NCLEX PN Physiological Integrity Test Review
C (Type 1 diabetes is characterized by hyperglycemia secondary the body's inability to create insulin. Corticosteroids cause a rise in blood sugar even in a non-diabetic patient by increasing insulin resistance and triggering the liver to release additional glucose)
Which lab value alteration is likely a result of corticosteroid treatment in a Type 1 diabetic patient diagnosed with pneumonitis? A-Sodium 138mEq/L (138mmol/L) B-Potassium 5.1mEq/L (5.1mmol/L) C-Glucose 200mg/dL (11.1mmol/L) D-Albumin 3.5g/dL (5.07µmol/L)
A (an opportunistic disease that occurs as a result of immunosuppression. Organ transplant patients can be at risk, as well)
Which opportunistic disease is an HIV/AIDS client at risk for? A-Kaposi sarcoma B-Fibroblastic sarcoma C-Synovial sarcoma D- Ewing sarcoma
B (High Fowler's position is the best position to avoid aspiration. Have an emesis basin and suction equipment nearby, since tube insertion can cause temporary nausea.)
With a stroke patient, what is the best position for insertion of a nasogastric (NG) tube? A-Trendelenburg B-High Fowler's C-Low Fowler's D-Supine
C (A patient is considered to have hypertension even if one of the parameters ( either diastolic or systolic) is elevated. This patient has prehypertension, defined as 120-139mmHg systolic or 80-89mmHg diastolic.)
The results of an adult patient's blood pressure screening on three occasions are: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information? A-Hypertension Stage 2 B-Normal blood pressure C-Hypertension Stage 1 D-Elevated blood pressure
B (Potentiation occurs when two drugs are taken together, and the action of one drug increases the action of the other, causing the pharmacologic response to be greater for one of the drugs.)
When a drug's effect is increased after a second drug is given, this interaction is called A-Absolution B-Potentiation C-Antagonism D-Synergism
D (Second degree heart block Type 2, which is also called Mobitz II or Hay, is a disease of the electrical conduction system of the heart. Second-degree AV block (Type 2) is almost always a disease of the distal conduction system located in the ventricular portion of the myocardium. The rhythm can be identified by: 1. Non-conducted p-waves (electrical impulse conducts through the AV node but complete conduction through the ventricles is blocked, thus no QRS). 2. P-waves are not preceded by PR prolongation as with second-degree AV block (Type 1). 3. Fixed PR interval. 4. The QRS complex will likely be wide.)
Which atrio-ventricular (A-V) heart block is called Mobitz II? A-Third-degree A-V heart block B-First-degree A-V heart block C-Complete A-V heart block D-Second-degree A-V heart block
C (Chronic hypoxia, from reduced air exchange, leads to low oxygen levels in the body. The kidneys respond to chronic hypoxia by releasing erythropoietin, which stimulates red blood cell production. The red blood cell count is elevated to compensate for the hypoxia, or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen.)
A patient who has a history of chronic bronchitis is admitted to the medical unit. The healthcare provider notes the red blood cell count is elevated. Which of these is the likely contributing factor to this lab result in this patient? A-Hypercapnia B-Decreased fluid intake C-Chronic hypoxia D-Insensible water loss
D (progressive neurodegenerative disease that impacts the motor system. Dopamine helps the brain control movement and coordination. Neurons in the brain slowly stop producing dopamine in patients who have PD, making it increasingly difficult to control muscles for movement, including fine motor movement needed to tie one's shoelaces)
A patient who is diagnosed with Parkinson's disease (PD) states, I can't tie my shoelaces anymore." The healthcare provider recognizes that this patient's problem is due to a deficiency in which of these neurotransmitters? A-Glutamate B-Serotonin C-Norepinephrine D-Dopamine
D (Damaged cells in the lungs can be replaced by healthy cells over long periods of time. The risk of developing lung cancer for this patient will be the same as a non-smoker in 15 years. The benefits of quitting smoking begin within 20 minutes, when the heartrate returns to normal. After one month, cilia in the lungs begin to repair. At one year, risk of heart disease is half that of a smoker's.)
A patient who recently stopped smoking asks a healthcare provider about the risks of developing lung cancer. The healthcare provider's best response is A-"If lung cancer hasn't developed yet, the ongoing risk is equivalent to a non-smoker." B-"In 8 months, the risk of developing lung cancer is twice as high as a non-smoker." C-"An elevated risk of developing lung cancer compared to a non-smoker will remain constant life-long." D-"In 15 years, the risk of developing lung cancer will be equivalent to a non-smoker."
B (Because the catheter may cause trauma to the vessels, the healthcare provider will monitor for hematoma formation and interference of circulation distal to the insertion site. Bleeding at the site is the most common complication)
A patient with a diagnosis of Wolff-Parkinson-White syndrome is undergoing a catheter ablation procedure. When caring for the patient after the procedure, which is the priority intervention? A-Assess level of consciousness every 20 minutes. B-Monitor insertion site and distal pulses. C-Auscultate apical pulse for a full minute every hour. D-Assist the patient to the bathroom to void.
A (The PR interval is the time from the onset of the P wave to the start of the QRS complex. It reflects conduction through the AV node. The normal PR interval is between 0.12-0.20 seconds in duration (three to five small squares). If the PR interval is greater than 0.20 seconds, a first-degree heart block is present.)
A client presents to the Emergency Department with signs of a myocardial infarction, and is admitted to the cardiac unit. The next day, the client denies chest pain. When the nurse reviews the ECG rhythm strip, the PR intervals are 0.16 seconds. How should the nurse interpret this rhythm? A-This is within normal PR interval limits. B-This is an early sign of reinfarction. C-The nurse should immediately notify the provider. D-The rhythm indicates a first-degree heart block.
A (A trough level should be drawn 30 minutes before the third or fourth dose. Typical trough level range for Vancomycin is 10-20 µg/mL. The reference range for peak levels is 25-50 µg/mL.)
A patient receiving Vancomycin has an order for a trough level to be drawn. When should the lab collect the blood sample? A-30 minutes before the infusion B-30 minutes after the infusion C-1 hour after the infusion D-1 hour before the infusion
C (Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; not wanting to eat. The impaction may need to be manually removed)
A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of A-constipation B-diarrhea C-fecal impaction D-bowel incontinence
C (Rebound tenderness is a sign of peritonitis that could be the result of rupture of the colon. It is a clinical sign that occurs during physical examination, referring to pain upon removal of pressure, not during application of pressure)
A patient diagnosed with ulcerative colitis is admitted to the medical unit. When assessing the patient, which of these findings would be of the most concern? A-Bloody diarrhea B-Oral temperature of 99.0 F (37.2 C) C-Rebound tenderness D-Borborygmi
C (Grapefruit and its juice contain furanocoumarins, which block the enzyme cytochrome P450 enzyme CYP3A4, which is involved in metabolizing many drugs, including calcium channel blockers. Medication blood levels can increase, becoming toxic. The levels of calcium channel blockers are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension. Grapefruit can interfere with other drugs, as well, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs.)
A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid? A-Eggs B-Bananas C-Grapefruit D-Milk
B (Orthostatic, or postural, hypotension is defined as a decrease of more than 20 mmHg systolic or more than 10 mmHg diastolic and a 10% - 20% increase in heart rate)
A patient is prescribed a new medication for the treatment of hypertension. While supine, the patient's blood pressure is 112/70 mmHg and the heart rate is 80/minute. The healthcare provider assesses the patient when the patient changes to a sitting position. Which of the following indicates the patient is experiencing orthostatic hypotension? A-BP 90/60, HR 68 B-BP 88/60, HR 100 C-BP 120/84, HR 82 D-BP 100/66, HR 90
A (Because thiazide diuretics produce an increase in urine output, the patient should avoid taking the medication in the evening so that sleep is not interrupted. Potassium is lost in the urine along with sodium and chloride, so the patient should be instructed to include potassium-rich foods in the diet to avoid hypokalemia. Examples of potassium-rich foods include avocados, spinach, sweet potatoes, yogurt, and bananas.)
A patient is prescribed a thiazide diuretic for the treatment of hypertension. When teaching the patient about the medication, which of the following will the healthcare provider include? A-"Be sure to include a number of foods in your diet that are rich in potassium." B-"Stop taking this medication if you notice changes in how much you urinate." C-"I will teach you how to take your radial pulse before taking the medication." D-"Take this medication each day with a large glass of water after your evening meal."
B (A hypertensive emergency is a sudden rise in blood pressure, with a reading of 180/120mmHg or higher. Immediate intervention is necessary. It may cause hypertensive retinopathy, resulting in hemorrhages, exudates, and/or papilledema)
A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency? A-Bradycardia B-Retinopathy C-Jaundice D-Urinary retention
C ( To decrease the risk of hemorrhage)
The clinic nurse is providing pre-operative instructions to a client. When reviewing the client's current medications, which one should the nurse advise the client to discontinue 5-7 days before surgery? A-Famotidine (Pepcid) B-Venlafaxine (Effexor) C-Warfarin (Coumadin) D-Montelukast (Singulair)
D (Juvenile idiopathic arthritis (JIA) is the most common type of arthritis in children under age 16. It typically causes joint pain and inflammation in the hands, knees, ankles, elbows and/or wrists, as well as other body parts)
The nurse assesses a 12-year-old child with a diagnosis of juvenile idiopathic arthritis (JIA) during a routine physical. Which of the following complaints by the child is the FIRST priority? A-"I have a hard time doing even simple things." B-"I hate that I'm different from my friends." C-"I'm afraid I will fall down during gym class." D-"My hands and knees really hurt all the time."
C (Battle's sign is bruising over the mastoid process. It is primarily caused by a type of serious head injury called a basilar skull fracture, or basal fracture, which occurs at the base of the skull)
The nurse is caring for a 17-year-old athlete who sustained a basilar skull fracture during a football game. The nurse knows to assess for Battle's sign in 24-48 hours post-injury. Where will the nurse observe this sign? A-Bruising in the periorbital area B-Recalcitrant epistaxis C-Ecchymosis behind the ear D-Petechiae across the cheeks
C (Moist desquamation is a consequence of radiation exposure, where the skin thins and then begins to weep because of loss of integrity of the epithelial barrier)
After 4 weeks of external radiation therapy, a client develops moist desquamation. This condition is characterized by A-A raised patch of blisters B-Erythema at the target area C-Weeping of the skin D-Purulent, itchy secretions
B (Antibiotics must be not be started until a blood culture test is drawn, as administering antibiotics may interfere with identifying the bacteria and the appropriate therapy.)
A 12 year-old male is admitted to the hospital several days after stepping on a sharp object that punctured his shoe and penetrated the bottom of his foot. Concerned about possible osteomyelitis, the doctor has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started? A-The admission orders are entered into the system. B-A blood culture lab test drawn. C-The first antibiotic dose is held until the parents are present. D-A complete blood count with differential is drawn.
C (The child who has asthma is at greatest risk for death secondary to anaphylaxis, a severe Type I hypersensitivity reaction caused by a food allergy. Type I hypersensitivity reactions can cause a range of signs and symptoms depending on the severity of the hypersensitivity response.)
A child with a peanut allergy has also recently been diagnosed with asthma. The healthcare provider instructs the parents on ways to prevent the child coming in contact with peanuts. This is because the child is at increased risk for which of these problems? A-Headache and seizures B-Projectile vomiting and diarrhea C-Anaphylaxis and respiratory failure D-Painful rash and urticaria
A (Gout is one of the most common forms of inflammatory arthritis and can cause extreme pain, joint swelling, warmth, and redness. he cause is a build-up of uric acid crystals in a joint; purines, found in many foods, produce uric acid during metabolism. Red meat, game, seafood, and alcohol are examples.)
A client comes to the clinic with complaint of severe pain in their big toe and is subsequently diagnosed with gout. The nurse knows that which of the following is true about gout? A-High-purine diets are a cause of gout. B-Symptoms are relieved during sleep. C-Beer helps flush uric acid from the body. D-Young females are most at risk.
A (Tic douloureux, or trigeminal neuralgia, is a chronic pain condition, stemming from one or more of the three branches of the trigeminal nerve, the Fifth Cranial Nerve. It is characterized by a sudden, severe, stabbing pain on one side of the face, and is considered to be one of the most painful conditions to affect humans.)
A client complains of a stabbing pain on one side of the face. The nurse suspects tic douloureux, caused by which cranial nerve? A-V B-VI C-IV D-VII
B (Chemical cardioversion, also called pharmacologic cardioversion, involves non-emergency treatment with a medication to convert the rhythm back into a normal sinus rhythm. Common drugs for A-fib are amiodarone, flecainide, dofetilide, propafenone, or ibutilide.)
A client with a diagnosis of atrial fibrillation (A-fib) is scheduled for a chemical cardioversion procedure. The nurse should anticipate which medication will be administered? A-Nifedipine (Procardia) B-Amiodarone (Cordorane) C-Verapamil (CALAN) D-Lidocaine (Xylocaine)
C (A TIA results from a blood clot that prevents oxygen from reaching an area of the brain. The only difference between a TIA and a stroke is the amount of time the clot is in place. One-third of TIA patients will progress to a stroke within a year.)
A clinician is providing education to a patient with a recent diagnosis of a transient ischemic attack (TIA). Which of the statements by the patient indicates that the patient understands the information? A-"TIAs are usually caused by large bleeds in the brain that resolve on their own." B-"Because TIAs don't cause permanent damage, I do not need to worry if I have another one." C-"I should seek medical attention immediately if I experience these symptoms again, because I could be having a stroke." D-"Transient ischemic attacks (TIAs) are often caused by small bleeds in the brain that resolve on their own."
D (A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia (blood glucose < 70 mg/dl). Symptoms include confusion , anxiety, sweating, chills, tachycardia, nausea, and dizziness. Respiratory acidosis is related to chronic conditions such as asthma, COPD, and neuromuscular disorders. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.)
A male patient with a history of type 1 diabetes is two days post-op following cholecystectomy. He has complained of nausea and can't tolerate solid foods. The nurse finds the patient confused and shaky. Which of the following most likely explains the patient's symptoms? A-Respiratory acidosis B-Hyperglycemia C-Diabetic ketoacidosis D-Hypoglycemia
A (Increased intra-cranial pressure (ICP) is caused by bleeding or swelling within the skull . Trauma is the most common cause. ICP can be life-threatening and must be monitored. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. Other signs are headache, confusion, unresponsive pupils, double vision, increased blood pressure, shallow breathing, and seizures)
A nurse is monitoring a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms should be reported immediately? A-Repeated vomiting B-Falling asleep at 10 pm C-Inability to identify short words D-Bulging anterior fontanel
D (Docusate is an emollient laxative that is prescribed to treat occasional constipation. It works by increasing absorption of water, leading to a soft stool. It is an over-the-counter (OTC) medication)
A nurse's neighbor tells the nurse that their provider recommended that the neighbor take docusate sodium (Colace). Which of the following statements by the nurse is correct? A-"You may experience mild headaches at first." B-"Your heartburn is going to go away." C-"You'll probably feel less anxious very soon." D-"You'll have regular bowel movements."
A (Cyanosis means that there is a blue color noted to the skin, mucous membranes, and nail beds, secondary to poorly oxygenated blood. When blood is fully oxygenated it appears bright red; when it lacks oxygen supply, the blood is a dark purple or bluish red.)
A nursing student on the medical surgical unit reads that a patient has cyanosis. When the student asks the instructor what cyanosis means, the instructor's best response would be A-"Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood." B-"Cyanosis is the primary indication that the patient has pneumonia." C-"Cyanosis is the blue coloring of skin and mucous membranes in the presence of highly oxygenated blood." D-"Cyanosis means the patient has been exposed to cyanide poisoning."
D (A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish-red and moist. A dry, dusky, or reddish purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for. Complications include problems maintaining appliance placement, leading to leakage and sore skin.)
A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these will alert the healthcare provider that the stoma has retracted? A-Dry and reddish-purple B-Narrowed and flattened C-Pinkish-red and moist D-Concave and bowl-shaped
C (Infection causes a stress response in the body by increasing hormones glucocorticoids and epinephrine, which suppress the natural immune response. These stress hormones work against insulin and cause an increase in blood glucose levels. With high glucose levels, white cells are slowed and take more time to fight the infection. Type 2 diabetics may temporarily require insulin during acute illnesses and hospitalizations, but they often return to their normal medication regimen after they recover.)
A patient diagnosed with type 2 diabetes mellitus is admitted to the medical unit with pneumonia. The patient's oral antidiabetic medication has been discontinued and the patient is now receiving insulin for glucose control. Which of the following statements best explains the rationale for this change in medication? A-Acute illnesses like pneumonia will cause increased insulin resistance B-Insulin administration will help prevent hypoglycemia during the illness C-Stress-related states such as infections increase risk of hyperglycemia D-Infection has compromised beta cell function so the patient will need insulin from now on
D (Because the bone marrow is not making an adequate amount of red blood cells and platelets, the patient will experience fatigue due to anemia, and bruising due to decreased platelets. Bone pain is caused by the stretching of the periosteum because of the excessive white blood cells. The CBC may show increased blasts, or immature white blood cells, crowding out the normal RBCs and platelets.)
A patient has recently been diagnosed with leukemia. Which of the following symptoms would a health care professional expect to see given this diagnosis? A-Paresthesia, facial rash, and abdominal pain B-Bradycardia, hypotension, and palpitations C-Dyspnea, malaise, and hypotension D-Bruising, fatigue, and bone pain
C (Because the patient is showing signs of impaired respirations, the priority intervention is to administer oxygen and support respirations (use the ABCs - airway, breathing, circulation - to determine the priority action). Asking more about the patient's history can then be done.)
A patient is brought to the Emergency Department (ED) by a friend. The patient is unresponsive and respirations are slow and shallow. Which of the following is the priority intervention? A-Ask the friend if they were using illicit drugs B-Check the patient's blood glucose level C-Administer 100% oxygen per nasal cannula D-Administer naloxone, per protocol
B (During primary hemostasis, a platelet plug is formed. Clotting factors are involved in secondary hemostasis (coagulation).Aspirin inhibits cyclooxygenase (COX) which promotes the synthesis of TXA_2. Because TXA_2 is necessary for platelet aggregation, primary hemostasis is inhibited. This is measured by bleeding time. Platelet activity is affected, but not the number of platelets.)
A patient is taking daily low-dose aspirin and experiences prolonged bleeding from a superficial cut. Which of the following lab results would be expected for this patient? A-Activated partial thromboplastin time (aPTT) 30 seconds B-Bleeding time of 8 minutes C-Platelets 150 x 10^9/L D-Prothrombin time (PT) 14 seconds
C (Hypovolemia is corrected by expanding the intravascular compartment. An isotonic IV solution will expand the intravascular compartment without affecting cells and tissues of other fluid compartments.)
A patient presents to the emergency department with a complaint of watery diarrhea for the past three days. Assessment findings include blood pressure - 100/60, pulse - 98, and dry mucous membranes. The healthcare provider would anticipate intravenous therapy administration with which of the following fluids? A-Colloid solution B-Hypertonic crystalloid C-Isotonic crystalloid D-Hypotonic crystalloid
A (The patient may not feel hungry due to chemotherapy-induced nausea, but should be encouraged to eat even if not hungry. Encouraging the patient to small meals frequently throughout the day can help avoid nutritional deficiencies and improve quality of life.)
A patient with a diagnosis of lung cancer is receiving chemotherapy and reports nausea and loss of appetite resulting in decreased food intake. What should the healthcare provider recommend to promote adequate nutrition? Advise the patient to A- Eat small meals throughout the day. B-Eat only when feeling hungry. C-Eat large meals but less frequently throughout the day. D-Eat only favorite foods to increase appetite.
C (The hematocrit does not assess coagulation; it reports the percentage of red blood cells (RBCs) in the blood.)
A patient with chronic hepatitis C is scheduled for a liver biopsy. Before the procedure, the nurse checks the most recent lab results. Which of the following laboratory tests does NOT assess coagulation? A-Platelet count B-Partial thromboplastin time C-Hematocrit D-Prothrombin time
B (The liver is the primary site for acetaminophen metabolism. The drug undergoes sulphation (binding to sulphate molecules) and glucuronidation (binding to glucuronide molecules) before elimination from the body. An overdose stresses the glucuronidation process, forcing the drug to be passed to another pathway (cytochrome P-450) which forms a toxic metabolite called NAPQI. As NAPQI accumulates, it causes liver damage, and possible liver failure.)
After an argument with her mother, an adolescent female takes an overdose of Tylenol (acetaminophen). The health care provider knows to watch for complications in which organ? A-Pancreas B-Liver C-Heart D-Kidney
C (This patient is suffering from diabetic ketoacidosis (DKA) caused by insulin deficiency, which prevents glucose from entering the cells. DKA is life-threatening and requires rapid intervention. Because the cells are not able to receive glucose, the body breaks down fat and muscle for energy)
An unresponsive patient with diabetes is brought to the emergency department with slow, deep respirations. Additional findings include: blood glucose 450 mg/dL (24.9 mmol/L), arterial pH 7.2, and urinalysis showing presence of ketones and glucose. Which of the following statements best describes the underlying cause of this patient's presentation? A-Nocturnal elevation of growth hormone results in hyperglycemia in the morning B-Hyperglycemia causes oxidative stress, renal dysfunction, and acidosis C-Lack of insulin causes increased counter-regulatory hormones and ketone release D-Hypoglycemia causes release of glucagon resulting in glycogenolysis and hyperglycemia
D ( Common side effects include: dry mouth, urinary retention, blurred vision, constipation, dizziness, pupil dilation, and cognitive changes)
Scopolamine and atropine are two examples of anticholinergic medications. All of the following are frequent side effects EXCEPT A-Cognitive changes B-Dry mouth C-Urinary retention D-Pupil constriction
A (Large bore catheters are necessary to prevent damage to blood cells. This also decreases development of clots from hemolysis. An 18 gauge needle is often the standard for blood administration.)
Before administering two units of whole blood, what type of intravenous (IV) device should be used? A-A large bore catheter to allow blood cells to pass easily into the patient. B-The smallest possible catheter to prevent pain on insertion. C-Whatever the doctor has ordered. Consult the patient's chart. D-The same IV device as previously used. Consult the patient's chart.
C (Clubfoot is the common name for Congenital Talpes Equino Varus (CTEV). Because a newborn's bones, joints and tendons are very flexible, treatment for clubfoot usually begins in the first week after birth. The goal of treatment is to improve the way the child's foot looks and works before he or she learns to walk, in hopes of preventing long-term disabilities. The Ponseti method is the most widely-practiced technique for initial treatment of infants born with club feet, yielding excellent short-and longterm results. The infant undergoes weekly manipulation and casting of the foot/feet for 12 weeks. Each cast holds the foot/feet in the corrected position, allowing for gradual reshaping. The final cast remains in place for 3 weeks, then the foot/feet are placed in orthotic shoes worn 23 hours a day for 3 months, then nightly until age 5. The child may also need a minor procedure that lengthens the Achilles tendon.)
Before discharge to home, the nurse is educating parents of a neonate with bilateral club feet. The nurse tells the parents that the infant will be treated with the Ponseti method. Which of the following statements about this method is correct? A-Treatment will continue for about 8-10 years. B-The Ponseti method is initiated at 3 months of age. C-The infant will get a weekly cast for 12 weeks. D-The procedure has a poor longterm prognosis.
A (A blood type and crossmatch is necessary to ensure a match between the blood donor and the patient who is receiving the blood. An incompatible match could result in severe adverse events and possible death)
Before receiving a transfusion of whole blood, the laboratory and blood bank require a sample of the patient's blood. Which test will be run? A-Blood type and crossmatch B-Blood type and antigen screen C-Blood culture and sensitivity analysis D-Complete blood count (CBC) and differential
B (Bronchovesicular sounds are heard over the major bronchi. In this picture (an anterior view), these sounds are heard around the sternum. Bronchial sounds are harsh, tubular sounds heard over the trachea. Vesicular sounds are soft, low-pitched sounds produced by air moving through the small bronchioles and alveoli.)
During a routine physical exam, the nurse auscultates the lungs of a client. What type of lung sounds will be auscultated in a healthy client when listening over the area indicated by the red X below? A-Alveolar B-Bronchovesicular C-Vesicular D-Bronchial
D (TPN can cause hyperglycemia, so blood glucose levels should be closely monitored. Because of the hypertonicity of the TPN solution, it must be administered via a central venous catheter. The high glucose and lipids makes the TPN an excellent medium for bacterial growth so administration sets should be changed every 24 hours if the TPN contains lipids.)
During an acute exacerbation of inflammatory bowel disease, a patient is to receive total parenteral nutrition (TPN) and lipids. Which of these interventions is the priority when caring for this patient? A-Monitor urine specific gravity every shift B-Infuse the solution in a large peripheral vein C-Change the administration set every 72 hours D-Monitor the patient's blood glucose per protocol
D (Patients should be instructed that it is normal to experience a warm sensation when IV contrast is injected. The feeling lasts 5-20 seconds)
During an arteriogram (angiogram), the patient suddenly says, "I'm feeling really hot." Which is the best response? A-"The heat indicates that the clots in the coronary vessels are dissolving." B-"You are having an allergic reaction to the dye. I will get an order for Benadryl." C-"Let me get your doctor to explain this sensation to you" D-"That feeling of warmth is normal when the dye is injected. It will last up to 20 seconds."
D (The heart rate will increase in an attempt to deliver more oxygen to the brain and body. Tachycardia is a pulse rate > 100bpm.)
During an assessment of a patient experiencing acute hemorrhage, the healthcare provider would most likely expect to find A-Hypotension B-Nausea C-Jaundice D-Tachycardia
A (A continuous bladder irrigation (CBI) is titrated to achieve and maintain an output of pale yellow or a pale yellow with a slight pink tinge. The nurse increases the flow rate if the drainage is red or if there are clots present; the flow rate is decreased for a clear output.)
Following a prostatectomy, the client is receiving continuous bladder irrigation (CBI) via a three-way Foley catheter. The provider has prescribed that the irrigation solution be titrated to maintain a drainage of which color? A-Pale yellow B-Sanguineous C-Dark yellow D-Colorless
C (The nurse should provide the fact that trapped air was the reason for the sound. Do not dismiss the son's concern or over-simplify the explanation.)
Following the death of a client, the hospice nurse and the client's son reposition the client. The son tells the nurse that his father seemed to breathe when they moved him. What is the nurse's most appropriate response? A-"I'm sure you're mistaken. Your father has passed." B-"Let's listen to his lungs. That will prove that he has died." C-"The sound you heard was trapped air escaping from his lungs." D-"I can assure you that this is very common after death."
B (Cor pulmonale, or right-sided heart failure, is the result of a lung condition, such as chronic bronchitis or COPD. The diseased lungs deliver less oxygen to the right ventricle, putting a strain on the heart from pulmonary hypertension. Over time, the right ventricle fails, causing increased venous pressure and liver enlargement (hepatomegaly).)
For a patient who is in the late stages of chronic bronchitis, which of the following would indicate the patient has developed cor pulmonale? A-Venous stasis ulcers B-Hepatomegaly C-Hypocapina D-Night sweats
B (The percentage of drug NOT protein bound is the amount of drug that is free to work as expected. In this case, 50% is unable to be effective, because it is protein-bound)
If a drug is 50% protein-bound, it means that A-50% of the drug destroys protein B-50% of the drug is available C-50% will pass through the intestines D-50% less protein should be eaten
A (Insulin is produced by the beta cells in the pancreas. When the beta cells are destroyed, no insulin is available. It must be provided by a source outside the body)
Parents of a 9-year-old girl with a new diagnosis of type 1 diabetes (T1D) ask the nurse what caused their daughter's disease. The nurse knows the pathology is A-Pancreatic beta cell destruction B-Increased hepatic glycogenesis C-Atrophy of alpha cells in the pancreas D- Cells become resistant to insulin
C (When pressure over a bony prominence is not relieved, the result is ischemia and damage to underlying tissue. In the earliest stage (Stage 1) skin remains intact, but appears red. The area does not blanch when touched. Skin temperature may be warmer.)
The earliest identifying sign for a developing pressure sore is a localized _______. A-coolness to touch B-loss of sensation C-change in color D-edema
D (NPH insulin is an intermediate-acting insulin, usually given once or twice a day. The peak effect of NPH insulin occurs 4-12 hours after administration, so the nurse should begin to monitor for signs of hypoglycemia at 10:00 AM)
The healthcare provider administers NPH insulin at 6:00 AM to a patient with diabetes. How soon will the patient show any signs hypoglycemia? A-8:00 AM B-7:00 AM C-9:00 AM D-10:00 AM
A (Pale nail beds of the toes indicate neurovascular damage. Other signs of neurovascular dysfunction in an extremity include: diminished or absent pedal pulses; capillary refill in toes > 3 seconds; inability to flex or extend the knee, foot, or toes; numbness or tingling in the foot.)
The healthcare provider is assessing a patient recovering from a total knee replacement. Which of these assessment findings indicates the patient is at risk of developing a complication from the surgery? A-Pale toenail beds B-Incision site edema C-Homan's sign negative D-Hemoglobin 12.5 g/dL
C (The A1c blood test gives information about the average levels of glucose for the previous three months. It is the most accurate method of tracking a patient's compliance. The A1C test is based on the attachment of glucose to hemoglobin, the protein in red blood cells that carries oxygen. In the body, red blood cells are constantly forming and dying, but typically they live for about 3 months. Test results are reported as a percentage. An A1c level below 5.7% is normal. A range of 5.8% to 6.4% is pre-diabetic. Type 2 diabetes is diagnosed with a level of 6.5% or higher. The A1C test is sometimes called the hemoglobin A1c, HbA1c, or glycohemoglobin test.)
The healthcare provider is assessing the glucose level of a patient with a diagnosis of diabetes. Which of these is most helpful in evaluating this patient's long-term glucose management? A-The patient's food diary B-Urine specific gravity C-Hemoglobin A1c D-Fasting blood glucose level
D (Tracheal deviation from midline is associated with a tension pneumothorax, which is a potential complication associated with central line insertion., caused by a collection of air between the chest cavity and the lung.)
The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion? A-Inspiration phase is greater than expiration B-Vesicular breath sounds noted on auscultation C-Diaphragmatic excursion of 3cm D-Tracheal deviation from midline
D (A sunken fontanelle (also spelled fontanel) is a sign of increasing dehydration, and is first noticed when dehydration progresses from mild to moderate. Mild dehydration may be evidenced by an increased thirst and decreased urine output. Anuria (no urine output) is a sign of severe dehydration)
The healthcare provider is caring for a 3-month-old infant diagnosed with infectious gastroenteritis. The infant is lethargic and the mucous membranes are dry. Which additional finding would support a diagnosis of moderate dehydration? A-Increased thirst B-Increased capillary refill C-Anuria D-Sunken fontanelle
B (If the endotracheal tube is inserted too far, it often goes into the right main stem bronchus. Air will then be delivered to the right lung and not the left. A low pressure alarm indicates a disconnection or a leak in the circuit. A high pressure alarm can mean an obstruction, such as a kink in the tubing or a need for suctioning.)
The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea? A-Low pressure alarm sounds B-Decreased breath sounds on the left side of the chest C-A high pressure alarm sounds D-Increased crackles auscultation bilaterally
A (Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage)
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? A-IV fluids to increase intravascular volume. B-Vasopressors to increase blood pressure. C-Antibiotics to treat the underlying infection. D-Corticosteroids to reduce inflammation.
D (Male patients often experience erectile dysfunction after AAA repair due to decreased blood flow to the pelvic area during surgery. Also, the expanding abdominal aorta can compress and damage the nerves and blood vessels of the penis. Patients are taught to palpate pulses below the level of the repair, not at the radial pulse)
The healthcare provider is evaluating effectiveness of discharge teaching for a male patient following an abdominal aortic aneurysm (AAA) repair. Which of these statements made by the patient indicates the teaching has been successful? A-"I will take my radial pulse each day and keep track of the rate." B-"I should avoid being around people who are sick." C-"I will be able to resume my usual work-out at the gym." D-"It is possible that I may experience some sexual dysfunction."
D (Beta-1 receptors are found in the cardiac conduction system and myocytes. Beta-1 blockade will slow discharge from the SA node and decrease speed through the AV node, slowing the heart rate. Propranolol (Inderal) decreases the strength of heart contractions, as well as the heart rate, resulting in less cardiac oxygen consumption.)
The healthcare provider is performing an assessment on a patient who is taking propranolol (Inderal) for supraventricular tachycardia. Which assessment finding is an indication the patient is experiencing an adverse effect of this drug? A-Paresthesia B-Dry mouth C-Urinary retention D-Bradycardia
C (Because of decreased production of erythropoietin, renal failure causes fewer red blood cells to be produced by the bone marrow. Also, hemodialysis can cause hemolysis, so this patient is at highest risk for anemia)
The healthcare provider is planning care for four patients. Which patient is most in need of interventions aimed at preventing anemia? The patient A-with a Jackson-Pratt drain. B-who has been NPO for 3 days. C-with renal failure on hemodialysis. D-who is a vegetarian.
C (A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total cholectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe, chronic constipation.
The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site? A-Right Upper Quadrant B-Left Upper Quadrant C-Right Lower Quadrant D-Left Lower Quadrant
B (A thoracentesis is performed to remove fluid or air from around the lungs; perform a biopsy; or administer medication into the pleural space. The patient should be sitting up, leaning over a bedside table with arms rested, feet supported on the ground or stool so the needle can be inserted appropriately.)
The healthcare provider is preparing a patient on the medical-surgical unit for a thoracentesis. Which of the following is the most appropriate position for the patient during the procedure? A-Prone, with both arms extended above the head. B-Sitting up, leaning over a bedside table and feet supported on the ground or stool. C-The head of bed elevated 45 degrees with the patient lying on the affected side. D-The head of the bed flat with the patient lying on the unaffected side.
D (Therapeutic INR levels are typically preferred to be slightly higher than normal limits. A general rule of thumb is for INR to be between 2.0 and 3.0 in someone who is receiving anticoagulation therapy. The other values would indicate increased risk of embolism, clot, or bleeding)
The healthcare provider is reviewing the International Normalized Ratio (INR) results of a patient with a history of embolic stroke. Which of the following indicates a therapeutic value for this patient? A-1.5 B-0.5 C-4.1. D-2.5
B (The patient has respiratory acidosis. The normal ranges for ABGs: pH is 7.35-7.45; PaCO2 is 35-45 mm Hg; HCO3 is 20-24eEq/L.. The increased acid has a depressant effect on the central nervous system, causing disorientation)
The healthcare provider is reviewing the arterial blood gas report for a child with severe, persistent asthma. The blood gas is: pH = 7.28, PaCO2 = 50 mmHg, HCO3 = 25. Which of these assessments are consistent with this child's arterial blood gas? A-Kussmaul respirations and muscle twitching B-Disorientation, headache, and flushed face C-Slow respirations, nausea, and vomiting D-Rapid, deep respirations and paresthesia
D (Menses may increase the risk of iron-deficiency anemia in some women. Pica, the craving to eat unusual substances like ice or dirt is a classic manifestation of iron-deficiency anemia).
The healthcare provider is seeing four patients at the neighborhood clinic. Which of these patients should the healthcare provider identify to be most at risk for iron-deficiency anemia? A-The obese patient with a history of gastric bypass surgery. B-The patient who has a diagnosis of chronic renal failure. C-The patient who follows a strict vegan diet. D-The woman of childbearing age reporting a craving for ice.
B (The patient with a pleural effusion and chest pain is the priority. The patient is demonstrating an actual problem that requires immediate assessment and intervention.)
The healthcare provider on pediatric unit has received her assignments for the day. Which of the following patients should the healthcare provider assess first? A-The 6-year-old with bronchitis with an intravenous (IV) antibiotic infusing at 30mL/hour. B-The 17-year-old with a left pleural effusion complaining of chest pain 9 on a 0 - 10 scale. C-The 3-year-old with asthma who has an oxygen saturation of 94% on room air. D-The 11-year-old with pneumonia waiting for discharge instructions.
B (Corticosteroids and other anti-inflammatory drugs work by reducing inflammation, swelling, and mucus production in the airways of a person with asthma.)
The healthcare provider prepares to administer a corticosteroid to a patient with a diagnosis of asthma. What is the rationale for administering this drug to this patient? A-Promote bronchodilation B-Decrease airway swelling C-Prevent respiratory infections D-Promote expectoration of mucus
A (To help prevent pneumonia and its complications, a one-time repeat pneumococcal vaccination is recommended for individuals who were less than 65 years old when they received their first vaccination. Some high-risk groups receive an initial pneumonia vaccine of PCV13 (pneumococcal conjugate) before age 65. The CDC recommends a second vaccination of PCV23 (pneumococcal polysaccharide) at age 65 for these patients. Patients who are 65 and older should receive both vaccines, one year apart.)
The healthcare provider prepares to administer a pneumococcal vaccine to a 65-year-old patient who has a diagnosis of chronic bronchitis. The patient states, "I got that vaccine 5 years ago." What is the most appropriate response by the healthcare provider? A-"Your last shot was when you were 60, so a repeat vaccination is recommended." B-"You will need this vaccination annually, just like the flu shot." C-"We can give you a flu shot instead of a pneumococcal vaccination." D-"This vaccination is given every other year to anyone with lung disease."
B (Whether a client is in the healthcare setting, or in the community, always immobilize the suspected break or fracture first. Call or phone for assistance before moving the client. Vital signs should be taken, but not as the first action)
The nurse enters a client's room and finds the client on the floor, with their arm at an awkward angle. The nurse suspects the arm may be broken. What is the nurse's FIRST action? A-Assist the client back to bed. B-Immobilize the client's arm. C-Notify the radiology department. D-Take a full set of vital signs.
B (A client with a fractured rib will complain of pain on inspiration, or when moving or coughing. There is also pain when the site is palpated. Respirations will be shallow and guarded; it will be nearly impossible for the client to take a deep breath. There may also be shortness of breath, as well as bruising at the site.)
The nurse in the Emergency Department assesses a client for a possible fractured rib. Which of the following characteristics will support the suspected diagnosis? A-Pain on expiration, with deep, rapid respirations B-Pain on inspiration, with shallow, guarded respirations C-Pain on expiration, with shallow, guarded respirations D-Pain on inspiration, with deep, rapid respirations
C (An inferior vena cava (IVC) filter is a type of vascular filter, a medical device that is implanted into the inferior vena cava to prevent life-threatening pulmonary emboli (PEs). Although an IVC can be left in permanently, some providers will remove it when the associated medical issue is resolved. Usually, anticoagulants can be discontinued)
The nurse is educating a client about their scheduled procedure to insert an inferior vena cava (IVC) filter. Which of the following teaching points is INCORRECT? A-Anticoagulant medication will be discontinued. B-The procedure is done in a same-day surgical center. C-The IVC filter will be replaced every six months. D-The IVC insertion procedure is safe and effective.
D (They should avoid dairy products, nuts and seeds, salt substitutes, fruits and vegetables that are naturally high in potassium, and chocolate. Legumes that are high in potassium include peanuts, soy beans, lentils, kidney beans, pinto beans, and lima beans)
The nurse is educating a client with chronic kidney disease (CKD) about the need to restrict potassium in their diet. Which of the following statements by the client indicates a need for further instruction? A-"I will have an apple instead of a banana." B-"I will choose sherbet instead of ice cream." C-"I'll cook with onions instead of tomatoes." D-"I can eat peanuts instead of popcorn."
A (The nurse should start by finding out how much the surgeon has told the client about the procedure. From there, the nurse can provide education as indicated. Radical neck dissection is a major surgical procedure that will require the client to have an extended recovery time, an altered appearance, a tracheostomy, and tube feedings)
The nurse is preparing a client for a radical neck dissection. Which is the FIRST question the nurse should ask the client? A-"What has your surgeon told you about this operation?" B-"Have you considered how this will change your life?" C-"Has anyone taught you how to communicate after surgery?" D-"Do you have a good support system at home?"
B (The most common complaint about wearing a cast is the itching sensation. Clients should never use an object (pencil, ruler, chopstick) to reach into the cast; this could break the skin and cause an infection. Powders and lotions are also not recommended. Appropriate interventions include: Locating the itch and tapping on it from outside the cast; blowing cool air from a blower dryer into the cast; and wrapping a watertight ice pack or a sealed bag of frozen vegetables on the outside of the cast to cool the itchy area.)
The parent of a child with a short leg fiberglass cast phones the clinic because their child complains of a constant itching inside the cast. Which intervention is appropriate for the nurse to suggest? A-Use a blunt-ended object to scratch. B-Tap on the cast at the itchy spot. C-Apply powder or a mild lotion. D-Trickle ice water into the cast.
D (Stomatitis is irritation of the lips, mouth, tongue, and oropharynx which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and quality of life. Warm saline rinses are non-irritating and help eliminate bacteria which can cause infection. Other nursing interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the physician.)
The patient receiving chemotherapy is experiencing stomatitis. The healthcare provider should offer the patient A-Hot soup for lunch and dinner B-Vigorous oral care with a commercial mouthwash C-Plenty of ice chips between meals D-Warm saline rinses four times each day
D (A decrease in level of consciousness or confusion is an early sign of increased intracranial pressure (ICP) and should be reported immediately. Vomiting can also occur with ICP, but is not related to food)
The pediatric nurse is caring for a 9-year-old girl with a diagnosis of medulloblastoma. Which of the following should the nurse report to the child's provider? A-Vomiting after eating a snack B-Urine output of 200 ml for the shift C-Blood pressure of 108/71 mm Hg D-Confusion about where she is
C (Food allergens commonly associated with allergic reactions in asthma include wheat, eggs, dairy products, citrus fruits, corn, tree nuts, and chocolate. Foods fried or cooked in Omega-6 oils can trigger an allergic response. Food allergies can be dangerous for people with asthma.)
The pediatric nurse is educating the parents of a child with a new diagnosis of asthma about recognizing food triggers. Of the following, which is MOST likely to cause an allergic reaction? A-Apple juice B-Salmon C-French fries D-Bananas
C (Metoprolol is a beta-adrenergic blocking agent, which can cause impotence, including erectile dysfunction or inability to achieve ejaculation. Other side effects include insomnia, fatigue, weakness, dry mouth and GI issues.)
The provider prescribes metoprolol (Lopressor) for a 47-year-old male client with a diagnosis of hypertension. The nurse educates the client about which common side effect of the medication? A-Mood swings B-Restless legs C-Erectile dysfunction D-Weight gain
A (The best way to change tracheotomy ties is to apply the new ones before removing the old ones. This keeps the tracheostomy in place during the process)
The safest method of changing a patient's tracheotomy ties is to A-Apply the new ties before removing the old ones. B-Ask the doctor to suture the tracheostomy in place C-Never attempt to change ties alone. D-Change ties as soon as possible after the patient has eaten.
D (Wound staging: Stage I: localized intact skin, with nonblanchable redness; Stage II: Partial-thickness loss of dermis, pink/red wound surface, no slough; Stage III: Full-thickness loss of dermis, subcutaneous tissue exposed, slough; Stave IV: Full-thickness loss of dermis with muscle, tendons, or bones exposed, slough or eschar may be present)
The wound care nurse is assessing a new client with a coccygeal pressure ulcer that is 4 cm x 7 cm. The nurse observes partial-thickness loss of dermis, a pink/red wound surface, and no slough. What wound stage is the pressure ulcer? A-Stage IV B-Stage I C-Stage III D-Stage II
A (Treatment for a DVT involves bed rest to avoid dislodging the clot; applying warm heat to reduce leg swelling, and elevating the affected leg, or both legs. Other nursing interventions include application of thigh-high TED hose, range-of-motion for the unaffected leg; vital signs q 4-6 hrs; administering heparin as ordered; and monitoring for complications of pulmonary embolism (PE), such as shortness of breath, chest pain, apprehension, cough, hemoptysis, tachypnea, crackles, tachycardia, diaphoresis, and fever.)
When a client is hospitalized with a deep vein thrombosis (DVT), which of the following nursing interventions is appropriate? A-Elevate the affected leg above the heart. B-Ambulate slowly every 8 hours for 10 minutes. C-Apply cold compresses to the affected leg. D-Do range-of-motion exercises for both legs.
C (Crepitus, also called crepitation, describes the grinding, grating, creaking, or popping sounds that occur when a joint moves. Crepitus is present when cartilage is lost. It is characterized by a popping, grating sound, or sometimes the patient feels bone rubbing against bone secondary to loss of cartilage)
When assessing a patient diagnosed with osteoarthritis (OA), the healthcare provider looks for which characteristic of this condition? A-Waddling gait B-Bilateral joint swelling C-Joint crepitus D-Decreased grip strength
A (Most chemotherapeutic agents have a high potential for causing nausea and vomiting. Up to 80% of patients experience chemotherapy-induced nausea and vomiting, which occurs when the vomiting center in the brain is stimulated during the chemotherapy infusion. Administering an antiemetic prior to beginning the infusion can prevent or minimize nausea and vomiting.)
When caring for a patient receiving intravenous chemotherapy for cancer, the healthcare provider will plan to administer the prescribed antiemetic to the patient A-Before starting the infusion. B-One half hour after the infusion has started. C-One hour after the infusion is complete. D-When the patient complains of nausea.
D (Regular deep breathing and coughing will help re-expand the collapsed lung)
When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care? A-Change the insertion site dressing daily using aseptic technique. B-Empty the drainage chamber every shift and record the amount. C-Vigorously massage the tube every 2 hours to promote drainage. D-Encourage the patient to breathe deeply and cough regularly.
D (Because abnormalities in sodium, potassium and calcium levels are likely to affect depolarization and repolarization of cardiac cells, it is most important for the healthcare provider to monitor these laboratory values)
When caring for a patient with a cardiac dysrhythmia, which laboratory value is a priority for the healthcare provider to monitor? A-PT and INR B-Hemoglobin and hematocrit C-BUN and creatinine D-Sodium, potassium, and calcium
D (Chronic bronchitis diminishes airflow during expiration, trapping carbon dioxide (CO2) in the lungs. The increased CO2 lowers the arterial pH, causing respiratory acidosis. The kidneys compensate for the chronic acidosis by conserving bicarbonate. This keeps the pH in a low-normal range, resulting in compensated respiratory acidosis.)
When evaluating the arterial blood gases (ABGs) of a patient with a 20 year history of chronic bronchitis, which of these would the healthcare provider expect? A-Metabolic alkalosis, compensated B-Metabolic acidosis, uncompensated C-Respiratory alkalosis, uncompensated D-Respiratory acidosis, compensated
B (A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to prevent excess fluid loss and maintain electrolyte balance)
When instructing a patient with Addison's disease about nutrition, which of the following diet modifications is NOT recommended? A-A high protein diet B-A restricted sodium diet C-A diet with adequate caloric intake D-A diet high in grains
B (According to BreastCancer.org, lumps are most likely to be cancerous if they do not cause pain, are hard, unevenly shaped, and immobile. Most malignant tumors first appear as single, hard lumps or thickenings. Commonly developing from the mammary glands or ducts, about 50% of malignant lumps generally appear in the upper, outer quadrant of the breast, extending into the armpit, where tissue is thicker than elsewhere)
Which characteristic of a breast lump is most likely to indicate the possibility of cancer? A-Soft B-Immobile C-Round D-Painful
A (Peak expiratory flow rate measures how quickly a patient can exhale. Peak expiratory flow decreases during an asthma exacerbation due to restricted airways)
Which of the following statements by the parent of a pediatric patient indicates further education is needed? A-"I should expect my child's peak expiratory flow to increase during attack." B-"Coughing that won't stop can be a sign of an asthma attack." C-"I might hear my child wheeze during an asthma attack." D-"My child might become restless if he is having trouble breathing."
B (MS is an inflammatory demyelinating disease of the central nervous system. Demyelination will cause slowed conduction and eventually loss of function. Vision loss and eye pain (optic neuritis) are early symptoms of MS due to inflammation of the optic nerve)
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)? A-Dementia B-Vision loss C-Muscle atrophy D-Clonus
B (Platelets (thrombocytes) are important for blood clotting. The normal range for platelets is 150,000-400,000mcL (150-400 x 10^9/L). This patient has thrombocytopenia and should be on bleeding precautions. Using a soft toothbrush, and flossing gently, can prevent the gum tissue from bleeding)
Which of these would be most important to include in discharge teaching for a patient with a platelet count of 40,000mcL (40 x 10^9/L)? A-"Be sure to take your aspirin with meals daily" B-"Use a soft toothbrush and floss gently" C-"You should take a multivitamin daily" D-"You may continue to shave with a straight edge razor"
