NCLEX mastery FB questions

An elderly woman is admitted to the hospital for a hip fracture related to osteoporosis. Which of the following patient medications decreases bone density? A. Risedronate B. Lispro C. Levothyroxine D. Propylthiouracil

C. Levothyroxine RATIONALE •Long term use of levothyroxine is associated with decreased bone density in the hip and spine in post-menopausal women. •Risedronate, lispro, and propylthiouracil are not associated with osteoporosis or decreased bone density.

A patient returns to the surgical unit after undergoing a transurethral resection of the prostate (TURP). The nurse prepares for continuous bladder irrigation using: A. Normal saline B. Dakin's solution C. Half normal saline with 5% dextrose D. Sterile water

A. Normal saline RATIONALE •Normal saline is used for continuous bladder irrigation because it is isotonic. •Dextrose solutions should never be introduced into the bladder. •Sterile water is too easily absorbed into the systemic circulation. •Dakin's solution is used for wound irrigation.

A patient is experiencing frequent runs of ventricular tachycardia. The nurse should obtain serum levels of: A. Potassium and magnesium B. Potassium and calcium C. Magnesium and calcium D. Potassium and sodium

A. Potassium and magnesium RATIONALE •Electrolyte imbalances are common causes of ventricular tachycardia, specifically, hypomagnesemia, hypokalemia, and hyperkalemia. •Calcium imbalances may cause QT and ST changes. •Sodium imbalances do not cause arrhythmias

A nurse is assessing a patient with acute pancreatitis. The nurse should be aware of which assessment findings that support the diagnosis? A. Recent weight loss and febrile B. Hypertension and bruising C. Wheezes and bradycardia D. Blood in the patient's stool and headache

A. Recent weight loss and febrile Rationale •Acute pancreatitis can cause an elevated temperature, weight loss, abdominal pain, nausea, & vomiting. •The other options are not associated with pancreatitis.

The nurse is instructing a patient diagnosed with acute gastritis. The patient asks about the causes of gastritis. The nurse should include which of the following risk factors in her response? (Select all that apply) A. Stress B. NSAID use C. Dairy products D. Inactivity E. Alcohol use F. Trauma

A. Stress, B. NSAID use E. Alcohol use F. Trauma RATIONALE •Gastritis, inflammation of the stomach lining, has many causes. Risk factors include stress, NSAID use, alcohol use, trauma, H. pylori, surgery, and burns. •Inactivity and dairy are not associated with gastritis.

A patient on a medical-surgical floor is experiencing delirium tremens. Which of the following medications can the nurse expect to be ordered for the management of this acute episode? A. Chlordiazepoxide B. Ziprasidone C. Naloxone D. Flumazenil

A. Chlordiazepoxide RATIONALE •Chlordiazepoxide is a benzodiazepine with a medium to long half-life. Chlordiazepoxide is used for alcohol withdrawal due to its hypnotic and sedative effects. Ativan is also used for alcohol withdrawal. •Ziprasidone is an atypical antipsychotic used to treat acute delirium, mania, and schizophrenia. •Naloxone is the antidote for opiates. •Flumazenil is the antidote for benzodiazepines.

A patient has had a DNR order for several years, but is now re-thinking this. The patient asks the nurse if he can change his DNR order, so all appropriate measures will be done to save his life. Which of the following responses is correct? A. "Not a problem, I will contact your physician immediately" B. "It is too late. Once you are DNR, you cannot change it" C. "Are you sure about this?" D. "You will have to ask the physician tomorrow during morning rounds"

A. "Not a problem, I will contact your physician immediately" Rationale •A patient can change their code status at anytime. •Waiting until the next day to talk to the physician could have negative consequences. The physician needs to be notified as soon as possible. •Questioning the patient's decision can damage the nurse-patient relationship making the patient defensive towards the nurse

A woman in the first trimester of her pregnancy is attending childbirth classes. What topics are most likely to be covered during this trimester? Select all that apply A. Complications and warning signs B. Nutrition C. False and true labor D. Fetal development E. Anatomy of pregnancy F. Fetal movements

A. Complications and warning signs B. Nutrition D. Fetal development, and E. Anatomy of pregnancy RATIONALE •During the early stages of pregnancy, childbirth classes should cover topics such as warning signs of complications, nutrition, anatomy, and fetal development. •Fetal movements, false labor, and signs of labor are usually covered in later childbirth classes.

A patient is admitted to the cardiac unit after having a myocardial infarction. Prioritize the nurse's next actions. 1. Insert an IV 2. Hook the patient up to a cardiac monitor 3. Initiate thrombolytic therapy 4. Provide the patient with water A. 2,1,3,4 B. 1,2,3,4 C. 1,3,2,4 D. 3,2,1,4

A. 2,1,3,4 RATIONALE •Standard nursing interventions for a myocardial infarction includes administration of nitroglycerin and morphine, placement of a cardiac monitor, administration of 2-4 L of oxygen, and I.V. catheter insertion. The nurse should first hook the patient up to a cardiac monitor in order to continuously assess the heart rhythm. •An IV should be initiated to provide treatment •Thrombolytic therapy may not be ordered by the physician depending on the patient's history. •While the patient may be allowed to drink water, the nurse should be alert to the potential for fluid overload and heart failure.

A nurse administering blood products should keep the infusion time under: A. 4 hours B. 6 hours C. 8 hours D. 2 hours

A. 4 hours •Blood infusions should not last longer that 4 hours due to the increased risk of sepsis. •Infusing blood products under 2 hours may be too fast for patients with cardiovascular compromise due to the risk of fluid overload.

A nurse is conducting an hourly neurological assessment on a post-stroke male patient. Upon assessment, the patient only moans and withdrawals to pain without opening his eyes. What is his total score in the Glasgow coma scale? A. 7 B. 8 C. 9 D. 10

A. 7 RATIONALE •Glasgow Coma Scale scores range from 3-15. Categories are eye opening response, verbal response and motor response. Scoring is calculated as follows: •Eye opening response: spontaneous-4 points, opens to verbal command-3 points, opens to pain-2 points, no response-1 point. •Verbal response: oriented-5, confused conversation but able to answer questions-4, inappropriate responses-3, incomprehensible speech-2, no response-1.

The nurse is assessing a child with white patches on his tongue that may be candidiasis (thrush). The nurse confirms this suspicion because candidiasis: A. Adheres to the tissue when scraped B. Causes excessive bleeding when scraped with a tongue blade. C. Only occurs on the tongue D. Produces a fruity smell

A. Adheres to the tissue when scraped Rationale Candidiasis adheres to the surface of the muscosa and tongue and is difficult to scrape off. Candidiasis can occur on the tongue, genitalia, and anus. It can also cause systemic infections. Candidiasis can cause bleeding when the patches are removed, but this will not happen when scraped with a tongue blade. Candidiasis does not produce a fruity smell.

The nurse is with a patient in the psychiatric unit watching for signs of alcohol withdrawal. Which of the following are early signs of withdrawal? *Select All That Apply* A. Anxiety B. Tremors C. Irritability D. Hypotension E. Tachycardia F. Hypersomnia

A. Anxiety B. Tremors C. Irritability E. Tachycardia Rationale •Alcohol withdrawal occurs within hours of cessataion and peaks after 1-2 days. Common symptoms include tremors, tachycardia, anxiety, diaphoresis, hallucinations, and confusion. •Alcohol withdrawal is not associated with hypotension or hypersomnia.

A nurse is caring for a patient who has left sided weakness due to a stroke. To avoid the risk of disuse syndrome, the nurse should: (Select all that apply) A. Assist the patient with passive and active ROM B. Encourage the patient to use his right side to perform ADLs C. Place the patient in a supine position D. Position the patient's affected arm with the hand slightly below the elbow and wrist E. Use boots to prevent foot drop F. Use a rolled washcloth to prevent hand contractures

A. Assist the patient with passive and active ROM E. Use boots to prevent foot drop RATIONALE •Use of boots (foot positioning aids) can reduce the risk of foot drop. •Passive and active ROM (as tolerated) of the affected areas will help the client to preserve function and mobility. •The other choices can promote disuse syndrome after a stroke.

A child is brought to the emergency room with a high fever, photophobia, and a headache. What important sign would a nurse use to check for meningeal irritation? A. Brudzinski's sign B. Cullen's sign C. Ortolani sign D. McBurney's sign

A. Brudzinski's sign RATIONALE •Meningeal irritability is assessed by illiciting a positive Brudzinski's and Kernig's signs, as well as an inability to flex the neck forward (nuchal rigidity). •Brudzinski's sign: after forced flexion of the neck there is a reflex flexion of the hip and knee and abduction of the leg. •Kernig's sign: After flexing the hip and knee at 90 degree angles, pain and resistance are noted. •Cullen's sign is the presence of superficial edema and bruising around the umbilicus. It is suggestive of acute pancreatitis or an intraabdominal bleed. •Ortolani's sign is a distinctive "clunk" heard after flexing and abducting a newborns hips. This is indicative of hip dysplasia. •McBurney's sign is deep tenderness or pain at McBurney's point, one-third the distance from the right anterior iliac spine and the navel. This is indicative of acute appendicitis.

The nurse is assessing a patient with systemic lupus erythematosus (SLE). Which of the following would the nurse expect to note? A. Butterfly rash on the face B. Recurrent deep vein thrombosis C. Hyperthyroidism D. Excessive hair growth

A. Butterfly rash on the face Rationale •A butterfly rash over the cheeks and bridge of the nose is a classic sign of SLE. Other signs include chest pain with inspiration, fatigue, fever, general discomfort, hair loss, mouth sores, photosensitivity, and weakness. •SLE is a systemic autoimmune disease that more common in women. There is no cure, but it is treated with immunosuppression. •Hypothyroidism and hair loss are commonly found in patient's with SLE. •Recurrent DVTs are not commonly associated with SLE.

A 40-year-old, G7, P4, A2, 36 weeks pregnant was admitted because of complaints of vaginal bleeding. She also noticed a lack of fetal activity in the 3 days prior to admission. The nurse's first action is to: A. Check for fetal heart tones B. Ask for ultrasound examination C. Ask for X-ray of the abdomen D. Palpate for fetal movement

A. Check for fetal heart tones RATIONALE •Finding the fetal heart tones is the easiest way to check status of the pregnancy in this situation. •If no fetal heart tones are noted, A sonogram is ordered to confirm fetal status. •There will be no fetal activity if the fetus dies in utero. •An x-ray of the abdomen should not be done in pregnancy and will not assess whether the fetus is alive or not.

The nurse is educating a patient scheduled to undergo a percutaneous transluminal coronary angioplasty (PTCA). The nurse explains that a balloon-tipped catheter will: A. Compress plaque against the walls of the coronary arteries B. Place a mesh device that keeps the coronary artery patent C. Be used to measure the coronary artery pressure D. Cauterize the plaque blocking the coronary artery

A. Compress plaque against the walls of the coronary arteries RATIONALE •During a PTCA, a balloon-tipped catheter is inserted into the femoral or radial artery and is advanced into the coronary arteries. Then, the balloon is inflated to compress the atheromatous plaque against the walls of the vessel, resulting in a patent vessel. •Option B describes the placement of a stent. •Option C describes a process done during cardiac catheterization. •Option D describes coronary atherectomy.

A patient prescribed to fentanyl is getting out of bed for the first time since surgery. The nurse is most concerned about which side effect of fentanyl? A. Dizziness B. Respiratory depression C. Nausea D. Constipation

A. Dizziness Rationale •Although all options are side effects of fentanyl (Sublimaze) and other opioids, dizziness is the most concerning while ambulating a patient. A patient awake enough to ambulate is not at risk for respiratory depression.

A 3-year-old is admitted to the hospital suspected of having congenital heart disease. Which of the following assessment findings is most likely to be seen? A. Exercise intolerance B. Frequent kidney infections C. Mental retardation D. Weight in 20th percentile since birth

A. Exercise intolerance Rationale •A child with congenital heart disease is likely to have exercise intolerance. The child often self-limits activity and takes frequent rest peroids. •Other signs and symptoms include shortness of breath, cyanosis, heart murmur, under-developed muscles, poor feeding, and respiratory infections.

A new mother is interested in seeing what her infant's eyes look like. Which is the most effective way for the nurse to stimulate the infant to open their eyes? A. Hold the infant in an upright position B. Stimulate the moro reflex C. Shine a penlight toward the infant's face D. Gently separate the infant's eyelids with the fingers

A. Hold the infant in an upright position RATIONALE •When held upright, an infant will open the eyes reflexively. •Separating the eyelids causes the eyes to close due to the blink reflex. •Moro reflex also causes the eyes to close. •Infants are sensitive to light and will close their eyes in the presence of a bright light.

A patient is being discharged after a bilateral nephrectomy. The patient will perform peritoneal dialysis at home. Which of the following actions best promote continuity of care? A. Home health nurse referral to provide follow-up visits to help with peritoneal dialysis B. Asking the patient's wife to provide adequate nutrition C. Physical therapy referral to improve patient mobility D. Notify the National Kidney Foundation to provide the patient with resources

A. Home health nurse referral to provide follow-up visits to help with peritoneal dialysis RATIONALE •In addition to thorough discharge instructions, the nurse should arrange for a home health nurse to assist the patient in performing dialysis to ensure proper technique. •Adequate nutritional support is important, but simply asking the wife to provide is not enough. The patient and his wife need detailed diet instructions. •Contacting the National Kidney Foundation and a physical therapist is not a priority.

A patient is taking spironolactone for the treatment of hypertension. The nurse notices EKG changes on the patient's heart monitor. What blood abnormality should the nurse suspect as the cause of such changes? A. Hyperkalemia B. Hypocalcemia C. Hypokalemia D. Leukocytosis

A. Hyperkalemia RATIONALE •Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, potentially resulting in cardiac arrhythmias. •Severe hypocalcemia and leukocytosis may cause cardiac arrhythmias, but they are not side effects of spironolactone. •Hypokalemia is associated with loop diuretics.

The nurse is assessing a patient diagnosed with acute pancreatitis. Which of the following assessment findings is least consistent with this diagnosis? A. Hypertension B. Weight loss C. Elevated temperature D. Epigastric pain radiating to the back

A. Hypertension RATIONALE •Hypertension is not associated with pancreatitis, although hypotension may be present. •Common symptoms of acute pancreatitis include upper epigastric pain that bores through the body to the back, nausea, vomiting, weight loss, and an elevated temperature.

The nurse is assessing an 8-year-old boy suspected of having Rocky Mountain spotted fever. Which of the following signs and symptoms would the nurse expect to find? A. Maculopapular rash that begins on the wrists and ankles and spreads centripetally B. Spasms of the jaw muscles and arching of the back C. Circular, outward expanding rash D. Stiff neck with a positive Kernig's sign

A. Maculopapular rash that begins on the wrists and ankles and spreads centripetally RATIONALE •Rocky Mountain spotted fever starts with a fever, usually within a few days of a tick bite. Along with a headache and myalgia, a maculopapular rash develops 2-6 days after the onset of a fever. The rash first appears in the wrists and ankles, then spreads centripetally to the trunk. •Rocky mountain spotted fever is the most common rickettsial disease seen in the United states and is transmitted by ticks. It can be a life-threatening illness if undiagnosed or untreated. •Stiff neck and a positive Kernig's sign is indicative of meningitis. •Spasms of the jaw and arching of the back are signs of tetanus. •A circular outward expanding rash is a classic sign of early Lyme disease.

The nurse is caring for a patient diagnosed with schizoaffective disorder. This disorder contains elements of schizophrenia and elements of which of the following disorders? A. Mood disorder B. Personality disorder C. Thought disorder D. Amnestic disorder

A. Mood disorder Rationale •According to the DSM-IV, schizoaffective disorder refers to patients suffering from psychotic or schizophrenic symptoms with elements of a mood disorder, such as mania or depression. •Choice B is incorrect because personality disorders and psychotic illnesses are not listed together on the same axis of the DSM-IV. •Thought disorder is incorrect because schizophrenia is considered a thought disorder. •Patients with schizoaffective disorder do not have symptoms of amnestic disorder.

A patient with chronic hepatitis is admitted to the hospital due to his declining status. The nurse assesses the patient and will most likely note: A. Muscle wasting B. Weight gain C. Reduced bleeding tendencies D. Increased axillary hair

A. Muscle wasting RATIONALE •Chronic hepatitis will eventually cause extensive damage to the liver. •The patient will often have muscle wasting, weakness, fatigue, weight loss, increased bleeding, decreased body hair, and peripheral edema

An elderly patient is prescribed ciprofloxacin for the treatment of a urinary tract infection (UTI). The nurse should inform the patient of which potential serious side effect? A. Tendon rupture B. Constipation C. Atrial fibrillation D. Ototoxicity

A. Tendon rupture RATIONALE •Ciprofloxacin and other fluoroquinolone antibiotics have a black box warning for the increased risk of tendon rupture. •Patients usually experience pain and edema around tendons that can eventually lead to rupture. Patients should be instructed to rest if they experience tendon pain or edema.

A 7-month-old infant suspected of cerebral palsy is being assessed by the nurse. Which of the following activities, as stated by the patient's mother, indicates the possible presence of cerebral palsy? A. The infant is unable to roll over B. The infant does not move when startled C. The infant does not react to loud noises D. The infant is unable to use a spoon

A. The infant is unable to roll over RATIONALE •In cerebral palsy, damage to the motor centers of the brain cause abnormal muscle tone, reflexes, and motor skills. •The infant should be able to roll over by 6 months of age. •Not reacting or moving to a loud or startling stimulus may be a problem with sensory organs. •A child should be able to use a spoon by 13-20 months of age.

A nurse is assessing a patient who has long standing hypertension. She knows that the condition is progressing to complications when which of the following sign is noted: A. Traces of protein in the urinalysis B. Dyspnea during activity C. Recurrent episodes of severe headache D. Fatigability

A. Traces of protein in the urinalysis RATIONALE •Proteinuria and albuminuria are early indicators of renal injury, often caused by hypertension. •Fatigability and headache are symptoms of hypertension and are not direct indicators of progressive disease or complications. •Dyspnea suggests respiratory problems.

Which of the following defects refers to the incomplete closure of the umbilical ring, resulting in the protrusion of the omentum and intestine through the opening? A. Umbilical hernia B. Inguinal hernia C. Noncommunicating hydrocele D. Communicating hydrocele

A. Umbilical hernia Rationale •An umbilical hernia is a protrusion of a portion of the intestine through the umbilical ring, muscle, and fascia surrounding the umbilical cord. This creates a bulging protrusion under the skin at the umbilicus. •Umbilical hernias occur most frequently in African American children and more often in girls than in boys. The structure is generally 1 to 2 cm in diameter but may be as big as an orange when children cry or strain. If the defect is more than 2 cm, surgery for repair will generally be indicated to prevent intestinal strangulation or intestinal obstruction. This is usually done when the child is 4-6 years of age. •Inguinal hernias result from incomplete closure of the tube (processus vaginalis) between the abdomen and the scrotum, leading to the descent of a portion of the intestine. •Noncommunicating hydroceles have residual peritoneal fluid trapped within the lower segment of the processus vaginalis. A communicating hydrocele is commonly associated with hernias because the processus vaginalis remains open from the scrotum to the abdominal cavity.

A patient came into the clinic due to an eye problem. Which of the following is a correct method to assess the function of the patient's cranial nerve (CN) II, the optic nerve? A. Use a Snellen chart B. Use a feather to check for a corneal reflex C. Use a penlight and check the pupils for reactivity D. Note for nystagmus by testing the extraocular movements

A. Use a Snellen chart RATIONALE •Use a snellen chart to assess for visual acuity and to check the function of cranial nerve II, the optic nerve. CN II also determines peripheral vision. •The Cranial Nerve II, the optic nerve has a sensory function that carries impulses for vision. It travels to the cerebrum, where visual impulses are perceived and interpreted. •The options to use a penlight, and note for nystagmus are associated with the function of cranial nerves III, IV, and VI (Oculomotor, trochlear, and abducens). •Corneal reflex is associated with CN V, the trigeminal nerve.

The nurse is caring for a patient with chronic renal failure (CRF) that has developed decreased erythropoietin synthesis. The nurse assesses the patient for: A. Weakness and fatigue B. Nausea and dizziness C. Dyspnea and intercostal retractions D. Cyanosis and hypercapnia

A. Weakness and fatigue RATIONALE •Erythropoietin is synthesized in the renal cortex. A decrease in production related to CRF leads to anemia, manifesting as weakness and fatigue. Dyspnea, pallor, malaise, and poor concentration are also common symptoms of anemia. •Nausea is not associated with anemia. •Intercostal retractions, cyanosis, and hypercapnia are generally related to problems with ventilation and perfusion.

A 5-year-old with severe osteomyelitis has not been responding to first line therapy. The nurse is ordered to initiate vancomycin I.V. every 6 hours to the patient. If the recommended dose is 10 mg/kg, what is the total daily dose of vancomycin if the patient weighs 44 lbs? A. 440 mg B. 800 mg C. 200 mg D. 888 mg

B. 800 mg RATIONALE •First convert the weight in lbs into kg, then multiply the patient's weight by 10 mg per dose, 4 doses per day. 44 lb/2.2 = 20 kg 20 kg x 10 mg per dose = 200 mg 200 mg x 4 doses per day = 800 mg

A new nurse is reviewing her patient assignments for the day. Which patient should the nurse assess first? A. A patient who underwent a renal biopsy two days ago B. A newly admitted patient with acute flank pain and hematuria C. A patient undergoing hemodialysis later today D. A patient having urinary retention related to BPH

B. A newly admitted patient with acute flank pain and hematuria Rationale •A new admission should be assessed first because little is known about the patient and he or she may be unstable. •A renal biopsy is a low-risk procedure. After two days without complications, the patient should be stable and not a priority. •A patient receiving hemodialysis should be assessed before the treatment. In this case, the treatment is scheduled for later in the day. Therefore, assessing the patient is a low priority •Urinary retention related to BPH is common among older men and does not require immediate attention from the nurse.

A patient is seen at the clinic for a routine physical examination. After the patient is assessed for evidence of peripheral vascular disease, the nurse explains that the most commonly used indicator for poor peripheral circulation is: A. Allen's test B. Ankle brachial pressure index C. Cardiac stress test D. Peripheral pulses

B. Ankle brachial pressure index RATIONALE •The ankle brachial index is the blood pressure ratio between the lower legs and the arms. Blood pressure in the lower legs is normally higher than the arm. A ratio below 1.0 indicates peripheral vascular disease. •Allen's test is used to assess blood supply to the hand. •Cardiac stress tests are used to measure the heart's ability to respond to stress. •Peripheral pulses are not a good indicator of peripheral vascular disease.

A 20-year-old primipara is admitted and diagnosed with pregnancy induced hypertension. Magnesium sulfate is ordered. Which of the following nursing responsibilities should be done before administering the drug? Select All That Apply A. Assess bowel function to prevent an ileus B. Assess urine output C. Check blood pressure D. Check respiratory rate, if its below 12 cycles per minute, withhold the drug E. Elicit a positive deep tendon refelx F. Perform a vaginal examination

B. Assess urine output C. Check blood pressure D. Check respiratory rate, if its below 12 cycles per minute, withhold the drug. E. Elicit a positive deep tendon reflex. Rationale Serum magnesium levels should be maintained at 3.5 to 7 mEq/L to prevent pre-eclampsic seizures. If the blood serum level rises above this, respiratory depression, hyporeflexia, cardiac arrhythmias, and cardiac arrest can occur. The nurse does not need to assess bowel function. As plasma magnesium rises above 4mEq/l, deep tendon reflexes lessen, disappearing altogether at 10mEq/l. Performing this test prior to administering the medication will help determine if levels are rising. Because magnesium is excreted from the body almost entirely through the urine, urine output must be monitored.

The nurse is administering an ACTH stimulation test to a patient suspected of having Addison's disease. Which of the following is true regarding the ACTH stimulation test? A. Blood is drawn 12 hours after ACTH administration B. Blood is drawn at baseline, 30 minutes and 60 minutes after ACTH administration C. Blood is drawn at baseline and 12 hours after ACTH administration D. Blood is drawn at baseline and 6 hours after ACTH administration

B. Blood is drawn at baseline, 30 minutes and 60 minutes after ACTH administration RATIONALE •First, cortisol and ACTH levels are drawn at baseline. Next, the nurse administers synthetic ACTH, I.V. Finally, cortisol and ACTH levels should be drawn at 30 minutes and 60 minutes after ACTH administration. •ACTH stimulation test is used to assess the adrenal glands response to stress. This is used to help diagnose or exclude Addison's disease and adrenal insufficiency.

A nurse is administering vesicant chemotherapy and is trying to protect against extravasation. Which of the following actions is most appropriate? A. Wear a gown and mask B. Check for blood return in the I.V. C. Use sterile technique when initiating chemotherapy D. Check for right patient, right medication, and right dose

B. Check for blood return in the I.V. RATIONALE •The nurse should confirm that the I.V. is in the vein by checking for blood return. •Vesicant chemotherapy can cause severe soft tissue damage when it infiltrates.

The nurse is caring for a patient that just underwent a bronchoscopy. The nurse should do which of the following interventions? A. Administer midazolam IV for conscious sedation B. Confirm the return of a gag reflex before advancing diet C. Encourage large amounts of oral fluids D. Administer vecuronium IV

B. Confirm the return of a gag reflex before advancing diet RATIONALE •The patient's gag reflex must return to normal before allowing oral intake. The procedural sedation may have impaired the gag reflex, which places the patient at risk for aspiration. •Midazolam, a benzodiazepine used for procedural sedation, is administered before the bnochoscopy. •Vecuronium is a paralyzing agent used during endotracheal intubation.

A patient is admitted to the psychiatric unit for psychosis. When asked how she got to the hospital, the patient responds, "I took my car, because people like brown hair" This response is a(n): A. Distractible speech B. Grandiose delusion C. Loose association D. Somatic delusion

C. Loose association RATIONALE •Loose association is a thought disorder characterized by frequent shifts between ideas or subjects. •Grandiose delusion is when a person is convinced he or she has special powers or abilities, or is a famous person. •Somatic delusion is the false belief that the body is diseased or abnormal, such as infested with parasites. •Distractible speech occurs when the subject is changed mid speech, in response to a stimulus.

The nurse is caring for a patient with a history of malingering. The nurse understands that malingering differs from somatic symptom disorders in that the former A. Misinterprets the symptoms B. Consciously fabricates symptoms for personal gain C. Has lost physical functions due to an emotional conflict D. Expresses feelings through physical symptoms

B. Consciously fabricates symptoms for personal gain RATIONALE People who malinger have no real physical symptoms or grossly exaggerate relatively minor symptoms. Their purpose is an external incentive or outcome such as financial compensation, obtaining drugs, avoiding work, or to gain sympathy. People who malinger can stop the physical symptoms as soon as they have gained what they wanted. In malingering disorders, people willfully control the symptoms. In somatic symptom disorders, patients do not voluntarily control their physical symptoms. Also patients with somatic symptom disorders are convinced that they harbor serious physical problems despite negative results during diagnostic testing.

The nurse is performing a physical assessment on a patient with an aortic dissection. Which of the following should the nurse avoid during the physical assessment? A. Inspection of the abdomen B. Deep palpation of the abdomen C. Auscultation of the abdominal aorta D, Repositioning the patient to the side

B. Deep palpation of the abdomen Rationale •Deep palpation of the abdomen may cause aortic rupture. The nurse should avoid deep palpation on patients with an aortic disection or AAA. •The nurse should inspect the abdomen for ecchymoses, including turning the patient to inspect the back for eechymoses. •The nurse should also auscultate the aorta for bruits.

The nurse is assessing a patient that underwent a cholecystectomy 2 days ago. The nurse notes that the patient has no bowel sounds. What should the nurse do next? A. Administer an enema B. Document the finding and continue assessing the patient's bowel function C. Flush the NG tube D. Notify the physician

B. Document the finding and continue assessing the patient's bowel function Rationale Bowel sounds are often absent 2-4 days after surgery due to manipulation of the bowel. This is an expected finding and should be documented. The other answer choices are not necessary given that this is an expected finding.

The nurse reviews the lab results of a patient at risk for thrombocytopenia. The patient's platelet count is 175,000 cells/mm³. The next appropriate action by the nurse is to: A. Notify the physician of the abnormally low platelet count B. Document the normal results C. Notify the physician of the abnormally high platelet count D. Place the patient on bleeding precautions

B. Document the normal results RATIONALE •The patient's platelet level is within normal range, the nurse should document this result. •Normal platelet values range from 150,000-400,000 cells/mm³. •Notifying the physician and placing the patient on bleeding precautions is not necessary.

A patient is taking triamterene (Dyrenium) as part of a multidrug regimen for congestive heart failure. What should the nurse assess when the patient has a potassium level of 6.8 mEq/L? A. Reflexes B. Electrocardiogram C. Bowel function D. Level of consciousness

B. Electrocardiogram Rationale •An elevated potassium level can cause lethal arrhythmias. The nurse should assess the patient's EKG immediately. •Normal potassium range is 3.5-5.0 mEq/L.

The nurse is caring for a patient with an arteriovenous (AV) fistula on the right arm, for hemodialysis treatments. To promote safety, the nurse should do which of the following? A. Use the fistula for all venepunctures B. Evaluate the fistula for the presence of a thrill or bruit C. Take blood pressure on the right arm D. Use the fistula for intravenous infusions

B. Evaluate the fistula for the presence of a thrill or bruit RATIONALE •Fistula patency should be assessed every four hours by auscultating for the presence of bruits and palpating for the presence of thrills. •Blood samples should not be taken from the fistula. •IV fluids should not be administered through a fistula except during hemodialysis, by a trained dialysis nurse. •Blood pressures should not be done on the arm with the fistula.

An infant with secondary lactose intolerance is being discharged. The nurse should instruct the mother to avoid which of the following? Select all that apply. A. Oats B. Formula C. Rye D. Breast milk E. Rice F. Cow's milk

B. Formula D. Breast milk F. Cow's milk RATIONALE •With lactose intolerance the child is unable to consume any dairy products or diarrhea and abdominal pain will develop. The infant will need to be introduced to a lactose free formula initially before slowly returning dairy milk to the diet. •Most infant formulas are milk based and should be avoided by those with lactose intolerance. •Celiac disease, or celiac sprue, is an injury to the mucosa of the small intestine caused by the ingestion of gluten (a toxic protein component) from oats, wheat, rye, barley, and related grains. •Rice does not contain gluten or lactose and can be eaten freely.

Which of the following would require careful monitoring for a child with attention deficit hyperactivity disorder taking Ritalin? A. Dental health B. Height and weight C. Excessive appetite D. Mouth dryness

B. Height and weight RATIONALE •Carefully monitor growth because Ritalin may decrease appetite, cause weightloss and growth retardation. Suggest small frequent meals and finger food snacks to help compensate for anorexia induced by Ritalin •Ritalin has side effects, which includes nervousness, restlessness, dizziness, impaired thinking, headache, loss of appetite and dry mouth. •Dental care is a concern for patients taking tricyclic antidepressants as they increase risk of dental caries (cavities).

The nurse is preparing a care plan for a patient with ascites related to cirrhosis. Which of the following nursing diagnoses should take priority? A. Excess fluid volume B. Ineffective breathing pattern C. Nutritional deficiency D. Risk of poisoning

B. Ineffective breathing pattern Rationale •Due to the accumulation of fluid in the abdomen, pressure is placed on the diaphragm and can interfere with breathing. This can lead to pneumonia or atelectasis. •The remaining nursing diagnoses are important, but do not take priority.

Fluids are normally found in which spaces? Select all that apply A. Peritoneal B. Intracellular C. Pericardal D. Intravascular E. Interstitial F. Pleural

B. Intracellular, D. Intravascular,E. Interstitial RATIONALE •Spaces that are susceptible to third-spacing include peritoneal, pericardial, pleural, and joint cavities. •Fluids are normally found in spaces such as inside the cells or intracellular space, around the cells or interstitial space, and in the bloodstream or the intravascular space.

A patient is septic from an acute Clostridium difficile infection and produces a higher than normal amount of lactic acid. Which of the following is MOST likely to occur? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic acidosis RATIONALE •Metabolic acidosis, from the formation of lactic acid, is common during sepsis. Respiratory Acidosis: •Respiratory system is the cause, ex. hypoventilation. •Increase in PCO2, decrease in pH •Compensation - Kidneys reabsorb Bicarb (HCO3) Metabolic Acidosis: •Caused by loss of bicarb or build up of acids, ex. lactic acidosis, diarrhea, renal failure, ketones, ammonium intoxication. Not caused by respiration. •HCO3 decreases, pH decreases •Compensation- hyperventilation to eliminate CO2 Respiratory Alkalosis: •Caused by excessive ventilation •Decrease in PCO2, increase in pH •Compensation - Kidneys excrete HCO3 Metabolic Alkalosis •Acid (H+) loss from emesis, diuretics. Or retention of HCO3 from medications, hyperaldosteronism •Increase in HCO3, Increase in pH •Compensation - Respiratory centers are not stimulated, this leads to hypoventilation and CO2 retention

A newborn baby with myelomeningocele is scheduled for surgical closure within 24 hours. The main reason for surgical repair is to do which of the following? A. Correct the neurologic deficit B. Minimize infection and prevent further damage to the spinal cord and roots C. Prevent hydrocephalus D. Decrease the risk of developing seizures

B. Minimize infection and prevent further damage to the spinal cord and roots Rationale •Surgery for neural tube disorders is done as soon after birth as possible (usually within 24 to 48 hours) to reduce the risk of infection through the exposed meninges and to prevent further damage to the nervous tissue. •The neurologic deficit cannot be corrected, but further damages can be prevented. •Following repair of the myelomeningocele, children may develop some degree of hydocephalus. •Seizures may still develop during the post operative period due to hydrocephalus.

A nurse is assessing multiple skin lesions on a patient with pemphigus vulgaris. The skin is easily rubbed off when the nurse applies slight friction. This best describes which of the following? A. Murphy's sign B. Nikolsky's sign C. Blumberg's sign D. O'Connor's sign

B. Nikolsky's sign RATIONALE •Nikolsky's sign is positive when slight friction or rubbing causes exfoliation of the skin. •A positive Nikolsky's sign is a hallmark of pemphigus vulgaris, a chronic autoimmune disease that causes painful blisters. •Blumberg's sign is the presence of rebound tenderness in the abdomen and is indicative of peritonitis. •Murphy's sign is indicative of cholecystitis. •O'Connor's sign does not exist.

The nurse is caring for a 16-year-old boy with multiple fractures. Around this age, people often experience closure of the epiphyses. After this occurs, which of the following is true? A. Bone lengthening continues, but thickness remains the same B. No additional bone lengthening occurs C. Bone lengthening increases D. Bone thickness increases

B. No additional bone lengthening occurs RATIONALE •The epiphyseal plates (epiphyses) are responsible for bone elongation in children. Once the plate closes during late adolescence or early adulthood, bone length no longer increases. •Bone thickening is not associated with closure of the epiphyses.

The nurse is caring for a patient diagnosed with antisocial personality disorder. Which of the following traits will most likely surface during assessment? A. Unstable self-image B. Poor judgment C. Dependent and self-critical D. Memory lapses

B. Poor judgement Rationale •A patient with antisocial personality disorder generally exercises poor judgment for various reasons. They pay no attention to the legality of their actions and do not consider morals or ethics when making decisions. •Their behavior is determined primarily by what they want with no empathy or regard to others. Deceit and manipulation are central characteristics of this disorder. •Memory lapses are found in patient with cognitive disorders. Unstable self image is present with borderline personality disorder. A dependent and self-critical attitude is manifested in patients with dependent personality disorder.

A patient has meconium stained amniotic fluid. Fetal scalp sampling indicates a blood ph of 7.12 and fetal bradycardia is present. Based on these findings, the nurse should take which action? A. Administer amnioinfusion B. Prepare for cesarean section C. Reposition the patient D. Start IV infusion as prescribed

B. Prepare for cesarean section RATIONALE •Based on the assessment, fetal acidosis is present. Infants with meconium stained amniotic fluid may have respiratory difficulties and bradycardia at birth. These findings pose a great threat to the newborn's well-being. Therefore, a cesarean section is required. •Amnioinfusion is an infusion of sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression. This is also done to dilute meconium in amniotic fluid, reducing the risk that the infant will aspirate thick meconium at birth. This procedure is done only if the patient does not experience fetal hypoxia.

An elderly woman is admitted to the hospital after several adverse reactions to her medications. This patient may benefit from: A. Longer administration intervals with increased dosages B. Smaller dosages C. Weekly visits to the physician D. Additional medications to reduce adverse effects

B. Smaller dosages RATIONALE •Elderly patients often have reduced hepatic and renal function. This can result in elevated blood levels and increased adverse effects. The patient would benefit from a decrease in her dosage. •Increased dosage with longer intervals could increase the amount of adverse effects. •Weekly visits to the physician would not change the patient's drug reactions. •Adding additional medications would further complicate the situation and not fix the underlying problem.

The nurse is preparing to administer human immune globulin to a patient. The nurse explains to the patient that these types of vaccines: A. Have their potency decreased to facilitate active immunity B. Are inactive toxic compounds that cause illness C. Are obtained from pooled human blood and provide antibodies to several diseases D. Are killed microbes that provide active immunity

C. Are obtained from pooled human blood and provide antibodies to several diseases RATIONALE •Immune globulin is a sterile solution of antibodies obtained from a pool of human blood. They are administered to protect against infectious diseases, but immunity is temporary. •Killed microbes describe killed or inactivated vaccines. •A decrease in potency describes attenuated or live vaccines. •Inactive toxic compounds describes toxoid vaccines.

An 8-year-old is brought to the emergency department by her mother. She is having intermittent episodes of loose stools and recurrent abdominal pain. The child is diagnosed with irritable bowel syndrome (IBS). Which of the following instructions will help reduce the frequency of symptoms? A. Increase intake of milk products B. Take psyllium fiber supplements C. Force fluids D. Avoid carbohydrates

B. Take psyllium fiber supplements Rationale •An increase in fiber is generally recommended, but not all studies agree. Due to its safety and frequent placebo effect, a trial of fiber supplementation should be implemented whether through foods or psyllium fiber supplements. •IBS is characterized by chronic abdominal pain, bloating, discomfort, and intermittent episodes of loose stools. IBS accounts for 30% of all referrals to gastroenterologists. •The cause of IBS is unknown. Recent research has supported inflammation, alterations in normal flora, and psychological stress as risk factors for IBS. Symptom management involves trialing multiple dietary changes. •A lactose free diet should be trialed in patients due to the similiarities of symptoms between IBS and lactose intolerance. •Forcing fluids may cause an excessive GI response, worsening symptoms of IBS. •IBS may be associated with impaired absorption of some carbohydrates (Fructose, fructans, lactose, sorbitol), but not all carbohydrates should be avoided.

The nurse is initiating continuous bladder irrigation on a patient that just underwent a prostatectomy. The nurse understands that the flow rate is adequate if: A. No urine output is noted B. The patient's urine is pale yellow or pale pink tinged C. The patient's urine is clear as water D. Output equals input

B. The patient's urine is pale yellow or pale pink tinged Rationale The goal of continuous irrigation is to maintain urine that is pale yellow or slightly pink. The infusion rate should be adjusted to maintain this urine color. If the urine contains a high concentration of blood or drainage from the surgical site, then the risk of forming a clot is increased dramatically. No urine output would indicate an obstruction, most like from a clot. If the urinary drainage is clear as water, the infusion should be slowed. Output should always equal input during continuous bladder irrigation, but this would not necessarily indicate an adequate flow rate. The flow needs to prevent blood and drainage from forming a clot, that is why the urine should be kept light pink or yellow.

The stroke patient asked the nurse regarding the difference between a cerebrovascular accident (CVA) and a transient ischemic attack (TIA). The nurse correctly says: A. TIA is permanent with long-term focal deficits B. There is spontaneous resolution of the neurologic deficit in a TIA C. In a TIA, there is intermittent but permanent motor and sensory deficits D. TIA does not have long-term neurologic deficits although it is a permanent disability

B. There is spontaneous resolution of the neurologic deficit in a TIA RATIONALE •Due to cerebral ischemia, there is a temporary loss of cognitive function that eventually resolves. A large portion of patient's with a TIA will suffer from a CVA and experience permanent deficits. •Transient Ischemic Attack (TIA) is a warning sign of an impending CVA. It has a brief period of neurologic deficit such as loss of vision, hemiparesis and, slurred speech. •A TIA is not permanent, and does not have long-term neurologic deficits. CVA may cause long-term deficits.

The physician is planning to wean a patient off a ventilator and asks the nurse for which of the following data important for assessing the patient's ventilatory status? A. Echocardiogram B. Breath sounds C. Arterial blood gas D. FiO2 needs of the patient

C. Arterial blood gas Rationale •ABG levels should be assessed prior to any ventilation changes to establish a baseline. ABG levels are often ordered 1 hour after the changes to assess for improvement. •Breath sounds and FiO2 requirements are important data, but do not neccesarily dictate ventilator settings or weaning. •An echocardiogram does not help in the assessment of a patient's respiratory status.

The nurse is assisting a patient who just delivered a healthy baby boy weighing 3,400 grams. Upon cord traction of placenta, she notices a sudden gushing of large amount of blood and the fundus is no longer palpable in the abdomen. What are the nursing interventions if uterine inversion is suspected? Select all that apply. A. Administer oxygen by mask B. Administering oxytocic C. Assess vital signs D. Discontinue uterotonic drugs E. Do not attempt to remove the placenta F. Establish IV access and fluids

C, D, E, F Assess vital signs Discontinue uterotonic drugs Do not attempt to remove the placenta Establish IV access and fluids Rationale •Never attempt to remove the placenta if it is still attached, because this will only create a larger surface area for bleeding. •When an inversion occurs, a large amount of blood suddenly gushes from the vagina. The fundus is not palpable in the abdomen. If the loss of blood continues unchecked, the woman will immediatey show signs of blood loss. •Uterine inversion may occur after the birth of the infant if traction is applied to the umbilical cord too soon or if pressure is applied to the uterine fundus when the uterus is not contracted. •Administering an oxytocic drug only compounds the inversion. •Assessment of vital signs and administration of oxygen is indicated, but not the priority intervention.

A patient with a recent head injury is in a coma. The patient had already identified his wife as power of attorney. The visitors ask you about what happened to the patient. Which of the following is the best response? A. "He suffered a brain injury and cannot wake up" B. "Ask him what happened" C. "I cannot talk about his situation with you. You will have to speak to his wife, who is the power of attorney" D. "I can't talk to you"

C. "I cannot talk about his situation with you. You will have to speak to his wife, who is the power of attorney" RATIONALE •The nurse must maintain patient confidentiality and cannot release information to friends. The nurse must respectfully explain the patient's right to privacy and to talk to the power of attorney with any questions. •The other responses are incorrect because they violate confidentiality or do not explain why the nurse cannot release information.

The nurse is discharging a patient that recently underwent surgery for an above-the-knee amputation (AKA) of the left lower extremity. The patient requires additional education if he states: A. "I should call my prosthetist if my prosthesis is not fitting correctly" B. "I will inspect the amputation site daily" C. "I should elevate the affected limb to reduce swelling" D. "I will change the limb sock every day"

C. "I should elevate the affected limb to reduce swelling" RATIONALE •Elevating the affected limb can cause flexion contractures of the hip and should be avoided. Sitting in a chair should be limited to one hour at a time. •To promote hip extension, the patient should lie prone several times a day. •The other statements are correct

The nurse is caring for a patient with AIDS. The nurse should implement neutropenic precautions when the patient's white blood cell count is: A. 11,500 cells/mm² B. 15,000 cells/mm² C. 3,000 cells/mm² D. 4,900 cells/mm²se

C. 3,000 cells/mm² RATIONALE •The normal range for white blood cells is 4,000 - 10,000 cells/mm². A value of 3,000 cells/mm² is considered low and neutropenic precautions should be implemented. •Neutropenic precautions include a private room, strict handwashing, screening nurses and visitors for transmittable diseases. •15,000 and 11,500 cells/mm² are elevated, possibly due to infection. •4,900 cells/mm² is a normal value.

A patient is admitted to the hospital with burns covering the entire anterior torso, anterior arms (bilateral), and anterior legs (bilateral). The nurse determines that the total body surface area that is affected is: A. 18% B. 36% C. 45% D. 54%

C. 45% Rationale •Anterior torso 18% •Anterior leg, 9% EACH •Both anterior arms, 9%

The nurse is preparing to defibrillate a patient with ventricular fibrillation. The nurse should double check the synchronizer switch because: A. A shock will not be delivered if the synchronizer switch is turned off B. The defibrillator must be synchronized with the closure of the semilunar valves C. A shock will not be delivered if the synchronizer switch is turned on D. The defibrillator must be synchronized with the patient's P wave

C. A shock will not be delivered if the synchronizer switch is turned on RATIONALE •Ventricular fibrillation is not shockable when the synchronizer is turned on. •The synchronizer switch is turned on when cardioverting a patient with arrhythmias containing QRS complexes, such as uncontrolled atrial fibrillation. Ventricular fibrillation does not contain a normal QRS complex. •Defibrillators do not synchronize with a P wave or closure of the semilunar valves

A nurse is preparing a blood transfusion for an anemic toddler. Which of the following blood transfusion matches would cause a hemolytic reaction? A. O-negative blood to a B-negative patient B. A-negative blood to an A-positive patient C. A-positive blood to an AB-negative patient D. B-positive blood to a B-positive patient

C. A-positive blood to an AB-negative patient RATIONALE •A hemolytic reaction occurs with a Rh or ABO incompatibility. •Giving Rh-positive blood to an Rh-negative patient would cause a reaction, but giving Rh-negative blood to an Rh-positive patient is safe if there is an ABO compatibility. •O-negative is the universal donor. •AB patients can receive both A & B blood types, as long as there is a Rh compatibility.

The nurse is creating a care plan for a patient with idiopathic thrombocytopenia pupura (ITP). Which of the following nursing interventions should be included? A. Administer a platelet transfusion B. Administer aspirin to reduce inflammation and pain C. Administer stool softeners to prevent straining D. Encourage coughing and deep breathing

C. Administer stool softeners to prevent straining Rationale Straining during defecation will cause a rise in intracranial pressure. A rise in ICP in a patient with thrombocytopenia increases the risk of an intracranial bleed. Stool softeners will decreasing straining. ITP is an autoimmune disorder that creates antibodies against platelets. Transfusing donor platelets is ineffective because they will be destroyed. Coughing and deep breathing also raise ICP. Aspirin decreases platelet aggregation, which increases the risk of bleeding. Aspirin is contraindicated in patient's with ITP.

A patient is receiving isotonic I.V. fluids at a rate of 150 mL/hour. Which of the following would indicate a need for more I.V. fluids? A. Jugular vein distention B. Peripheral edema C. Amber urine D. Serum potassium of 3.4 mEq/L

C. Amber urine Rationale •Amber or dark urine is highly concentrated and may signal dehydration. The patient needs additional fluids. •Jugular vein distention and peripheral edema would indicate fluid overload. •A serum potassium of 3.4 mEq/L is only slightly low and does not require additional fluids. However, the administration of potassium chloride may be required.

To confirm the diagnosis of acute lymphoblastic leukemia, the nurse would prepare the patient for which of the following tests? A. Lumbar puncture B. Blood culture C. Bone marrow biopsy D. Complete blood count

C. Bone marrow biopsy Rationale •A bone marrow biopsy is performed to confirm the diagnosis of leukemia through the examination of abnormal cells in the bone marrow. •With ALL, bone marrow overproduces immature lymphocytes and soon becomes unable to continue normal production of other blood components. ALL is the most common type of leukemia in children. •A lumbar puncture is performed to detect invasion into the CNS, but is not used to confirm the diagnosis. •An abnormal CBC may suggest leukemia, but it is not used to confirm the diagnosis. •A blood culture may be performed if infection is suspected.

A 9-year-old diagnosed with leukemia is also being treated for epilepsy. The physician prescribes carbamazepine 100 mg PO twice per day. The nurse should question this order because: A. This is a lethal dose B. Carbamazepine is not approved for children C. Carbamazepine causes bone marrow suppression D. Carbamazepine is for diabetes

C. Carbamazepine causes bone marrow suppression RATIONALE •Carbamazepine causes bone marrow suppression. In a patient with leukemia, bone marrow suppression is already a concern, and the use of carbamazepine could worsen her condition. •Carbamazepine is approved for the use in children, and this is an accurate dose.

The nurse is caring for a patient with hyperaldosteronism when the patient's cardiac monitor alarms due to an arrhythmia. The nurse should: A. Check intake and output B. Check peripheral pulses C. Check the patient's potassium level D. Illicit Trousseau's sign

C. Check the patient's potassium level Rationale •Hyperaldosteronism can lead to hypokalemia and fatal heart arrhythmias. •Hyperaldosteronism is caused by adrenal hyperplasia, adrenal adenomas, juxtaglomerular tumor, and renal artery stenosis. •Due to the excess secretion of aldosterone, sodium and water retention are elevated while potassium is excreted. This leads to hypertension, fluid overload, hypokalemia, metabolic alkalosis, and other electrolyte imbalances.

Which of the following should be avoided if the neonate has hypospadias? A. Catheterization B. Administration of diuretics C. Circumcision D. Intravenous pyelography

C. Circumcision RATIONALE •Circumcision should be delayed until after surgical repair because the foreskin is used for grafting. •Hypospadias refers to the condition in which the urethral opening is located below the glans penis or anywhere along the ventral surface of the penile shaft. •Catheterization may be used to ensure urinary elimination. •Diuretics are not contraindicated in a patient with hypospadias. •Intravenous pyelography is contraindicated if the child has an allergy to iodine or shellfish.

A 9-year-old girl is admitted to the hospital with cystic fibrosis. She also has a history of frequent respiratory infections. The child's susceptibility to respiratory infections is directly related to the fact that cystic fibrosis causes which of these physiological alterations? A. Collapsed lung B. Distention of the alveoli C. Formation of mucus plugs in the bronchioles D. Obstruction of the alveoli

C. Formation of mucus plugs in the bronchioles RATIONALE •Children with cystic fibrosis have a generalized dysfunction of the exocrine glands. Mucus secretions of the body, particularly in the pancreas and the lungs have difficulty flowing through gland ducts. •Bacteria thrive in the excessively thick mucus of the lungs. Secretions accumulate in the respiratory tract, causing obstruction, air trapping and increasing the incidence of respiratory infections. •Cystic fibrosis is a chronic disorder of the exocrine glands characterized by abnormally thick pulmonary secretions. Cystic fibrosis affects the pancreas, respiratory system, gastrointestinal tract, salivary glands and reproductive tract. •A collapsed lung will occur in patients with emphysema. Cystic fibrosis involves obstructed bronchioles not alveoli.

A 70-year-old patient diagnosed with testicular cancer has had testicular surgery. On the day of discharge the nurse gave him instructions and told him correctly that: A. He must not be fitted for a prosthesis for at least 6 months B. He must refrain from sitting for long periods of time C. He must report a fever to the physician D. He should not drive for at least 6 weeks

C. He must report a fever to the physician RATIONALE •If the patient experiences chills, fever, drainage, redness, or increasing pain, the physician should be notified because it may be a sign of infection. •The risks associated with prolonged sitting with post-testicular surgery is not as high as with prostate surgery. With prostate surgery, sitting must be avoided because it can cause hemorrhage. •With testicular surgery, a prosthesis is often inserted during the surgical procedure. •The patient may be allowed to drive one week after testicular surgery.

A nurse is gathering health history information from a newly admitted patient. The patient denies any known diseases but gives the nurse a bottle of gemfibrozil that she has been taking for one year. The nurse should question the patient about the presence of what disease? A. Hypertension B. Atrial fibrillation C. Hyperlipidemia D. Type 2 diabetes

C. Hyperlipidemia RATIONALE •Gemfibrozil is a fibric acid derivative that is used to lower cholesterol and triglycerides. Fibrates increase lipoprotein breakdown and clearance. •Gemfibrozil is not used in the treatment of hypertension, atrial fibrillation, or type 2 diabetes.

The nurse is assessing a patient with hypoparathyroidism for electrolyte imbalances. The nurse notes a positive Chvostek's sign, indicating: A. Hypercalcemia B. Hyperphosphatemia C. Hypocalcemia D. Hypophosphatemia

C. Hypocalcemia Rationale •A positive Chvostek's sign occurs when the nurse taps the facial nerve at the angle of the jaw, resulting in the facial muscles contracting and twitching. This is caused by low serum calcium. •Hypoparathyroidism is caused by trauma, removal, or autoimmune destruction of the parathyroid gland. •Hypoparathyroidism results in hypocalcemia due to increased urinary excretion and decreased absorption in the bowel. Hyperphosphatemia is also a result.

The nurse is assessing a septic patient with hypotension and tachycardia. The nurse reviews the patient's lab results and expects an elevation of: A. Ammonia B. Hemoglobin C. Lactate D. Platelets

C. Lactate RATIONALE •Lactate (or lactic acid) is elevated in sepsis due to low tissue perfusion and oxygenation. This causes the creation of energy through anaerobic metabolism, which forms lactic acid as a waste product. •Sepsis is not associated with an increase in hemoglobin, platelets, or ammonia.

A patient has requested an oral contraceptive to reduce the risk of pregnancy. The physician prescribes ethinyl estradiol 30-drospirenone 3 to be cycled for 21 days and followed by a 7 day break. Which classification of contraceptive is ethinyl estradiol 30-drospirenone 3? A. Multiphasic B. Implant C. Monophasic D. Extended cycle

C. Monophasic RATIONALE •Ethinyl estradiol 30-drospirenone 3, trade name Yasmin, is a monophasic oral contraceptive. •Monophasic contraceptives contain the same dose of estrogen and progesterone for the entire dosing schedule. The patient receives 21 days of the active drug, which is then followed by a 7 day period of a placebo to allow withdrawal bleeding. •Multiphasic contraceptives contain both estrogen and progesterone at different dosages throughout the cycle.

The Epstein-Barr virus is associated with which of the following neoplasms? A. Choriocarcinoma B. Lymphangioma C. Nasopharyngeal carcinoma D. Oral carcinoma

C. Nasopharyngeal carcinoma Rationale Epstein-Barr virus, frequently referred to as EBV, is a member of the herpesvirus family which is best known as the cause of infectious mononucleosis. EBV appears to play an important role in the emergence of Burkitt's lymphoma and nasopharyngeal carcinoma, two rare forms of cancer.

When assessing a patient for posture and appearance, the nurse recognizes that the patient is lying still and complaining of abdominal pain. Slight jarring of the bed causes agonizing pain. The nurse assesses that the origin of the pain may be: A. Biliary B. Meningeal C. Peritoneal D. Renal

C. Peritoneal Rationale This pain may be of peritoneal origin. This is a well-localized pain that causes rigidity of the abdominal muscles where the pain increases with any pressure or motion. Pain of renal origin begins in the flank area and may radiate to the lower abdomen, back, and groin. Pain of biliary origin is in the right upper quadrant and may radiate to the right shoulder. Pain of meningeal origin is associated with headache, nuchal rigidity, and photophobia. Pain is increased when the neck is flexed toward the chest.

The nurse is examining a patient at an internal medicine clinic. Which of the following clinical manifestations would support a diagnosis of systemic lupus erythematosus (SLE)? A. Weight gain, fatigue, and butterfly rash B. Butterfly rash, fever, fatigue, and diarrhea C. Proteinuria, fever, fatigue, and butterfly rash D. Butterfly rash, edema, and hypothermia

C. Proteinuria, fever, fatigue, and butterfly rash RATIONALE •Symptoms commonly caused by SLE include chest pain with inspiration, fatigue, fever, general discomfort, hair loss, mouth sores, photosensitivity, and weakness. •Proteinuria is due to autoimmune kidney damage. •Edema, weight gain, hypothermia, and diarrhea are not commonly caused by SLE.

A patient with full-thickness circumferential burns to the left arm is in need of an escharotomy. The nurse understands that the desired outcome of this procedure is: A. Reduce arm edema B. Debridement of infected tissue C. Return of circulation distal to the burn D. Reduce scarring

C. Return of circulation distal to the burn RATIONALE •Escharotomies are performed when circumferential burns compromise circulation to the extremity. •An incision is made down the affected extremity to relieve pressure caused by edema. The depth of the incision is limited to the eschar tissue. •Reduced edema is an outcome of escharotomies, but edema alone does not require an escharotomy.

A patient is admitted to the psychiatric unit for suicidal ideation. The physician prescribes escitalopram and asks the nurse to review the side effects with the patient. The nurse should include which common side effect in the patient's education? A. Confusion B. Constipation C. Sexual dysfunction D. Weight Loss

C. Sexual dysfunction RATIONALE •Escitalopram is a selective serotonin reuptake inhibitor (SSRI). •Common SSRI side effects include sexual dysfunction, nausea, diarrhea, headache, dizziness, dry mouth, and weight gain, drowsiness, and insomnia.

A nurse is assessing an adult patient whose glasgow coma scale score is indicative of a coma. The patient's score is most likely: A. One B. Zero C. Six D. Nine

C. Six Rationale •A GCS score of eight or less defines coma. The lowest achievable score is three, which means deep coma. Fifteen is a perfect score. •The Glasgow Coma Scale is a practical scale that independently evaluates three features such as Best Eye Opening, Best Motor Response, and Best Verbal Response. •The other options are incorrect because the lowest score that can be achieved is three points. A GCS score of nine does not indicate coma.

A 2-year-old boy is admitted to the hospital with celiac disease. Which of the following symptoms should be present upon assessment? A. Regurgitation, projectile vomiting, and dehydration B. Steatorrhea, currant jelly stools, and regurgitation C. Steatorrhea, deficiency of fat soluble vitamins, malnutrition, and distended abdomen D. Regurgitation, deficiency of fat soluble vitamins, and steatorrhea

C. Steatorrhea, deficiency of fat soluble vitamins, malnutrition, and distended abdomen RATIONALE •Children with celiac disease may develop an inability to absorb fat. As a result, they develop steatorrhea (bulky, foul-smelling, fatty stools), deficiency of fat soluble vitamins, malnutrition, and a distended abdomen from bulky stools. •When children with celiac disease ingest gluten, changes occur in the intestinal mucosa that prevent absorption of foods across the intestinal mucosa. •Regurgitation is found in children with GERD. •Pyloric stenosis causes projectile vomiting. •Currant jelly stool happens in intussuception.

The nurse is caring for a patient scheduled for a transsphenoidal hypophysectomy. Before the surgery, which of the following interventions is appropriate to assess the patient for potential complications? A. Assess temperature every 2 hours B. Check serum hemoglobin and hematocrit C. Test blood glucose every 4 hours D. Test urine for nitrates

C. Test blood glucose every 4 hours Rationale This patient is scheduled for removal of the pituitary gland, due to hypersecretion of cortisol. Excess cortisol increases insulin resistance and elevates blood glucose. Nitrates in urine and an elevated temperature can be signs of infection, but are not indicative of complications related to excess cortisol. Hemoglobin and hematocrit alterations are not associated with cortisol secretion.

The nurse draws blood from a patient with acute chest pain and nausea. Which of the following troponin-I levels would indicate the presence of a myocardial infarction? A. 0.01 ng/ml B. 0.02 ng/ml C. 0.03 ng/ml D. 0.05 ng/ml

D. 0.05 ng/ml RATIONALE •Troponin-I level of greater than 0.03 is indictative of myocardial damage. •Troponin-I is more specific for cardiac muscle injury than CK-MB and is elevated sooner. •The remaining options are all within normal limits.

A patient with a head injury was admitted and the nurse plans to monitor his hypothalamic function. To perform this, the nurse should monitor which parameters? A. Pupillary responses and heart rate B. Blood pressure and gastric aspirate C. Urinary output and temperature D. Skin integrity and respiratory rate

C. Urinary output and temperature RATIONALE •To monitor hypothalamic function it is important to assess urinary output and temperature. The hypothalamus regulates body temperature, osmolality of body fluids, hunger, and satiety. •A patient with a head injury may have increased intracranial pressure that causes hypothalamic dysfunction. This may lead to hypo/hyperthermia, SIADH, and diabetes insipidus. •Blood Pressure is controlled by the brainstem not the hypothalamus. Gastric aspirate must be checked for presence of blood because it is common for head injury patients to get stress ulcers. •Pupillary response is dependent on the area of edema in the brain and heart rate is controlled by the brainstem. •Skin integrity is not a parameter for hypothalamic function monitoring and respiratory rate is also controlled by the brainstem.

A patient is seen in the clinic for a follow-up related to chronic gastritis. The nurse should be alert for which vitamin deficiency? A. Vitamin C B. Vitamin E C. Vitamin B12 D. Vitamin B6

C. Vitamin B12 RATIONALE •Chronic gastritis leads to deterioration of the lining of the stomach, leading to the inability to secrete intrinsic factor. Intrinsic factor is required for the absorption of vitamin B12.

The nurse is caring for a deteriorating patient going into cardiogenic shock. The nurse expects to note which manifestation? A. Bounding pulse B. Extreme diuresis C. Weak, thready pulses D. Slow pulses

C. Weak, thready pulses RATIONALE •Cardiogenic shock results in inadequate circulation of blood due to failure of the heart to pump effectively. •Manifestations of reduced circulation include tachycardia, hypotension, weak and thready pulse, decrease in urinary output, and cool, clammy skin.

The nurse is caring for a patient at risk for premature ventricular contractions (PVCs). While monitoring the patient's EKG rhythm, the nurse should look for: A. Narrow QRS complexes B. Peaked P waves with a narrow QRS complex C. Wide QRS complexes in the absence of P waves D. Wide QRS complexes in the presence of inverted P waves

C. Wide QRS complexes in the absence of P waves Rationale PVCs are wide, bizarre QRS complexes in the absence of P waves. There is generally a pause that follows the PVC.

The nurse is caring for a patient who recently underwent an abdominal aortic aneurysm repair. The nurse monitors the patient for which complication? A. Hemorrhage B. Pulmonary embolism C. Infection D. Acute renal failure

D. Acute renal failure D. Acute renal failure Rationale •During a AAA repair, a stent graft is placed in the aorta to support the lumen and reduce pressure on the aneurysm sac. If the stent graft is placed wrong, it can block the renal arteries and cause renal failure. •Hemorrhage is more common before the AAA repair, when the aneurym ruptures. •Emboli and infection are also complications of a AAA repair, but they are less common than renal failure

Which type of white blood cells release histamine during an anaphylactic reaction? A. Neutrophils B. Lymphocytes C. Eosinophils D. Basophils

D. Basophils Rationale •During an allergic or anaphylactic reaction, basophils release histamine, leading to vasodilation, increased capillary permeability, and bronchospam. •Neutrophils defend against bacteria and fungi and produce relatively small inflammatory responses as first responders. •Lymphocytes defend against viral infections and do not release histamine during an allergic reaction. •Eosinophils primarily defend against parasitic infections and are important in allergic responses. However, they primarily release interleukin, not histamine.

A patient is being evaluated for abdominal pain. The nurse elicits Murphy's sign, or pain in the right upper quadrant along the costal margin. A positive Murphy's sign is indicative of: A. Cirrhosis B. Hepatitis C. Pyelonephritis D. Cholecystitis

D. Cholecystitis Rationale •A positive Murphy's sign is indicative of gall bladder inflammation. Cholecystitis is confirmed via ultrasound. •After the patient breathes out, the nurse firmly palpates below the right costal margin, mid-clavicular line. The patient is instructed to take a deep breath while the nurse deeply palpates. If the patient stops inhaling or winces, the test is positive.

A patient has an elevated serum osmolality and a serum sodium level of 159 mEq/L. The most beneficial I.V. fluid would be: A. Dextrose 10% in water (D10W) B. Dextrose 5% in Lactated ringer's (D5LR) C. Dextrose 5% in normal saline (D5NS) D. Dextrose 5% in water (D5W)

D. Dextrose 5% in water (D5W) RATIONALE •The patient is in a hypertonic state and should not receive hypertonic fluid. D5W is the only isotonic fluid and is the correct choice. •D5NS, D10W, and D5LR are all hypertonic fluids.

May is a postpartum patient and has complaints of fever, chills, malaise, lethargy, anorexia, abdominal pain, cramping, uterine tenderness and purulent foul smelling lochia. Laboratory data finds an elevation of leukocytes. Based on the above clinical findings, the nurse suspect which of the following conditions? A. Osteogenic Sarcoma B. Mastitis C. Endometriosis D. Endometritis

D. Endometritis RATIONALE •Endometritis is an infection of the endometrium (lining of the uterus). It can occur during pregnancy, after childbirth or be unrelated to pregnancy (then it is called pelvic inflammatory disease). •Endometritis is usually caused by organisms that are normal inhabitants of the vagina and cervix. •The major signs and symptoms are fever, chills, malaise, lethargy, anorexia, abdominal pain, and cramping, uterine tenderness and purulent, foul smelling lochia.

The parents of a 7-year-old with Cystic Fibrosis are concerned about having another child and passing their affected genes to their future children. Which of the members of the health care team should the nurse refer the parents to? A. Pediatrician B. Gynecologist C. Social worker D. Genetic counselor

D. Genetic counselor Rationale •A genetic counselor is specially trained in genetic disorders and can provide the parents with education, screening, and treatment options. •Pediatricians, Gynecologists, and social workers do not usually receive additional specialized training in genetic disorders or genetic counseling.

Upon the delivery of a newborn, the APGAR score of the child within the first minute was five, this means: A. Serious danger and needs resuscitation B. Good and just needs suctioning C. Strong and doesn't need any clearing of airways D. Guarded and may need clearing of airway

D. Guarded and may need clearing of airway RATIONALE •An infant scoring 5 means that the condition is guarded and a may need clearing of the airway and/or supplementary oxygen. •An infant scoring below 4 is considered critical and may need resuscitation. •A score of 7 to 10 is considered good, indicating that the baby doesn't need clearing of airways. •The APGAR is assessed at 1 minute and 5 minutes after birth.

A patient is admitted to the hospital after his urinalysis showed significant proteinuria. The nurse determines that the patient is suffering from nephritic syndrome, rather than nephrotic syndrome, because of: A. Hyperlipidemia B. Periorbital edema C. Hypoalbuminemia D. Hematuria

D. Hematuria RATIONALE •Nephritic syndrome is similar to nephrotic syndrome in that they both involve increased permeability of the glomerulus, leading to proteinuria, hypoalbuminemia, and hyperlipidemia. •Hematuria does not occur in nephrotic syndrome. •Nephritic syndrome often occurs after streptococcal glomerulonephritis and causes azotemia, oliguria, and hypertension.

A patient recently prescribed with ezetimibe asks the nurse why he needs this medication. Understanding the mechanism of action, the nurse knows ezetimibe is used to treat: A. Osteoporosis B. Hypertension C. Congestive Heart Failure D. Hyperlipidemia

D. Hyperlipidemia RATIONALE •Ezetimibe inhibits the intestinal absorption of cholesterol and is often combined with a statin.

A 10-year-old male is admitted to the acute care facility after having a tonic-clonic seizure. What priority nursing action would the nurse do immediately after the seizure? A. Observe for signs and symptoms of respiratory distress B. Provide a calm, restful environment C. Monitor vital signs and neurologic status every 15 minutes until the child is fully awake D. Maintain a patent airway with the child lying on his side until he is alert and responsive

D. Maintain a patent airway with the child lying on his side until he is alert and responsive Rationale •The first priority nursing action is to maintain a patent airway with the child lying on his side. The side-lying position reduces the risk of aspiration. •Monitoring vital signs and neurologic status provides information about the extent of involvement and resolution of the seizure. •Respiratory distress may indicate aspiration. This should be prevented by using the side-lying position.

The nurse is assessing a patient after returning from surgery. After reviewing the patient's white blood cell differential, the nurse should notify the physician of: A. Basophils 0.5% B. Eosinophils 2% C. Lymphocytes 20% D. Neutrophils 82%

D. Neutrophils 82% Rationale Neutrophils should account for 55-70% of all white blood cells. An elevation in neutrophils is indicative of a bacterial infection. The physician should be notified because the patient is at risk for infection and complications after surgery. Lymphocytes, 20-40% Eosinophils, 1-4% Basophils, 0.5-1%

A patient is admitted to the hospital after having multiple seizures and fosphenytoin (Cerebyx) is administered. The patient's phenytoin blood level is 19 mcg/mL. The nurse would expect to see which side effect? A. Agitation B. Bradycardia C. No side effects noted, therapeutic level is within normal limits. D. Nystagmus

D. Nystagmus Rationale The therapeutic phenytoin level is 10-20 mcg/mL. Even at therapeutic levels, side effects such as nystagmus can occur. Other side effects include paresthesia, sedation, ataxia, rash, tachycardia, hypotension, birth defects, and gingival hyperplasia. Fosphenytoin (Cerebyx) is a phenytoin prodrug, both are hydantoin anticonvulsants.

A patient is brought into the emergency department with a pheochromocytoma. In order to reverse the lethal symptoms of this disease, the nurse prepares to infuse: A. Norepinephrine B. Atropine C. Dopamine D. Phenoxybenzamine

D. Phenoxybenzamine RATIONALE •Due to the high level of catecholamines, both alpha and beta blockers are required, particularly alpha blockers. Phenoxybenzamine is the preferred alpha blocker. •Pheochromocytoma is a rare catecholamine secreting tumor in the adrenal gland. •The patient's blood pressure and heart rate should be stablized until the patient undergoes an adrenalectomy. •Norepinephrine and dopamine are catecholamines and should not be administered to a patient with a pheochromocytoma. •Atropine is used for symptomatic bradycardia and is not indicated in the treatment of pheochromocytoma.

The nurse is assessing a 4-year-old complaining of a fever, chills, headache, and malaise with firm and tender cervical lymph nodes. What laboratory test is used to confirm the diagnosis of infectious mononucleosis? A. WBC count revealing leukocytosis B. CBC revealing increased lymphocytes C. Positive heterophile antibody test D. Positive Epstein-Barr virus antibody test

D. Positive Epstein-Barr virus antibody test RATIONALE •Epstein Barr virus antibody test is used to confirm diagnosis if the Monospot test is negative and the patient has symptoms of mononucleosis. •The Monospot test, or heterophile antibody test, is a quick test used for mononucleosis, but it may produce false negatives. •Mononucleosis is usually caused by the Epstein-Barr virus and causes severe fatigue and malaise. Swollen tonsils and lymph nodes, stomach ache, and flu like symptoms are generally present. •Leukocytosis and lymphocytosis are indicative of infection, but not specific to mononucleosis.

The nurse is assessing an aggressive and short tempered man that became a city champion boxer. Which of the following defense mechanisms is he using? A. Displacement B. Projection C. Reaction formation D. Sublimation

D. Sublimation RATIONALE •Sublimation is the redirecting of unacceptable feelings or behaviors into an acceptable channel •Projection is an unconscious blaming of one's own unacceptable attributes or thoughts on someone else. •Reaction formation is exhibiting acceptable behavior to make up for or negate unacceptable thoughts. •Displacement is the redirecting of anger toward someone or something less threatening.

A patient is administered chlorpromazine (Thorazine) for acute psychosis. The nurse should be alert for which potential side effect? A. Cerebral edema B. Hypertensive crisis C. Serotonin syndrome D. Tardive dyskinesia

D. Tardive dyskinesia Rationale Chlorpromazine (Thorazine), like most typical antipsychotics, can cause extrapyramidal side effects, such as tardive dyskinesia, akathisia, and dystonia. Serotonin syndrome and hypertensive crisis have not been associated with the use of typical antipsychotics. Cerebral edema has been reported with the use of Thorazine, but this adverse effect is not common.

Is a nurse required to obtain consent from an 8-year-old patient who is undergoing a heart transplant? A. Since the child is a minor, he does not need to be informed about the surgery because his mother gives consent B. The child only needs to know the risks of the surgery while his mother gives consent C. The child must sign the informed consent form D. The child must be informed about the surgery, while his mother gives consent

D. The child must be informed about the surgery, while his mother gives consent RATIONALE •Any child who is in the concrete operations stage of development must give assent, not consent. This is usually any child over 7 years of age. •Assent means knowledge of the surgery and agreement with the parent or other person giving consent.

The nurse is caring for a patient who underwent a thyroidectomy. Which of the following items should the nurse keep at the patient's bedside? A. I.V. potassium chloride B. Heated blanket C. I.V. adenosine for unstable tachycardia D. Tracheostomy kit

D. Tracheostomy kit RATIONALE •Due to the location of the thyroid gland, the patient is at risk for airway edema and obstruction. An emergency tracheostomy kit should be at the bedside at all times. •Hypokalemia is not associated with a thyroidectomy. •A heated blanket may be needed due to cold intolerance, but this does not need to be at the bedside. •Tachycardia may occur due to a thyroid storm after a thyroidectomy. This seems counter-intuitive, but this can occur intraoperatively and postoperatively due to thyroid gland manipulation during surgery. This is a very rare occurrence and does not require the nurse to keep adenosine next to the bedside.

The nurse is educating a patient scheduled for an inferior vena cava (IVC) filter placement. The patient has a history of multiple pulmonary emboli. The nurse explains to the patient that the purpose of an IVC filter is to: A. Compliment anticoagulation therapy but preventing clot formation B. Dissolve blood clots in the blood C. Prevent clot formation in the lungs D. Trap blood clots in the blood

D. Trap blood clots in the blood Rationale An IVC filter is a vascular filter used to trap emboli floating in the vena cava. It helps prevent pulmonary emboli. An IVC filter does not dissolve clots or prevent clot formation.