Kap test 2
19. A patient has a Levin tube connected to intermittent low suction. At 7 AM , the nurse charts that there is 235 cc of greenish drainage in the suction container. At 3 PM , the nurse notes that there is 445 cc of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift? 1. 150 cc. 2. 210 cc. 3. 295 cc. 4. 385 cc.
(1) correct-445 - 235 = 210 - 60 = 150 (2) does not subtract 60 cc of fluid used to irrigate Levin tube
22. A college student comes to the college health services with complaints of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumber puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were made? 1. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, Hct 38%, WBC 18,000/mm3 2. CSF with RBCs present, Hgb 10 g/dL, Hct 37%, WBC 8,000/mm3. 3. CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC 7,000/mm3 4. CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm3
(1) correct-CSF normally clear, colorless; normal WBC 5,000-10,000 per cubic millimeter, normal Hgb (male 13.5-17.5 g/dL, female 12-16 g/dL), normal Hct (male 41-53%, female 36-46%)
14. During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."
(1) correct-Erikson states that trust results from interaction with dependable, predictable primary caretaker
1. The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients? 1. An 18-month-old with respiratory syncytial virus. 2. A 4-year-old with Kawasaki disease. 3. A 10-year-old with Lyme's disease. 4. A 16-year-old with infectious mononucleosis.
(1) correct-acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children
52. A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania? 1. Agitation, grandiose delusions, euphoria, difficulty concentrating. 2. Difficulty in decision-making, preoccupation with self, distorted perceptions. 3. Paranoia, hallucinations, disturbed thought processes, hypervigilance. 4. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
(1) correct-characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior
58. The physician suggests play therapy for a 7-year-old girl who is having some difficulty adjusting to her parents' impending divorce. The nurse knows this type of therapy is useful because 1. young children have difficulty verbalizing emotions. 2. children hesitate to confide in anyone but their parents. 3. play is an enjoyable form of therapy for children. 4. play therapy is helpful in preventing regression.
(1) correct-children have difficulty putting feelings into words; play is how they express themselves
42. A client with a reactive depression has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities in the 1. morning hours. 2. middle of the day. 3. afternoon hours. 4. evening hours.
(1) correct-client with reactive depression has the highest level of physical and psychic energy in the morning
36. The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication? 1. Nausea. 2. Visual disturbances. 3. Tinnitus. 4. Ataxia.
(1) correct-common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
61. A fluid challenge of 250 cc of normal saline infused over 15 min is ordered for a client with possible acute renal failure. The nurse understands that the fluid challenge is given to 1. rule out dehydration as the cause of oliguria. 2. increase cardiac output and fluid volume. 3. promote the transfer of intravascular fluid to the intracellular space. 4. dilute the level of waste products in the intravascular fluid
(1) correct-expected response after a fluid challenge on normally functioning kidneys is an increase in urine output; will occur if low urine output is due to dehydration; if it is due to acute renal failure, there will continue to be oliguria
24. The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test? 1. Breast-fed babies need to be a week old for the test, and infants on formula can be tested in three days. 2. The infant can have water but should not have formula for six hours before the test. 3. The test will need to be repeated at six weeks and at the three-month check-up. 4. Blood will be drawn at three one-hour intervals; there is no specific preparation.
(1) correct-formula or cow's milk contains high phenylalanine levels; test can be done after three days of formula intake; if mother is breastfeeding, infant will need to return in one week for test
32. A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become 1. darker and more pigmented. 2. ruddy and oily. 3. puffy and scaly. 4. pale and dry.
(1) correct-increase in melanocyte-stimulating hormone results in "eternal tan"
74. What are two major side effects of haloperidol (Haldol) the nurse should anticipate? 1. Blood dyscrasia and extrapyramidal symptoms. 2. Hearing loss and unsteady gait. 3. Nystagmus and vertical gaze palsy. 4. Alteration in level of consciousness and increased confusion.
(1) correct-major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)
12. The nurse recognizes which of these symptoms as characteristic of a panic attack? 1. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy. 2. Decreased blood pressure, chest pain, choking feeling. 3. Increased blood pressure, bradycardia, shortness of breath. 4. Increased respiratory rate, increased perceptual field, increased concentration ability.
(1) correct-panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of "losing it" or going crazy
35. A client is readmitted with a recurrent urinary tract infection. The client is to be discharged home on methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids? 1. Milk. 2. Juices. 3. Water. 4. Tea.
(1) correct-should limit intake of alkaline foods and fluids, such as milk
7. A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings? 1. Hypotension, backache, low back pain, fever. 2. Wet breath sounds, severe shortness of breath. 3. Chills and fever occurring about an hour after the infusion started. 4. Urticaria, itching, respiratory distress.
(1) correct-signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
66. A client has developed a low intestinal obstruction. The nurse would anticipate which of the following findings? 1. Nausea, vomiting, abdominal distention. 2. Explosive, irritating diarrhea. 3. Abdominal tenderness with rectal bleeding. 4. Midepigastric discomfort, tarry stool.
(1) correct-there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease
50. The nurse is observing a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions? 1. Posterior and anterior base of right side. 2. Right anterior chest between the fourth and sixth intercostals. 3. Left of the sternum, midclavicular, at right fifth intercostal. 4. Posterior chest wall, midaxillary, right side.
(2) correct-RML is found in the right anterior chest between the fourth and sixth intercostal spaces
71. Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and decreased serum potassium. 4. Tachycardia with complaints of night sweats.
(2) correct-clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising
53. A client is admitted to the outpatient oncology unit for his routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 ml/mm3 , and calcium 5 mEq/L. Based on these assessments, which of the following should be the priority nursing diagnosis? 1. Risk for activity intolerance related to decrease in red cells. 2. Risk for infection related to low white cell count. 3. Risk for anxiety; secondary to hypoparathyroid disease. 4. Risk for fluid volume deficit due to decreased fluid intake.
(2) correct-clients with a low WBC count are susceptible to infection
55. A client receives morphine sulfate after being admitted to the emergency room in acute respiratory distress. He is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure. 2. Decrease in anxiety. 3. Depression of the sympathetic nervous system. 4. Enhanced ventilation and decreased cyanosis.
(2) correct-morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema
2. The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia? 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Tachycardia. 4. Severe hypotension.
(2) correct-severe headache results from rapid onset of hypertension
48. A nursing assistant reports to the RN that a patient with anemia is complaining of weakness. Which of the following responses by the nurse to the nursing assistant is BEST? 1. "Listen to the patient's breath sounds and report back to me." 2. "Set up the patient's lunch tray." 3. "Obtain a diet history from the patient." 4. "Instruct the patient to balance rest and activity."
(2) correct-standard, unchanging procedure; decrease cardiac workload
68. In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the client to exercise regularly to strengthen which muscles? 1. Anal sphincter. 2. Abdominal. 3. Trapezius. 4. Rectus femoris.
(2) correct-strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine
70. When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.
(2) correct-stress of an unfamiliar situation or environment may lead to confusion in elderly clients
5. The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height? 1. Her diet is low in calories and high in iron. 2. Her diet is low in calories and low in iron. 3. Her diet is high in calories and low in iron. 4. Her diet is high in calories and high in iron.
(3) correct-900 x 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500- 1,800 kcal/day); 3 mg x 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required
41. The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has to have the CBI. Which of the following responses by the nurse is BEST? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."
(3) correct-continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
47. During a prenatal visit, a client states: "I have been very nauseated during my first trimester, and I don't understand the reason." Which of the following responses by the nurse is BEST? 1. "You are nauseated because of the fatigue you are feeling." 2. "The nausea is due an increase in the basal metabolic rate." 3. "The nausea is caused by a secondary elevation in the hormones produced by the endocrine system." 4. "If you eat different kinds of foods, you won't be nauseated."
(3) correct-during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system
67. A 42-year-old man with metastatic lung cancer is admitted to the hospital. His orders include: do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses him, his BP is 86/50, respirations are 8, and he is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV, is ordered STAT. In planning care for this man, it is IMPORTANT for the nurse to know that 1. the BP and respirations will need to increase before a second dose of Narcan can be given. 2. Narcan should not be given to the man because of his DNR status. 3. a dose of Narcan may need to be repeated in 2-3 minutes. 4. Narcan is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.
(3) correct-half-life of Narcan is short; may go back into respiratory depression; may need to be repeated
4. A 21-year-old woman at 16-weeks gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by this test? 1. Tetralogy of Fallot. 2. Talipes equinovarus. 3. Hemolytic disease of the newborn. 4. Cleft lip and palate.
(3) correct-maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis
9. Under the supervision of the registered nurse, a student nurse is changing the dressing of a 49-year- old woman with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, would require an intervention by the registered nurse? 1. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine. 2. The student nurse applies two sterile precut 4x4s to the catheter insertion site. 3. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site. 4. The student nurse securely tapes the edges of the sterile dressing with paper tape.
(3) correct-should clean from insertion site outward toward outer abdomen
56. A 28-year-old client is admitted to the hospital unit with hepatitis A. The nurse knows that the client's overall care during hospitalization should include which of the following? 1. Protective isolation. 2. Airborne precautions. 3. Standard precautions. 4. Droplet precautions.
(3) correct-standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence
6. A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include 1. the time and circumstances under which the rash was noted. 2. the explanation given to the client and family of the reason for the rash. 3. notation on an allergy list and notification of the doctor. 4. the need for application of corticosteroid cream to decrease inflammation.
(3) correct-suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
38. The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse? 1. 11 months of age. 2. 14 months of age. 3. 17 months of age. 4. 20 months of age.
(4) correct-by 24 months may be able to achieve daytime bladder control
51. When caring for a client with myasthenia gravis, an important nursing consideration would be to 1. prevent accidents from falls as a result of vertigo. 2. maintain fluid and electrolyte balance. 3. control situations that could increase intracranial pressure and cerebral edema. 4. assess muscle groups toward the end of the day.
(4) correct-client has increased muscle fatigue, needs more assistance toward end of day
30. The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome? 1. Prevent iron deficiency anemia. 2. Decrease touch to prevent overstimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.
(4) correct-frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function
25. Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the 1. color of the medication solution. 2. patient's pulse and temperature. 3. time of the last analgesic dose the patient received. 4. patency of the patient's vein.
(4) correct-is very important to determine absolute patency of the vein; extravasation will cause necrosis
46. The nurse should anticipate the client with a gastric ulcer to have pain 1. two to three hours after a meal. 2. at night. 3. relieved by ingestion of food. 4. one-half to one hour after a meal.
(4) correct-pain related to a gastric ulcer occurs about one-half to one hour after a meal and rarely at night; is not helped by ingestion of food
17. The nurse is aware that which of the following assessments would be indicative of hypocalcemia? 1. Constipation. 2. Depressed reflexes. 3. Decreased muscle strength. 4. Positive Trousseau's sign.
(4) correct-positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia
72. A patient with type I diabetes mellitus (IDDM) asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST? 1. "Human insulin is less likely to cause you to have a localized allergic reaction to the injection." 2. "Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia." 3. "Human insulin prevents the development of long-term damage to the eyes and kidneys." 4. "Human insulin does not cause the formation of antibodies because the protein structure is identical to your own."
(4) correct-protein molecules are identical with human insulin
64. The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients? 1. A patient with a chest tube who is ambulating in the hall. 2. A patient with a colostomy who requires assistance with an irrigation. 3. A patient with a right-sided cerebral vascular accident (CVA) who requires assistance with bathing. 4. A patient who is refusing medication to treat cancer of the colon.
(4) correct-requires assessment skills of the RN
21. The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman. The nurse in the outpatient clinic teaches the client about the medication. The nurse should encourage the client to make sure her diet has adequate 1. sodium. 2. protein. 3. potassium. 4. iron
.(1) correct-alkali metal salt acts like sodium ions in body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity
45. A 69-year-old woman has been receiving total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse would expect the patient to exhibit 1. tinnitus, vertigo, blurred vision. 2. fever, malaise, anorexia. 3. diaphoresis, confusion, tachycardia. 4. hyperpnea, flushed face, diarrhea
.(3) correct-insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
23. A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to 1. provide an avenue for nutrients to flow past an obstructed area. 2. prevent fluid and gas accumulation in the stomach. 3. administer drugs that can be absorbed directly from the intestinal mucosa. 4. remove fluid and gas from the small intestine.
1. (4) correct-Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus
27. A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying need for help. 4. Emotionally distressed and needing assistance.
1. (4) correct-sexual assault by rape is a crisis situation for both victim and family members and friends
63. The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales? 1. The nurse believes that the client's symptoms reflect alcohol withdrawal. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows that the client is not psychotic. 4. The nurse routinely checks on the doctor's orders.
1) correct-medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
65. During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint? 1. An infant with septicemia. 2. A child with a tonsillectomy. 3. An infant with cleft lip repair. 4. A child with meningitis.
3) correct-arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line
34. A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question? 1. Propranolol (Inderal), 80 mg PO QID. 2. Verapamil (Nifedipine), 40 mg PO TID. 3. Tetrahydrozoline (Visine), 2 gtts OU TID. 4. Timolol (Timoptic solution), 1 gtt OU QD.
3) correct-contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
13. The physician diagnoses Graves' disease for a 28-year-old woman seen in the clinic. The nurse would expect the client to exhibit which of the following symptoms? 1. Lethargy in the early morning. 2. Sensitivity to cold. 3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.
3) correct-increased metabolic rate causes weight loss even with increased appetite
69. The nurse is planning care for a client with a diagnosis of paranoid schizophrenia. The nurse knows that questioning the client about his false ideas will 1. cause him to defend the idea. 2. help him clarify his thoughts. 3. facilitate better communication. 4. lead to a breakdown of the defense.
(1) correct-contraindicated; encourages patient to engage in further distortion of reality
15. Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration and nutrition while restrained.
(2) correct-assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
54. The nurse is caring for a client with Ménière's disease. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn her head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client's peripheral visual field.
(2) correct-by decreasing movement of client's head, vertigo attacks may be decreased
39. Which of the following nursing actions has the HIGHEST priority in caring for the client with hypoparathyroidism? 1. Develop a teaching plan. 2. Plan measures to deal with cardiac dysrhythmias. 3. Take measures to prevent a respiratory infection. 4. Assess laboratory results.
(2) correct-cardiac dysrhythmias related to low serum calcium would be the highest priority
8. The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with 1. aggressive behaviors and angry feelings. 2. self-identity and self-esteem. 3. focusing on reality. 4. family boundary intrusions.
(2) correct-clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do
3. A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include 1. explaining that the client will be walking with a prosthesis soon after surgery. 2. encouraging the client to share his feelings and fears about the surgery. 3. taking the informed consent form to the client and asking him to sign it. 4. evaluating how the client plans to maintain his schoolwork during hospitalization.
(2) correct-discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
49. A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress? 1. Bradycardia. 2. Tachypnea. 3. General pallor. 4. Irritability.
(2) correct-increase in the respiratory rate is an early sign of hypoxia, also for tachycardia
10. The home care nurse is performing an assessment of a client with pneumonia secondary to chronic pulmonary disease. Which of the following goals is MOST appropriate? 1. Maintain and improve the quality of oxygenation. 2. Improve the status of ventilation. 3. Increase oxygenation of peripheral circulation. 4. Correct the bicarbonate deficit.
(2) correct-to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
40. A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging? 1. Decreased frequency. 2. Incontinence. 3. Sphincter reflexes decrease. 4. Formation of bladder stones.
(2) correct-ureters, bladder, and urethra loose muscle tone results in stress and urge incontinence
73. A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following? 1. Hyperactive deep tendon reflexes. 2. Peripheral neuropathy affecting the hands. 3. Disorientation to person, place, and time. 4. Impaired concentration and memory loss.
(3) correct-approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
33. Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection? 1. Anxiety related to the mastectomy. 2. Impaired skin integrity related to the mastectomy. 3. Pain related to surgical incision. 4. Self-care deficit related to dressing changes.
(3) correct-immediately after surgery, the priority is optimizing the client's comfort
20. The nurse is caring for a patient during a radium implant. During the removal of the implant, it is MOST important for the nurse to take which of the following actions? 1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. 2. Handle the radium carefully using forceps and rubber latex gloves. 3. Chart the date and time of removal along with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.
(3) correct-important that accurate documentation be maintained on the internal radium implant
31. A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to the joint to provide for stability. 4. The student nurse holds the skin taut to stabilize the vein.
(3) correct-inappropriate; movement in area could cause displacement
16. The geriatric residents of a long-term care facility are engaged in a reminiscing group. The nurse knows that the primary goal of this type of group activity is to 1. provide psychosocial educational opportunities for stress and coping. 2. provide an avenue for physical exercise. 3. provide an environment for social interaction and companionship. 4. reorient and provide a reality test for confused clients.
(3) correct-primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members
60. The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching has been successful? 1. "The dye used in the test will turn my urine green for about 24 hours." 2. "I will be put to sleep for this procedure. I will return to my room in two hours." 3. "This procedure will take about 90 minutes to complete. There will be no discomfort." 4. "The wires that will be attached to my head and chest will not cause me any pain."
(3) correct-procedure takes approximately 90 minutes, not painful
75. A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST? 1. A new mother is breastfeeding her two-day-old infant who was born five days early. 2. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis. 3. An elderly woman discharged from the hospital three days ago with pneumonia. 4. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
(4) correct-symptoms of pulmonary edema; requires immediate attention
29. Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Note subjective data, such as "My breathing is much improved now." 2. Note objective findings, such as decreased respiratory rate and pulse. 3. Consult with the respiratory therapist to determine effectiveness. 4. Auscultate the chest for change or clearing of adventitious breath sounds.
(4) correct-to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions
44. The nurse is caring for a homebound client with a urinary catheter. The client's husband states that he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion? 1. The nurse notes that the bladder is distended. 2. The client complains of a constant urge to void. 3. The nurse notes that the urine is concentrated. 4. The client complains of a burning sensation.
. (1) correct-bladder distention is one of the earliest signs of obstructed drainage tubing
57. The nurse knows that the MOST reliable client measure for evaluating the desired response diuretic therapy is to 1. obtain daily weights. 2. obtain urinalysis. 3. monitor Na and K 4. measure intake. level
. (1) correct-effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights
59. A 69-year-old man is receiving dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician? 1. PT 12 seconds and Hgb 15 g/dL. 2. BUN 18 mg/dL and creatinine 1.0 mg/dL. 3. K+ 3.4 mEq/L and CA+ 5/5 mEq/L. 4. AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.
1. (3) correct-normal K+ 3.5-5.0 mEq/L, normal Ca+ 4.5-5.3 mEq/L, indicates hypokalemia and hypercalcemia (4) normal AST (SGOT) 8-20 U/L, normal ALT (SGPT) 8-20 U/L
43. The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client? 1. Identity versus identity diffusion. 2. Intimacy versus isolation. 3. Integrity versus despair and disgust. 4. Industry versus inferiority.
2) correct-is the stage for 19- to 35-year-olds
62. The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse would observe which of the following symptoms? 1. Decerebrate posturing, BP 160/100, pulse 56. 2. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004. 3. Glucosuria, osmotic diuresis, loss of water and electrolytes. 4. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.
2) correct-signs of dehydration, increased output, low specific gravity, normal 1.010-1.030
18. When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST? 1. After pursed-lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.
2) correct-specimens should be obtained in the early morning because secretions develop during the night
26. The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements? 1. "It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart." 2. "It is my responsibility to witness the signature of the patient before surgery is performed." 3. "It is my responsibility to explain the surgery and ask the patient to sign the consent form." 4. "It is my responsibility to answer questions that the patient may have before surgery."
3) correct-physician should provide explanation and obtain patient's signature
11. A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of this procedure? 1. "This test is performed by sticking my finger and measuring the results." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 6-8 weeks." 4. "I must follow my diet carefully for several days before the test."
3) correct-when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC
37. The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea. 2. Distended abdomen with ascites. 3. Minimal bowel sounds in all four quadrants. 4. Distended abdomen with complaints of pain.
4) correct-if an obstruction is present, the abdomen will become distended and painful
28. A clinic nurse is taking a health history from a 34-year-old man newly diagnosed with Buerger's disease. The nurse would expect the client's complaints to include 1. heart palpitations. 2. dizziness when walking. 3. blurred vision. 4. digital sensitivity to cold.
4) correct-vasculitis of blood vessels in upper and lower extremities
