Med Surge Final Exam

What chart is used to test visual acuity?

Snellen eye chart

Cranial nerve ___ has an important role in both balance and hearing.

VIII

Self-imposed starvation

anorexia

Inflammation of the appendix

appendicitis

What maintains the eyes intraocular pressure?

aqueous humor

Medical term for perception of sound

audition

A condition of extreme and chronic irritation of the lower esophagus

barrett esophagus

Binge or binge and purge

bulimia

What is the breakdown of larger molecules into smaller molecules?

catabolism

Inflammation of the gallbladder

cholecystitis

Gallbladder stones

cholelithiasis

Chronic degenerative disease of the parenchymal cells of the liver

cirrhosis

Which structure provides color?

cones

Condition in which the client has infrequent, hard bowel movements accompanied by mucus

constipation

What is the receptor for touch found in the skin?

corpuscle

Consists of stools that are liquid or semiliquid and often very light colored

diarrhea

The cerebellum helps to maintain _______________

equilibrium

What disease is the abdominal dilation of vessels of the esophagus

esophageal varices

What is the name of the tube that extends from the inner ear and communicates with the nasopharynx?

eustachian tube

Commonly called indigestion, it occurs in acure, chronic, and toxic forms.

gastritis

An uncomfortable burning sensation in the lower chest, which often radiates upward toward the neck

heart burn

Swollen veins of the anus or rectum

hemorrhoids

Results from abdominal muscle weakness which allows a portion of the GI tract to push through

hernia

Name of viral infection which causes open sores on the lips

herpes simplex

A condition in which part of the stomach protrudes through the diaphragm

hiatal hernia

Which teeth tear and cut food?

incisors

Spastic colon

irritable bowel

What is the teaching term for chewing?

mastication

What can be used to flush an ear with an insect?

mineral oil

Which part of the brain is responsible for getting visual information?

occipital

Which nerve carries the visual image to the brain?

optic

Inflammation of the pancreas

pancreatitis

Sound is conducted via the _____ and middle ear.

pinna

Term for normal loss of near focusing vision?

presbyopia

What is the name of the receptor in the inner ear responsible for equilibrium?

propriorceptor

What is the term for the portion of the sensory system which receives the stimulus?

receptor

The term for bending light rays is __________.

refracting

What structure provides the black and white shapes of the eye?

rods

Place in order of sound interpretation

sound source external environment external auditory canal tympanic membrane

Inflammation of the mouth

stomatitis

What is the receptor for taste found on the tongue?

taste buds

The sense of balance and equilibrium is centered in the _____ and saccule of the inner ear.

urticle

Prescription drugs may have potential drug interaction with which of the following? Select all that apply. A. Dietary supplements B. Herbs C. Homeopathic remedies D. Other prescription drugs E. Water

A. Dietary supplements B. Herbs C. Homeopathic remedies D. Other prescription drugs

A client with a history of pruritis asks the nurse what can be done to prevent a recurrence. What should the nurse instruct this client? Select all that apply. A. Shower immediately after swimming B: Wash new clothes before wearing C: Wear cotton gloves at night D: Engage in light jogging or running for exercise E: Keep skin dry and avoid the use of lotion

A. Shower immediately after swimming B: Wash new clothes before wearing C: Wear cotton gloves at night

The nurse is reading the laboratory reports for a client who has severe rheumatoid arthritis. Which of the following tests may show inflammation related to an infection or inflammatory condition? Select all that apply. A.CBC B.ESR C.Uric acid levels D.Blood levels of calcium E.RF

A.CBC B.ESR E.RF

A client has been diagnosed with renal cancer and asks the nurse about the function of the ureters. Which is the function of the ureters? A.Conducts urine to the urinary bladder. B.Acts as a reservoir for the urine before elimination C.Conducts urine to the outside for elimination D.Extracts waste from the blood and from urine

A.Conducts urine to the urinary bladder.

The nurse is teaching a class on the respiratory system. Which are protective reflexes which should be included in teaching? Select all that apply. A.Coughing B.Sneezing C.Yawning D.Tracheotomy E.Expiration

A.Coughing B.Sneezing C.Yawning

A 60 year old client diagnosed with arthritis is being cared for at a healthcare facility. What client teachings must the nurse provide when caring for this client? Select all that apply. A.Exercise daily even if pain occurs B.Always turn doorknobs away from the radial side C.Perform low-impact exercises such as bicycling D.Apply heat over the joints before exercise E.Sleep on a soft bed to reduce pain

A.Exercise daily even if pain occurs C.Perform low-impact exercises such as bicycling D.Apply heat over the joints before exercise

The nurse is performing a focused assessment of a client to check for musculoskeletal disorders. Which of the following data would be collected using nursing assessment techniques? Select all that apply. A.Palpate skin temperature for warmth B.Percuss soft tissues, joints, and muscles C.Perform range of motion exercises D.Observe emotional responses to the disorder E.Observe posture, coordination, and body build

A.Palpate skin temperature for warmth C.Perform range of motion exercises D.Observe emotional responses to the disorder E.Observe posture, coordination, and body build

Which are functions of the thoracic cage? Select all that apply A.Protects heart B.Protects lungs C.Protects the liver D.Protects intestine E.Supports shoulder girdle

A.Protects heart B.Protects lungs C.Protects the liver E.Supports shoulder girdle

A client is diagnosed with a sinus infection. The nurse realizes that this infection may result in which of the following symptoms? A.Weight of the skull changes B.Vocal resonance changes C.Ability to filter oxygen D.Ability to provide an area for medication

A.Weight of the skull changes B.Vocal resonance changes

When assessing an older client, the nurse knows that the affects of aging are noted in the skin as well as in all body tissues and organs. Which are indicators of aging? Select all that apply A.Wrinkling B.Loss of subcutaneous fat C.Atrophy of glands D.Weight loss E.Fractures of bones

A.Wrinkling B.Loss of subcutaneous fat C.Atrophy of glands

The nurse is reviewing the similarities and differences between a male and female urethra. What is the length of the female urethra? A: 1.5 inches B: 3 inches C: 5.5 inches D: 8 inches

A: 1.5 inches

The physician orders 20 mg promethizine q6h, prn cough. Available is promethizine 10 mg per tsp. How many mL will the nurse administer? A: 10 mL/dose B: 6 mL/dose C: 30 mL/dose D: 5 mL/dose

A: 10 mL/dose

The nurse is assisting in the education of clients about the structure and function of the respiratory system. The nurse is reviewing the process of internal respiration versus external respiration. Which statement below describes an impairment in internal respiration? A: A buildup of carbon dioxide within the cells B: A buildup of carbon dioxide within the alveoli of the lungs C: A buildup of oxygen within the cells D: A buildup of oxygen within the alveoli of the lungs

A: A buildup of carbon dioxide within the cells

It is determined that a client experiencing respiratory difficulty needs a tracheotomy. When explaining this process to the client, the nurse will state that it is a(n): A: Artificial opening in the trachea B: Lid or cover of cartilages C: Opening on either side of the vocal cord D: Chemical that lines the walls of the alveoli

A: Artificial opening in the trachea

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body? A: Autograft B: Allograft C: Homograft D: Heterograft

A: Autograft

Patient education regarding a fistula or graft includes which of the following? Select all that apply. A: Check daily for thrill and bruit. B: Avoid compression of the site. C: No IV or blood pressure taken on extremity with dialysis access. D: No tight clothing. E: Cleanse site b.i.d.

A: Check daily for thrill and bruit. B: Avoid compression of the site. C: No IV or blood pressure taken on extremity with dialysis access. D: No tight clothing.

Nightingale opened the first nursing school outside a hospital in 1860. Some principles of the Nightingale School for Nurses are still taught today. A beginning nursing student asks about the principles taught by the Nightingale Nursing School. What should the nurse's answer include? Select all that apply. A: Cleanliness is vital to recovery B: Cure is better than prevention C: The nurse must work as a member of a team D: The nurse must use discretion, but must follow the physician's orders E: Clinical skills outweigh textbook knowledge

A: Cleanliness is vital to recovery C: The nurse must work as a member of a team D: The nurse must use discretion, but must follow the physician's orders

The mother of a preadolescent male asks the nurse for indications that puberty is occurring. What should the nurse respond to this mother? Select all that apply. A: Development of facial hair B: Visible development of musculature C: Voice will start getting higher pitched D: Broadening of shoulders E: Increased hair growth all over the body

A: Development of facial hair B: Visible development of musculature D: Broadening of shoulders E: Increased hair growth all over the body

Which of the following are the effects of a large prostate ? Select all that apply. A: Difficulty in urination B: Difficulty in defecation C: Incontinence D: Pain in the testes E: Inability to have an erection

A: Difficulty in urination C: Incontinence E: Inability to have an erection

A male client is diagnosed with benign prostatic hypertrophy. What should the nurse tell the client are the effects of this diagnosis on the genitourinary system? Select all that apply. A: Difficulty urinating B: Urinary retention C: Incontinence of urine D: Inability to have an erection E: Development of testicular cancer

A: Difficulty urinating B: Urinary retention C: Incontinence of urine D: Inability to have an erection

A nurse is caring for a client with hemoptysis. Which of the following statements is true concerning hemoptysis and the nursing care measures for it? Select all that apply. (pg 1546) A: Frequently caused by bronchiectasis B: Take measures to reduce the humidity C: Encourage the client to breathe deeply D: Provide special mouth care to the client E: Perform a portugal drainage procedure.

A: Frequently caused by bronchiectasis C: Encourage the client to breathe deeply D: Provide special mouth care to the client E: Perform a portugal drainage procedure.

Which of the following may result in the lung being un-able to exchange gas? Select all that apply. (Pg 297) A: Immobility B: Shaken baby syndrome C: Thoracic surgery D: Pneumonia E: Lung Surgery

A: Immobility C: Thoracic surgery D: Pneumonia E: Lung Surgery

A 22-year-old female client presents to the clinic for an annual Pap smear. The nurse is reviewing the risk factors for developing cervical cancer with the client. Which of the following are risk factors for developing cervical cancer? Select all that apply. A: Infection with human papillomavirus (HPV) B: One sexual partner over a lifetime C: Sexual activity at a young age D: Maternal history of a cancer including cervical cancer E: Occasional sexual activity

A: Infection with human papillomavirus (HPV) C: Sexual activity at a young age D: Maternal history of a cancer including cervical cancer

Which of the following is used to decrease potassium level seen in acute renal failure? A: Kayexalate B: Sorbitol C: IV dextrose 50% D: Calcium supplements

A: Kayexalate

What is considered the bad cholesterol? A: LDL tip: (L=lousy cholesterol, H=Happy cholesterol) B: HDL C: CDL D: SOL

A: LDL tip: (L=lousy cholesterol, H=Happy cholesterol)

he client is complaining of "sticking pain" when she breathes. What may be the cause of this type of pain? Select all that apply. A: Lung tumor B: Sinus infection C: Tuberculosis D: Lung abscess E: Pneumonia

A: Lung tumor C: Tuberculosis D: Lung abscess E: Pneumonia

A client is concerned that an itchy skin area is cancerous. What should the nurse instruct the client regarding risk factors for the development of skin cancer? Select all that apply. A: People older than 40 years old B: Fair-skinned people C: Light-haired, light-eyed people D: Dark-haired people E: Dark-eyed people

A: People older than 40 years old B: Fair-skinned people C: Light-haired, light-eyed people

The nurse is assisting the respiratory therapist to obtain a specimen from a client using Bronchoalveolar lavage. Which disease is this test most often used to diagnose? A: Pulmonary tuberculosis B: COPD C: Bronchitis D: Pneumonia

A: Pulmonary tuberculosis

The client enters the emergency room with difficulty breathing. The nurse assesses the client and suspects a pneumothorax. Which assessment observations would indicate that a client has possible pneumothorax? Select all that apply. (pg 1547-48) A: Severe dyspnea. B: Asymmetrical chest. C: Dull, radiating pain (it's a sharp pain) D: Drop in BP. E: Mediastinal shift towards affected side.

A: Severe dyspnea. B: Asymmetrical chest. D: Drop in BP. E: Mediastinal shift towards affected side

Which nursing assessment finding indicates the post-amputation client has not met expected outcomes ? A: Stump swollen and irritated B: Demonstrates desensitization massage C: Resumes participation in self-care D: Well-approximated incision line

A: Stump swollen and irritated

Which sign may be helpful in identifying carpal tunnel syndrome? A: Tinel's B: Babinski's C: Brudzinski's D: Kernig's

A: Tinel's

The nurse determines that fluid and electrolyte treatment for full-thickness burns has been effective when what was assessed in the client weighing 90 kg? Select all that apply. A: Urine output 45 mL per hour B: Heart rate 100 beats per minute C: Systolic blood pressure 110 mm Hg D: Respiratory rate 28 per minute E: Temperature 101°F

A: Urine output 45 mL per hour B: Heart rate 100 beats per minute C: Systolic blood pressure 110 mm Hg

The nurse is providing education to the client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which nursing measures should be included in teaching for clients experiencing chronic obstructive pulmonary disease (COPD) to improve ventilation and to overcome hypoxic states? Select all that apply. (pg 1542) A: Use of bronchodilators, expectorants, and liquefying agents B: Decreased fluid intake (500 to 1,000 mL/day) C: Continuous use of oxygen D: Limited activity E: Use of Fowler position F: Eating small, frequent meals

A: Use of bronchodilators, expectorants, and liquefying agents E: Use of Fowler position F: Eating small, frequent meals

The nurse is instructing a client about menopause. What should the nurse include as indications that this physiological change is occurring? Select all that apply. A: Weight gain B: Thinning hair C: Itchy skin D: Cold flashes E: Insomnia

A: Weight gain B: Thinning hair C: Itchy skin E: Insomnia

A client is prescribed to receive a solution that has 25% of a solute. What is the strength as a fraction? A: ¼ (parts of the solute per 100 % of solution=25%=¼ as a fraction) B: ½ C:¾ D: ⅗

A: ¼ (parts of the solute per 100 % of solution=25%=¼ as a fraction)

Which are the sudoriferous glands in the body? Select all that apply. A:Apocrine glands B:Eccrine glands C:Mammary glands D:Ceruminal glands E:Sebaceous glands

A:Apocrine glands B:Eccrine glands C:Mammary glands

An elderly client needs assistance with frequent urges to void. What are the nursing interventions that should be performed when caring for the client? Select all that apply. A:Watch for bladder infection B:Allow for bathroom visits once every 6 hours C:Administer diuretics carefully D:Monitor the fluid intake and output every shift E:Perform straight catheterization every shift

A:Watch for bladder infection C:Administer diuretics carefully D:Monitor the fluid intake and output every shift

A client has a diagnosis of pernicious anemia due to a loss of intrinsic factor. An order has been issued. What treatment will the nurse most likely need to prepare to administer to the client? 1. Vitamin B12 injection 2. A blood transfusion 3. A dose of heparin subcutaneously 4. Intravenous fluids

Answer: a Cognitive Level: Analyze Explanation: The intrinsic factor is needed for the absorption of vitamin B12, which is needed for the development of red blood cells. When the intrinsic factor is missing, whether due to age or another factor, vitamin B12 is not absorbed and requires replacement by injection. A blood transfusion will not replace vitamin B12. Heparin is an anticoagulant and is not the treatment for pernicious anemia. IV fluids will not be of help in this condition.

The nurse is preparing a client for an abdominal paracentesis. What priority action by the nurse will help prevent complications? a. Have the client void before the procedure. b. Ensure the client has had a bowel movement within 24 hours. c. Have the client lie in the supine position. d. Insert an indwelling catheter.

Answer: a Cognitive Level: Apply Explanation: Ask the client to void immediately before the procedure because it will help to avoid rupture of the urinary bladder by the needle. Keep the client in Fowler position, because it will facilitate drainage and assist breathing. It is not necessary for the client to have a bowel movement prior to the procedure since it will not prevent complications. An indwelling catheter is not necessary and may introduce pathogens in the sterile bladder unless the client is unable to void.

A client has a new colostomy created during surgery to remove a mass in the sigmoid colon. The client is very upset and states, "I can't look at that!" What is the best response by the nurse? a. "Would you like to talk about it? I can answer questions you may have." b. "You will have to look at it sometime. You are going to care for it." c. "You should be thankful this procedure removed your tumor and saved your life." d. "You don't have to look at it. Let's get a family member to learn the care."

Answer: a Cognitive Level: Apply Explanation: The best response by the nurse is to allow the client to express feelings and to answer questions. The client who has a colostomy or ileostomy may need assistance with adjustment. Naturally, the client wonders how life will be disrupted and may be particularly concerned about the effect on sexual relationships, care of the colostomy or ileostomy, and acceptance of family and friends. Encourage and teach the client to be independent as soon as possible: Teach how to remove and apply a new appliance, how to perform skin care around the stoma, and how and what to report about bowel changes. As the client becomes physically able to take care of the stoma, a sense of freedom and independence is created. Many teaching sessions may be necessary to wean the client from the dependence of nursing care to independent self-care. Family members and friends may also be part of the teaching-learning process, but the client will most likely be the one most responsible for the care. Allow the client to express feelings. Encourage questions and correct any misconceptions the client might have. It might be a long time before the client can truly accept the stoma, although the client may be able to care for it physically within 4 to 5 days. Grief reaction to loss of body function is common. Informing the client they should be grateful does not address the client's grief.

The nurse is caring for a client who was hit in the left eye with a softball. The eye is edematous and painful to touch. What is the priority intervention by the nurse? a. Apply a cold pack. b. Apply a warm compress. c. Have the client lay flat for 12 hours to decrease swelling. d. Place drops in the eye to decrease pain.

Answer: a Cognitive Level: Apply Explanation: The initial intervention by the nurse should be to apply a cold pack or compress to the eye to minimize pain and edema. A warm compress should be applied after 24 to 48 hours. Lying flat will not decrease the swelling and is not a necessary intervention. Drops are not necessary for trauma to the eye.

A client is scheduled for a cholecystectomy. Prior to the procedure, the client asks the nurse, what will happen without my gallbladder?" What is the best response by the nurse? a. "Another structure such as the liver will take over its function." b. "You will not have solid stools." c. "You will have to take insulin because you will have an inability to process glucose." d. "You will have to take medication to help your blood clot."

Answer: a Cognitive Level: Understand Explanation: After the removal of the gallbladder, other structures, particularly the liver, take over its functions. The client will have solid stools after the gallbladder is removed. The pancreas is the organ that involves the ability to regulate glucose levels. The liver regulates coagulation; the gallbladder does not have that function.

What information can the nurse provide to the client about prevention of cataract formation? Select all that apply a. Wear sunglasses when outside with amber, orange, or brown lenses. b. Do not stare at a computer screen for prolonged periods of time. c. Instill saline drops twice daily into both eyes. d. Make sure eyeglasses fit well. e. Wear contact lenses rather than glasses.

Answer: a, b Cognitive Level: Apply Explanation: Long-time exposure to ultraviolet (UV) light can cause the lens to become cloudy or milky, a cataract. This can be replaced with an artificial lens. UV exposure can also contribute to macular degeneration. To best protect the eyes from dangerous UV rays, sunglasses with amber, orange, or brown lenses are recommended. It is also important not to stare at a computer screen for long periods of time without a break.

The nurse is assisting a visually impaired client with meals. What nursing interventions will assist the client with maintaining independence and dignity? Select all that apply. a. Place food in the same "clock position" on the plate. b. Tell the client what is being served. c. Feed the client so food will not spill. d. Tell the client where food is located. e. Prepare finger foods so the client will not have to use utensils.

Answer: a, b, d Cognitive Level: Apply Explanation: When assisting a visually impaired client with meals, it is important to maintain the client's independence and dignity. Place the food in the same clock position on the plate, tell the client what is being served so he/she can choose to eat it or not, and indicate where the food is located on the plate so the client can eat independently. The client should be able to eat anything according to the assigned diet and not only finger foods. Do not feed clients but allow them to feed themselves.

A client informs the nurse that due to a busy work schedule, the need to defecate is often ignored and he then often feels constipated. What is the first action by the nurse? a. Give the client a soap suds enema. b. Auscultate for bowel sounds. c. Administer a laxative. Instruct the client to defecate when the urge is present.

Answer: b Cognitive Level: Apply Explanation: Ignoring the need to defecate can result in constipation and the overuse of laxatives. The first intervention the nurse should perform is the auscultation of bowel sounds. Hypoactive or absent bowel sounds may indicate a more serious condition, such as a bowel obstruction. A soapsuds enema or laxative is not indicated until the client has been screened appropriately. The client should be instructed to defecate when the urge is present after other interventions have been performed.

The nurse inserts a nasogastric tube (NGT) for a client. What is the most reliable action that the nurse should take to ensure correct placement? a. Aspirate stomach contents. b. Obtain a chest x-ray. c. Instill 14 to 20 mL of air and auscultate. d. Test the pH of gastric contents.

Answer: b Cognitive Level: Apply Explanation: Providing that the radiograph is read correctly, the most reliable method is x-ray visualization. The most common traditional practices are first to aspirate the tube, which should yield a small amount of watery colored fluid (i.e., stomach contents), followed next by auscultation of air. About 15 to 20 mL of air is instilled at the same time as the nurse listens with a stethoscope placed approximately 3 in (8 cm) below the sternum. If the tube is in the stomach, you should be able to hear the air enter (e.g., a "whooshing" sound). Checking by auscultation can be inaccurate because it is not always possible to differentiate between respiratory air sounds and stomach air sounds. Evidence-based practice has shown other, often more accurate, methods of testing NG placement. Capnography can be used to detect carbon dioxide if the tube is in the respiratory tract. The pH of aspirates can probably detect the normally high acidity content of the stomach. There are exceptions to the pH testing method, which make pH testing misleading at times.

A client informs the nurse that he is color blind. What colors does the nurse determine the client will likely have difficulty distinguishing? a. White and black b. Red and green c. Blue and purple d. Orange and pink

Answer: b Cognitive Level: Understand Explanation: Color blindness" is an error in the production of photopigments in the cones. It causes difficulty in distinguishing between colors, particularly red and green.

A client is being discharged after the creation of an ileostomy. What dietary information should the nurse reinforce? Select all that apply. a. Maintain a clear liquid diet for 1 month. b. Chew food very well. c. Avoid meat that is in a casing such as hot dogs. d. Eliminate gas forming foods. Blend all foods.

Answer: b, c, d Cognitive Level: Apply Explanation: The person with an ileostomy needs to monitor the diet more closely. The most common complication following an ileostomy is food blockage. Foods that tend to cause blockage include dried fruits, popcorn; many vegetables and nuts; and meats in casings, such as frankfurters. Undigested food obstructs the bowel just prior to the stoma, preventing stool passage. A person with an ileostomy must chew food very well. This person may also have difficulty with odor from flatus; eliminating common gas-forming foods usually helps. It is not necessary to blend the foods but is important for the client to ensure adequate fluid intake. A clear liquid diet is not necessary.

The nurse is providing ileostomy care for a client and observes redness and a yeast-like growth around the site. After notifying the healthcare provider and receiving an order, what intervention will the nurse most likely provide? a. Application of Neosporin ointment b. Application of alcohol to the area c. Application of nystatin powder d. Washing the area with soap and water

Answer: c Cognitive Level: Apply Explanation: If redness or a yeast-appearing growth appears, consult with the healthcare provider. An order to treat the area with an antifungal powder, such as nystatin (Mycostatin), may be given. Complications, such as yeast infections, lead to longer healing times and poorly fitting appliances. Neosporin ointment is an antibiotic cream and therefore ineffective for fungal infections. Give special skin care around the stoma. After the gastrostomy or stoma has healed, clean it with soap and water. Do not use soap if it irritates the client's skin. Do not use alcohol. Soap and alcohol can cause skin dryness, which can lead to skin breakdown. If a client's skin is damaged around a stoma, appliances do not fit properly and generally leak, leading to further skin breakdown.

A client is experiencing indigestion, bloating, excess gas and constipation due to delayed gastric emptying. What suggestion offered by the nurse may help alleviate these symptoms? a. Limit the amount of fluid intake. b. Increase the amount of dairy in the diet. c. Limit spicy and gas forming foods. d. Decrease the amount of fiber ingested.

Answer: c Cognitive Level: Apply Explanation: Limiting spicy and gas-forming foods in the diet can decrease the symptoms experienced by the client. Fluid and fiber intake should not be limited. Dairy can cause the symptoms if the client is lactose intolerant, however, that was not mentioned in the scenario.

A client is being considered as a candidate for a cochlear implant. What data gathered by the nurse would support the client's candidacy? a. The client has mild mental retardation. b. The client has a history of schizophrenia. c. The client is unable to recognize words spoken. d. The client expects hearing will resume normally after surgery.

Answer: c Cognitive Level: Apply Explanation: The potential candidate for cochlear implant must be an otherwise healthy individual with no evidence of mental retardation or psychological disorder. The client must be unable to recognize words spoken away from the line of vision and be realistic and optimistic about the results.

The nurse is reinforcing education regarding the use of eye drops during treatment for a client who has been diagnosed with conjunctivitis. What is a priority for the nurse to include? a. Warm the solution briefly in the microwave prior to use. b. Save the unused solution for use if the infection returns. c. Be sure not to touch the eye with the dropper. d. Use the drops for the other member of the family who has conjunctivitis.

Answer: c Cognitive Level: Apply Explanation: The solution is not required to be warmed and a microwave causes "hot spots" in the solution that may cause burns. The solution should be discarded after the completed course of medication due to the possibility of contamination of the solution. The dropper should not touch the eye because it may cause contamination of the dropper and reinfect the eye. The client should not share the solution because cross-contamination may occur.

The nurse asks a client to use the eyes to follow finger movements to the left and right and then to close and open the eyes. Which cranial nerve will the nurse document as intact if the client is able to perform these movements? a. Cranial Nerve I b. Cranial Nerve II c. Cranial Nerve III d. Cranial Nerve IV

Answer: c Cognitive Level: Apply Explanation: Three pairs of extraocular (outside the eye) muscles, attached to the sclera, move the eyeball. Another muscle, attached to the upper eyelid, holds the eye open; when this muscle relaxes, the eyelid shuts. The oculomotor nerve (cranial nerve III) innervates some of the voluntary muscles that move the eyeball and eyelid. This cranial nerve is also involved in some autonomic eye reactions, such as pupil accommodation to varying degrees of light.

The nurse is caring for a client with anal sphincter insufficiency who is bed-confined and requires ADL (activities of daily living) assistance. What nursing actions should be included when caring for this client? Select all that apply. a. Turn the client every 2 hours. b. Insert a rectal tube. c. Provide pads on the bed. d. Ensure a bedside commode is readily accessible for the client. e. Use barrier cream to protect the skin.

Answer: c, d, e Cognitive Level: Analyze Explanation: It is important to protect the bed linens so that the client can be more easily cleaned without removing all the bed linens. A bedside commode that is placed by the bedside can be of assistance if the client feels the need to defecate. Barrier cream applied to the buttocks will help prevent impaired skin integrity. Rectal tubes may damage the mucosa of the rectum and should not be routinely used. Turning the client will help with prevention of skin breakdown but is not related to anal sphincter insufficiency.

The primary care provider orders ear irrigation for a client. What situation requires the nurse to question this order? a. The client has a scratch on the external canal. b. The client has a foreign body in the ear. c. The ear canal has impacted cerumen. d. The eardrum may be punctured.

Answer: d Cognitive Level: Analyze Explanation: An ear irrigation may be performed to rinse drainage or medication from the ears and to remove wax or foreign bodies. It is done only with a physician's order. Do not irrigate the ear if the client's eardrum is punctured. This will cause damage to the ear and hearing. A scratch on the external canal is not a contraindication for ear irrigation. A foreign body may be flushed out with a gentle irrigation. Impacted cerumen is an indication for irrigation of the ear canal to remove impacted wax.

An older adult client informs the nurse of a "terrible ringing in the ears." What question would be a priority to ask the client? a. "Do you irrigate your ears?" b. "When was the last time you had an ear examination?" c. "Does anyone in your family have this problem?" d. "What medications do you take?"

Answer: d Cognitive Level: Apply Explanation: Certain medications: quinine, aminoglycosides (i.e., gentamicin, streptomycin), aspirin, loop diuretics (e.g., furosemide [Lasix]) may cause ototoxicity and a "ringing" sensation in the ears.

A client states to the nurse, "I am taking a trip by plane and the last time I flew, the problems with my ears were awful!" What suggestion can the nurse provide to alleviate discomfort? a. Use a Q-tip to remove impacted wax to decrease pressure when flying. b. Insert saline drips into both ears every hour while flying. c. Irrigate the ear prior to the trip to remove wax and decrease pressure. d. Chew gum to promote swallowing.

Answer: d Cognitive Level: Apply Explanation: The eustachian tube opens during swallowing or yawning. Its function is to equalize the pressure in the middle ear with atmospheric pressure; that is, to equalize the pressure on both sides of the tympanic membrane so the drum vibrates freely. (If the tympanic membrane cannot vibrate freely, hearing is impaired.) For this reason, it is often suggested that people chew gum (to promote swallowing) or yawn frequently when flying—to equalize the pressures. If the pressures are not equal in flying or in activities such as deep-sea diving, the person will experience pain, which may be severe. A ruptured eardrum may also result.

Order: IV aminophylline to infuse at 5 mg/hr IV: 0.5 g aminophylline in 500 mL D5W. How many ml/hr will the nurse set on the IV pump? A. 75 mL/hr B. 5 mL/hr C. 50 mL/hr D. 0.5 mL.hr

B. 5 mL/hr

he nurse lists the hormones produced by the kidney on the white board. Which hormone is produced by the kidneys? A. Aldosterone B. Erythropoietin C. Atrial natriuretic peptide D. Antidiuretic hormone

B. Erythropoietin

The functions of the ureters and the urethra are different. Which is a function of the urethra? A.Extracts wastes from the blood, balances bodily fluids, and forms urine. B.Conducts urine from the bladder to the outside of the body for elimination. C.Serves as a reservoir for urine D.Conducts urine from the kidneys to the urinary bladder.

B.Conducts urine from the bladder to the outside of the body for elimination.

A client presents in the emergency room with increased respirations. The physician orders an arterial blood gas to be drawn. Which diagnostic test result would indicate the cause of a client's increased respirations? A.Low carbon dioxide B.High carbon dioxide C.High oxygen D.High pH

B.High carbon dioxide

The nurse is receiving report from the previous shift. The nurse states that the patient has bradypnea. The nurse understands that this means: A.Difficulty breathing while lying down B.Slower than normal respirations C.Increase in depth of breaths D.Labored or difficulty breathing

B.Slower than normal respirations

A nurse is caring for a client with ESRD. What should the nurse monitor this client for? Select all that apply. A: Increased appetite B: Anasarca C: Uremic frost D: Hypotension E: Bleeding disorders

B: Anasarca C: Uremic frost E: Bleeding disorders

The nurse is providing education to the client newly diagnosed with tuberculosis. The nurse will give which of the following instructions to the client? A: Instruct the client to keep the doors of the room closed at night. B: Ask the client to eat a diet rich in protein and vitamins A and C. C: Take precautions to prevent transmission through the feco-oral route. D: Dispose the infectious waste of the client in biohazardous waste receptacles.

B: Ask the client to eat a diet rich in protein and vitamins A and C.

A client is admitted to the emergency department after an automobile accident and complains of a stiff neck. The nurse is reviewing with the client that diagnostic tests will be ordered. What vertebrae ensure that the head can turn freely and will need diagnostic xrays completed to determine if there is any injury? A: Atlas B: Axis C: Sacrum D: Coccyx

B: Axis

A nurse is preparing a dressing to be applied to the first-degree burns on a client's face. Which of the following should the nurse use as a topical agent in the dressing? A: Methotrexate B: Bacitracin C: Psoralen D: Calcipotriene

B: Bacitracin

A female client who is taking oral contraceptives is diagnosed with metrorrhagia. Which of the following describes this condition? A: Absence or stoppage of menses B: Bleeding between menstrual periods C: Excessive bleeding during menstruation D: Painful menstruation

B: Bleeding between menstrual periods

The nurse caring for a client with a varicocele explains the side effects of this condition. With what disorder is this condition associated? A: Thyroid disorder B: Infertility C: Undescended testicle D: Epididymitis

B: Infertility

The nurse explains to a client with a family history of breast cancer the difference between benign and malignant neoplasms. Which of the following is a characteristic of a malignant neoplasm? A: Round or oval shape B: Irregular shape and hard C: Movable D: Smooth border

B: Irregular shape and hard

A nurse is educating a client about what to expect with a bronchoscopy. Which instruction is the most important for the nurse to provide the client. (pg1524) A: Avoid taking food 3 hours before the procedure. B: Maintain a side-lying position after the bronchoscopy. C: Cough out the mucus secretions after the procedure. D: Start a soft, semisolid diet when the gag reflex returns.

B: Maintain a side-lying position after the bronchoscopy.

A nurse is caring for a client after a laryngectomy. Which of the following postoperative nursing care measures should be employed when caring for the client? SATA A: Reestablish oral feeding of the client B: Remove secretions through the tracheostomy tube C: Administer oxygen using a mask or T-piece D: Instruct the client to wear a thin, filmy scarf over the opening E: Instruct the client to attend speech therapy sessions

B: Remove secretions through the tracheostomy tube C: Administer oxygen using a mask or T-piece E: Instruct the client to attend speech therapy sessions

The human body has the ability to compensate for pH imbalances through the adjusting of the respiratory rate. Which acid-base imbalance is most likely to result in hyperventilation? (pg 297) A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis

B: Respiratory alkalosis

The prescriber ordered 150 mg of a drug IM stat. The directions on the 500 mg vial read, ³Add 9.7 mL NS and the strength will be 100 mg/mL. ́ How many milliliters of the reconstituted solution will you administer? A:1.0 mL/dose C:2.0 mL/dose D:2.5 mL/dose

B:1.5 mL/dose

The nursing student is suctioning the client for the first time. The nurse will explain to the student some of the possible effects which may occur during this process. Which of these are associated with this procedure? Select all that apply A:Syncope B:Dysrhythmia C:Hyperventilation D:Vasodilation E:Desaturation F:Hypovolemia

B:Dysrhythmia E:Desaturation

The nurse is caring for a client with an upper respiratory disorder. Which infection in which body organs are included in this diagnosis? Select all that apply. A:Reestablish oral feeding of the client. B:Remove secretions through the tracheostomy tube. C:Administer oxygen using a mask or T-piece. D:Instruct the client to wear a thin, filmy scarf over the opening E:Instruct the client to attend speech therapy sessions.

B:Remove secretions through the tracheostomy tube. C:Administer oxygen using a mask or T-piece. E:Instruct the client to attend speech therapy sessions.

A 60-year old client undergoing preoperative chemotherapy and radiation therapy for prostate cancer has developed proctitis and cystitis. What nursing intervention should the nurse perform for this client? A. Provide a diet that has high fiber content B. Avoid the administration of antidiarrheal agents C. Carefully monitor the client's urine output D. Instruct the client about signs of urinary incontinence

C. Carefully monitor the client's urine output

What substance, when present in the urine, would indicate a disease or malfunction of the urinary system? A. Urea B. Pigments C. Protein D. Sodium

C. Protein

A teenager presents at the ER with severe scrotal and abdominal pain, vomiting, and nausea. He tells the nurse that he participated in a polar bear plunge in his community(jumping into cold water off-seasson). What conditions would the nurse suspect? A. Hydrocele B. Phimosis C. Torsion of the spermatic cord D. Varicocele

C. Torsion of the spermatic cord

The student nurse is following a nurse caring for a client who has paracentesis performed to help relieve dyspnea. The student nurse understands that the client is at greatest risk for which adverse effect? A.Pneumonia B.Punctured Lung C.Shock D.Pulmonary Edema

C.Shock

An older adult client has just been admitted with pneumonia. The client tells the nurse, I have never had pneumonia before, and nobody in my family has ever suffered from pneumonia. I don't understand how I contracted this disease.Which statement by the nurse would be most appropriate? A: "You should not worry about it." B: "You could have had it in the past and just not known it." C: "Advanced age is a risk factor for pneumonia." D: "Immobility can help prevent the disease."

C: "Advanced age is a risk factor for pneumonia."

The health care provider orders prednisolone 2 mg/kg/day to be given every 8 hours for a child diagnosed with nephrotic syndrome. The child weighs 42 lb. The medication is available in a solution of 3mg/mL. What is the amount per dosage in mL for this child? A: 1.2 mL B: 3.8 mL C: 4.2 mL D: 12.6 mL 1mL/3mg x 2mg/1kg x 1kg/2.2 lbs x 42 lbs/ dose=12.72/3= 4.2mL

C: 4.2 mL mL/3mg x 2mg/1kg x 1kg/2.2 lbs x 42 lbs/ dose=12.72/3= 4.2mL

There are many disorders which cause dyspnea. Which condition is an example of an obstructive disorder of the respiratory tract? A: Pleural effusion B: Fibrosis C: Asthma D: Pulmonary embolism

C: Asthma

The nurse reconstitutes a medication on December 15, 2013 at 1400 hours that has a potency of 1 week. What is the expiration date of this medication? A: December 21 2013 1400 hours B: December 21 2013 2400 hours C: December 22 2013 1400 hours D: December 22 2013 2400 hours

C: December 22 2013 1400 hours

The shaft of a long bone is known as which of the following? A: Epiphysis B: Periosteum C: Diaphysis D: Condyle

C: Diaphysis

A client has been diagnosed with respiratory acidosis. The nurse understands that this means that there is: A: Too little carbon dioxide in the blood B: Presence of food in the respiratory passage C: Excess carbon dioxide in the blood D: Inflammation of the pleura

C: Excess carbon dioxide in the blood

A client with diabetes asks the nurse, "If I can't do heavy exercise, what's the point in exercising?" What response by the nurse can encourage the client to perform moderate exercise? Select all that apply A: It will prevent the use of insulin B: It will prevent cancer C: It will enhance energy levels D: It will reduce stress E: It will provide relaxation

C: It will enhance energy levels D: It will reduce stress E: It will provide relaxation

A pulse oximeter measures the _______ in the blood. A:Hemoglobin B:Carbon dioxide C:Oxygen saturation D:None of the answers are correct

C:Oxygen saturation

The nurse is attempting to determine if the client has hypoxemia. What test would be the best to make this determination? A.Chest X-ray B.Computed tomography scan C.Pulmonary angiography D.Arterial blood gases

D.Arterial blood gases

When educating the client who is a heavy smoker about his increased risk of developing various kinds of cancer, what should the nurse instruct the client to watch out for as the first sign of bladder cancer? A: Loss of body weight B: Pain in the flanks C: Sensation of a mass in the flanks D: Blood in the urine without any pain

D: Blood in the urine without any pain

The nurse is caring for the client following surgery for a urinary diversion. The client refuses to look at the stoma or participate in its care. The nurse formulates a nursing diagnosis of: A: Anticipatory grieving B: Situational low self esteem C: Deficient knowledge: Stoma care D: Disturbed body image

D: Disturbed body image

A nurse is assessing a 24-year-old client for testicular cancer. When educating the client, what should the nurse mention as a risk factor for developing testicular cancer? A: Engaging in frequent sexual activity B: Getting married at an early age C: Being older than 50 years old D: Having an undescended testicle

D: Having an undescended testicle

he nurse consults a nutritionist to help plan a diet for a client who has third-degree, full-thickness burns on 30% of his body. Which of the following types of diets would the nutritionist recommend? A: Low calorie, high carbohydrate B: High calore, high carbohydrate C: Low calorie, high protein D: High calorie, high protein

D: High calorie, high protein

The nurse is reviewing the functions of the ovaries, uterus, clitoris, and vagina with a group of high school students. What would be the best response by a high school student about the function of the clitoris? A: Produces female gametes or ova and secretes female sex hormones B: Receives the fertilized ovum and provides housing and nourishment for a fetus C: Receives sperm, provides an exit for menstrual flow, and serves as the birth canal D: Small erectile structure that responds to sexual stimulation

D: Small erectile structure that responds to sexual stimulation

The nurse has to figure out a clients body mass index using a calculator readily available on the internet. The result reveals that the clients BMI is 43. Based on this information, what does this number reveal about this client that needs to be documented on the electronic medical record? A: Ideal body weight B: Healthy body weight C: Obese D: Very Obese

D: Very Obese

Name the diagnostic exam which involves the introduction of a camera through the mouth into the stomach

EGD

Medical term for black, tarry stool

Melena