PreBoard III Nursing Practice III
37. In preparing for the admission, the nurse anticipates that which of the following will be prescribed as a priority in the management of the current crisis? A. Administration of oxygen B. Fluid administration C. Red blood cell transfusion D. Genetic counseling
A. Administration of oxygen
88. Which nursing observation indicates that a male client with a kidney stone is experiencing renal colic? A. Severe flank pain radiating toward the testicles B. Stress incontinence with full bladder C. Hematuria and severe burning on urination D. Enuresis with hyperalbuminuria
A. Severe flank pain radiating toward the testicles
15. Mr. Tessa is recovering from abdominal surgery. During the immediate postoperative period, which action should the nurse take to help prevent hypostatic pneumonia? A. Splint the incisional area while the client breathes deeply. B. Have the client use an incentive spirometer four times daily. C Encourage the client to exhale through pursed lips. D. Support the client in an orthopneic position.
A. Splint the incisional area while the client breathes deeply.
7. The Physician prescribes promethazine hydrochloride (Phenergan) for a client who is being prepared for surgery. What's the purpose of administering this drug to this client? A. To provide sedation. B. To inhibit oral secretions. C. To prevent bleeding problems. D. To enhance wound healing.
A. To provide sedation.
48. A client with Peritonitis has a Salem sump that's connected to low suction. Which strategy should the nurse include in the plan of care? A. Turn the client from side to side for every 4 hours. B. Irrigate the nasogastric tube through the blue opening. C. Measure nasogastric drainage every 24 hours. D. Increase the suction control to high if no drainage appears.
A. Turn the client from side to side for every 4 hours.
28. Currently, the most widely used test for diagnosing pulmonary embolus is: A. deep leg veins B. lung tissue C. spiral CT D. right atrium
A. deep leg veins
18. A client in another room is diagnosed as having pulmonary tuberculosis, and one of the drugs the Physician orders is Pyrazinamide (PZA). The nurse evaluates that the teaching concerning the drug was effective when the client says, "I will: A. drink at least 2 quarts of fluid a day" B. take the medication 2 hours after each meal" C. report any changes in vision to the physician" D. expect a discoloration of urine sweat, and tears"
A. drink at least 2 quarts of fluid a day"
27. Nurse Thelma is providing discharge teaching for the patient who was hospitalized with pulmonary embolism. Which of the following statements by the patient indicates a need for further review of information? A. "I should be as active as possible every day at home." B. "I will need to change my vena cava filter once per week." C. "I should notify my doctor if I develop warmth or swelling in my legs." D. "I will need to be on anticoagulant therapy for a while."
B. "I will need to change my vena cava filter once per week."
19. Tuberculosis is confirmed, and Isoniazid (INH) and Rifampin (Rifadin) therapy were prescribed for a client. The client says, "I've never had to take so much antibiotic for an infection before." The nurse should explain: A. "Rifampin prevents side effects from INH" B. "This type of organisms is difficult to destroy" C. "You'll need only one medication when you get better" D. "Your infection is well advanced and needs aggressive therapy"
B. "This type of organisms is difficult to destroy"
22. The nurse is preparing to provide discharge teaching to a patient with Emphysema. Which of the following instruction should the nurse include for this patient? A. "You may use your oxygen at 4L/min by nasal cannula." B. "You should try to drink at least two liters of fluid per day." C. "You should try to reduce your smoking to two cigarettes per day." D. "You should be sure to weigh yourself daily and notify the doctor."
B. "You should try to drink at least two liters of fluid per day."
92. A nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor that is producing excessive aldosterone (primary hyperaldosteronism). The nurse appropriately tells the client which of the following? A. "You will most likely need to undergo chemotherapy after surgery." B. "You will need to take hormone replacements for the rest of your life." C. "You will need to wear an abdominal binder after surgery." D. "You will not require any special long term treatment after surgery."
B. "You will need to take hormone replacements for the rest of your life."
55. Irritable bowel syndrome is diagnosed by: A. Laboratory values that demonstrate bowel inflammation B. A careful history and physical examination C. An emergent abdominal CT with contrast D. Placing the patient on laxatives on constipations
B. A careful history and physical examination
5. A client had a Myocardial Infarction yesterday. His cardiac monitor shows 6 to 8 PVC's per minute, with occasional couplets. The best action by the nurse at this time is to : A. Monitor the client for development of ventricular tachycardia. B. Administer the ordered PRN dose of Lidocaine. C. Perform a precordial thump. D. Initiate manual chest compressions.
B. Administer the ordered PRN dose of Lidocaine.
52. The nurse is caring for a client with irritable bowel syndrome. Irritable bowel syndrome is characterized by: A. Development of pouches in the wall of the intestine B. Alternating bouts of constipation and diarrhea C. Swelling, thickening, and abscess formation D. Hypocalcemia and iron-deficiency anemia
B. Alternating bouts of constipation and diarrhea
69. Nurse Delia is caring for another client who had an orthopedic injury of the leg requiring surgery. Postoperatively, which nursing assessment is of highest priority? A. Checking for bladder distention B. Assessing for Homans' sign C. Monitoring for extremity shortening D. Monitoring for heel breakdown
B. Assessing for Homans' sign
90. Another 56 year old client develops recurrent Urolithiasis. What mineral will most likely be restricted in the client's diet? A. Phosphorus B. Calcium C. Magnesium D. Sodium
B. Calcium
77. Post-operatively, the nurse should further assess to: A. Provide the client a toothbrush for mouth care B. Check the nasal dressing for the "halo sign" C. Tell the client to cough forcibly every 2 hours D. Ambulate the client when he is fully awake
B. Check the nasal dressing for the "halo sign"
24. As the nurse assists a client with breathing exercise, the client says, "I don't feel any better, why should I bother learning how to do these exercises?" How should the nurse respond? A. Tell the client that the physician ordered the exercises B. Encourage the client to express feelings. C. Ask if the client would like to do the exercises at another time. D. Inform the physician of the client's statements.
B. Encourage the client to express feelings.
Situation: A nurse is caring for a client who is scheduled for an adrenalectomy. 91. The nurse plans to administer which medication in the preoperative period to prevent Addison's crisis? A. Spironolactone (Aldactone) intramuscularly B. Methylprednisolone sodium succinate (Sulo-Medrol) intravenously C. Prednisone (Deltasone) orally D. Fludrocortisone (Florinef) subcutaneously
B. Methylprednisolone sodium succinate (Sulo-Medrol) intravenously
82. The diet ordered for a client with calcium-based renal calculi is to contain 400 mg of calcium, a low calcium level. The foods permitted on this diet would include: A. Chocolate pudding B. Roast beef with baked potato C. Salmon loaf with cheese sauce D. Vanilla ice cream with chocolate syrup and nuts
B. Roast beef with baked potato
84. Nurse Carrie is instructing the client about recommended daily fluid consumption. The nurse should tell the client to drink approximately: A. 4 cups per day. B. 8 cups per day. C. 12 cups per day. D. 16 cups per day.
C. 12 cups per day.
Situation : An 82-year-old man is brought to the emergency department because of severe pain in his left leg from his groin downward. He has a history of atrial fibrillation and hypertension. He states that the pain began suddenly when he got out of bed prior to arrival in the emergency department. 61. The physical examination of a patient with an acute arterial occlusion would reveal: A. Palpable peripheral pulses B. A red, warm extremity C. A pale, cold extremity D. Intermittent Claudication
C. A pale, cold extremity
34. A Schilling test is ordered for a client who is suspected of having pernicious anemia. Nurse Iya recognizes that the primary purpose of the Schilling test is to determine the client's ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12
C. Absorb vitamin B12
50. A community health nurse is assessing a client who has begun using peritoneal dialysis. The nurse determines that which manifestation noted in the client would most likely indicate the onset of peritonitis? A. Temperature of 99.0 oF oral B. History of gastrointestinal (GI) upset 1 week ago C. Cloudy dialysate output D. Presence of crystals in dialysate output
C. Cloudy dialysate output
SITUATION: Mr. Sevilla, a 50 year old man has driven himself to the emergency department (ED) after vomiting bright red blood twice within 6 hours. He arrives alert & oriented but appears anxious. He is able to provide a vague history but admits to drinking "a few" last weekend. He knows that he is "supposed to stop drinking" & takes "something for his stomach," but he cannot recall the medication. He complains of intermittent dizziness & fatigue that has been worsening over the past 2 days. His skin is dry & pale. His abdomen is slightly distended. He reports pain (4 on a scale of 10) in the midepigastric area. Capillary refill is longer than 3 seconds, BP= 140/90 mm Hg, PR= 110 bpm, RR= 24 bpm, and T= 99°F (37.2°C). 56. What is the priority nursing diagnosis for Mr. Sevilla? A. Risk for aspiration related to active bleeding B. Anxiety related to the uncertainty of his health status C. Deficient fluid volume related to vomiting of blood and gastric secretions D. Noncompliance related to alcohol consumption and medication use
C. Deficient fluid volume related to vomiting of blood and gastric secretions
47. If rebound tenderness is found when assessing the abdomen, the emergency nurse knows that: A. It is frequently a sign of a malignancy B. It is normal to have abdominal rebound tenderness C. Rebound tenderness is a sign of peritoneal irritation D. Rebound tenderness occurs only when the patient is nauseated
C. Rebound tenderness is a sign of peritoneal irritation
Situation: A newly admitted Mr. Ruben, a 30 years old has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. 36. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. A. Adjust the room temperature B. Give a bolus of IV fluids C. Start O2 D. Administer meperidine (Demerol) 75mg IV push
C. Start O2
43. Nurse Rolly is caring for a client diagnosed with Polycythemia vera. In planning care for this client, Nurse Rolly should include which of the following health teachings: A. Wear tight or constrictive clothing especially garters and girdles B. Floss between your teeth C. Take anticoagulants as prescribed D. Perform strenuous exercises daily
C. Take anticoagulants as prescribed
59. You are performing additional assessment and history taking for Mr. Sevilla. Which finding should you immediately report to the Physician? A. Melena Stools B. History of nonsteroidal anti-inflammatory drug use C. Tense, rigid abdomen D. Probable positive human immunodeficiency virus status
C. Tense, rigid abdomen
14. A client underwent abdominal surgery 6 hours ago. At 6 p.m., the client receives an order of Meperidine (Demerol) 50 mg, as needed. Two hours later, the client complains of incisional pain. Which action should the nurse take? A. Place a heating pad against the client's abdomen. B. Repeat the Meperidine dose. C. Turn the client onto his side and place a pillow behind the back. D. Give the client half the ordered dosage of Meperidine.
C. Turn the client onto his side and place a pillow behind the back.
12. A client had abdominal surgery 2 days ago. Which observation indicates that peristaltic activity has returned? The client is : A. belching. B. hungry. C. passing flatus. D. thirsty.
C. passing flatus.
98. Another client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would Nurse Kiko's next action be? Obtain a crash cart Check the calcium level Assess the dressing for drainage Assess the blood pressure for hypertension
Check the calcium level
8. The client returns to the unit from surgery with a BP= of 90/50, PR= 132, and RR= 30. Which action by the nurse should receive priority? Continuing to monitor the vital signs Contacting the Physician Asking the client how he feels Asking the LPN to continue the post-op care
Contacting the Physician
4. A client is receiving a continuous intravenous infusion of Heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time is 65 seconds. Nurse Jojie anticipates that which action is needed? A. Discontinuing the Heparin infusion B. Increasing the rate of the Heparin infusion C. Decreasing the rate of the Heparin infusion D. Leaving the rate of Heparin infusion as is
D. Leaving the rate of Heparin infusion as is
Situation: When subtotal thyroidectomy is the treatment of choice , the patient must be adequately prepared to avoid postoperative complications. Nurse Noah is assigned to take care to 76. A nurse is caring for a client who has undergone transphenoidal surgery for a pituitary adenoma. In the postoperative period, the nurse teaches the client to: A. Remove the nasal packing after 48 hours B. Cough and deep breathe hourly C. Take the acetaminophen (Tylenol) for severe headache D. Report frequent swallowing or postnasal drip
D. Report frequent swallowing or postnasal drip
72. The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is: A. Body image disturbance related to swelling of neck B. Anxiety-related to changes in body image C. Altered nutrition: less than body requirements, related to difficulty in swallowing D. Risk for ineffective airway clearance related to pressure on the trachea
D. Risk for ineffective airway clearance related to pressure on the trachea
40. What is the best position for Mr. Ruben if he experience a sickle cell crisis? A. Side-lying with knees flexed B. Knee-chest C. High Fowler's with knees flexed D. Semi-Fowler's with legs extended on the bed
D. Semi-Fowler's with legs extended on the bed
30. The most effective means of preventing development of pulmonary embolism is: A. encourage frequent coughing and deep breathing. B. forcing fluids to at least 3000 mL/day C. limiting ambulation to no more than once per day D. preventing development of deep vein thrombosis
D. preventing development of deep vein thrombosis
94. Which of the following is a priority for the nurse to monitor in a client with Pheochromocytoma? a. Weight b. Serum glucose c. Blood pressure d. Temperature
c. Blood pressure
13. An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: Administer oxygen via nasal cannula Have Narcan (naloxone) available Prepare to administer blood products Prepare to do cardio resuscitation
Have Narcan (naloxone) available
Situation: Health education is very essential in clients with hematologic disorders. Nurse Rolly is teaching Mr. Kirk with Polycythemia vera about prevention of the disease. One of the major roles of Nurses' based from the National Core Competencies is the Beginning Nurse's Role on Care Client Care. 41. Nurse Rolly implements the health education plan utilizing appropriate teaching strategies.Which of the following statements by Mr. Kirk indicates a need for further teaching? "I will drink 500mL of fluid or less each day." "I will wear support hose when I am up." "I will use an electric razor for shaving." "I will eat foods low in iron."
"I will drink 500mL of fluid or less each day."
85. Which of the following factors can contribute to the formation of renal calculi? A. Hypocalcemia. B. Heart failure. C. Hypothyroidism. D. Changes in urine pH.
D. Changes in urine pH.
32. Nurse Iya is providing education to the patient with Pernicious Anemia. Which of the following statements by the patient indicates comprehension of the information? A. "I will need to take vitamin B12 replacement for the rest of my life." B. "Once I get over this episode, I will not need to take the medicine regularly." C. "If I add vitamin B12 rich foods to my diet consistently, I don't need medication." D. "I have a higher chance of developing Alzheimer's because of B12 deficiency."
A. "I will need to take vitamin B12 replacement for the rest of my life."
44. Which client statement would indicate to Nurse Rolly that the client with Polycythemia vera is in need of further instruction? A. "I'll be flying overseas to see my son and grandchildren for the holidays." B. "I plan to do my leg exercises at least three times a week." C. "I'm going to be walking in the mall every day to build up my strength." D. "At night when I sleep, I like to use two pillows to raise my head up."
A. "I'll be flying overseas to see my son and grandchildren for the holidays."
67. Mr. Sam is being discharged after treatment of deep vein thrombosis. Coumadin (warfarin) 2.5 mg daily is prescribed. The nurse recognizes that which of the following statements indicates that the client understands the effects of Coumadin? A. "I'll use an electric razor to shave my legs." B. "I'll have a podiatrist cut my toenails." C. "I need to eat more salads and fresh fruits." D. "I will take aspirin instead of Tylenol for headaches."
A. "I'll use an electric razor to shave my legs."
23. A client with Emphysema is to receive oxygen by nasal cannula. Which measure should the nurse take when caring for this client? A. Maintain the oxygen flow rate at no more than 3 L/minute. B. Increase the oxygen flow rate up to 6 L/minute, if required. C. Teach the client to adjust the oxygen flow rate as needed. D. Change the oxygen tubing at each shift.
A. Maintain the oxygen flow rate at no more than 3 L/minute.
100. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for Nurse Kiko to obtain? A. A history of radiation treatment in the neck region B. Any history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client's food intake
A. A history of radiation treatment in the neck region
62. The patient's leg is pale and cold. No pulses are palpated and the patient is in severe pain. The emergency nurse should prepare the patient with an acute arterial occlusion for: A. An invasive procedure to relieve the occlusion, such as percutaneous transluminal angioplasty or a thromboendarectomy B. anticoagulant therapy using molecular-weight heparin as an outpatient, with an appointment with a surgeon within 24 hours. C. Application of posterior splint to immobilize the extremity until he can be seen is the surgical clinic within 24 hours D. Application of anti-embolic hose to decrease the risk of pulmonary embolus and pressure ulcers on the affected extremity
A. An invasive procedure to relieve the occlusion, such as percutaneous transluminal angioplasty or a thromboendarectomy
70. A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan? A. Assess for signs of abnormal bleeding B. Anticipate an increase in the heparin drip rate C. Instruct the client regarding the drug therapy D. Increase the frequency of vascular assessments
A. Assess for signs of abnormal bleeding
73. The Physician has order thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should: A. Assess the client for allergies B. Bolus the client with IV fluid C. Tell the client he will be asleep D. Insert a urinary catheter
A. Assess the client for allergies
89. The Physician prescribes aluminum hydroxide gel for a client with phosphatic -based urinary calculi. The nurse should teach the client that this medication will decrease the serum phosphorus by: A. Binding with phosphorus in the intestine B. Preventing absorption of phosphorus in the stomach C. Promoting excretion of excessive urinary phosphorus D. Dissolving stones as they pass through the urinary tract
A. Binding with phosphorus in the intestine
Situation: Abdominal pain is the most common symptom of Peritonitis. Assessment of the patient's pain, including the location is important and may help in determining the cause of peritonitis. 46. A client is admitted to the nursing unit in acute abdominal pain. The Physician diagnosed Peritonitis. Abdominal assessment reveals three of the following findings. Which one wouldn't occur with peritonitis? A. High-pitched bowel sounds B. Abdominal distension C. Diffuse abdominal pain D.Constipation
A. High-pitched bowel sounds
42. Mr. Kirk is admitted with a diagnosis of Polycythemia Vera. Nurse Rolly should closely monitor the him for: A. Increased blood pressure B. Decreased respiration C. Increased urinary output D. Decreased oxygen saturation
A. Increased blood pressure
10. A client returns from surgery. Which nursing diagnosis takes priority at this time? A. Ineffective breathing pattern B. Deficient fluid volume C. Imbalanced nutrition: Less than body requirements. D. Diarrhea
A. Ineffective breathing pattern
68. Another adult is hospitalized with deep vein thrombophlebitis. During the first few days of therapy, Nurse Delia should: A. Keep the client in Trendelenburg position. B. Apply ice packs three or four times daily to relieve pain. C. Massage the affected leg once a shift. D. Encourage the client to perform active range of motion exercises with both legs each shift.
A. Keep the client in Trendelenburg position.
20. A client is diagnosed with tuberculosis associated with HIV infection. The test results that are crucial for the nurse to review before starting antitubercular pharmacotherapy are: A. Liver function studies B. Pulmonary function studies C. Electrocardiogram and echocardiogram D. White blood cell count and sedimentation rate
A. Liver function studies
75. The nurse is caring another client with an endemic goiter. The nurse recognizes that the client's condition is related to: A. Living in an area where the soil is depleted of iodine B. Eating foods that decrease the thyroxine level C. Using aluminum cookware to prepare the family's meals D. Taking medications that decrease the thyroxine level
A. Living in an area where the soil is depleted of iodine
78. The nurse is caring for another client scheduled for removal of the pituitary gland. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria
A. Nasal congestion
2. Nurse Jojie checks the laboratory result for a serum Digoxin level that was prescribed for another client earlier in the day and notes that the result is 2.4 ng/ml. Nurse Jojie should take which immediate action? A. Notify the physician B. Check the client's last pulse rate C. Record the normal value on the client's flow sheet D. Administer the next dose of the medication as scheduled
A. Notify the physician
53. The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important? A. Reinforcing the need for a balanced diet B. Encouraging the client to drink 16 ounces of fluid with each meal C. Telling the client to eat a diet low in fiber D. Instructing the client to limit his intake of fruits and vegetables
A. Reinforcing the need for a balanced diet
58. Which task is appropriate to assign to a Novice nurse? A. Repeat measurement of vital signs every 2 hours B. Gather equipment for nasogastric NG lavage C. Check the blood glucose level every 2 hours D. Notify the family (with the patient's permission)
A. Repeat measurement of vital signs every 2 hours
Situation : Management of Perioperative patients demands the use of knowledge , judgment and skills based on the principles of nursing science, especially to those clients who are receiving sedative medications. 6. The nurse is providing care for a pre-operative patient who normally takes Enalapril (Vasotec). The nurse will verify with the Physician whether or not to hold the drug prior to surgery because it is likely to cause which of the following during surgery? A. hypotension B. impaired cardiac function C. respiratory depression D. bronchospasm
A. hypotension
Situation: Some patients with kidney stones may be asymptomatic until the calculi become too large. The goal of the treatment is surgical management depending on the location and size of the calculi. 86. A client has had a kidney stone removed, and the nurse instructs him in measures to decrease kidney stone formation in the future. Which statement by the client indicates to the nurse that he understood the teaching? A. "I should begin a daily 45-minute jogging program." B. "I should consume at least 2500 ml of fluid daily." C. "I should report nocturia that occurs once a night." D. "I will ingest megadoses of vitamins C and daily."
B. "I should consume at least 2500 ml of fluid daily."
Situation: The goal in the treatment of Goiter is to block the adverse effects of over secretion of thyroid hormones. 71. A 45-year-old has a simple goiter. She is being seen by the community health nurse for teaching and follow-up regarding nutritional deficiencies related to her goiter. The client's problems are most likely associated with which nutritional deficiency? A. Calcium. B. Iodine. C. Iron. D. Sodium.
B. Iodine.
80. The client who is 80 hours post-transphenoidal hypophysectomy reports numbness on the upper lip and gum, a headache when reclining, and has a tendency to kick around small rugs in the room when walking. The nurse should do which of the following? A. Inform the client that these are normal responses and will disappear over 2 to 3 weeks B. Assess neuromuscular function and incisional area and then report all findings to the surgeon C. Immediately arrange for the client to be transported to the hospital for treatment of increased intracranial pressure. D. Assess vital signs, fluid volume status, bowel function and nutrition status.
B. Assess neuromuscular function and incisional area and then report all findings to the surgeon
49. On the third postoperative day after a Subtotal Gastrectomy, a client complains of severe abdominal pain. The nurse palpates the client's abdomen and notes rigidity. The nurse should first: A. Assist the client to ambulate B. Assess the client's vital signs C. Administer the prescribed analgesics D. Encourage the use of the spirometer
B. Assess the client's vital signs
63. When assessing the client with acute arterial occlusion, the nurse would expect to find: A. Peripheral edema in the affected extremity B. Minute blackened areas on the toes C. Pain above the level of occlusion D. Redness and warmth over the affected area
B. Minute blackened areas on the toes
99. Nurse Kiko is caring for a client who has returned to the Physician's office for follow-up after a Parathyroidectomy with autotransplantation of some parathyroid tissue into the forearm. The client has been taking oral calcium and D supplements since discharge 2 weeks ago. Which statement by the client indicates an understanding of the medical management following this type of surgical procedure? A. "Do you think I'll always have to take these pills?" B. "The thought of taking these pills for the rest of my life makes me shudder!" C. "I can't wait for the transplant to start working. I'm tired of taking all these pills!" D. "Well, I guess the transplant isn't working because my calcium levels are still low."
C. "I can't wait for the transplant to start working. I'm tired of taking all these pills!"
74. Another adult is admitted to the hospital for removal of a simple goiter. The nurse understands that a simple goiter is caused by A. Low intake of fat-free foods. B. Excessive thyroid-stimulating hormone (TSH) stimulation. C. Excessive adrenocorticotropic hormone (ACTH) stimulation. D. Low intake of goitrogenic foods.
B. Excessive thyroid-stimulating hormone (TSH) stimulation.
Situation : Clients with Cardiovascular disease need to be strictly assessed and monitored. These include report of symptoms, physical findings, medications and confirming laboratory data. Nurse Jojie is a critical care nurse assigned to clients with cardiac dysrhythmias. 1. A client with atrial fibrillation who is receiving maintenance therapy of Warfarin sodium has a prothrombin time of 35 seconds. Based on the prothrombin time, Nurse Jojie anticipates which of the following prescriptions: A. Adding a dose of heparin sodium B. Holding the next dose of warfarin C. Increasing the next dose of warfarin D. Administering the next dose of warfarin
B. Holding the next dose of warfarin
95. A nurse is preparing postoperative discharge instructions for a client who had one adrenal gland removed. The nurse includes which of the following in the instructions? A. The need for lifelong replacement of all adrenal hormones B. Instructions about early signs of a wound infection C. The reason for maintaining a diabetic diet D. Teaching proper application of an ostomy pouch
B. Instructions about early signs of a wound infection
29. The major hemodynamic consequence of massive pulmonary embolus is: A. increased systemic vascular resistance leading to left heart failure. B. pulmonary hypertension, which ultimately leads to right heart failure C. obstruction of the portal vein, which leads to ascites D. embolism to the internal carotids, which results in stroke
B. pulmonary hypertension, which ultimately leads to right heart failure
83. A client is scheduled for extracorporeal shock wave lithotripsy (ESWL). In teaching the client about ESWL, Nurse Carrie should inform the client that the calculi will be: A. dissolved. B. shattered. C. radiated. D. suctioned
B. shattered.
Situation: A client with Emphysema is scheduled for discharge. During discharge preparation, the nurse reminds the client to stop smoking. The client replies angrily," Who are you to tell me what to do? I'm older than you." 21. Which response by the nurse would be most appropriate? A. "I'm giving you this information in your best interest." B. "You have the right to make your own decisions." C. "I don't mean to be disrespectful." D. "If you don't want to take my advice, do whatever you wish."
C. "I don't mean to be disrespectful."
57. Which actions are appropriate in the care of this patient? (Select all that apply.) 1. Start a peripheral intravenous (IV) line using a 22-gauge catheter 2. Initiate input and output monitoring with hourly urine measurements 3. Check emesis and stool for occult blood 4. Monitor hemoglobin level and hematocrit every 4 hours. 5. Maintain the patient in a semi- or High Fowler position. 6. Prepare the patient for surgery A. 1,2,4,5 C. 2,3,4,5 B. 1,3,4,5,6 D. 2,3,4,5,6
C. 2,3,4,5
Situation: Many factors are involved in the incidence and type of stone formation which include dietary, genetic and occupational influences. Nurse Carrie is planning a care plan with the goals of relief of pain and to prevent urinary tract obstruction. 81. Nurse Carrie would expect a client with renal calculi to complain of: A. Irritability and twitching B. Dry, itchy skin, and pyuria C. Frequency and urgency on urination D. Pain radiating from kidney to shoulder
C. Frequency and urgency on urination
65. An adult client has severe arteriosclerosis obliterans and complains of intermittent claudication after walking 20 feet. How should the nurse plan to position the client when she is in bed? A. Supine with legs elevated. B. In semi-Fowler's position with knees extended. C. In reverse Trendelenburg position. D. In Trendelenburg position.
C. In reverse Trendelenburg position.
Situation : Damage to the endothelium of veins may be caused by trauma or external pressure and may occur anytime a venipuncture is performed. Nurse Delia is gathering important health information among clients towards the prevention of complications. 66. Mr. Sam 56-year-old obese is recovering from a bowel resection for cancer of the colon. On his third post-op day he complains that the area around the calf of his leg is warm and tender. Suspecting he may have developed a thrombus, the nurse performs a thorough assessment. When assessing for common clinical manifestations of deep vein thrombosis, the nurse will observe the client for : A. Absence of a pulse distal to the clot. B. Cyanosis distal to the clot. C. Pain on dorsiflexion. D. Reddened area around the clot.
C. Pain on dorsiflexion.
Situation: Nurses need to be aware of conditions that predispose clients to pulmonary embolism. However, as age increases, the risk becomes greater due to the development of arteriosclerosis associated with aging. Thelma, the medical nurse is conducting an admission assessment for clients with pulmonary embolism. 26. Nurse Thelma is caring for a patient diagnosed with pulmonary embolus. Which of the following treatments should the nurse anticipate for this patient? A. bronchoscopy to remove retained pulmonary secretions B. bronchodilators to improve ventilation/perfusion matching C. administration of a heparin drip to prevent clot extension D. antibiotic therapy to eradicate persistent microorganisms
C. administration of a heparin drip to prevent clot extension
3. A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A Troponin T blood specimen is obtained and the results indicate a level of 0.6 ng/ml. Nurse Jojie determines that this result indicates a : A. normal level B. low value that indicates possible gastritis C. level that indicates a myocardial infarction D. level that indicates the presence of possible angina
C. level that indicates a myocardial infarction
33. Nurse Iya knows that the teaching regarding the use of vitamin B12 injections to treat pernicious anemia is understood when client states, "I must take the drug: A. when feeling fatigued" B. until my symptoms subside" C. monthly, for the rest of my life" D. during exacerbations of anemia"
C. monthly, for the rest of my life"
38. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? A. Body temperature of 99°F or less B. Toes moved in active range of motion C. Sensation reported when soles of feet are touched D. Capillary refill of < 3 seconds
D. Capillary refill of < 3 seconds
9. The nurse is caring for an elderly patient who was admitted for short tem hospitalization following elective surgery.Upon reviewing the patient's medication record, the nurse become concerned about administering which of the following medications to his patients? SELECT ALL THAT APPLY. 1. furosemide (Lasix) 2. Ketorolac (toradol) 3. Vancomycin 4. Acetaminophen (Tylenol) A. 1, 2, 3 C. 2, AND 4 ONLY B. 1, 2, 4 D. 2, 3, 4
D. 2, 3, 4
35. The Physician orders 0.2 mg of Cyanocobalamin (vitamin B12) IM for a client with Pernicious Anemia. A vial of the drug labeled 1 ml = 100 mcg is available. Nurse Iya should administer: A. 0.5 ml B. 1.0 ml C. 1.5 ml D. 2.0 ml
D. 2.0 ml
39. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? A. A family vacation in the Rocky Mountains B. Chaperoning the local boys club on a cold trip C. Traveling by airplane for business trips D. A bus trip to the Museum of Natural History
D. A bus trip to the Museum of Natural History
87. The client has had a Nephrolithotomy for a removal of a kidney stone. He returns to his room with a right nephrostomy tube after surgery. What is a priority nursing action? A. Irrigate the tube with 30 ml of normal saline solution four times a day B. Clamp the tube if drainage is excessive C. Advance the tube 1 inch every 8 hours D. Ensure that the tube is draining freely
D. Ensure that the tube is draining freely
60. Despite your best effort at therapeutic communication, Mr. Sevilla refuses to cooperate with the NG tube insertion. He threatens to leave "if you stick that tube down my nose again." What should you do first? A. Physically restrain him and insert the tube B. Explain the "against medical advice" (AMA) form C. Notify the nursing supervisor and patient advocate D. Page the physician and document the attempt
D. Page the physician and document the attempt
45. Nurse Rolly is performing discharge teaching on a client with Polycythemia vera. Which would be included in the teaching plan? A. Avoid large crowds B. Keep the head of the bed elevated at night C. Wear socks and gloves when going outside D. Recognize clinical manifestations of thrombosis
D. Recognize clinical manifestations of thrombosis
54. Clinical symptoms of irritable bowel syndrome include: A. Acute abdominal pain located around the umbilicus B. Regular disturbance of defecation with only diarrhea C. Nausea with projectile vomiting D. Recurrent, episodic, cramp-like abdominal pain
D. Recurrent, episodic, cramp-like abdominal pain
79. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client? Place the client in Trendelenburg position for postural drainage Encourage coughing and deep breathing every 2 hours Elevate the head of the bed 30° Encourage the Valsalva maneuver for bowel movements
Elevate the head of the bed 30°
Situation: The body needs vitamin B12 to make red blood cells. A special protein, called intrinsic factor, helps the intestines absorb vitamin B12. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. Nurse Iya is assigned to care for clients having Vitamin B12 deficiencies. 31. Nurse Iya is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would Nurse Iya include in the physical assessment? Palpate the spleen Take the blood pressure Examine the feet for petechiae Examine the tongue
Examine the tongue
93. Which of the following questions should the nurse ask during an admission interview for a client admitted with diagnosis of Pheochromocytoma? a. "Do you ever feel or noticed an increase in heart beating?" b. "Do you suddenly feel warm and flushed when you get out of bed?" c. "Do your symptoms subside when you eat simple sugars?" d. "Do the attacks make you feel like you want to rest awhile and sleep?"
a. "Do you ever feel or noticed an increase in heart beating?"
Situation: Operating Room Nurse Kiko, received a client as endorsed by another nurse from a medical station for a scheduled surgical management. 96. Nurse Kiko should include which of the following in the preoperative teaching plan for a client with hyperthyroidism that is scheduled to have a portion of his parathyroid gland removed? a. Force fluids to at least 3000ml per day b. Take over-the-counter supplements of Vit. D daily c. Maintain bed rest as much as possible d. Adhere strictly to a high calcium diet
a. Force fluids to at least 3000ml per day
64. To determine if a client with complaints of pain after walking five blocks is experiencing intermittent claudication, the nurse would ask : a. "Is there pain in the calf muscle?" b. "Does pain always occurs when you walk that distance?" c. "Do you experience leg swelling?" d."Is the pain cramp-like?"
b. "Does pain always occurs when you walk that distance?"
Situation: Tuberculosis is an infection of the lung tissue which requires a prolonged exposure to bacilli to produce an infection. 16. A student health nurse is conducting Tuberculosis (TB) testing. Students who had purified protein derivative (PPD) test 48 hours ago have returned to have the results read and documented. The nurse determines that the test is positive if which of the following is present? a. The client complains of itching at the site b. There is large area of erythema c. There is an induration of 10mm or greater d. A bruise is present at the site of injection
c. There is an induration of 10mm or greater
17. The nurse is admitting a client with suspected tuberculosis (TB) to the acute care unit. The nurse places the client in airborne precautions until a confirmed diagnosis of TB can be made. Which of the following tests is a priority to confirm the diagnosis? a. Chest X-ray that is positive for lung lesions b. Positive purified protein derivative(PPD) c. Sputum positive for Blood(Hemoptysis) d. Sputum culture positive for Mycobacterium Tuberculosis
d. Sputum culture positive for Mycobacterium Tuberculosis
97. The postoperative orders for a client who has had the parathyroid gland removed include using Chvostek 's signs to assess for signs of tetany. Which of the following is the appropriate assessment technique Nurse Kiko should implement? a. Occlude the blood flow in the wrist b. Observe respiratory rate and depth c. Listen for crowing sound with inspiration d. Tap sharply over the facial nerves
d. Tap sharply over the facial nerves
25. The erythrocyte value of Mr. Lope and Mr. Bong is always decreased. History reveals that they are chronic smoker. They are admitted in the pulmonary unit. Mr. Lope and Mr. Bong were diagnosed with emphysema. Clients with Emphysema should receive only 1 to 3 L/minute of oxygen, if needed, because of the risk of losing hypoxic drive. Which of the following statements is correct about hypoxic drive? The client: a. breathes only when his oxygen levels climb above a certain point. b. doesn't notice the needs to breathe. c. breathes only when his carbon dioxide level dips below a certain point. d. breathes only when his oxygen levels dip below a certain point.
d. breathes only when his oxygen levels dip below a certain point.
Situation : Careful assessment provides important clues about irritable bowel syndrome which enables the nurse to provide appropriate management . The health care provider should establish a trusting relationship with the patient at the onset of treatment. 51. Lenny, a client who has irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give her? a. Low-fat, low-fiber. b. High-fiber, high-fat. c. Low-fiber, high-fat. d. low-fat, high fiber.
d. low-fat, high fiber.