a consistent systolic blood pressure level greater than 140 mmHg and a consistent diastolic blood pressure level greater than 90 mmHg.

General Nursing Board 101 PREBOARD Nursing Practice 3 (PART 1) http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=19 PREBOARD Nursing Practice 3 (PART 1) Post by admin on Aug 18, 2010, 1:42pm 1. After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis? a.)Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact b.)Parents' active participation in child's physical or emotional care c.)Parents' failure to use available support systems or agencies to assist in coping d.)Evidence of adaptation to parental role changes C. RATIONALE: A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis. 2. An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation? a.)Ask the parents not to visit the child until he has adjusted to the new environment. b.)Ask the physician to explain to the child why he needs to stay in the health care facility. c.)Explain to the child that he must act like an adult while he's in the facility. d.)Have the parents stay with the child and participate in his care. D. RATIONALE: Allowing the parents to stay and participate in the child's care can provide support to the parents and the child. The other interventions won't address the client's diagnosis and may exacerbate the problem. 3. A 13 year old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: a.)send the child home to recover. b.)inspect the child for uneven shoulder height or uneven hip height. c.)arrange for the child to have spinal X-rays as soon as possible. d.)ask the child's parent to take him to a physician immediately. B. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child. 4. The nurse is caring for a child who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report: a.)pain at the injection site.

b.)generalized urticaria. c.)mild temperature elevation. d.)local swelling at the injection site. B. RATIONALE: Generalized urticaria can herald the onset of a life-threatening episode and medical assistance should be sought immediately. A child may experience some pain, redness at the sight, mild temperature elevation, or localized swelling. These reactions can be treated symptomatically and aren't lifethreatening. 5. The nurse is caring for a child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action wouldn't be appropriate for the nurse to take? a.)Helping the child and family obtain necessary equipment, supplies, and medication b.)Pointing out to the parents ways in which they might have done things differently c.)Providing referrals to local community agencies and the Cystic Fibrosis Foundation d.)Encouraging the parents to allow their child to follow as normal a childhood as possible B. RATIONALE: The nurse should avoid being critical when talking with parents about how they have handled their child's disease or condition. The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support. Providing referrals to local community agencies and the Cystic Fibrosis Foundation is also an appropriate intervention. The child should be treated as much like a normal child as possible. 6. The nurse is caring for a client who was involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: a.)reintroduce the tube and attach it to water seal drainage. b.)call the physician and obtain a chest tray. c.)cover the opening with petroleum gauze. d.)clean the wound with povidone-iodine and apply a gauze dressing. C. RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions. 7. A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by: a.)decreasing respiratory tract edema. b.)lowering anxiety. c.)drying secretions. d.)increasing fluid intake. A. RATIONALE: The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them and it doesn't increase the child's fluid intake. 8. An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause: a.)cerebral edema. b.)dehydration. c.)heart failure. d.)hypovolemic shock. A. RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood. 9. The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply: a.)"Yes, you should have a Pap test after the onset of menstruation."

b.)"No, you aren't sexually active." c.)"Yes, you're 16 years old." d.)"No, you aren't 21 years old." B. RATIONALE: A 16-year-old female client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed. 10. A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be: a.)"This is very abnormal, your child must be sick." b.)"Let's see about further developmental testing." c.)"Don't worry, this is normal for her age." d.)"Maybe you just haven't seen her do it." B. RATIONALE: At age 12 months, a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Options A and D aren't therapeutic and can cut off communication with the mother. Option C misleads the mother with false reassurance. 11. An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include: a.)slapping, kicking, and punching others. b.)poor hygiene and weight loss. c.)loud crying and screaming. d.)pulling hair and hitting. B. RATIONALE: Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, punching, pulling hair, and hitting are examples of forms of physical abuse. Loud crying and screaming aren't abnormal findings in a 3-year-old child. 12. A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? a.)"I told my husband to give my son aspirin for his fever." b.)"I'll ask the physician about giving the baby an immunization shot." c.)"I don't have to worry because I've had the measles." d.)"I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son." D. RATIONALE: Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until age 12 to 15 months. Measles is rubeola and won't provide immunity for rubella. 13. The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to: a.)resolve conflict with parents. b.)develop an identity and independence. c.)develop trust. d.)plan for the future. B. RATIONALE: The adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures along with development. Adolescents rarely finalize plans for the future; this usually happens later in adulthood. 14. What's the best advice for a nurse to give to the parents of a 2-year-old child who frequently throws temper tantrums? a.)Move the toddler to a different setting. b.)Allow the toddler more choices. c.)Ignore the behavior when it happens. d.)Give in to the toddler's demands. C. RATIONALE: Ignore tantrum behavior because attention to the behavior can reinforce the undesirable behavior. Changing settings can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be

offered only allowable and reasonable choices. It's ill-advised to give in to the toddler's demands because doing so only promotes tantrum behavior. 15. A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is: a.)developmental readiness of the child. b.)consistency in approach. c.)the mother's positive attitude. d.)developmental level of the child's peers. A. RATIONALE: If the child isn't developmentally ready, the child and parent will become frustrated. Consistency is important when toilet training is started. The mother's positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn't useful. 16. A mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response? a.)Let the child know that he'll be punished for lying. b.)Ask him why he isn't telling the truth. c.)It's probably due to his vivid imagination and creativity. d.)Acknowledge him by saying, "That's a pretend story." D. RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Imagination and creativity need to be acknowledged. 17. A mother is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be? a.)6 months b.)4 months c.)8 months d.)10 months D. RATIONALE: A 10-month-old child can sit alone and understands object permanence, so he would look for the hidden toy. At 4 to 6 months of age, children can't sit securely alone. At 8 months of age, children can sit securely alone but can't understand the permanence of objects. 18. The mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake? a.)Allow the child to feed herself. b.)Use specially designed dishes for children; for example, a plate with the child's favorite cartoon character. c.)Only serve the child's favorite foods. d.)Allow the child to eat at a small table and chair by herself. A. RATIONALE: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. It's important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation. 19. The nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with: a.)diabetes. b.)leukemia. c.)asthma. d.)cystic fibrosis. B. RATIONALE: Leukemia causes immunosuppression, so inactivated rather than live viruses should be administered. Children with the other conditions listed can receive live virus vaccines because they aren't immunosuppressed. 20. A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should:

a.)perform chest physiotherapy every 4 hours. b.)give pancreatic enzymes as ordered. c.)place the child in an oxygen tent and have oxygen administered continuously. d.)serve a high-calorie diet. A. RATIONALE: Chest physiotherapy aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort. 21. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition related to impaired physical mobility. Which of the following is most likely to occur with this condition? a.)Decreased protein catabolism b.)Increased calorie intake c.)Increased digestive enzymes d.)Increased carbohydrate need D. RATIONALE: Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased not decreased protein catabolism is present. Decreased appetite not increased is a problem. Digestive enzymes are decreased not increased. 22. The nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have: a.)dysuria and urine retention. b.)perineal ulcers and erosions. c.)bilateral inguinal lymphadenopathy. d.)burning or tingling on vulva, perineum, or vagina. D. RATIONALE: Burning and tingling genital discomfort is the most common initial finding. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria. 23. A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and: a.)a barking cough. b.)a high fever. c.)sudden onset. d.)dysphagia. A. RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low-grade. Croup has a gradual onset, and dysphagia isn't a symptom. 24. A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the 2-year-old child is to: a.)expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible. b.)ask the mother to wait briefly outside until the assessment is over. c.)tell the child the nurse is going to listen to his chest with the stethoscope. d.)allow the child to handle the stethoscope before listening to his lungs. D. RATIONALE: Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should expose only one area at a time during assessment and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. Also, comfort the child with objects with which he's familiar. The child should be given limited choices to allow autonomy, such as "Do you want me to listen first to the front of your chest or your back?" 25. A 2-year-old child is brought to the emergency department with suspected croup. Which of the following assessment findings reflects increasing respiratory distress? a.)Intercostal retractions b.)Bradycardia

c.)Decreased level of consciousness d.)Flushed skin A. RATIONALE: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis. 26. An emergency department nurse is caring for a child diagnosed with croup. The nebulizer treatment of choice for a child with croup is: a.)albuterol (Ventolin). b.)metaproterenol (Alupent). c.)racepinephrine. d.)ipratropium (Atrovent). C. RATIONALE: Racemic epinephrine is an adrenergic used to reduce inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta<-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma. 27. The nurse administers racemic epinephrine to a child. Ten minutes after administration, the nurse should be alert for: a.)respiratory distress. b.)profound tachycardia. c.)signs of improved oxygenation. d.)diminished cyanosis. A. RATIONALE: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea, restlessness, cyanosis). Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color). 28. An 8-month-old male is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: a.)increased myelination. b.)intracranial hypotension. c.)cerebral hyperemia. d.)a slightly thicker cranium. C. RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension not hypotension places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable, causing the child to receive a more severe injury. 29. The nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include: a.)a depressed fontanel. b.)slurred speech. c.)tachycardia. d.)an altered level of consciousness. D. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge if he had increased ICP. The child can't speak at this age, but a change in cry may be noted. Bradycardia not tachycardia is a sign of increased ICP. 30. A 12-month-old child fell down the stairs and a basilar skull fracture is suspected. The nurse should look for: a.)cerebrospinal fluid otorrhea. b.)deafness. c.)raccoon eyes. d.)Battle's sign. A. RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull frontal, ethmoid, sphenoid, temporal, or occipital. Otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Raccoon eyes and Battle's sign occur primarily in orbital fractures.

31. A child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect: a.)subdural hematoma. b.)epidural hematoma. c.)subarachnoid hemorrhage. d.)concussion. B. RATIONALE: An initial loss of consciousness followed by transient consciousness leading to unconsciousness is caused by epidural hematoma. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. Concussion may result in a brief loss of consciousness. 32. A visibly upset mother carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should: a.)take the infant from the mother and offer to help. b.)take the infant and mother to a treatment room. c.)call the resuscitation team and the supervisor. d.)call security and the hospital administration. B. RATIONALE: Taking the infant and mother into a treatment room for assessment provides privacy and a controlled environment. The mother should be allowed to remain with her child if she wishes. If she doesn't want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Security isn't warranted in this situation. 33. While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should: a.)attempt rescue breaths. b.)attempt to reposition the airway a third time. c.)administer five back blows. d.)attempt to ventilate with a handheld resuscitation bag. C. RATIONALE: The child's airway is blocked despite attempts to establish it. The next step is to clear the airway with back blows and chest thrusts. Breaths can't be administered until the airway is patent. After two attempts to position the airway, the nurse can assume the airway is blocked. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent. 34. A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds that he still isn't breathing and that he has no pulse. The nurse should then: a.)resume CPR beginning with breaths. b.)declare her efforts futile. c.)resume CPR beginning with chest compressions. d.)call for assistance. D. RATIONALE: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions. 35. A neonate arrives at the emergency department in full cardiopulmonary arrest. Resuscitation efforts fail, and he's pronounced dead. The cause of death is sudden infant death syndrome (SIDS). Which of the following is true regarding the etiology of SIDS? a.)It occurs in suspected child abuse cases. b.)It occurs primarily in neonates with congenital lung problems. c.)It occurs primarily in black neonates. d.)It occurs more commonly in neonates who sleep in the prone position. D. RATIONALE: SIDS occurs in seemingly healthy neonates. However, more neonates who sleep in the prone position are affected. Because of the pooling of blood that occurs in the child with SIDS, child abuse is sometimes suspected. No correlation to race or lung disease exists. 36. The nurse is providing care for a mother whose child has died. The mother tells the nurse that she's angry with God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate? a.)Ineffective coping b.)Spiritual distress

c.)Powerlessness d.)Ineffective denial B. RATIONALE: The mother's expression of anger toward God is an indication of spiritual distress. Expressions of anger are a normal part of the grieving process and don't indicate ineffective coping. Although the mother may indeed be experiencing feelings of powerlessness, this isn't the most accurate diagnosis of her feelings as indicated by the assessment data. There's no evidence of denial on the mother's part. 37. A 2-year-old client is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: a.)question the mother about the child's allergies. b.)initiate standard precautions. c.)evaluate the child's neurologic status. d.)examine the child's throat and ears. C. RATIONALE: These are signs of meningitis and the priority is to evaluate neurologic status. Petechiae aren't allergic reactions. Standard precautions should be used when there's the risk of contacting body fluids (contact precautions should be instituted for the client diagnosed with meningitis). Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis. 38. A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers: a.)express negativism. b.)have reliable verbal responses to pain. c.)have a good concept of danger. d.)have little fear. A. RATIONALE: Toddlers' increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain they respond just as strongly to painless procedures as they do to painful ones. They have little concept of danger and have common fears. 39. A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds on to furniture when he walks. The nurse should ask the mother: a.)how long the child has been like this. b.)if the child can walk without holding on to furniture. c.)how the child's condition today differs from his normal condition. d.)if the child always drools. C. RATIONALE: Identify the chief complaint from how the child was previously behaving at home. Asking how long the child has been like this may be interpreted poorly by the caregiver. Focus on what the child can do and not on what he can't do to preserve the family's self-esteem. Focusing on negative aspects of the child's behavior is inappropriate. 40. The nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncuffed tube because the: a.)vocal cords provide a natural seal. b.)trachea is shorter. c.)larynx is anterior and cephalad. d.)cricoid cartilage is the narrowest part of the larynx. D. RATIONALE: The cricoid cartilage in the toddler is the narrowest part of larynx and provides a natural seal. This keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. The trachea is shorter and the larynx is anterior and cephalad, but these aren't reasons to choose an uncuffed tube. 41. The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can: a.)prepare the child by positive self-talk. b.)establish a time limit to get ready for the procedure. c.)hold and rock him and give him a security object. d.)count and sing with the child. C. RATIONALE: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object may be comforting to the

child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; but the success of these tactics depends on the child. 42. The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? a.)Adolescents can't follow detailed instructions. b.)Adolescents are worried about appearing different from their peers. c.)Adolescents' fine motor coordination isn't sufficiently developed to administer treatments. d.)Adolescents have a well-developed sense of self-identity. B. RATIONALE: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this will help the nurse construct an effective teaching plan. Adolescents can follow detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives toward establishing a sense of identity. 43. A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess? a.)Severe sore throat, drooling, leaning forward to breathe b.)Low-grade fever, stridor, barking cough c.)Pulmonary congestion, productive cough, fever d.)Sore throat, fever, general malaise A. RATIONALE: A child with acute epiglottiditis appears acutely ill, and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, leaning forward with the neck hyperextended, high fever, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles are indicative of pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis. 44. When caring for a child with epiglottiditis, the nurse should first: a.)examine his throat. b.)prepare him for tracheotomy. c.)administer I.V. fluids. d.)administer antibiotics. B. RATIONALE: Acute epiglottiditis is an emergency situation that may require tracheotomy or endotracheal intubation. Inflammation of the epiglottis can cause the airway to swell so that it can't rise and totally obstructs the airway. Never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottiditis are present. This maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are a priority. After a patent airway is secured, antibiotics may be given to treat Haemophilus influenzae, a common cause of acute epiglottiditis. 45. A 4-month-old infant is brought to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that: a.)the baby will need to fast before the test. b.)a sample of blood will be necessary. c.)a low-sodium diet is necessary for 24 hours before the test. d.)a low-intensity, painless electrical current is applied to the skin. D. RATIONALE: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. After pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test.

46. The nurse is taking a history from the parents of a child admitted with Reye's syndrome. Which illness would the nurse expect the parents to report their child having the previous week? a.)Chickenpox b.)Bacterial meningitis c.)Strep throat d.)Lyme disease A. RATIONALE: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome. 47. A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to: a.)place ice packs on the client's painful joints. b.)administer antibiotics. c.)provide oral and I.V. fluids. d.)administer folic acid supplements. C. RATIONALE: Priority care for the child in a sickle cell crisis includes providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial. Daily supplements of folic acid will help counteract anemia. 48. A nurse caring for a client who is 4 weeks pregnant should expect to collect which assessment findings? a.)Presence of menses b.)Uterine enlargement c.)Breast sensitivity d.)Fetal heart tones C. RATIONALE: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy. 49. A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer: a.)ritodrine (Yutopar). b.)bromocriptine (Parlodel). c.)magnesium sulfate. d.)betamethasone (Celestone). A. RATIONALE: Ritodrine reduces frequency and intensity of uterine contractions by stimulating B<adrenergic receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother). 50. The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? a.)Increased maternal blood pressure of 150/90 mm Hg b.)Decreased amount of vaginal bleeding c.)Fetal heart rate of 80 beats/minute d.)Maternal heart rate of 65 beats/minute C. RATIONALE: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean section to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate delivery. General Nursing Board 101 PREBOARD Nursing Practice 3 (PART 2) http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=20

PREBOARD Nursing Practice 3 (PART 2) Post by admin on Aug 18, 2010, 1:44pm 51. Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which nursing intervention is most appropriate for this client? a.)Provide her with the information and teach her the skills she'll need to understand and cope during birth. b.)Provide her with written information about the birthing process. c.)Have a more experienced pregnant woman assist her. d.)Do nothing in hopes that she'll begin coping as the pregnancy progresses. A. RATIONALE: Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs. 52. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to: a.)assess the client's readiness to stop. b.)suggest that the client reduce the daily number of cigarettes smoked by one-half. c.)provide the client with the telephone number of a formal smoking cessation program. d.)help the client develop a plan to stop. A. RATIONALE: Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop smoking for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation. 53. The nurse is recording an Apgar score for a neonate. The nurse should assess: a.)heart rate, respiratory effort, temperature, reflex irritability, and color. b.)heart rate, respiratory effort, reflex irritability, and color. c.)heart rate, respiratory effort, temperature, and color. d.)heart rate, respiratory effort, temperature, sucking reflex, and color. B. RATIONALE: When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth, but they aren't components of the Apgar score. 54. The nurse is teaching the mother of a neonate about the importance of immunizations. The nurse should teach her that active immunity: a.)develops rapidly and is temporary. b.)occurs by antibody transmission. c.)results from exposure of an antigen through immunization or disease contact. d.)may be transferred by mother to neonate. C. RATIONALE: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission. It occurs rapidly but is temporary. Passive immunity may be transferred by the mother to the neonate. 55. When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her? a.)"I'll report increased frequency of urination." b.)"If I have blurred or double vision, I should call the clinic immediately." c.)"If I feel tired after resting, I should report it immediately." d.)"Nausea should be reported immediately." B. RATIONALE: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.

56. The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate? a.)Encourage breast-feeding so that she can get her rest and get healthier. b.)Encourage breast-feeding because it's healthier for the neonate. c.)Encourage breast-feeding to facilitate bonding. d.)Discourage breast-feeding because HIV can be transmitted through breast milk. D. RATIONALE: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case. 57. A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a.)peripheral acrocyanosis. b.)bradycardia. c.)lethargy. d.)jaundice. C. RATIONALE: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia, not bradycardia, is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia. 58. The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? a.)Weak sucking response b.)Enlarged breast tissue c.)Soft skin d.)Vernix caseosa B. RATIONALE: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen. 59. A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but she's concerned because she isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by: a.)referring her to counseling. b.)telling her such feelings are normal in the beginning of pregnancy. c.)exploring her feelings. d.)recommending she talk her feelings over with her husband. B. RATIONALE: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time. 60. A woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should: a.)recognize these as normal early pregnancy signs and symptoms. b.)question her further about these signs and symptoms. c.)tell her that she'll need blood work and urinalysis. d.)tell her that she may be excessively worried. A. RATIONALE: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic. 61. A client with hypotonic labor dysfunction has been started on oxytocin (Pitocin). Despite adequate contractions, the fetus doesn't descend lower than 0 station. The physician recommends cesarean delivery. The client and her husband are confused because she had given birth previously to an average-size neonate. They ask several questions about cesarean birth. What would be the most accurate nursing diagnosis for this client? a.)Anger related to loss of planned birth experience b.)Anxiety related to lack of knowledge about the need for cesarean birth c.)Acute pain related to long, unproductive labor

d.)Fear related to the unknown B. RATIONALE: The couple's questions indicate their lack of knowledge. Anxiety is expected because a cesarean delivery was unplanned. The other options aren't indicated by the stated assessment data. 62. The nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to: a.)take sleeping pills for a restful night's sleep. b.)try to get more rest by going to bed earlier. c.)take her prenatal vitamins. d.)tell her not to worry because the fatigue will go away soon. B. RATIONALE: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. 63. The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: a.)"Now isn't a good time to begin dieting because you are eating for two." b.)"Let's explore your feelings further." c.)"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." d.)"The prenatal vitamins should ensure the baby gets all the necessary nutrients." C. RATIONALE: Depriving the developing fetus of nutrients can cause serious problems, and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or neonate needs; they work in congruence with a balanced diet. 64. The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: a.)start using insulin. b.)start taking an oral antidiabetic drug. c.)monitor her urine for glucose. d.)be taught about diet. D. RATIONALE: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall dietary intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels. 65. The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that: a.)the delivery may need to be induced early. b.)the delivery must be by cesarean. c.)the mother will carry to term safely. d.)it's too early to tell. A. RATIONALE: Early induction or early cesarean delivery are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary. 66. A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to stressing the importance of taking the vitamins, the nurse should advise the client to: a.)switch brands. b.)take the vitamin on a full stomach. c.)take the vitamin with orange juice for better absorption. d.)take the vitamin first thing in the morning. B. RATIONALE: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women

nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea. 67. A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation? a.)Keeping him away from drafts b.)Putting a blanket between him and cold surfaces c.)Putting a cap on his head d.)Drying him thoroughly after a bath D. RATIONALE: Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss caused by evaporation. Keeping a neonate away from drafts prevents heat loss caused by convection. Keeping a neonate off a cold surface, such as a scale, prevents the heat loss caused by conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss caused by radiation. 68. The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward: a.)ensuring adequate nutrition. b.)preventing infection. c.)promoting neural tube sac drainage. d.)conserving body heat. B. RATIONALE: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac. 69. nurse is conducting a neonate assessment of a boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation? a.)Limited abduction of the affected leg b.)Unequal gluteal folds c.)Lengthening of the limb on the affected side d.)Crepitus of the affected hip on movement B. RATIONALE: Unequal gluteal folds are signs of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted. 70. The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful? a.)Placing the neonate flat during feedings b.)Providing fluids with a small spoon c.)Placing the nipple in the cleft palate d.)Burping the neonate frequently D. RATIONALE: Because a neonate with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. A neonate with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons aren't used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration. 71. A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client isn't in labor. Which nursing intervention should the nurse perform? a.)Allow the client to ambulate with assistance. b.)Perform a vaginal examination to check for cervical dilation. c.)Monitor the amount of vaginal blood loss. d.)Notify the physician for a fetal heart rate of 130 beats/minute. C. RATIONALE: Estimate the amount of blood loss by such measures as weighing perineal pads or counting

the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute. 72. A nurse in a prenatal clinic is assessing a 28-year-old who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? a.)Glycosuria, hypertension, seizures b.)Hematuria, blurry vision, reduced urine output c.)Burning on urination, hypotension, abdominal pain d.)Hypertension, edema, proteinuria D. RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia. 73. A client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home health visits? a.)"The community health nurse will help fix my meals." b.)"The community health nurse will give me my antihypertensive medication." c.)"The community health nurse will check me and my baby and talk with my physician." d.)"The community health nurse will give me prenatal care so that I won't have to see my physician." C. RATIONALE: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia, this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician. 74. A client who is 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Which nursing diagnosis takes the highest priority? a.)Risk for deficient fluid volume b.)Anxiety c.)Acute pain d.)Impaired gas exchange A. RATIONALE: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but risk for deficient fluid volume through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Acute pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss. 75. A client delivered a healthy full-term baby girl 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action? a.)Tachycardia and hypotension b.)Gush of vaginal blood when she stands up c.)Blood stain (5.1 cm) in diameter on the abdominal dressing d.)Complaints of abdominal pain A. RATIONALE: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartal woman who has been sitting and may suddenly gush out when she stands up. A blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in the size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to

feel pain at the incision site once her anesthesia has worn off. 76. A nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test? a.)A 3-day-old neonate who has been fed I.V. since birth b.)A 2-day-old neonate who has been breast-fed c.)A 1-day-old neonate receiving formula d.)A breast-fed neonate being discharged within 24 hours of birth B. RATIONALE: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who is discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours. 77. The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says: a.)"I won't use insulin if I'm sick." b.)"I need to use insulin each day." c.)"If I give myself an insulin injection, I don't need to watch what I eat." d.)"I'll monitor my blood glucose levels twice a week." B.RATIONALE: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily. 78. A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a boy. Which priority intervention should be included in the care plan for the neonate during his first 24 hours? a.)Administer insulin subcutaneously. b.)Administer a bolus of glucose I.V. c.)Provide frequent early feedings with formula. d.)Avoid oral feedings. C. RATIONALE: The neonate of a mother with diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia. 79. A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus? a.)Soft, at the level of the umbilicus b.)Firm (1.9 cm) below the umbilicus c.)Firm, at the level of the umbilicus d.)Boggy, midway between the umbilicus and symphysis pubis C. RATIONALE: Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. 80. Which finding is considered normal in a neonate during the first few days after birth? a.)Weight loss of 25% b.)Birth weight of 2,000 to 2,500 g

c.)Weight loss then return to birth weight d.)Weight gain of 25% C. RATIONALE: Babies lose approximately 10% of their birth weight during the first 3 or 4 days, due to the loss of excess extracellular fluids and meconium as well as limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 2,700 to 4,000 g. 81. The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse? a.)"Why don't you wait and see how things go? You may be tired of breast-feeding by then." b.)"Let your daycare provider give the baby formula in a bottle and breast-feed when you're home." c.)"Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work." d.)"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle." D. RATIONALE: Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the neonate at daycare. This will also keep the mother's milk production up. 82. Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy? a.)Abdominal pain, vaginal bleeding, and a positive pregnancy test b.)Hyperemesis and weight loss c.)Amenorrhea and a negative pregnancy test d.)Copious discharge of clear mucus and prolonged epigastric pain A. RATIONALE: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture, but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucus isn't indicative of an ectopic pregnancy, and referred shoulder pain, not epigastric pain, should be expected. 83. The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rh (D)negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? a.)Administration of Rh (D) Immune Globulin I.M. to the neonate within 72 hours b.)Administration of Rh (D) Immune Globulin I.M. to the mother within 72 hours c.)Injection of Rh (D) Immune Globulin to the mother during her 6 week follow-up visit d.)Administration of Rh (D) Immune Globulin I.M. to the mother within 3 months B. RATIONALE: When a mother is Rh (D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth due to the exchange of maternal and fetal blood during delivery. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rh (D) Immune Globulin within 72 hours, no antibodies will be formed. Rh (D) Immune Globulin may also be given to the mother during pregnancy, if the neonate is Rh-positive. The neonate isn't given Rh (D) Immune Globulin. 84. On the 9th postpartum day, a client breast-feeding her neonate experiences pain, redness, and swelling of her left breast. She's diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? a.)Wear a loose-fitting bra to avoid constricting the milk ducts. b.)Stop breast-feeding permanently. c.)Take antibiotics until the pain is relieved. d.)Use a warm moist compress over the painful area. D. RATIONALE: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.

85. The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement? a.)"I'll apply warm, moist compresses to my breasts." b.)"I'll breast-feed every 1& to 3 hours." c.)"I'll use an electric breast pump." d.)"I'll wear a bra 24 hours per day." B. RATIONALE: Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement. 86. The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a.)One fingerbreadth above the umbilicus b.)One fingerbreadth below the umbilicus c.)At the level of the umbilicus d.)Below the symphysis pubis B. RATIONALE: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis. 87. The nurse is helping to prepare a client for discharge following childbirth. During a teaching session, the nurse instructs the client to do Kegel exercises. What's the purpose of these exercises? a.)To prevent urine retention b.)To relieve lower back pain c.)To tone the abdominal muscles d.)To strengthen the perineal muscles D. RATIONALE: Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They also improve vaginal tone and help prevent stress incontinence and hemorrhoids. Kegel exercises can't prevent urine retention, relieve lower back pain, or tone abdominal muscles. 88. The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? a.)7 weeks b.)11 weeks c.)17 weeks d.)21 weeks B. RATIONALE: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation. 89. The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy? a.)Iron deficiency anemia b.)Varicosities c.)Nausea and vomiting d.)Gestational diabetes A. RATIONALE: Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes. 90. The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?

a.)A glass of milk b.)A cup of hot tea c.)A liquid antacid d.)A glass of orange juice D. RATIONALE: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron. 91. The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy? a.)Hypoglycemia b.)Crackles c.)Bradycardia d.)Hyperkalemia B. RATIONALE: Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia. 92. The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching? a.)"I'll need to lie perfectly still." b.)"You won't need to come in and check on me while I'm wearing this monitor." c.)"I can lie in any comfortable position, but I should stay off my back." d.)"I know that the external monitor increases my risk of a uterine infection." C. RATIONALE: A woman with an external monitor should lie in the position that's most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who is wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection. 93. The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? a.)Encouraging ambulation b.)Serving a nutritious diet c.)Promoting adequate hydration d.)Performing nipple stimulation D. RATIONALE: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions. 94. A client treated for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? a.)Report a heart rate greater than 120 beats/minute to the physician. b.)Take terbutaline every 4 hours, during waking hours only. c.)Call the physician if the fetus moves 10 times in 1 hour. d.)Increase activity daily if not fatigued. A. RATIONALE: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home. 95. The nurse is caring for a client in labor. Which assessment finding indicates fetal distress? a.)Lack of meconium staining b.)Early decelerations in fetal heart rate during contractions c.)An increase in fetal heart rate with fetal scalp stimulation

d.)Fetal blood pH less than 7.20 D. RATIONALE: A fetal blood pH less than 7.20 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.20 to 7.30 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. The other options are normal findings. 96. The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction? a.)Deep breathing b.)Shallow chest breathing c.)Deep, cleansing breaths d.)Chest panting B. RATIONALE: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated. 97. The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? a.)Administer ephedrine to raise her blood pressure. b.)Administer oxygen using a mask. c.)Place the woman flat on her back with her legs raised. d.)Ensure adequate hydration before the anesthetic is administered. D. RATIONALE: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in a supine position can contribute to hypotension because of uterine pressure on the great vessels. 98. A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate? a.)Gently pulling at the neonate 's head as it's delivered b.)Holding the neonate 's head back until the physician arrives c.)Applying gentle pressure to the neonate 's head as it's delivered d.)Placing the mother in a Trendelenburg position until the physician arrives C. RATIONALE: Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the mother. Never pull at the neonate 's head or hold the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties. 99. The nurse is caring for a client who is in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate? a.)Checking for the umbilical cord around the neonate 's neck b.)Placing antibiotic ointment in the neonate 's eyes c.)Turning the neonate's head to the side, to drain secretions d.)Assessing the neonate for respirations A. RATIONALE: After the neonate 's head is delivered, the nurse should check for the cord around the neonate 's neck. If the cord is around the neck, it should be gently lifted over the neonate 's head. Antibiotic ointment, to prevent gonorrheal conjunctivitis, is administered to the neonate after birth, not during delivery of the head. The neonate's head isn't turned during delivery. After delivery, the neonate is held with his head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently

suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after delivery. 100. The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? a.)Apply an ice pack to her perineum. b.)Take a Sitz bath. c.)Perform perineal care after voiding or a bowel movement. d.)Drink plenty of fluids. A. RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a Sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.

General Nursing Board 101 PREBOARD Nursing Practice 4 (PART 1) http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=21 PREBOARD Nursing Practice 4 (PART 1) Post by admin on Aug 18, 2010, 1:47pm 1. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? a. At bedtime b. On arising c. Immediately after a meal d. On an empty stomach Ans: C drugs that cause gastric irritation, such as ibuprofen (Motrin), are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should used warmth and stretching until he gets food in his stomach. 2. When preparing a teaching plan for the client with osteoarthitis who is taking celexocib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren) is that celecoxib is less likely to produce which of the following? a. Hepatotoxicity b. Renal toxicity c. Gastrointestinal (GI) bleeding d. Nausea and vomiting Ans: C the major advantage of celecoxib (Celebrex), the new generation of cyclooxygenase-2 (COX-2) inhibitors, over diclofenac (Voltaren), a COX-1 inhibitor, is that celecoxib is less likely to produce GI problems such as ulcers and bleeding. There is no evidence of less hepatotoxicity, renal toxicity, or nausea and vomiting with COX-2 inhibitors. 3. The client diagnosed with osteoarthritis states, My friend takes steroid pills for her rheumatoid arthritis. Why dont take steroids for my osteoarthritis? The nurses response to the client is based on an understanding of which of the following? a. Intra-articular corticosteroid injections are used to treat osteoarthritis b. Oral corticosteroids can be used in osteoarthritis c. A systemic effect is needed in osteoarthritis d. Rheumatoid arthritis and osteoarthritis are two similar diseases Ans: A- Rheumatoid arthritis and osteoarhtritis are two different diseases. Cortecosteroids are used for patient with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral cortecosteroids are avoided because they can cause an acceleration of osteoarthritis. 4. In preparation for total knee surgery, a 200-pound client with osteoarthritis is being discharged from the hospital to lose weight to reduce the risks of anesthesia. In conjunction with a weight loss program, which of the following exercises would the nurse recommend as best if t he client has no contraindications?

a. Weight lifting b. Walking c. Aquatic exercise d. Tai chi exercise Ans: C When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allow the client o burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote a healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the clients osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be best exercise for this client to help with weight loss. 5. The physician recommends a total hip replacement for a client with osteoporosis who reports increasingly severe pain in the left hip. The nurse would initiate the preoperative teaching plan for the client, beginning with which of the following? a. Teaching how to prevent hip flexion b. Demonstrating coughing and deep breathing techniques c. Showing the client what an actual hip prosthesis looks like d. Assessing the clients fears about the procedure Ans: D- before implementing teaching plan, the nurse should determine the clients fears about the procedure. Only then the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the clients needs. In the preoperative period, the clients needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the clients fear has been assessed. and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity. 6. After the client undergoes a total knee replacement for severe osteoarthritis, which of the following assessment findings would lead the nurse to suspect possible nerve damage? a. Numbness b. Bleeding c. Dislocation d. Pinkness Ans: A- The urse would suspect a nerve damage if numbness is present. However, the damage is short term and related to edema or long term and related to permanent nerve damage would not be clear at this point. The nurse need to continue to assess the clients neurovascular status, including pain, pallor, pulselessnes, parenthesis, and paralysis (the five Ps). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequatwe circulation to area. Numbness would suggest neurologic damage. 7. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and inability to move the extremity. The nurse interprets these findings as indicating which of the following? a. A developing infection b. Bleeding in the operative site c. Joint dislocation d. Glue seepage into soft tissue Ans: C The joint has dislocated when the client with total joint prosthesis develops sudden severe pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness erythema, and possibly drainage and separation of the wound. Bleeding could be external (eg. Blood visible from the wound or on the dressing) or internal and manifested by signs of shock (eg. Pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue dries into hard fixed form before the wound is closed 8. Which of the following would the nurse assess in a client with an intracapsular hip fracture? a. Internal rotation b. Muscle flaccidity c. Shortening of affected leg d. Absence of pain in the fracture area Ans: C- With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture. 9. When developing the plan of care for an older adult client with a hip fracture, which of the following chronic health problems would the nurse be lest likely to assess in the client? a. Hypertension

b. Cardiac decompensation c. Pulmonary disease d. Multiple sclerosis Ans: D Multiple sclerosis would be the least likely chronic health problem for an older adult with a hip fracture, Typically, multiple sclerosis is consider a severe crippling disorder of young adults. Hypertension is a common chronic health problems in older adults. Cardiac decompensation is common on older adults; it arises from cardiac musculature changes and age-related changes in the heart. This comorbid condition can complicate the treatment and care when the older adult experiences a hip fracture. Pulmonary disease commonly arises from age-related changes in the respiratory system. These comorbid conditions can complete the treatment and care when the other adult experiences a hip fracture. 10. When teaching a client with an extracapsular hip fracture scheduled for surgical internal fixation with the insertion of a pin, the nurse bases the teaching on the understanding that this surgical repair is the treatment of choice for which of the following reasons? a. Hemorrhage at the fracture site is prevented b. Neurovascular impairment risk is decreased c. The risk for infection at the site is lessened d. The client is able to be mobilized sooner Ans: D insertion of a pin for the internal fixation of a extracapsular fractured hip provides good fixation of the fracture. The fracture is site is stabilized and fractured bone ends are well approximated. As result, the client is able to be mobilized sooner, thus reducing the risks of complications related to immobility. Internal fixation with a pin insertion does not prevent hemorrhage or decrease the risk for neurovascular impairment, potential complications associated with any joint or bone surgery. It does not lessen the clients risk infection at the site. 11. A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, Why does she have this tube inserted in her hip? Which of the following responses by the nurse demonstrates understanding of the primary purpose for this drainage tube? a. The tube helps us to detect a wound infection early on. b. This way we wont have to irrigate the wound. c. Fluid wont be allowed to accumulate at the site. d. We have a way to administer antibiotics into the wound. Ans: C the primary purpose of the drainage tube is to prevent fluid accumulation in the wound. Fluid when it accumulates creates dead space. Elimination of the dead space by keeping the wound free of fluid greatly enhances wound healing and helps prevent abscess formation. Although the characteristics of the drainage from the tube, such as a change in color or appearance, may suggest a possible infection, this is not the tubes primary purpose. The drainage tube does not eliminate the need for wound irrigation or provide a way to instill antibiotics into the wound. 12. When assessing a client who has just received a femoral head prosthesis, which of the following would alert the nurse to the possibility of neurologic a. Decreased distal pulse b. Inability to move c. Diminished capillary refill d. Coolness to the touch Ans: B being unable to move the affected leg suggest neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise. 13. A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities would the nurse instruct the client to avoid? a. Crossing the legs while sitting down b. Sitting on a raised commode seat c. Using an abductor splint while lying on the side d. Rising straight from a chair to a standing position Ans: A any activity or position that causes flexion, adduction, or internal rotation of greater than 90 degrees should be avoided until the soft tissue surrounding the prosthesis has stabilized, at approximately 6 weeks. Crossing the feet while sitting down can lead to dislocation of the femoral head from the hips socket. Sitting on a raised commode seat prevents hip flexion and adduction. Using an abductor splint while sidelying keeps the hip joint in abduction, thus preventing adduction and possible dislocation. Rising straight from a chair to a standing position is acceptable for this client because this action avoids hip flexion,

adduction, and internal rotation of greater than 90 degrees. 14. The nurse encourages the client who has had a femoral head prosthesis placement to use which of the following types of chairs to sit in during the first 6 to 8 weeks after surgery? a. A desk-type swivel chair b. A padded upholstered chair c. A high-backed chair with armrests d. A recliner with an attached footrest Ans: C a high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate. 15. While assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning, which of the following would pose the greatest hazard to the client as a risk for falling at home? a. A 4-year-old cooker spaniel b. Scatter rugs c. Snack tables d. Rocking chairs Ans: B although pets and furniture such as snack tables and rocking chairs may pose a problem, scatter rugs are the single greatest hazard in the home, especially for elderly people who are ensure and unsteady with walking. Falls have been found to account for almost half of the accidental deaths that occur in the home. The risk for falls is further compounded by the clients need for crutches. 16. Which of the following activities would the nurse instruct the client with low back pain to avoid? a. Keeping light objects below the level of the elbows when lifting b. Leaning forward while bending the knees c. Exceeding prescribed exercise program d. Sleeping on the side with legs flexed Ans: C the client with low back should not exceed prescribed exercises even though they may think, If this will make me well, double will make me well quicker. When exceeding prescribed exercise programs, the clients muscle may be unconditioned and easily tired, leading to injury and increased pain. To use proper body mechanics when lifting light objects, the client should bring the item close to the center of gravity, which occurs when the object is kept below the level of the elbows. Leaning forward while bending the knees allows for the muscles of the thigh to be used instead of those of the lower back. Sleeping on the side with the legs flexed is appropriate because the spine is kept in a neutral position without twisting or pulling on muscles. 17. A client was brought to the hospital because he could not get out of bed because of low back pain radiating down to his right heel and lateral foot. When developing the clients plan of care, which of the following categories of medication would the nurse anticipate the physicians ordering? a. Angiotensin-converting enzyme (ACE) inhibitors b. b- adrenergic blocking agents c. Nonsteroidal anti-inflammatory drugs (NSAIDs) d. Barbiturates Ans: C for the client who has back pain radiating down to his right heel and lateral foot, suggesting radiculopathy of a herniated disc at L5-S1, typically the physician would order NSAIDs, oral analgesics, and muscle relaxants. ACE inhibitors are indicated for clients with hypertension and those with heart failure unresponsive to conventional therapy. b-blockers are indicated for clients with cardiovascular disorders, such as hypertension and angina, and also for migraine prophylaxis. Barbiturates are central nervous system depressants, they are indicated for clients with seizure or insomnia and for those being prepared for surgery. 18. A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating which of the following? a. Motor changes b. Postural deformity c. Alteration of reflexes d. Sensory changes Ans: B standing with a flattened spine slightly titled forward and slightly flexed to the affected side

indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation. 19. Which of the following positions would be most comfortable for a client with a ruptured disc at L5-S1 right? a. Prone b. Supine with the legs flexed c. High fowlers d. Right Sims Ans: B a supine position with the clients legs flexed is the most comfortable position because it allows for the disc to recess off of the nerve, thus alleviating the pressure and pain. The prone position cause hyperextension of the spine and increased pressure of the disc on the nerve root on the right. A ruptured disc at L5-S1 right is a term commonly used in the analysis of a history and physical examination, magnetic resonance image, or myelogram to identify a ruptured disc compressing the right nerve root exiting the L5S1 spinous process, as opposed to the central area or the left nerve foot of that spinous process. If the ruptured area of the disc were in the central area of the spinous process, the prone position and hyperextension might relieve the disc pressure on the nerve. A high-Fowlers or sitting position increases the pressure of the disc on the nerve root because of gravity, as does a right Sims position. 20. The client with a herniated intervertebral disc schedule for a myelogram asks the nurse about the procedure. The nurse explains that radiographs will be taken of the clients spine after an injection of which of the following? a. Sterile water b. Normal saline solution c. Liquid nitrogen d. Radiopaque dye Ans: D myelography, used to determine the exact location of a herniated disk, involves the use of radiopaque dye (usually an iodized oil, but in some instances water-soluble compound). In some instances, used for an air-contract study. 21. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc? a. Informing the client that the procedure is painless b. Taking a thorough history of past surgeries c. Checking for previous complaints of claustrophobia d. Starting an intravenous line at keep-open rate Ans: D an intravenous line is not required for an MRI client has an intravenous line, it is usually converted an intermittent infusion device, such as a heparin to avoid infiltration during transport of the client and completion of the procedure. When a contrast agents used, the client is moved out of the cylinder, the contrast material is injected, and the client is moved back-in. an MRI scan is painless. Typically the staff position, the client with pillows, blankets, ear plugs, and muscle to ensure client comfort, before the procedure started. A history of past surgeries is important, especially if the surgery involved implantation of any metallic devices (eg, implants, clips, pacemakers). Additionally, the nurse needs to assess for any hearing aids, electronic devices, shrapnel, bra hooks, necklace jewelry, credit cards, zippers, or any type of metal that the magnet of the MRI unit would attract. Although open MRI units are now available, they are not in widespread use. Therefore, the nurse needs to check determine whether the client is claustrophobic because this unit is a closed cylinder in which the client hears popular noise. A number of clients develop claustrophobic that causes the procedure to be cancelled. If the clients claustrophobic, the procedure may need to be rescheduled after an open MRI unit is located or made available. 22. A client complaining of numbness from the back of his left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states, a left lumbar laminectomy of L3-4. Based on the nurses understanding of the clients complaints and intended surgical procedure which of the following would the nurse do next? a. Have the client sign the consent form b. Call the surgeon c. Change the consent form d. Review the clients history Ans: B based on the clients complaints, the nurse should call the surgeon to verify the location of the surgery. The clients complains indicate radiculopathy of ___ but the consent form states L3-4, radiculopathy

L3-4 involves pain radiating from the back to the tocks to the posterior thigh to the inner calf. The nurse must act as a consent until the correct procedure is identified and confirmed on the consent. The nurse has legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history if contradictory, the physician should be contacted to clarify the situation. Ultimately, it is the surgeons responsibility to identify the site of surgery specified on the surgical consent form. 23. After a bilateral lumbar laminectomy at L5-S1, which of the following is a priority nursing diagnosis for the client in the immediate postoperative phase? a. Impaired physical mobility related to back pain b. Imbalanced nutrition: less than body requirements related to postoperative status c. Bowel incontinence related to decreased physical activity d. Disturbed body image related to fear of disfiguring surgical scar Ans: A impaired physical mobility related to back pain, muscle spasms, and tissue manipulation is a priority after a laminectomy, because based on individual factors such as the length of time of the disease and previous scarring or injury to the muscles or nerves before the surgery, spasms and pain can be quite severe. Imbalances nutrition: less than body requirements related to inability to eat in the supine position is not a priority problem because the client is encouraged to take fluids as soon as the gag reflex returns, no nausea is present, and bowel sounds begin to return. Bowel incontinence related to decreased physical activity is not a priority problem because the client is encouraged to sit up and to ambulate to the bathroom with assistance as soon as the anesthesia wears off. Disturbed body image related to fear of disfiguring surgical scar should also not be a priority problem because the laminectomy incision is commonly small, possibly as small as 1 inch for a lumbar laminectomy L5-S1 bilateral. 24. Immediately after the lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled? a. Muscles spasms b. Nausea c. Shivering d. Dry mouth Ans: B ondansetron hydrochloride (zofran) is a selective serotonin receptor antagonist tat acts centrally to control the clients nausea in the postoperative phase. It does not control muscle spasms, shivering, or dry mouth. 25. After a laminectomy, the client states, The doctor said that I can do anything I want to. Which of the following activities, if stated by the client, indicates need for further teaching? a. Drying the dishes b. Sitting outside on firm cushions c. Making the bed walking from side to side d. Sweeping the front porch Ans: D sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there. 26. When developing the drainage teaching plan for a client who has undergone a lumbar laminectomy L4-5 left and will be returning to work in 6 weeks, which of the following actions would the nurse encourage the client to avoid? a. Placing one foot on a stepstool during prolonged standing b. Sleeping on the back with support under the knees c. Maintaining average body weight for height d. Sitting whenever possible Ans: D after a lumbar laminectomy L4-5 left, a client who is returning to work should avoid sitting whenever possible, if the client must sit, he or she should sit only in chairs that allows the knees to be higher than the hips and support the arms to maintain correct body alignment and reduce undue stress on the spine. Maintaining good body postures is most important after a lumbar laminectomy L4-5 left. By 6 weeks after the surgery, the client should have regained stamina. To maintain correct body posture, the client should also place one foot on a stepstool during prolonged standing. Sleeping on the back with a support under the knees is effective in maintaining correct body posture. Maintaining an average weight for

height is important in maintaining a healthy back because carrying extra weight caused undue stress on back muscles. 27. A male client, who had normal preoperative baseline data except for dysfunction associated with this operative diagnosis, underwent a spinal fusion yesterday. Which of the following nursing assessments would alert the nurse to the development of a possible complication? a. Lateral rotation of the head and neck b. Clear yellowish fluid on the dressing c. Use of the standing position to void d. Nonproductive cough Ans: B clear yellowish fluid on the dressing may be cerebral spinal fluid, this fluid must be tested for glucose to determine whether it is cerebral spinal fluid. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The patient should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the bodys defense mechanism to help clear the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick yellow sputum would indicate the complication of a respiratory infection. 28. After a spinal fusion, a client is required to wear a back brace. Which of the following would the nurse expect to do before applying the brace? a. Have the client in bed lying on the side b. Verify with the physician the position to use c. Ask the client to stand with arms held out to the side d. Encourage the client to sit in a straight chair Ans: B the nurse should verify with the surgeon the preferred position to use before applying the brace. Traditionally, the client who had a spinal fusion was asked to lie on the side and log roll onto the brace. Now doctors also have clients stand and sit for the brace application. Therefore, the nurse needs to verify the surgeons preference. 29. After teaching a client required to wear a back brace after a spinal fusion, which of the following client statements indicate effective teaching about skin protection measures with the brace? a. I will apply lotion before putting on the brace. b. I will be sure to pad area around my iliac crest. c. I can use baby powder under the brace to absorb perspiration. d. I should wear a thin cotton undershirt under the brace. Ans: D the client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, which could lead to skin irritation and breakdown. Applying lotion is nor recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow) and irritants from the lotion can cause further irritation. Applying extra padding (eg, to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder is not recommended because the irritation from the talcum also can cause irritation and skin breakdown. 30. When developing the teaching plan for a client scheduled for a spinal fusion, which of the following would the nurse expect to include? a. The client typically experiences more pain at the donor site than at the fusion site than at the fusion site b. The surgeon will apply a simple gauze dressing to the donor site c. Neurovascular checks are unnecessary if the fibula is the donor site d. The clients level of activity restriction is determined by the amount of pain Ans: A typically, the do not site causes more pain than the fused site does because inflammation, swelling, and venous oozing around the nerve endings in the donor site, where the subcuticular tissue was removed, occurs during the first 24 to 48 hours postoperatively. After surgery, the surgeon applies a pressure dressing to the donor site to compress the veins that were transected for the removal subcutaneous tissue but that did not stop oozing blood after surgical cauterization during the surgical procedure. Pressure on a transected vein, which is low pressure, stops the oozing and loss of blood from the venous site. When the donor site is the fibula, neurovascular checks must be performed every hour to ensure adequate neurologic function of and circulation to the area. The surgeon, not the degree or amount of pain, specifies activity restrictions.

31. The nurse determines that the client who has had a lumbar laminectomy with a spinal fusion understands his protective instructions when he places his feet in which of the following positions when sitting in a chair? a. On the floor with the feet flat b. On a low footstool c. In any comfortable position with legs uncrossed d. On a high footstool so the feet are level with the chair seat Ans: A a client who has had back surgery should place his feet flat on the floor to avoid strain on the incision. Placing the feet on a low or high footstool or in any other position of comfort with the legs uncrossed increases the pressure on the suture line and increases the inflammation around the involved nerve root, thereby increasing the risk for possible rerupture of the disc site. 32. When developing the plan of care for a client undergoing a lumbar laminectomy, which of the following activities would be contraindicated during the initial postoperative period? a. Assisting with her daily hygiene activities b. Lying flat in bed c. Walking in the hall d. Sitting all afternoon in her room Ans: D after a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the patient needs to return to her optimal level of functioning as soon as possible. There is no limitation on the patients participation ion daily hygiene activities except for her individual response of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was preformed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical patients. In addition, walking provides the postoperative lumbar laminectomy patient an opportunity to build u p endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing the, 33. Which of the following exercises would the nurse advise the client to avoid after a lumbar laminetcomy? a. Knee-to-chest lifts b. Hip tilts c. Sit-ups d. Pelvic tilts Ans: C sit-ups are not recommended for the client who has had a lumbar laminectomy, because these exercises place too great a stress on the back. Knee-to-chest lifts, hip tilts, and pelvic tilt exercises are recommended to strengthen back and abdominal muscles. 34. When obtaining the history of a client with peripheral vascular disease who requires an amputation, which of the following would the nurse identify as the least likely factor contributing to the clients peripheral vascular disease? a. Uncontrolled diabetes mellitus for 15 years b. A 20-pack-year history of cigarette smoking c. Current age of 39 years d. A serum cholesterol concentration of 275 mg/dL Ans: C typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease, uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/dL are considered a risk factor for peripheral vascular disease. 35. When assessing the client with severe arterial occlusive disease and gangrene of the left great toe, which of the following findings would the nurse observe in the clients left leg and foot? a. Edema around the ankle b. Loss of hair on the lower leg c. Thin, soft toenails d. Warmth in the foot

Ans: B the client with severe arterial occlusive disease and gangrene of the left great toe would have lost the ___ on the leg due to decreased circulation to the ___. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin ___ toenails (ie, thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically the foot would be to cold if a severe arterial occlusion were present. 36. A client with absent peripheral pulses and pain at rest is scheduled for an arterial Droppler study of the affected extremity. Which of the following would the nurse include when preparing the client for this test? a. Have the client sign a consent form of the procedure b. Administer a pretest sedative as appropriate c. Keep the client tobacco-free for 30 minutes before the test d. Wrap the clients affected foot with a blanket Ans: C the client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arterial. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive narcotic analgesic, not a sedative, to control, the ___ the blood pressure cuffs are inflated during the Droppler studies to determine the ankle-to brachial pressure index. The clients ankle should not be considered with a blanket, because the weight of the blanket on the ishemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet at the affected foot. 37. The client with peripheral arterial disease says, Ive really tried to manage my condition well. Which of the following, if reported by the client during the history, would the nurse determine as appropriate for this client? a. Resting with the legs elevated above the level of the heart b. Walking slowly but steadily for 30 minutes twice a day c. Minimizing activity as much and as often as possible d. Wearing antiembolism stockings at all times when out of bed Ans: B slow, steady walking is a recommended activity in the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the above the heart is an appropriate strategy for reducing venous congestion, wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause t he disease to worsen. 38. Which of the following would the nurse include in the teaching plan for a client with arterial insufficiency to the feet is being managed conservatively? a. Daily lubrication of the feet b. Soaking the feet in warm water c. Applying antiembolism stocking s d. Wearing firm, supportive leather shoes Ans: A daily lubrication, inspection, cleaning, and pattern dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the foot in a warm water should be avoided, because soaking on lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so that client may be unable to detect water that is too warm, thus placing the client at risk clients with venous insufficiency, are inappropriate for clients for with arterial insufficiency could lead to worsening of the condition. Footwear should be roomy, soft, and protective and allow to circulate. Therefore, firm, supportive leather shoes would be appropriate. 39. While the nurse is providing preoperative teaching, the client says, I hate the idea of being an invalid after they cut off my leg. Which of the following would be the nurses most thermometric response? a. At least you will still have one good leg to use. b. Tell me more about how youre feeling. c. Lets finish the preoperative teaching. d. Youre lucky to have a wife to care for you. Ans: B encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, At least you will still have one good leg to use, that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that

the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term invalid. The nurse needs to focus on this concern and not to try to complete the teaching first before discussing what is on the clients mind. The clients needs, not the nurses needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the clients wife caring for him may reinforce the clients feelings of helplessness as an invalid. 40. The client asks the nurse, Why cant the doctor tell me exactly how much of my leg hes going to take off? Dont you think I should know that? The nurse responds based on the understanding that the final decision about the level of amputation required depends primarily on which of the following? a. The need to remove as much of the leg as possible b. The adequacy of the blood supply to the tissues c. The ease with which a prosthesis can be fitted d. The clients ability to walk with a prosthesis Ans: B the level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the clients ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant. 41. A client who has a history of mitral valve prolapse tells the nurse during a clinical visit that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate? a. The physician will need to revaluate the status of your heart condition before your dental appointment. b. Be sure to remind your dentist that you have a heart condition. c. It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections. d. We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned. Ans: D clients who are at risk for developing infective endocarditis due to cardiac conditions such as mitral valve prolapse must take prophylactic antibiotics before any dental procedure that may cause bleeding. The client is not more susceptible to developing oral infections. Rather, the client is more susceptible to developing endocarditis that results from oral bacteria that enter the circulation during the dental procedure. The physician does not necessarily need to re-evaluate the heart condition of a client who is stable, but antibiotics must be prescribed. It is not enough to simply remind the dentist about the heart condition. 42. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the clients daily care? a. Assess the oral cavity each time mouth care is given and record observations b. Use a soft toothbrush to brush the clients teeth after each meal c. Swab the clients tongue, gums, and lips with a soft foam applicator every 2 hours d. Rinse the clients mouth with mouthwash several times a day Ans: B a soft toothbrush should be used to brush the clients teeth after every meal and more often as needed. Mechanical cleansing is necessary to maintain oral health, stimulate gingival, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the nursing assistant. Swabbing with a safe foam applicator does not provide enough friction to cleanse the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use. 43. During the assessment of a clients mouth, the nurse notes the absence of saliva. The client is complaining of pain in the area of t he ear. The client has been NPO for several days because of the insertion of a nasogastric tube. Based on these findings, the nurse suspects that the client may be developing which of the following mouth conditions? a. Stomatitis b. Oral candidiasis c. Parotitis d. Gingivitis

Ans: C the lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis, to inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventive measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth. Oral cadidiasis (thrush) causes bluish-white mouth lesions. Gingivitis can be recognized by the inflamed gingival and bleeding that occur during toothbrushing. 44. The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation? a. Use of alcohol b. Frequent use of mouthwash c. Lack of vitamin B12 d. Lack of regular teeth cleaning by a dentist Ans: A chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors. Additional risk factors include chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin B12 and lack of regular teeth cleaning appointments have not been implicated as primary risk factors for oral cancer. 45. A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. He tells the occupational health nurse at his place of employment that he has not smoked a cigarette for 3 weeks, but is afraid he is going to slip up and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the clients comments? a. Dont worry about it. Everybody has difficulty quitting smoking, and you should expect to as well. b. If you increase your self-control, I am sure you will be able to avoid smoking. c. Try taking a couple of days of vacation to relieve the stress of your job. d. It is good that you can talk about your concerns. Try calling a friend when you want to smoke. Ans: D it is important for individuals who are engaged in smoking cessation efforts to feel comfortable with sharing their fears of failure with others and seeking support. Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a client that he found anticipate failure. Telling the client to exercise more self-control dose not provide him with support. Taking a vacation to avoid job pressures does not address the issue of fearing he will smoke a cigarette when in a stressful situation. 46. A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. What is the nurses priority in regard to care in the immediate postoperative phase? a. Prevent nausea and vomiting b. Maintain a patent airway c. Provide frequent airway d. Establish a way for the client to communicate Ans: B the priority of care in the immediate postoperative phase is to maintain a patent airway. The nurse should observe the client carefully for signs of respiratory distress. If the client becomes nauseated, antiemetics should be administered to decrease the chance of vomiting with obstruction of the airway and aspiration of vomitus. Providing frequent oral hygiene and an alternative means of communication are important aspects of nursing care, but maintaining a patent airway is most important. 47. A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the assistant on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the assistant? a. Keep the client in a side-lying position with the head slightly elevated b. Do not reposition the client without the assistance of a registered nurse c. The client can assume any position that is comfortable d. Keep the clients head elevated on two pillows at all times Ans: A- immediately after surgery the client should be placed on the side with the head slightly elevated. This position helps facilitate removal of secretions and decreases the likelihood of aspiration should vomiting occur. A registered nurse does not need to be present to reposition the presence of the nurse. Although it is important to elevate the head, there is no need to keep the clients head elevated on two pillows unless that

position is comfortable for the client. 48. A client who has had her jaws wired begins to vomit. What should be the nurses first action? a. Insert a nasogastric tube and connect it to suction b. Use wire cutters to cut the wire c. Suction the clients airway as needed d. Administer an antiemetic intravenously Ans: C the nurses first action is to clear the clients airway as necessary. Inserting a nasogastric tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest. 49. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? a. An intestinal obstruction has developed b. Additional ulcers have developed c. The esophagus has become inflamed d. The ulcer is perforated Ans: D the body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually extreme pain. This may occur over several hours or days. It is a medical emergency requiring immediate intervention. An intestinal obstruction would not cause midepigastric pain. Esophageal inflammation or the development of additional ulcers would not cause a rigid, boardlike abdomen. 50. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? a. Ineffective coping related to fear of diagnosis of chronic illness b. Deficient knowledge related to unfamiliarity with significant signs and symptoms c. Constipation related to decreased gastric motility d. Imbalanced nutrition: less than body requirements related to gastric bleeding Ans: B black, tarry stools are an important warning of bleeding in peptic ulcer disease. Digested blood in the stool because it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider.

General Nursing Board 101 PREBOARD Nursing Practice 4 (PART 2) http://nsgbrd101.proboards.com/index.cgi?board=answers&action=display&thread=22 PREBOARD Nursing Practice 4 (PART 2) Post by admin on Aug 18, 2010, 2:00pm 51. The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that research indicates that many peptic ulcer are the result of which of the following? a. Work-related stress b. Helicobacter pylori infection c. Diets high in fat d. A genetic defect in the gastric mucosa Ans: B recent research has indicated that most peptic ulcers may be caused by Helicobacter pylori, which is a gram-negative bacterium. If this organism is detected through diagnostic tests, treatment of the ulcer will indicate the use of antibiotics and bismuth compounds such as Pepto-Bismol. It has not been proven that work-related stress or a genetic defect causes ulcers. Diets high in fat do not cause peptic ulcer disease. 52. A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information which nursing diagnosis would be most appropriate? a. Imbalanced nutrition: less than body requirements related to anorexia b. Disturbed sleep pattern related to epigastric pain

c. Ineffective coping related to exacerbation of duodenal ulcer d. Activity intolerance related to abdominal pain Ans: B based on the data provided, the most appropriate nursing diagnosis would be disturbed sleep pattern. A client with a duodenal ulcer commonly awakens during the night with pain. The clients feelings of anxiety do not necessarily indicate that she is coping ineffectively. 53. The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? a. Bland foods b. High-protein foods c. Any foods that are tolerated d. Large amounts of milk Ans: C diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts. 54. The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurses response to observing these actions should be based on knowledge that: a. Involvement with his job will keep the client from becoming bored b. A relaxed environment will promote ulcer healing c. Not keeping up with his job will increase the clients stress level d. Setting on the clients behavior is an important nursing responsibility Ans: B a relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Not keeping up with his job will probably increase the clients stress level, but the nurses response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a clients behavior; clients must make the decision to make lifestyle changes. 55. A client with peptic ulcer has been instructed to avoid intense physical activity and stress. Which activity should the client incorporate into the home care plan? a. Conduct physical activity in the morning so that he can rest in the afternoon b. Have the family agree to perform the necessary yard work at home c. Give up jogging and substitute a less demanding hobby d. Incorporate periods of physical and mental rest in his daily schedule Ans: D it would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environment. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful. 56. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? a. Before meals b. With meals c. At bedtime d. When pain occurs Ans: C ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. 57. A client has been taking aluminum hydroxide (Amphojel) 30 mL is six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the clients constipation? a. The client has not been including enough fiber in his diet

b. The client needs to increase his daily exercise c. The client is experiencing a side effect of the aluminum hydroxide d. The client has developed a gastrointestinal obstruction Ans: C it is most likely that the client is experiencing a side effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction. 58. A client is taking an antacid for treatment of peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? a. I should take my antacid before I take my other medications. b. I need to decrease my intake of fluids so that I dont dilute the effects of my antacid. c. My antacid will be most effective if I take it whenever I experience stomach pains. d. It is best for me to take my antacid 1 to 3 hours after meals. Ans: D antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drugs action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing side effects increases. Therefore, the client should not take antacids as often as desired to control pain. 59. Which of the following would be an expected outcome for a client with peptic ulcer disease? a. The client will demonstrate appropriate use of analgesics to control pain b. The client will explain the rationale for eliminating alcohol from the diet c. The client will verbalize the importance of monitoring hemoglobin and hematocrit every 3 months d. The client will eliminate contact sports from his or her lifestyle Ans: B alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The clients hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing. 60. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of potential complication? a. The client complains of a sore throat b. The client displays signs of sedation c. The client experiences a sudden increase in temperature d. The client demonstrates a lack of appetite Ans: C the most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process. 61. The nurse is completing a health assessment of a 42-year-old woman with suspected Graves disease. The nurse should asses this client for: a. Anorexia b. Tachycardia c. Weight gain d. Cold skin Ans: B-graves disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increase metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

62. A female client with thyrotoxicosis would probably report which changes related to the menstrual cycle during initial assessment? a. Dysmenorrhea b. Metrorrhagia c. Oligomenorrhea d. Menorrhagia Ans: C- A change in menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism. 63. Prophylthiouracil (PTU) is prescribed for a client with Graves disease to decrease circulating thyroid hormone. The nurse should teach the client to immediately report which of the following signs and symptoms? a. Sore throat b. Painful, excessive menstruation c. Constipation d. Increased urine output Ans: A- The most serious side effect of PTU are leukopenia and agranulocytosis, which usually occur within the first three months of treatment. The client should be thought to promptly report to the health care provider any signs and symptoms of infection, such as sore throat and fever. Any client complaining of sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be held until the result are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy. 64. A client with thyrotoxicosis says to the nurse, I am so irritable. I am having problems at work because I lose my temper very easily. Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? a. Your behavior is caused by temporary confusion brought on by your illness. b. Your behavior is caused by the excess thyroid hormone in your system. c. Your behavior is caused by your worrying about the seriousness of your illness. d. Your behavior is caused by the stress of trying to manage a career and cope with illness. Ans: B- A typical signs of thyrotoxicosis is irritability caused by the high level of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed. 65. Serum concentrations of thyroid hormones and thyroid-stimulating hormone (TSH) are tests ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis? a. Elevated thyroid hormone concentrations and normal TSH b. Elevated TSH and normal concentrations and elevated TSH c. Decreased thyroid hormone concentrations and elevated TSH d. Elevated thyroid hormone concentrations and decreased TSH Ans; D- Elevated serum concentrations of thyroid hormones and suppressed serum TSH are the features of thyrotoxicosis. Decreased or absent serum TSH is very accurate indicator of thyrotoxicosis. Increase level of circulating thyroid hormones cause the feedback mechanism to the brain to suppress TSH secretion. 66. The nurse should teach the client to prevent corneal irritation from mild exophthalmos by: a. Massaging the eyes at regular intervals b. Instilling an ophthalmic anesthetic as ordered c. Wearing dark-colored glasses d. Covering both eyes with moistened gauze pads Ans C- Treatment of mild opthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eye from corneal irritation. Treatment of opthalmopathy should be performed in consultation with an opthalmologist. Massaging the eye will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering

the eyes with moist gauze pads is not satisfactory nursing measure to protect the eyes of the client with exopthalmus because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exopthalmus, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased. 67. A client with Graves disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? a. The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy. b. The radioactive iodine reduces uptake of thyroxine and thereby improves your condition. c. The radioactive iodine lowers the levels of thyroid hormones by slowing your bodys production of them. d. The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced. Ans: D- Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. Use of RAI is often recommended for many clients with Graves disease, especially the elderly. The treatment results in medical thyroidectomy. RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving the RAI is the destruction of thyroid follicular cells. It is possible to slow the production of the thyroid hormones with RAI. 68. Which of the following nursing diagnoses would most likely be appropriate for a client with Graves disease performing self-care after treatment with RAI in the form of sodium iodide 131I? a. Risk for injury related to altered level of consciousness b. Ineffective breathing pattern related to effects of radioactive iodine c. Total self-care deficit related to the need for immobilization after RAI therapy d. Risk for ineffective therapeutic regimen related to lack of knowledge about disease management Ans: D- management of the disease process is priority for the client who has undergone RAI therapy with sodium iodide 131I. Signs of hyperthyroidism usually persist for 1 to 2 months and may be still present for up to 1 year until thyroid hormone production stops. Permanent hypothyroidism is the major complication of radioactive treatment. At that time, the client will be able to recognize symptoms of hypothyroidism. Changes in level of consciousness or breathing pattern are not expected. The client does not need to be immobilized after RAI treatment. 69. After treatment with RAI in the form of sodium iodide 131I, the nurse teaches the client to: a. Monitor signs and symptoms of hyperthyroidism b. Rest for 1 week to prevent complications of the medication c. Take thyroxine replacement of the remainder of the clients life d. Assess for hypertension and tachycardia resulting from altered activity Ans: C- The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism. 70. A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps; a. Slow progression of exophthalmos b. Reduce the vascularity of the thyroid gland c. Decrease the bodys ability to store thyroxine d. Increase the bodys ability to excrete thyroxine Ans: B- SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that present a hazard during surgery. Preparation of the client or surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exopthalmus, and it does not decrease the bodys ability to store thyroxine or increase the bodys ability to excrete thyroxin. 71. Which of the following measures is most recommended when preparing SSKI for administration? a. Pour the solution over ice chips

b. Mix the solution with water, milk or fruit d. Dilute the solution with water, milk fruit juice and have the client drink it with a straw Disguise the solution in a pureed fruit or vegetable Ans: C- SSKI should be diluted well in milk, water, juice, or carbonated beverage before administration to disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a pure would put the SSKI in contact with the teeth. 72. The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this primarily to monitor for signs of which of the following? a. Internal hemorrhage b. Decreasing level of consciousness c. Laryngeal nerve damage d. Upper airway obstruction Ans: C- Laryngeal nerve damage is not a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps to Asses for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhages are detected by changes in vital signs. The clients level; of consciousness can be partially assed by asking her to speak, but it is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate pattern. 73. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: a. Begin total parenteral nutrition b. Start a cutdown infusion c. Administer tube feedings d. Perform a tracheostomy Ans: D- Equipment for an emergency tracheostomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set , oxygen and suction equipment, and suture removal set ( for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Intravenous infusion via a cutdown is not expected possible treatment for thyroidectomy. Tube feedings are not anticipated emergency care. 74. Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy? a. Pains in the joints of the hands and feet b. Tingling in the fingers c. Bleeding on the back of the dressing d. Tension on the suture line Ans: B- Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of tetany is numbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur from 1 to 7 days postoperatively. Late signs of tetany include seizures, contraction of the glottis, and respiratory obstruction. Pains in the joints of the hands and feet are not early symptoms of tetany. Bleeding on the back of the dressing is related to possible incisional complications. Tension on the suture line may indicate swelling, infection, or internal bleeding, but it is not related to tetany. 75. Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? a. Sodium phosphate b. Calcium gluconate c. Echothiophate iodide d. Sodium bicarbonate Ans: B- The client with tetany is suffering from hypocalcemia, which is treated by administering an intravenous preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then

necessary until parathyroid function returns. Sodium phosphate is a laxative. Echothiopate iodide is an eye preparation used as miotic for antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid. 76. A 60-year-old woman is diagnosed with hypothyroidism. Signs and symptoms of hypothyroidism include: a. Tachycardia b. Weight gain c. Diarrhea d. Anorexia Ans: B- Typical symptoms of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, hair loss, constipation, and numbness and tingling of fingers. Tachycardia is sign of hyperthyroidism, not hypothyroidism. Diarrhea and anorexia are not symptoms of hypothyroidism. 77. Appropriate nursing diagnoses for a client with hypothyroidism would probably include which of the following? a. Risk for injury (corneal abrasion) related to incomplete closure of eyelid b. Imbalanced nutrition: less than body requirements related to hypermetabolism c. Deficient fluid volume related to diarrhea d. Activity intolerance related to fatigue associated with the disorder Ans: D- A major problem for the person with hypothyroidism is fatigue. Other sign and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism. 78. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: a. The effects of thyroid hormone replacement therapy and will diminish over time b. Related to the thyroid hormone replacement therapy and will not diminish over time c. A normal part of having a chronic illness d. Most likely related to low thyroid hormone levels and will improve with treatment Ans: D- Hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking the thyroid hormone and TSH levels. This client needs to know that these feelings may be related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does not cause depression. Depression may accompany chronic illness, but it is not normal. 79. A 55-year-old male client has recently been diagnosed with type 2 diabetes mellitus (DM) and is prescribed the sulfonylurea compound tolbutamide (Orinase). He is concerned about the diagnosis and says he knows nothing about diabetes. The nurse determines that the client needs teaching and support. The nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions? a. Potentiating the action of insulin b. Lowering the renal threshold of glucose c. Stimulating insulin release from functioning beta cells in the pancreas d. Combining with glucose to render it inert. Ans: C oral hypoglycemic agents of the sulfonylurea group, such as tolbutamide (Orinase),lower the blood glucose level by stimulating functioning beta cells in the pancreas to release insulin. These agents also increase insulins ability to bind to the bodys cells. They may also act to increase the number of insulin receptors in the body. Tolbutamide does not potentiate the action of insulin. Tolbutamide does not lower the renal threshold of glucose, which would not be a factor in the treatment of diabetes in any case. Tolbutamide does not combine with glucose to render it inert. 80. When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following: a. Avoid going barefoot b. Buy shoes a half size larger c. Cut toenails at angles d. Use heating pads for sore throat

Ans: A the client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn, because they will cause blister that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because at risk for burns to insensitivity to temperature. 81. A client with DM asks the nurse to recommend something to remove corns from his toes. The nurse should advise him to: a. Apply a high-quality corn plaster to the area b. Consult his physician or podiatrist about removing the corns c. Apply iodine to the corns before peeling them off d. Soak his feet in borax solution to peel off the corns Ans: B a client with diabetes should be advised to consult a physician or podiatrist for corn removal because of the danger or traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a physician or podiatrist. 82. A client with DM presents to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the clients hands. The client says, Im so clumsy. Im always cutting my finger cooking or burning myself on the iron. Which of the following responses by the nurse would be most appropriate? a. Wash all wounds in isopropyl alcohol. b. Keep all cuts clean and covered. c. Why dont you have your children to do the cooking and ironing? d. You really should be fine as long as you take your daily medication. Ans: B proper and careful first-aid treatment is important when a client with diabetes has a skin cut or laceration. The skin should be kept supple and as free or organisms as possible. Washing and bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the skin. Having the children help is an unrealistic suggestion and does not educate the client about proper care of wounds. Tight control of blood glucose levels through adherence to the medication regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored. 83. The client with DM says, If I could just avoid what you call carbohydrates in my diet, I guess I would be okay. The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following? a. Carbohydrates only b. Fats and carbohydrates only c. Protein and carbohydrates only d. Proteins, fats, and carbohydrates Ans: D DM is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The clients diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamin. 84. A client with type 1 DM is admitted to the emergency department. Which of the following respiratory patterns requires immediate action? a. Deep, rapid respirations with long expirations b. Shallow respirations alternating with long expirations c. Regular depth of respirations with frequent pauses d. Short expirations and inspirations Ans: A deep, rapid respirations with long expirations is indicative of Kussmauls respiration, which occurs in metabolic acidosis. The respirations increase in rate and depth, and the breath has a fruity or acetonelike odor. This breathing pattern is the bodys attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis. 85. The nurse should caution the client with DM who is taking a sulfonylurea medication that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? a. Hypokalemia b. Hyperkalemia

c. Hypocalcemia d. Disulfiram (Antabuse)-like symptoms Ans: D a client with diabetes who takes any first-or second-generation sulfonylurea should be advised to avoid alcohol intake. Sulfonylurea in combination with alcohol can cause serious reactions of disulfiram (Antabuse)-like reactions including flushing, angina, palpitations, and vertigo. Serious reactions such as seizures and possibly death may also occur. Hypokalemia, Hyperkalemia, and hypocalcemia do not result from taking sulfonylureas in combination with alcohol. 86. A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which of the following statements would demonstrate to the nurse that the client understands the instructions? a) I should limit the use of the inhaler to early morning and bedtime use. b) It is important to not shake the canister, because that can damage the spray device. c) I should hold one nostril closed while I insert the spray into the other nostril. d) The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall. Ans: C- When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the nostril to ensure the best inhalation of the spray. Use of inhaler is not limited to mornings and bedtime. The canister should be taken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize the inhalation of medication. 87. Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? a) The client maintains a fluid intake of 800 mL every 24 hours b) The client experiences chills only once a day c) The client coughs productively without chest discomfort d) The client experiences less nasal obstruction and discharge Ans: D- A client recovering from upper respiratory tract infection should report decreasing or no nasal discharge or obstruction. Daily fluid intake should be increased to more than 1 L every 24 hours to liquefy secretions. The temperature should be below 100F (37.8C) with no chills or diaphoresis. A productive cough with chest pain indicates pulmonary infection, not an upper respiratory tract infection. 88. The nurse teaches the client how to instill nasal drops. Which of the following techniques is correct? a) The client uses sterile technique when handling the dropper b) The client blows the nose gently before instilling drops c) The client uses a new dropper for each installation d) The client sits in a semi-fowlers position with the head tilted forward after administration of the drops Ans: B- The client should blow the nose before instilling nose drops. Instilling nose drops is a clean technique. The dropper should be cleaned after each administration, but it does not to be changed. The client should assume a position that will allow the medication to reach the desired area; this is usually supine position. 89. A client with acute sinusitis is examined in an ambulatory clinic. The nurse can anticipate the use of which of the following medications in the clients treatment plan? a) Antibiotics b) Antihistamines c) Bronchodilators d) Oral corticosteroids Ans: A- The plan of care for a client who has acute sinusitis includes antibiotics to treat the bacterial infection. In addition the nasal cortecosteroids and decongestants are frequently ordered to decrease mucosal inflammation and edema. Nasal cortecosteroids are preferred to oral cortecosteroids because they do not produce systematic side effects when used as prescribed. Anti histamines can promote an increase in secretion viscosity and continued symptoms; they should be avoided. Bronchodilators are ineffective in sinusitis. 90. The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis? a) Avoid the use of caffeinated beverages b) Perform postural drainage every day c) Take hot showers twice daily d) Report a temperature of 102oF (38.9oC) or higher Ans: C- The client with chronic sinusitis should be instructed to take hot showers in the morning and evening to promote drainage of secretions. There is no need to limit caffeine intake. Performing postural drainage

will inhibit removal of secretions, not promote it. Clients should elevate the head of the bed to promote drainage. Client should report all temperature higher than 100.4F (38C), because a temperature that is high can indicate infection. 91. Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination? a) A 60-year-old man with a hiatal hernia b) A 36-year-old woman with three children c) A 50-year-old woman caring for a spouse with cancer d) A 60-year-old woman with osteoarthritis Ans: C- Individuals who are household members or home care providers for high-risk individuals are high priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for the husband with a cancer has the highest priority of the clients described, because her husband is likely to be immunocompromised and particularly susceptible to flu. A healthy 60-year old man or 36-year-old woman is not in a high priority category for influenza vaccination than a home care provider. 92. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client? a) Use your nasal decongestant spray regularly to help clear your nasal passages. b) Ask the doctor for antibiotics. Antibiotics will help decrease the secretion. c) It is important to increase you activity. A daily brisk walk will help promote drainage. d) Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks. Ans: D- it is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the clients symptoms; in fact walking outdoors may increase them if the client is allergic to pollen. 93. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? a) It is likely that the client is developing a secondary bacterial pneumonia. b) The assessment findings are consistent with influenza and are to be expected c) The client is getting dehydrated and needs to increase her fluid intake to decrease secretions d) The client has not been taking her decongestants and bronchodilators as prescribed Ans: A- pneumonia is the most common complication of influenza, especially in the elderly. The development of purulent cough and crackles may be an indicative of bacterial infection and are consistent with diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu. 94. Guaifenesin 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose? a) 5.0 mL b) 7.5 mL c) 9.5 mL d) 10.0 mL Ans: B- 300 mg/x= 200 mg/ 5 ml; x= 7.5 mL 95. Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible side effect of this drug? a) Constipation b) Bradycardia c) Diplopia d) Restlessness Ans:D Side effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the central nervous system (CNS) The most common CNS side effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side effects include tachycardia, hypertension, palpitations and arrhythmias. Constipation and diplopia are not side effects of pseudoephedrine. Tachycardia and not bradycardia is a side effect of pseudoephedrine.

96. A 27-year-old woman has had elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact? a) Complaints of nausea b) Repeated swallowing c) Increased respiratory rate d) Increased pain Ans: B- Because of the dense nasal packing, bleeding may not be apparent through the nasal drip pad. Instead the blood may run down the throat, causing the client to swallow frequently. The back of the throat, where blood will be apparent, can be assessed with a flashlight. An accumulation of blood in the stomach can cause nausea and vomiting, but nausea would not be the initial indicator of bleeding. 97. A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client? a) Avoid activities that elicit the valsalva maneuver b) Take aspirin to control nasal discomfort c) Avoid brushing the teeth until the nasal packing is removed d) Apply heat to the nasal area to control swelling Ans: A- The client should be instructed to avoid any activities that cause Valsalvas maneuver (eg. Constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture line. The client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the clients appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area. 98. Which of the following statements would indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery? a) I should not shower until my packing is removed. b) I will take stool softeners and modify my diet to prevent constipation. c) Coughing every 2 hours is important to prevent respiratory complications. d) It is important to blow my nose each day to remove the dried secretions. Ans: B- Constipation can cause straining during defecation, which can induce bleeding. Showering is not contraindicated. The client should take measure to prevent coughing, which can cause bleeding. The client should avoid blowing her nose for 48 hours after the packing is removed. Thereafter, she should blow her nose gently, using the open-mouth technique to minimize bleeding in the surgical area. 99. The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included? a) After surgery, nasal packing will be place for 7 to 10 days b) Normal saline dose drops will need to be administered preoperatively c) The results of the surgery will be immediately obvious postoperatively d) Aspirin-containing medications should not be taken for 2 weeks before surgery Ans: D- Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline drops are not routinely administered pre-operatively. The result of surgery will not be obvious immediately after surgery because of edema and ecchymosis. 100. Which of the following assessments would be a priority immediately after nasal surgery? a) Assessing the clients pain b) Inspecting for periorbital ecchymosis c) Assessing respiratory status d) Measuring intake and output Ans: C- Immediately after nasal surgery, ineffective breathing patterns may develop as a result of nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assessing airway obstruction is a priority Assessing for pain is important, but it is not as a high priority as assessment of the airways. It is too early to detect ecchymosis. Measuring intake and output is not typically a priority nursing assessment after nasal surgery.