NCLEX Study Questions for Maddy so she doesn't FAIL!! Part 6
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: A. Allergies to pineapples and bananas B. A history of streptococcal infections C. Prior therapy with phenytoin D. A history of alcohol abuse
Correct Answer: A history of streptococcal infections Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. Due to streptokinase's thrombolytic mechanisms of action, patients need monitoring for bleeding. The patient's thrombin time, prothrombin time, partial thromboplastin time, complete blood count, and any signs of bleeding demand careful surveillance. Patients also need monitoring for signs and symptoms of reinfarction or vessel occlusion.
Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) and is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it? A. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." B. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." C. "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." D. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."
Correct Answer: A. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS.
Johnny, a firefighter, was involved in extinguishing a house fire and is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Atelectasis C. Bronchitis D. Pneumonia
Correct Answer: A. Adult respiratory distress syndrome (ARDS) Severe hypoxia after smoke inhalation is typically related to ARDS.
After a motor vehicle accident, Armand, a 22-year-old client, is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling? A. Air leak B. Adequate suction C. Inadequate suction D. Kinked chest tube
Correct Answer: A. Air leak Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space.
Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons? A. Alveolar damage in the infarcted area. B. Involvement of major blood vessels in the occluded area. C. Loss of lung parenchyma. D. Loss of lung tissue.
Correct Answer: A. Alveolar damage in the infarcted area. The infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts.
When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result? A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B. Emergent; the client is poorly oxygenated. C. Normal. D. Significant; the client has alveolar hypoventilation.
Correct Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels.
Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture? A. Fracture of the distal radius. B. Fracture of the olecranon. C. Fracture of the humerus. D. Fracture of the carpal scaphoid.
Correct Answer: A. Fracture of the distal radius. Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds
Correct Answer: A. Have a Protime done monthly Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. The client will need to have his blood tested to tell how well the medication is working. The blood test, called prothrombin time (PT or protime), is used to calculate the International Normalized Ratio (INR). INR helps the healthcare provider determine how well warfarin is working to prevent blood clots and if the dose needs to be adjusted.
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the: A. Head of the pancreas B. Proximal third section of the small intestines C. Stomach and duodenum D. Esophagus and jejunum
Correct Answer: A. Head of the pancreas During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach is removed and anastomosed. It is the most often used surgery to treat pancreatic cancer that's confined to the head of the pancreas. After performing the Whipple procedure, the surgeon reconnects the remaining organs to allow the client to digest food normally after surgery.
The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of: A. Impaired clotting mechanism B. Varix formation C. Inadequate nutrition D. Trauma of invasive procedure
Correct Answer: A. Impaired clotting mechanism Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to: A. Lessen the amount of cellular damage B. Prevent the formation of blisters C. Promote movement D. Prevent pain and discomfort
Correct Answer: A. Lessen the amount of cellular damage Rapid continuous rewarming of frostbite primarily lessens cellular damage. Rapid rewarming is the single most effective therapy for frostbite. Heat conduction and radiation from deeper tissue circulation prevents freezing and ice crystallization until the skin temperature drops below 0°C.
An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC? A. Low platelet count B. Elevated fibrinogen levels C. Low levels of fibrin degradation products D. Reduced prothrombin time
Correct Answer: A. Low platelet count In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases.
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test. B. A decreased TSH level. C. An increase in the TSH level after 30 minutes during the TSH stimulation test. D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay.
Correct Answer: A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism.
The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: A. Perform the Valsalva maneuver as the catheter is advanced B. Turn his head to the left side and hyperextend the neck C. Take slow, deep breaths as the catheter is removed D. Turn his head to the right while maintaining a sniffing position
Correct Answer: A. Perform the Valsalva maneuver as the catheter is advanced The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line.
Stacy was diagnosed with acute lymphoid leukemia (ALL). She was discharged from the hospital following her chemotherapy treatments. Which statement of Stacy's mother indicated that she understands when she will contact the physician? A. "I should contact the physician if Stacy has difficulty in sleeping". B. "I will call my doctor if Stacy has persistent vomiting and diarrhea". C. "My physician should be called if Stacy is irritable and unhappy". D. "Should Stacy have continued hair loss, I need to call the doctor".
Correct Answer: B. "I will call my doctor if Stacy has persistent vomiting and diarrhea". Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the healthcare provider.
Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? A. "Inject insulin into healthy tissue with large blood vessels and nerves." B. "Rotate injection sites within the same anatomic region, not among different regions." C. "Administer insulin into areas of scar tissue or hypertrophy whenever possible." D. "Administer insulin into sites above muscles that you plan to exercise heavily later that day."
Correct Answer: B. "Rotate injection sites within the same anatomic region, not among different regions." The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next.
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates an understanding of phantom limb pain? A. "The pain will go away in a few days." B. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication." C. "The pain is psychological because your foot is no longer there." D. "The pain and itching are due to the infection you had before the surgery."
Correct Answer: B. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication." Pain related to phantom limb syndrome is due to peripheral nervous system interruption. A recent study estimated that there were about 1.6 million people with limb loss in the USA in 2005 and this number was projected to increase by more than double to 3.6 million by the year 2050. Vascular problems, trauma, cancer, and congenital limb deficiency are among the common causes of limb loss. The number of traumatic amputations has also increased since the beginning of conflict in Iraq and Afghanistan. The incidence of PLP has been reported to range from 42.2 to 78.8% in patients requiring amputation
Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child? A. 1.2 ml B. 2.4 ml C. 3.5 ml D. 4.2 ml
Correct Answer: B. 2.4 ml .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer's lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client's IV to deliver how many drops per minute? A. 18 B. 21 C. 35 D. 40
Correct Answer: B. 21 3000 x 10 divided by 24 x 60.
When prioritizing care, which of the following clients should the nurse Olivia assess first? A. A 17-year-old client 24-hours post appendectomy. B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome. C. A 50-year-old client 3 days post myocardial infarction. D. A 50-year-old client with diverticulitis.
Correct Answer: B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation.
Mr. Jay develops hepatic encephalopathy. Which clinical manifestation is most common with this condition? A. Increased urine output B. Altered level of consciousness C. Decreased tendon reflex D. Hypotension
Correct Answer: B. Altered level of consciousness Changes in behavior and level of consciousness are the first signs of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? A. Pitting edema of the legs B. An irregular apical pulse C. Dry mucous membranes D. Frequent urination
Correct Answer: B. An irregular apical pulse Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician.
Brittany who is undergoing chemotherapy for her throat cancer is experiencing stomatitis. To promote oral hygiene and comfort, the nurse-in-charge should: A. Provide frequent mouthwash with normal saline. B. Apply viscous Lidocaine to oral ulcers as needed. C. Use lemon glycerine swabs every 2 hours. D. Rinse mouth with Hydrogen Peroxide.
Correct Answer: B. Apply viscous Lidocaine to oral ulcers as needed. Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care.
Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder? A. Calcium and sodium B. Calcium and phosphorous C. Phosphorus and potassium D. Potassium and sodium
Correct Answer: B. Calcium and phosphorous In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture.
The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is: A. Anaphylactic shock B. Cardiogenic shock C. Distributive shock D. Myocardial infarction (MI)
Correct Answer: B. Cardiogenic shock Cardiogenic shock is shock related to ineffective pumping of the heart.
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? A. Administer an antibiotic B. Contact the physician for an order for immune globulin C. Administer an antiviral D. Tell the client that he should remain in isolation for 2 weeks
Correct Answer: B. Contact the physician for an order for immune globulin The client who is immunosuppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. If the patient knows that he has been exposed to measles and his CD4 count is less than 200, he should talk to his doctor about whether post-exposure prophylaxis (PEP) with immunoglobulin may be an option. PEP may provide some protection or lessen the severity of infection if it occurs. If the CD4 count is 200 or greater, PEP can also include getting the MMR vaccine. Ideally, PEP should be administered within 72 hours of exposure to measles.
Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)? A. Acetylsalicylic acid (ASA) B. Corticosteroids C. Methotrexate D. Vitamin K
Correct Answer: B. Corticosteroids Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets.
The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body systems? A. Brain B. Muscle spasm C. Renal dysfunction D. Myocardial irritability
Correct Answer: B. Muscle spasm Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia.
The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin's disease? A. Pericarditis B. Night sweat C. Splenomegaly D. Persistent hypothermia
Correct Answer: B. Night sweat In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritus.
Marco falls off his bicycle and injures his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway? A. Release of Calcium B. Release of tissue thromboplastin C. Conversion of factors XII to factor XIIa D. Conversion of factor VIII to factor VIIIa
Correct Answer: B. Release of tissue thromboplastin Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Option A: Calcium is released to assist the conversion of factors X to Xa. Option C: Conversion of factors XII to XIIa are part of the intrinsic pathway. Option D: Conversion factors VIII to VIIIa are part of the intrinsic pathway.
Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm? A. Lower back pain, increased blood pressure, decreased red blood cell (RBC) count, increased white blood (WBC) count. B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. C. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count. D. Intermittent lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
Correct Answer: B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can't be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn't increase. For the same reason, the RBC count has decreased - not increased. The WBC count increases as cells migrate to the site of injury.
Patrick who is diagnosed with liver cirrhosis is experiencing symptoms of hepatic encephalopathy. The physician ordered 50 ml of Lactulose p.o. every 2 hours. Patrick suddenly develops diarrhea. The nurse best action would be: A. "I'll see if your physician is in the hospital". B. "Maybe you're reacting to the drug; I will withhold the next dose". C. "I'll lower the dosage as ordered so the drug causes only 2 to 4 stools a day". D. "Frequently, bowel movements are needed to reduce sodium level".
Correct Answer: C. "I'll lower the dosage as ordered so the drug causes only 2 to 4 stools a day". Lactulose is given to a patient with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experiences diarrhea, it indicates overdosage and the nurse must reduce the amount of medication given to the patient. The stool will be mushy or soft. Lactulose is also very sweet and may cause cramping and bloating.
Nurse Lourdes is teaching a client recovering from Addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions? A. "I'll take my hydrocortisone in the late afternoon, before dinner." B. "I'll take all of my hydrocortisone in the morning, right after I wake up." C. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." D. "I'll take the entire dose at bedtime."
Correct Answer: C. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.
Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)? A. Less than 5 years B. 5 to 7 years C. 10 years D. More than 10 years
Correct Answer: C. 10 years Epidemiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years. The interval from HIV infection to the diagnosis of AIDS ranges from about 9 months to 20 years or longer, with a median of 12 years.
After cardiac surgery, a client's blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following? A. 46 mm Hg B. 80 mm Hg C. 95 mm Hg D. 90 mm Hg
Correct Answer: C. 95 mm Hg Use the following formula to calculate MAPMAP = systolic + 2 (diastolic)MAP = 126 mm Hg + 2 (80 mm Hg)MAP = 286 mm HgMAP = 95 mm Hg
A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive? A. AB Rh-positive B. A Rh-positive C. A Rh-negative D. O Rh-positive
Correct Answer: C. A Rh-negative Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It's important that a person with Rh-negative blood receives Rh-negative blood.
The term "blue bloater" refers to a male client under which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Asthma C. Chronic obstructive bronchitis D. Emphysema
Correct Answer: C. Chronic obstructive bronchitis Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis.
JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it's effective for gout? A. Replaces estrogen. B. Decreases infection. C. Decreases inflammation. D. Decreases bone demineralization.
Correct Answer: C. Decreases inflammation. The action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid.
A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following orders should the nurse Oliver anticipate? A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel D. Electroencephalogram, alkaline phosphatase, and aspartate aminotransferase levels, basic serum metabolic panel
Correct Answer: C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. An electrocardiogram evaluates the complaints of chest pain, laboratory tests determine anemia, and the stool test for occult blood determines blood in the stool.
Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias? A. Dressler's syndrome B. Polycythemia C. Essential thrombocytopenia D. Von Willebrand's disease
Correct Answer: C. Essential thrombocytopenia Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency virus.
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating: A. Packed fruits B. Salt C. Fresh raw pepper D. Ketchup
Correct Answer: C. Fresh raw pepper Fresh raw or whole pepper is not allowed unless thoroughly cooked in food. A low-bacteria diet is designed to reduce exposure to bacteria and other pathogens that can make one sick. It's often prescribed for people who are at a greater risk of infection because they're currently not making enough white blood cells due to certain illnesses or medical treatments.
Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma? A. High corticotropin and low cortisol levels B. Low corticotropin and high cortisol levels C. High corticotropin and high cortisol levels D. Low corticotropin and low cortisol levels
Correct Answer: C. High corticotropin and high cortisol levels A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels.
During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is: A. Notify the physician. B. Flush the IV line with saline solution. C. Immediately discontinue the infusion. D. Apply an ice pack to the site, followed by warm compress.
Correct Answer: C. Immediately discontinue the infusion Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complications.
A client with hypertension asks the nurse which factors can cause blood pressure to drop to normal levels? A. Kidneys' excretion to sodium only. B. Kidneys' retention of sodium and water. C. Kidneys' excretion of sodium and water. D. Kidneys' retention of sodium and excretion of water.
Correct Answer: C. Kidneys' excretion of sodium and water. The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic blood pressure by regulating blood volume.
Ruby is receiving thyroid replacement therapy, develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life threatening complications? A. Exophthalmos B. Thyroid storm C. Myxedema coma D. Tibial myxedema
Correct Answer: C. Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken.
Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate? A. "Your son had a mild concussion, acetaminophen is strong enough." B. "Aspirin is avoided because of the danger of Reye's syndrome in children or young adults." C. "Narcotics are avoided after a head injury because they may hide a worsening condition." D. Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP)."
Correct Answer: C. Narcotics are avoided after a head injury because they may hide a worsening condition. Narcotics may mask changes in the level of consciousness that indicate increased ICP.
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose's: A. Onset to be at 2 p.m. and its peak to be at 3 p.m. B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m. C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. D. Onset to be at 4 p.m. and its peak to be at 6 p.m.
Correct Answer: C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct? A. Osteoarthritis is rarely debilitating. B. Osteoarthritis is a rare form of arthritis. C. Osteoarthritis is the most common form of arthritis. D. Osteoarthritis affects people over 60.
Correct Answer: C. Osteoarthritis is the most common form of arthritis Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.
Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is: A. Elevated serum complement level B. Thrombocytosis, elevated sedimentation rate C. Pancytopenia, elevated antinuclear antibody (ANA) titer D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels
Correct Answer: C. Pancytopenia, elevated antinuclear antibody (ANA) titer Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels.
A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He's now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions? A. Bronchitis B. Pneumonia C. Pneumothorax D. Tuberculosis (TB)
Correct Answer: C. Pneumothorax Pneumothorax is defined as the presence of air or gas in the pleural cavity, which can impair oxygenation and/or ventilation.
Timothy's arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents which of the following conditions? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
Correct Answer: C. Respiratory acidosis Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis.
Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypnea. She has a decreased level of consciousness. These signs indicate which of the following conditions? A. Asthma attack B. Pulmonary embolism C. Respiratory failure D. Rheumatoid arthritis
Correct Answer: C. Respiratory failure The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure.
If a client requires a pneumonectomy, what fills the area of the thoracic cavity? A. The space remains filled with air only. B. The surgeon fills the space with a gel. C. Serous fluids fill the space and consolidate the region. D. The tissue from the other lung grows over to the other side.
Correct Answer: C. Serous fluids fill the space and consolidate the region Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung.
Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful? A. "I will wear the stockings until the physician tells me to remove them." B. "I should wear the stockings even when I am asleep." C. "Every four hours I should remove the stockings for a half hour." D. "I should put on the stockings before getting out of bed in the morning."
Correct Answer: D. "I should put on the stockings before getting out of bed in the morning. Promote venous return by applying external pressure on veins.
Molly Sue is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. Her mother states to the nurse that it is hard to see Molly Sue with no hair. The best response for the nurse is: A. "Molly Sue looks very nice wearing a hat". B. "You should not worry about her hair, just be glad that she is alive". C. "Yes, it is upsetting. But try to cover up your feelings when you are with her or else she may be upset". D. "This is only temporary; Molly Sue will re-grow new hair in 3-6 months but may be different in texture".
Correct Answer: D. "This is only temporary; Stacy will re-grow new hair in 3-6 months but may be different in texture". This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child's disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.
Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values? A. 15 mm Hg B. 30 mm Hg C. 40 mm Hg D. 80 mm Hg
Correct Answer: D. 80 mm Hg A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.
After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first? A. Call for help. B. Obtain vital signs. C. Ask the client to "lift up". D. Apply gloves and assess the groin site.
Correct Answer: D. Apply gloves and assess the groin site. Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding.
Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? A. Elevated serum acetone level. B. Serum ketone bodies. C. Serum alkalosis. D. Below-normal serum potassium level.
Correct Answer: D. Below-normal serum potassium level. A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency.
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus? A. Above-normal urine and serum osmolality levels. B. Below-normal urine and serum osmolality levels. C. Above-normal urine osmolality level, below-normal serum osmolality level. D. Below-normal urine osmolality level, above-normal serum osmolality level.
Correct Answer: D. Below-normal urine osmolality level, above-normal serum osmolality level In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level.
Francis with leukemia has neutropenia. Which of the following functions must be frequently assessed? A. Blood pressure B. Bowel sounds C. Heart sounds D. Breath sounds
Correct Answer: D. Breath sounds Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required.
Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver which laboratory test indicates liver cirrhosis? A. Decreased red blood cell count B. Decreased serum acid phosphatase level C. Elevated white blood cell count D. Elevated serum aminotransferase
Correct Answer: D. Elevated serum aminotransferase Hepatic cell death causes the release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.
The term "pink puffer" refers to the female client with which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Asthma C. Chronic obstructive bronchitis D. Emphysema
Correct Answer: D. Emphysema Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They're pink and usually breathe through pursed lips, hence the term "puffer."
A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions? A. Asthma attack B. Atelectasis C. Bronchitis D. Fat embolism
Correct Answer: D. Fat embolism Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by: A. Passing water through a dialyzing membrane B. Eliminating plasma proteins from the blood C. Lowering the pH by removing nonvolatile acids D. Filtering waste through a dialyzing membrane
Correct Answer: D. Filtering waste through a dialyzing membrane Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. Dialysis largely replicates the functions of the kidneys in patients with chronic kidney failure. Hemodialysis takes over the key tasks of the kidneys, removing waste materials, toxins, excess salt and fluids from the body.
Olivia had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted? A. Pancytopenia B. Idiopathic thrombocytopenic purpura (ITP) C. Disseminated intravascular coagulation (DIC) D. Heparin-associated thrombosis and thrombocytopenia (HATT)
Correct Answer: D. Heparin-associated thrombosis and thrombocytopenia (HATT) HATT may occur after CABG surgery due to heparin use during surgery.
Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis? A. Influenza B. Sickle cell anemia C. Leukemia D. Hodgkin's disease
Correct Answer: D. Hodgkin's disease Hodgkin's disease typically causes fever, night sweats, weight loss, and lymph node enlargement.
A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders? A. Diabetes mellitus B. Diabetes insipidus C. Hypoparathyroidism D. Hyperparathyroidism
Correct Answer: D. Hyperparathyroidism Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing polyuria.
A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with negative pressure. B. Infection requires close contact; therefore, the door may remain open. C. Transmission is highly likely, so the client should wear a mask at all times. D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
Correct Answer: D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important.
Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is: A. It dilates peripheral blood vessels. B. It decreases sympathetic cardio acceleration. C. It inhibits the angiotensin-converting enzymes. D. It inhibits the reabsorption of sodium and water in the loop of Henle.
Correct Answer: D. It inhibits reabsorption of sodium and water in the loop of Henle. Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure.
For a client with Graves' disease, which nursing intervention promotes comfort? A. Restricting intake of oral fluids. B. Placing extra blankets on the client's bed. C. Limiting intake of high-carbohydrate foods. D. Maintaining room temperature in the low-normal range.
Correct Answer: D. Maintaining room temperature in the low-normal range. Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range.
Which of the following treatments is a suitable surgical intervention for a client with unstable angina? A. Cardiac catheterization B. Echocardiogram C. Nitroglycerin D. Percutaneous transluminal coronary angioplasty (PTCA)
Correct Answer: D. Percutaneous transluminal coronary angioplasty (PTCA) PTCA can alleviate the blockage and restore blood flow and oxygenation.
A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following? A. Testing for ketones in the urine. B. Testing urine specific gravity. C. Checking temperature every 4 hours. D. Performing capillary glucose testing every 4 hours.
Correct Answer: D. Performing capillary glucose testing every 4 hours. The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia.
Alvin with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
Correct Answer: D. Respiratory alkalosis A client with massive pulmonary embolism will have a large region and blow off large amounts of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.
A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? A. Acute asthma B. Chronic bronchitis C. Pneumonia D. Spontaneous pneumothorax
Correct Answer: D. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath.
A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this? A. Allogeneic B. Autologous C. Syngeneic D. Xenogeneic
Correct Answer: D. Xenogeneic A xenogeneic transplant is between a human and another species.
