NP3
18. A client with Diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is not responding to nonsteroidal anti-inflammatory drugs. The client complains that the pain is particularly worse at night. Which medication will you advocate for first? A. Amitriptyline (Elavil) C. Hydromorphone (Dilaudid) B. Corticosteroids D. Lorazepam (Ativan)
A. Amitriptyline (Elavil)
24. Another client had a unilateral Adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative for the nurse to take is to: A. Check the blood pressure C. Evaluate the urinary output B. Monitor the temperature D. Check the specific gravity of the urine
A. Check the blood pressure
72. The nurse finds it difficult to relieve Tonio's pain satisfactorily. Which of the following measures should the nurse take into consideration when continuing efforts to promote comfort? A. Improve the nurse-client relationship B. Enlist the help of the client's family C. Allow the client additional time to work through his or her own responses to pain. D. Arrange to have the client share a room with a client who has little pain
A. Improve the nurse-client relationship
Situation: Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle. Cora a 48 years old woman is diagnosed of Mitral Stenosis. Because the client has Mitral Stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client's past compliance with medical regimens. 86. 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
A. Medication therapy
77. When a person's blood pressure drops, the kidneys respond by: A. Secreting renin. B. Producing aldosterone C. Slowing the release of ADH D. Increasing urine output.
A. Secreting renin.
8. Marco is being taught insulin administration and self-monitoring of blood glucose levels. The nurse tells Marco that the major benefit of self-monitoring of blood glucose level is A. blood glucose is maintained at close to normal levels. B. materials and laboratory expenses are cost-efficient. C. dependence on the health care system is reduced. D. larger but fewer doses of insulin are required.
A. blood glucose is maintained at close to normal levels.
87. Ms. Cora 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
B. Protamine sulfate
80. Nurse Randy assesses a client in the ward and notes that he has a weak, irregular pulse, as well as soft, flabby muscles. These findings are indicative of which electrolyte imbalance? A. hypercalcemia B. hypernatremia C. hypokalemia D. hypomagnesemia
C. hypokalemia
78.. The main extracellular Cation is: A. Calcium. C. Magnesium. B. Potassium. D. Sodium.
D. Sodium.
50. The Physician has prescribed Novalog insulin for a client with Diabetes Mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? A. "I will make sure I eat breakfast within 10 minutes of taking my insulin." B. "I will need to carry candy or some form of sugar with me all the time." C. "I will eat a snack around three o'clock each afternoon." D. "I can save my dessert from supper for a bedtime snack."
A. "I will make sure I eat breakfast within 10 minutes of taking my insulin."
83. Nurse Dennis now is reinforcing health teaching to this client with stable Angina. Which statement by the patient indicates a correct understanding of the teaching? A. "I will stay indoors during heat advisories, using fans to keep cool" B. "I will use a small, lightweight shovel for removing snow from my drive" C. "I am able to have sex if I can climb a flight of stairs without chest pain" D. "I will rest for 30 minutes after eating any large, heavy meals"
A. "I will stay indoors during heat advisories, using fans to keep cool"
49. Mr. Felipe is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse's teaching? A. "When drawing up my insulin, I should draw up the regular insulin first." B. "When drawing up my insulin, I should draw up the NPH insulin first." C. "It doesn't matter which insulin I draw up first." D. "I cannot mix the insulin, so I will need two shots."
A. "When drawing up my insulin, I should draw up the regular insulin first."
Situation: Today's technology has led to more complex procedures in Preoperative Nursing. Nurse Leila a Surgical Nurse for 5 years still prioritizes the comprehensive assessment of clients to identify the surgical risk factors. 56. The client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? A. An elevated white blood cell count B. An abdominal bruit C. A negative Babinski reflex D. Pupils that are equal and reactive to light
A. An elevated white blood cell count
34. The Physician has ordered intravenous fluid with potassium for a client admitted with Gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should: A. Assess the urinary output B. Obtain arterial blood gases C. Perform a dextrostick D. Obtain a stool culture
A. Assess the urinary output
Situation: A male client 48 years old, married and works as a policeman is diagnosed with Angina. He is now being treated in the hospital. Medications are given and rest is encouraged. Nurse Dennis is attending to this client. 81. Which patient teaching is a priority when a calcium channel blocker such as Norvasc is prescribed for treatment of Angina. A. Avoid eating grapefruit or drinking grapefruit juice B. Rest at frequent intervals in semi reclining position C. Take at bedtime because the drug may cause fatigue and drowsiness D. Do not take sublingual nitroglycerine in conjunction with Amlodipine
A. Avoid eating grapefruit or drinking grapefruit juice
63. Nurse Arnold is planning to do preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). The nurse plans to include in the discussion that the most frequent cause of postoperative pain will be: A. Bladder spasms B. Bleeding within the bladder C. Tension on the Foley catheter D. The lower abdominal incision
A. Bladder spasms
14. Because of prolonged bile drainage from a T-tube, Mrs. Laba may develop a symptom related to a lack of fat soluble vitamins such as: A. Easy bruising C. Excessive jaundice B. Muscle twitching D. Tingling of the fingers
A. Easy bruising
Situation: Nurse Olympia learned from a seminar update that "Pain " is the fifth vital sign. It is significant for planning an effective care plan for pain management. 71. A 34-year-old man named Tonio from Bukidnon is admitted with multiple injuries from a motor vehicle accident. He complains of severe pain and requests frequent medication. One of the student nurses on duty expresses surprise, saying, "I thought Bukidnon people were very stoic about pain." Which is the nurse's best response about pain? A. Expression and perception of pain vary widely from person to person B. Tolerance of pain is about the same in all people C. Tolerance of pain is determined by a person's genetic makeup D. Pain perception is about the same in all people
A. Expression and perception of pain vary widely from person to person
Situation: Mrs. Laba, 48 years old has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. 11. Nurse Riza conducts a nutritional assessment. She should determine whether Mrs. Laba: A. Has a deficiency of Vitamin A, D, K C. Consumes excessive amounts of protein B. Eats adequate amount of dietary fiber D. Has excessive levels of potassium and folic acid
A. Has a deficiency of Vitamin A, D, K
Situation: Mr. Paco, a 58 year old who works in a Social Security System is admitted for renal failure. He is being assessed further to determine if the cause is prerenal, renal, or postrenal. 36. If the cause is prerenal, which condition most likely caused the renal failure? A. Heart failure B. Glomerulonephritis C. Ureterolithiasis D. Aminoglycoside toxicity
A. Heart failure
62. Nurse Arnold has done also preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. The nurse determines that the client needs further clarification if the client stated that the procedure: A. Is done under general anesthesia. B. Is rarely associated with complications C. Eliminates the need for anticoagulant therapy D. May cause congestion when clots get trapped at the filter.
A. Is done under general anesthesia.
70. Which statement about a person's character is evident in the Operating Room team? A. It reflects the moral values and beliefs that are used as guides to personal behavior and actions B. It refers to the quality of being righteous, correct, fair and impartial C. It assists in the control of feelings, thoughts and emotions in the face of difficulty D. It encourages the constructive use of the pleasure of the senses
A. It reflects the moral values and beliefs that are used as guides to personal behavior and actions
85.. An IV infusion of Nitroglycerine is prescribed for a patient with unstable Angina, but after reviewing current medications taken within the last 24 hours, the nurse should withhold this order because of which drug? A. Levitra C. Integrilin B. Lovenax D. Atromid-S
A. Levitra
57. A client was transferred to the hospital unit as a direct admit from a small community hospital. While Nurse Leila is obtaining part of the admission history information, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 90/70, heart rate of 130, and respiratory rate of 24. What is the nurse's initial action? A. Lower the head of the bed B. Initiate an IV with a large bore needle C. Notify the physician D. Call for the cardiopulmonary resuscitation team
A. Lower the head of the bed
Situation: Nurse Lewel as a surgical nurse is aware that the management of the Perioperative clients demands the use of knowledge and skills based on the principles of surgical nursing practice. The following are different clients in the Perioperative unit. 21. Nurse Lewel is caring for a client with Acromegaly. Following a transphenoidal hypophysectomy, the nurse should: A. Monitor the client's blood sugar C. Place the client in low Trendelenburg position B. Suction the mouth and pharynx every hour D. Encourage the client to cough
A. Monitor the client's blood sugar
25. A client with an inguinal hernia asks Nurse Lewel why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to: A. Prevent strangulation of the bowel C. Decrease secretion of the bile salts B. Prevent malabsorptive disorders D. Increase intestinal motility
A. Prevent strangulation of the bowel
74.. After administering Meperidine Hydrochloride (Demerol), the nurse determines its effectiveness as an analgesic was related to its ability to: A. Reduce the perception of pain B. Decrease the sensitivity of pain receptors C. Interfere with pain impulses traveling along sensory nerve fibers D. Block the conduction of pain impulses along the central nervous system
A. Reduce the perception of pain
55. A client who took an overdose of a prescribed medication was inserted with Gastric Lavage. The nurse assesses the client carefully for which of the following as a priority to detect possible complications of treatment? A. Respiratory status and breath sounds B. Heart and blood pressure C. Skin color and body temperature D. Urine output and peripheral edema
A. Respiratory status and breath sounds
Situation: Lucio is a 24 year-old newly diagnosed Type I diabetic patient. 1. Lucio asks what Type I Diabetes Mellitus is. You would reply that it is a diabetes that is A. insulin dependent. B. non-insulin dependent. C. gestation related. D. a complication of pancreatitis.
A. insulin dependent.
89.. Good dental care is an important measure in reducing the 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 / an : A. manual toothbrush B. electric toothbrush C. irrigation device D. dental floss
A. manual toothbrush
9. Marco asks about ketoacidosis. The nurse explains that the primary cause of the development of ketoacidosis is A. not taking insulin regularly. B. a GI disturbance. C. an insulin overdosage. D. an omitted meal.
A. not taking insulin regularly.
7. In teaching Marco, it is important to initially evaluate his A. present understanding of diabetes. B. dietary modification. C. understanding of the exchange list. D. ability to administer insulin.
A. present understanding of diabetes.
68. Scrub Nurse Blaze is assigned to assist an operation for Cholecystectomy. She is aware that a break in sterile technique during surgery would occur when she touches: A. the mask with gloved hands B. gloved hands to the gown at chest level C. the drape of the indecision site with gloved hands D. the lower arms to the instruments on the instrument tray
A. the mask with gloved hands
82.. After completion of a teaching session, which statement by the patient would indicate a need for further teaching regarding medications for management of Angina? A. "I will monitor my heart daily while taking atenolol" B. "B complex vitamins work together with Lipitor to help keep blood vessels healthy" C. "I will remove my transdermal Nitroglycerine patch at bedtime and reapply in the morning" D. "Arising slowly and avoiding sudden position changes will keep me from getting dizzy and possibly falling"
B. "B complex vitamins work together with Lipitor to help keep blood vessels healthy"
28. While a client is receiving a blood transfusion, the client develops flank pain, chills, fever and hematuria. Nurse Rita recognizes that the client is probably experiencing: A. An allergic transfusion reaction C. A Pyrogenic transfusion reaction B. A hemolytic transfusion reaction D. An Anaphylactic transfusion reaction
B. A hemolytic transfusion reaction
47. Mrs. Montes has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should: A. Administer the two medications together. B. Administer the medication in two injections. C. Draw up the Lantus insulin and then the regular insulin and administer them together. D. Contact the doctor because this medication should not be given to the same client.
B. Administer the medication in two injections.
2. Lucio volunteers that he has a friend who has Diabetes insipidus. He inquires if they are similar. The nurse responds, "No. Diabetes insipidus is not caused by a lack of insulin but by a lack of? A. ACTH B. Anti-diuretic hormone C. Glucose D. Glucocorticoid
B. Anti-diuretic hormone
92. Nurse Nathan is caring for Lucia who is receiving a Thiazide diuretic for Hypertension. Based on this information, when guiding the client to select foods from the daily menu, the nurse should explain that a good food choice is: A. Apples B. Broccoli C. Cherries D. Cauliflower
B. Broccoli
5. Lucio develops pallor, cool skin, diaphoresis and unconsciousness. In this emergency, the nurse prepares to administer A. D5W B. D50 C. Regular insulin D. Epinephrine
B. D50
97. A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. The nurse should include that: A. Housework must be done by professional house cleaners B. Damp-dusting the house will help limit dust particles in the air C. The condition must be accepted because dust cannot be limited D. The house must be redecorated because the environment must be dust-free
B. Damp-dusting the house will help limit dust particles in the air
Situation: Mrs. Montes, a diabetic for 6 years was admitted for unstable condition of her diabetes. She was living with her 16 year old niece who is not also knowledgeable about her medications. Nurse Aleli is conducting a nursing care plan for Mrs. Montes. 46. Nurse Aleli is preparing to administer regular insulin by continuous IV infusion for Mrs. Montes with Diabetic Ketoacidosis. The nurse should: A. Mix the insulin with Dextrose 5% in Water B. Flush the IV tubing with the insulin solution and discard the first 50mL C. Avoid using a pump or controller with the infusion D. Mix the insulin with Ringer's lactate
B. Flush the IV tubing with the insulin solution and discard the first 50mL
Situation: Marco receives continuing medical and nursing care. 6. While doing a health teaching, the nurse explains which pathophysiology causes diabetic retinopathy? A. Adhesions B. Hemorrhaging C. Corneal abrasions D. Optic edema
B. Hemorrhaging
99.. The child woke in the middle of the night with dyspnea, restlessness, wheezing, and cough. Mother and child spent the night in a reclining chair. His mother declares, "He is having an asthma attack." What is the priority nursing diagnosis? A. Disturbed Sleep Patterns related to difficulty breathing B. Impaired Gas Exchange related to thickening of bronchial wall and mucous C. Caregiver Role Restrain related to duration of a chronic health condition D. Fatigue related to inadequate tissue oxygenation
B. Impaired Gas Exchange related to thickening of bronchial wall and mucous
79.. Hypertonic solutions cause fluids to move from the: A. Interstitial space to the intracellular space. B. Intracellular space to the extracellular space. C. Extracellular space to the intracellular space. D. Extracellular space to the interstitial space.
B. Intracellular space to the extracellular space.
88. Before a client's discharge after Mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon? A. Showering B. Lifting anything heavier than 10 lbs. C. a program of gradually progressive walking D. light housework
B. Lifting anything heavier than 10 lbs.
22. Nurse Lewel is responding to a post-operative client on a mechanical ventilator who begins to fight the ventilator. Which medication will be ordered for the client? A. Sublimaze (fentanyl) C. Versed (midazolam) B. Pavulon (pancuronium bromide) D. Atarax (hydroxyzine)
B. Pavulon (pancuronium bromide)
94. A cardiac catheterization using the femoral artery approach was performed to a client to assess the degree of coronary artery thrombosis. Which nursing action following the procedure is unsafe for the client? A. Encouraging the client to increase fluid intake B. Placing the client's bed in a Fowler's position C. Resuming prescribed precatheterization medications D. Instructing the client to move the toes when checking circulation, motion and sensation.
B. Placing the client's bed in a Fowler's position
SITUATION: Pedro 7 years old is admitted to the hospital with Acute Respiratory Distress Syndrome. Upon auscultation, wheezes were noted on both lung fields. 96.. The nurse understands that this client may have difficulty breathing because of: A. A too rapid expulsion of air B. Spasms of the bronchi, which trap the air C. Hyperventilation due to an anxiety reaction D. An increase in the vital capacity of the lungs
B. Spasms of the bronchi, which trap the air
23. Nurse Lewel received a client from O.R. who had undergone a surgery with a total knee replacement. Which of the following findings requires immediate nursing intervention? A. Bloody drainage of 30mL from the Davol drain is present. B. The Continuous Passive Motion (CPM) is set on 90° flexion. C. The client is unable to ambulate to the bathroom. D. The client is complaining of muscle spasms.
B. The Continuous Passive Motion (CPM) is set on 90° flexion.
Situation: Nurse Randy is aware that fluids and electrolytes balance is crucial for life. This is an essential assessment that should be considered by the health team. Nurse Randy reviews the following principles on this fluid balance. 76.. Hydrostatic pressure, which pushes fluid out of the capillaries, is opposed by colloid osmotic pressure, which involves: A. Reduced renin secretion. B. The pulling power of albumin to reabsorb water. C. An increase in ADH secretion. D. Aldosterone production.
B. The pulling power of albumin to reabsorb water.
44. When a client is diagnosed with Ulcerative Colitis, the nurse should be alert for the complication of A. Intestinal obstruction. B. Toxic megacolon. C. Malnutrition from malabsorption. D. Fistula formation.
B. Toxic megacolon.
48. The Physician has prescribed NPH insulin to Mr. Felipe a 57 year old client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? A. "I will make sure I eat breakfast within 2 hours of taking my insulin." B. "I will need to carry candy or some form of sugar with me all the time." C. "I will eat a snack around three o'clock each afternoon." D. "I can save my dessert from supper for a bedtime snack."
C. "I will eat a snack around three o'clock each afternoon."
15. Mrs. Laba is to be discharged; she asks whether there are any dietary restrictions that must be followed. Nurse Riza would recognize that the dietary teaching was understood when Mrs. Laba tells a family member: A. "I will need to avoid fatty foods for the rest of my life." B. "I should not eat those foods that upset me before I had surgery." C. "Most people can tolerate a regular diet after this type of surgery." D. "Most people need to eat a high protein diet for several months after surgery."
C. "Most people can tolerate a regular diet after this type of surgery."
84.. One of the major causes of Angina and MI is CAD. Which of the following findings are components of the clustered symptoms called metabolic syndrome, which promotes CAD? 1. BP 146/90 2. Blood glucose >116mg/dL 3. LDL 38mg/dL 4. HDL 62mg/dL 5. Waist measurement 38 inches A. 1 2 3 C. 1 2 3 5 B. 1 2 3 4 D. 1 3 5
C. 1 2 3 5
4. Lucio needs to receive insulin injection. The nurse teaches the diabetic patient that regular insulin peaks A. 30 minutes B. 1 hour C. 2 to 4 hours D. 4 to 6 hours
C. 2 to 4 hours
35. The Physician ordered for replacement of fluids to a client with Gastroenteritis of D5 Lactated Ringer's 1,000 ml solution to run for 6 hours. Compute for the rate of flow. The drop factor rate is 15 gtts/ cc. A. 31-32 gtts/min. B. 31-32 gtts / cc. C. 41-42 gtts / min. D. 41-42 gtts / cc.
C. 41-42 gtts / min.
19. Which client is most likely to receive Opioids for extended periods of time? A. A client with fibromyalgia C. A client with progressive pancreatic cancer B. A client with phantom limb pain in the leg D. A client with trigeminal neuralgia
C. A client with progressive pancreatic cancer
100. As the nurse approach the child, which presentation would concern the nurse most and require immediate intervention? A. Alert and irritable, lying recumbent on the examination table B. Awake and nervous, sitting upright and crying, skin pale and dry C. Agitated, sweating, and sitting upright with shoulders hunched forward D. Asleep in side-lying position breathing through open mouth
C. Agitated, sweating, and sitting upright with shoulders hunched forward
37. Mr. Paco in acute renal failure becomes severely anemic and the Physician prescribed two units of packed red blood cells (RBCs). The nurse should plan to administer each unit: A. as quickly as the client can tolerate the infusions. B. over 30 minutes to an hour. C. Between 1 and 4 hours. D. up to 4 hours but no longer.
C. Between 1 and 4 hours.
29. Another client, Mr. Novo who is in a hypovolemic shock has a hematocrit value of 20 %. Nurse Rita should anticipate that the Physician will order: A. Serum albumin C. Blood replacement B. Ringer's lactate D. High molecule dextran
C. Blood replacement
Situation: A Nurse reported to the ward unit 30 minutes before the start of duty to familiarize herself with the different conditions of the clients to facilitate nursing management. After receiving an endorsement, the nurse admitted a client with a diagnosis of Duodenal ulcer. 16. The client will most likely report that his abdominal discomfort decreases when he: A. Avoids eating C. Eats a meal or snack B. Rests in a recumbent position D. Sits upright after eating
C. Eats a meal or snack
12. Mrs. Laba undergoes an abdominal cholecystectomy with common duct exploration. In the immediate post-op period, the nursing action that should assume the highest priority for Mrs. Laba would be: A. Irrigating the Y -tube frequently C. Encouraging coughing and deep breathing B. Changing the dressing at least BID D. Promoting an adequate fluid intake by mouth.
C. Encouraging coughing and deep breathing
75. Another client in the ward is arousing from a coma and keeps saying "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain with attempts to: A. Tolerate the pain B. Decrease the perception of pain C. Escape the source of pain D. Divert attention from the source of pain
C. Escape the source of pain
54. The nurse working in the Emergency department learns that a client will be arriving who took an overdose of Acetaminophen (Tylenol) a short while ago. The nurse should anticipate that which of the following tubes will be used to evacuate the client's stomach upon arrival? A. Minnesota B. Sengstaken-Blakemore C. Ewald D. Miller-Abbott
C. Ewald
39. Mr. Paco with acute renal failure has an elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information due to uremia. The nurse avoids which of the following when communicating with his client? A. Giving simple, clear directions B. Including the family in discussions related to care C. Giving thorough, lengthy explanations of procedures D. Explaining treatments using understandable language
C. Giving thorough, lengthy explanations of procedures
64. The patient has a right to information regarding the operation or other invasive procedure and potential effects . This right is achieved through: A. Doctor's round B. Pre-operative visit C. Informed Consent D. Charting
C. Informed Consent
40. The nurse is reviewing a urinalysis report for Mr. Paco with acute renal failure and notes that the results are highly positive for Proteinuria. The nurse interprets that this client has which type of renal failure? A. Prerenal failure B. Postrenal failure C. Intrinsic renal failure D. Atypical renal failure
C. Intrinsic renal failure
52. Nurse Olivia enters the room of a client who underwent insertion of a nasoenteric tube for partial bowel obstruction the previous evening. She notes that the tube is not taped at the nose. Which of the following action is most appropriate at this time? A. Call the physician immediately. B. Tape the tube in place. C. Note the finding on the client's flow sheet. D. Call the radiology department to see if an abdominal x-ray has been done.
C. Note the finding on the client's flow sheet.
Situation: There are some clients during surgery that needs Blood Transfusion. Rita an O.R. Nurse received an order for blood transfusion for radical mastectomy. She must strictly check the blood typing as well as the serial number before the administration. 26. A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with: A. A positive blood C. O negative blood B. B positive blood D. AB negative blood
C. O negative blood
Situation: Mr. Bawas, a 48 year old who has Gastroenteritis and is on Digitalis has laboratory values of: K= 3.2 mEq/L, Na = 136 mEq/L, Ca = 4.8 mEq/L, and CI= 98 mEq/L. 31. The nurse would record which of the following on the client's plan of care? A. Monitor for hyperkalemia. B. Avoid foods rich in potassium. C. Observe for digitalis toxicity. D. Observe for Trousseau's and Chvostek's signs.
C. Observe for digitalis toxicity.
98. The nurse is teaching the client with Asthma how to perform a peak respiratory flow rate measurement. The nurse tells the client to: A. Inhale an average-size breath B. Blow out as slowly as possible C. Record the final position of the indicator D. Form a loose seal with the mouth around the mouthpiece
C. Record the final position of the indicator
SITUATION: Lucia a 64 year old factory worker complaining of early morning headache is admitted to the ER department. Upon assessment she was diagnosed to have Hypertension with complications. Nurse Nathan should be knowledgeable in providing the necessary consideration for clients with cardiovascular conditions. 91. The Physician prescribed a diuretic for a client with hypertension. When providing client teaching, the nurse explains that diuretics reduce BP by: A. Facilitating vasodilation B. Promoting smooth muscle relaxation C. Reducing the circulating blood volume D. Blocking the sympathetic nervous system
C. Reducing the circulating blood volume
43. The nurse is caring for a 26-year-old who was recently diagnosed with ulcerative colitis. The nurse has been giving dietary instructions to help prevent exacerbation of his inflammatory bowel disease. Which dietary choice indicates that the client understands the dietary instructions? A. Mango B. Celery. C. Refined Cereals. D. Star apple
C. Refined Cereals.
27. When administering blood, it is important for Nurse Rita to: A. Administer each unit within a 6 hour period B. Use a volume control infusion pump to administer the blood C. Run the blood at a slower rate during the first 5 to 10 minutes D. Draw blood samples from the client immediately after each unit is transfused
C. Run the blood at a slower rate during the first 5 to 10 minutes
10. In the nurse's education session for Marco, which concept is essential to include when developing the plan of care? A. All diabetic teaching needs to be accomplished within 20 hours before discharge. B. Insulin injection sites should be cleaned with iodine prior to injection. C. Snacks should be ingested prior to physical exertion. D. Urine sugar levels should be checked prior to insulin administration.
C. Snacks should be ingested prior to physical exertion.
20. A newly admitted client has Sickle Cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all of the following interventions are ordered, which should be done first? A. Adjust the room temperature C. Start O2 B. Give a bolus of IV fluids D. Administer meperidine (Demerol) 75mg IV push
C. Start O2
3. When is a patient with Diabetes Mellitus, Type I, most vulnerable to ketoacidosis? A. When fasting 2-3 days a week B. When taking too much insulin C. When under a lot of stress D. When eating too many carbohydrates
C. When under a lot of stress
67. Goals for patient safety in the operating room (OR) include the universal Protocol, in which: A. all surgical centers of any type must submit reports on patient safety infarctions to the accreditation agencies B. the members of the surgical team stop whatever they are doing to check that all sterile items have been properly prepared C. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site D. all members of the surgical team pause right before surgery is started to meditate for 1 minute to decrease stress and possible errors
C. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site
Situation: Perioperative and perianesthesia nursing includes a wide variety of nursing functions associated with the patient's surgical experience during the perioperative period. 66. Every staff nurses utilizes a Preoperative checklist is used on the day of surgery to ensure that: A. the patient is correctly identified B. patient's families have been informed as to where they can accompany and wait for patients C. all preoperative orders and procedures have been carried out and records are complete D. preoperative medications are the last procedure carried out before the patient is transported to the operating room
C. all preoperative orders and procedures have been carried out and records are complete
65. Nurse Arnold who is receiving client in the preoperative area of the operating room notice that is scheduled for a partial mastectomy and axillary lymph node removal the following week. Nurse Arnold should make sure that the client is well educated about her surgery by: A. talking with the nursing staff at the physician's office to find out what the client has been taught and her level of understanding. B. making sure that the post-anesthesia care unit nurses know what to teach the client before discharge. C. providing all of the preoperative teaching before surgery. D. having the post-operative nurses teach the client because she'll be too anxious before surgery.
C. providing all of the preoperative teaching before surgery.
33. Another client, a 93-year-old adult is hospitalized for the treatment of Gastroenteritis complicated by dehydration and hyponatremia. The nurse expects that an early symptom of hyponatremia exhibited by the client was A. ataxia. C. thirst. B. hunger. D. weakness.
C. thirst.
73. The client's Physician decides to change the analgesia medication from Meperidine Hydrochloride (Demerol) 75 mg I.M. every 4 hours as needed to Meperidine hydrochloride by the oral route. What dosage of oral Meperidine should be given to provide an equivalent analgesic dose? A. 25 to 50 mg C. 125 to 150 mg B. 75 to 100 mg D. 250 to 300 mg
D. 250 to 300 mg
38. The nurse who is caring for Mr. Paco in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client's mean arterial pressure falls below: A. 140 C. 100 B. 120 D. 80
D. 80
42. A Nursing Diagnosis appropriate for a client who has Ulcerative Colitis is: A. Abdominal pain, related to decreased peristalsis. B. Diarrhea related to hyperosmolar intestinal contents. C. Excess fluid volume related to increased water absorption by intestinal mucosa. D. Activity intolerance related to fatigue.
D. Activity intolerance related to fatigue.
93. Lucia's condition was not relieved by diuretics. She begins to complain of chest pain radiating to her shoulder. Emergency angiogram was performed and revealed blocked arteries. An immediate cardiac catheterization was done. The most important nursing action after a client undergoes cardiac catheterization via the femoral artery is to: A. Provide a bed cradle B. Check for a pulse deficit C. Elevate the head of the bed D. Asses the groin for bleeding
D. Asses the groin for bleeding
59. After the physician explains the surgery to the client, Nurse Leila provides the client with information about surgery, answers the client's questions, and allows the clients to agree or refuse to have surgery. Which of the following ethical principle is best described by the nurse actions? A. Nonmaleficence B. Beneficence C. Truth telling D. Autonomy
D. Autonomy
95. The nurse is caring for another client scheduled to undergo cardiac catheterization for the first time. The nurse tells the client that the: A. Procedure is performed in the operating room B. Initial catheter insertion is quite painful; after that, there is little or no pain C. Client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard X-ray table for about 4 hours D. Client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough or palpitations.
D. Client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough or palpitations.
45. A client experiences an exacerbation of Ulcerative Colitis. Test results reveal elevated serum osmolality and urine specific gravity. What's the most likely explanation for these test results? A. Renal insufficiency B. Hypoaldosteronism C. Diabetes insipidus D. Deficient fluid volume
D. Deficient fluid volume
30. The Physician orders 2 units of blood to be infused to Mr. Novo. Before blood administration, Nurse Rita's highest priority should be: A. Obtaining the client's Vital Signs B. Allowing the blood to reach room temperature C. Monitoring the hemoglobin and hematocrit levels D. Determining proper typing and cross-matching of the blood
D. Determining proper typing and cross-matching of the blood
13. Nurse Riza is aware that Mrs. Laba's T-tube has been inserted during a resection of the pancreas to: A. Divert the bile flow to the cystic duct B. Drain blood and pus from the operative site C. Prevent postoperative infection at the site of the incision D. Facilitate bile drainage while the common bile duct is edematous
D. Facilitate bile drainage while the common bile duct is edematous
17. The Charge nurse attends to a client with chronic pain who reports that the morning shift nurses have not been responding to requests for pain medication. What is her initial action? A. Check the medication administration records (MARs) and nurses' notes for the past several days. B. Ask the nurse educator to provide in-service training about pain management. C. Perform a complete pain assessment and take a pain history. D. Have a conference with the nurses responsible for the care of this client.
D. Have a conference with the nurses responsible for the care of this client.
Situation: Many modalities are available for the diagnostic assessment of the Gastrointestinal Tract (GIT) and other nursing management related to GIT disorders. Nurses should support and educate patients who are undergoing diagnostic evaluation. 51. A client with a partial bowel obstruction will have a Nasoenteric tube placed by the physician later in the day. Nurse Olivia explains to the client that which of the following positions will be utilized following tube placement so it will migrate to the intended area? A. Flat on the left side C. Head of bed elevated and on the left side B. Flat and on the right side D. Head of bed elevated and on the right side
D. Head of bed elevated and on the right side
Situation: Arnold is an Operating room Nurse preparing for different patients to be operated. Health teaching is very essential activity before any minor or major operation to facilitate fast recovery of clients. 61. Nurse Arnold is preparing to conduct preoperative teaching with a client scheduled for radical neck dissection. The nurse initially focuses on: A. Client's usual coping behaviors B. Client's dependable support systems C. Postoperative communication techniques D. Information already supplied by the surgeon
D. Information already supplied by the surgeon
53. A client is placed on enteral feedings via nasogastric tube to meet nutritional goals. Which of the following assessments should be included in a plan of care in order to maintain fluid balance? A. Assess the skin area around the tube site. B. Weigh the client every other day. C. Maintain strict I&O and flush the tube once a day to ensure patency. D. Irrigate the tube with water as ordered and include this fluid in total I&O.
D. Irrigate the tube with water as ordered and include this fluid in total I&O.
32. Further assessment to Mr. Bawas revealed that he has been vomiting for three days. He has taken baking soda without relief. His blood gases are as follows: pH 7.49, PaCO² 45, and HCO³ 30. The nurse would expect which of the following to be included in the plan of care? A. Have the client drink at least eight glasses of water in the first day. B. Administer NaHCO³ IV as per physician's orders. C. Continue sodium bicarbonate for nausea. D. Monitor electrolytes for hypokalemia and hypocalcemia.
D. Monitor electrolytes for hypokalemia and hypocalcemia.
60. Identify the client who is a high risk for developing respiratory problems in the postoperative course: A. The client is ambulatory B. The client has no history C. The client has undergone genitourinary surgery D. The client is obese
D. The client is obese
58. The Surgical Unit admitted clients for surgery. Which client can best be assigned to the newly licensed nurse? A. The client receiving chemotherapy C. The client with a TURP B. The client post-coronary bypass D. The client with diverticulitis
D. The client with diverticulitis
Situation: A 23-year-old man with a long history of Ulcerative Colitis is experiencing an exacerbation of the disease and is admitted with severe diarrhea, electrolyte disturbance, and severe abdominal pain. He questions the nurse about his prognosis. 41. The best response to this inquiry is: A. Ask your physician. B. It is rarely fatal. C. It depends on the form of the disease. D. You sound concerned.
D. You sound concerned.
90.. 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
D. pulmonary circulation
69. Nurse Blaze have just handled the surgeon a suture. Which scissors she will have it ready to hand to the Surgeon to cut the suture with? A. curved mayo B. metzenbaun C. Potts D. straight mayo
D. straight mayo
