NURSING PRACTICE IV Care of Clients with Physiologic and Psychosocial Alterations

1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to

suspect organ rejection?

a. Sudden weight loss

b. Polyuria

c. Hypertension

d. Shock

2. The immediate objective of nursing care for an overweight, mildly hypertensive male

client with ureteral colic and hematuria is to decrease:

a. Pain

b. Weight

c. Hematuria

d. Hypertension

3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal

thyroidectomy is performed. The nurse is aware that this medication is given to:

a. Decrease the total basal metabolic rate.

b. Maintain the function of the parathyroid glands.

c. Block the formation of thyroxine by the thyroid gland.

d. Decrease the size and vascularity of the thyroid gland.

4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia

also can develop in the client who is diagnosed with:

a. Liver disease

b. Hypertension

c. Type 2 diabetes

d. Hyperthyroidism

5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma.

Nurse Ruby should monitor the client for the systemic side effect of:

a. Ascites

b. Nystagmus

c. Leukopenia

d. Polycythemia

6. Norma, with recent colostomy expresses concern about the inability to control the

passage of gas. Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.

b. Decrease fluid intake at meal times.

c. Avoid foods that in the past caused flatus.

d. Adhere to a bland diet prior to social events.

7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse

would evaluate that the instructions were understood when the client states, “I should:

a. Lie on my left side while instilling the irrigating solution.”

b. Keep the irrigating container less than 18 inches above the stoma.”

c. Instill a minimum of 1200 ml of irrigating solution to stimulate

evacuation of the bowel.”

d. Insert the irrigating catheter deeper into the stoma if cramping

occurs during the procedure.”

8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and

electrolyte imbalances. The client is somewhat confused and complains of nausea and

muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance,

the nurse would expect to:

a. Administer Kayexalate

b. Restrict foods high in protein

c. Increase oral intake of cheese and milk.

d. Administer large amounts of normal saline via I.V.

9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV

fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should

set the flow to provide:

a. 18 gtt/min

b. 28 gtt/min

c. 32 gtt/min

d. 36 gtt/min

10.Terence suffered form burn injury. Using the rule of nines, which has the largest percent

of burns?

a. Face and neck

b. Right upper arm and penis

c. Right thigh and penis

d. Upper trunk

11. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after

falling from a 2-story building. When assessing the client, the nurse would be most

concerned if the assessment revealed:

a. Reactive pupils

b. A depressed fontanel

c. Bleeding from ears

d. An elevated temperature

12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.

Which information given by the nurse shows her knowledge deficit about the artificial

cardiac pacemaker?

a. take the pulse rate once a day, in the morning upon awakening

b. May be allowed to use electrical appliances

c. Have regular follow up care

d. May engage in contact sports

13.The nurse is ware that the most relevant knowledge about oxygen administration to a

male client with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.

b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client

breath.

c. Oxygen is administered best using a non-rebreathing mask

d. Blood gases are monitored using a pulse oximeter.

14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are

inserted, and one-bottle water-seal drainage is instituted in the operating room. In the

postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on

his back. The nurse is aware that this position:

a. Reduce incisional pain.

b. Facilitate ventilation of the left lung.

c. Equalize pressure in the pleural space.

d. Increase venous return

15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect

afterward, the nurse's highest priority of information would be:

a. Food and fluids will be withheld for at least 2 hours.

b. Warm saline gargles will be done q 2h.

c. Coughing and deep-breathing exercises will be done q2h.

d. Only ice chips and cold liquids will be allowed initially.

16.Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect

hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

a. hypernatremia.

b. hypokalemia.

c. hyperkalemia.

d. hypercalcemia.

17.Ms. X has just been diagnosed with condylomata acuminata (genital warts). What

information is appropriate to tell this client?

a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a

Papanicolaou (Pap) smear annually.

b. The most common treatment is metronidazole (Flagyl), which should eradicate the

problem within 7 to 10 days.

c. The potential for transmission to her sexual partner will be eliminated if condoms are

used every time they have sexual intercourse.

d. The human papillomavirus (HPV), which causes condylomata acuminata, can't be

transmitted during oral sex.

18.Maritess was recently diagnosed with a genitourinary problem and is being examined in

the emergency department. When palpating the her kidneys, the nurse should keep which

anatomical fact in mind?

a. The left kidney usually is slightly higher than the right one.

b. The kidneys are situated just above the adrenal glands.

c. The average kidney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-1/8") wide.

d. The kidneys lie between the 10th and 12th thoracic vertebrae.

19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is

aware that the diagnostic test are consistent with CRF if the result is:

a. Increased pH with decreased hydrogen ions.

b. Increased serum levels of potassium, magnesium, and calcium.

c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.

d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her

chart while the nurse was out of the room, Katrina asks what dysplasia means. Which

definition should the nurse provide?

a. Presence of completely undifferentiated tumor cells that don't resemble cells of the

tissues of their origin.

b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.

c. Replacement of one type of fully differentiated cell by another in tissues where the

second type normally isn't found.

d. Alteration in the size, shape, and organization of differentiated cells.

21. During a routine checkup, Nurse Mariane assesses a male client with acquired

immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most

common AIDS-related cancer?

a. Squamous cell carcinoma

b. Multiple myeloma

c. Leukemia

d. Kaposi's sarcoma

22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal

(subarachnoid) block during surgery. In the operating room, the nurse positions the client

according to the anesthesiologist's instructions. Why does the client require special

positioning for this type of anesthesia?

a. To prevent confusion

b. To prevent seizures

c. To prevent cerebrospinal fluid (CSF) leakage

d. To prevent cardiac arrhythmias

23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal

pressure and nausea. The first nursing action should be to:

a. Auscultate bowel sounds.

b. Palpate the abdomen.

c. Change the client's position.

d. Insert a rectal tube.

24.Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How

should the nurse Patricia position the client for this test initially?

a. Lying on the right side with legs straight

b. Lying on the left side with knees bent

c. Prone with the torso elevated

d. Bent over with hands touching the floor

25.A male client with inflammatory bowel disease undergoes an ileostomy. On the first day

after surgery, Nurse Oliver notes that the client's stoma appears dusky. How should the

nurse interpret this finding?

a. Blood supply to the stoma has been interrupted.

b. This is a normal finding 1 day after surgery.

c. The ostomy bag should be adjusted.

d. An intestinal obstruction has occurred.

26.Anthony suffers burns on the legs, which nursing intervention helps prevent

contractures?

a. Applying knee splints

b. Elevating the foot of the bed

c. Hyperextending the client's palms

d. Performing shoulder range-of-motion exercises

27.Nurse Ron is assessing a client admitted with second- and third-degree burns on the

face, arms, and chest. Which finding indicates a potential problem?

a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.

b. Urine output of 20 ml/hour.

c. White pulmonary secretions.

d. Rectal temperature of 100.6° F (38° C).

28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on

his own. To help the client avoid pressure ulcers, Nurse Celia should:

a. Turn him frequently.

b. Perform passive range-of-motion (ROM) exercises.

c. Reduce the client's fluid intake.

d. Encourage the client to use a footboard.

29.Nurse Maria plans to administer dexamethasone cream to a female client who has

dermatitis over the anterior chest. How should the nurse apply this topical agent?

a. With a circular motion, to enhance absorption.

b. With an upward motion, to increase blood supply to the affected area

c. In long, even, outward, and downward strokes in the direction of hair growth

d. In long, even, outward, and upward strokes in the direction opposite hair growth

30.Nurse Kate is aware that one of the following classes of medication protect the ischemic

myocardium by blocking catecholamines and

sympathetic nerve stimulation is:

a. Beta -adrenergic blockers

b. Calcium channel blocker

c. Narcotics

d. Nitrates

31.A male client has jugular distention. On what position should the nurse place the head of

the bed to obtain the most accurate reading of jugular vein distention?

a. High Fowler’s

b. Raised 10 degrees

c. Raised 30 degrees

d. Supine position

32.The nurse is aware that one of the following classes of medications maximizes cardiac

performance in clients with heart failure by increasing ventricular contractility?

a. Beta-adrenergic blockers

b. Calcium channel blocker

c. Diuretics

d. Inotropic agents

33.A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated

low-density lipoprotein (LDL) level. Which of the following dietary modifications is not

appropriate for this client?

a. Fiber intake of 25 to 30 g daily

b. Less than 30% of calories form fat

c. Cholesterol intake of less than 300 mg daily

d. Less than 10% of calories from saturated fat

34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with

an acute myocardial infarction. Which of the following actions would breach the client

confidentiality?

a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before

transferring the client to that unit

b. The CCU nurse notifies the on-call physician about a change in the client’s condition

c. The emergency department nurse calls up the latest electrocardiogram results to check

the client’s progress.

d. At the client’s request, the CCU nurse updates the client’s wife on his condition

35. A male client arriving in the emergency department is receiving cardiopulmonary

resuscitation from paramedics who are giving ventilations through an endotracheal (ET)

tube that they placed in the client’s home. During a pause in compressions, the cardiac

monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable

pulse. Which of the following actions

should the nurse take first?

a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.

b. Check endotracheal tube placement.

c. Obtain an arterial blood gas (ABG) sample.

d. Administer atropine, 1 mg L.V.

36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina

determines that mean arterial pressure (MAP) is which of the following?

a. 46 mm Hg

b. 80 mm Hg

c. 95 mm Hg

d. 90 mm Hg

37. A female client arrives at the emergency department with chest and stomach pain and a

report of black tarry stool for several months. Which of the following order should the nurse

Oliver anticipate?

a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels

b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.

c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum

metabolic panel.

d. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic

serum metabolic panel

38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the

following conditions is suspected by the nurse when a decrease in platelet count from

230,000 ul to 5,000 ul is noted?

a. Pancytopenia

b. Idiopathic thrombocytopemic purpura (ITP)

c. Disseminated intravascular coagulation (DIC)

d. Heparin-associated thrombosis and thrombocytopenia (HATT)

39. Which of the following drugs would be ordered by the physician to improve the platelet

count in a male client with idiopathic thrombocytopenic purpura (ITP)?

a. Acetylsalicylic acid (ASA)

b. Corticosteroids

c. Methotrezate

d. Vitamin K

40. A female client is scheduled to receive a heart valve replacement with a porcine valve.

Which of the following types of transplant is this?

a. Allogeneic

b. Autologous

c. Syngeneic

d. Xenogeneic

41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows

the initial response to the injury in the extrinsic pathway?

a. Release of Calcium

b. Release of tissue thromboplastin

c. Conversion of factors XII to factor XIIa

d. Conversion of factor VIII to factor VIIIa

42. Instructions for a client with systemic lupus erythematosus (SLE) would include

information about which of the following blood dyscrasias?

a. Dressler’s syndrome

b. Polycythemia

c. Essential thrombocytopenia

d. Von Willebrand’s disease

43. The nurse is aware that the following symptoms is most commonly an early indication of

stage 1 Hodgkin’s disease?

a. Pericarditis

b. Night sweat

c. Splenomegaly

d. Persistent hypothermia

44. Francis with leukemia has neutropenia. Which of the following functions must frequently

assessed?

a. Blood pressure

b. Bowel sounds

c. Heart sounds

d. Breath sounds

45. The nurse knows that neurologic complications of multiple myeloma (MM) usually

involve which of the following body system?

a. Brain

b. Muscle spasm

c. Renal dysfunction

d. Myocardial irritability

46. Nurse Patricia is aware that the average length of time from human immunodeficiency

virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?

a. Less than 5 years

b. 5 to 7 years

c. 10 years

d. More than 10 years

47. An 18-year-old male client admitted with heat stroke begins to show signs of

disseminated intravascular coagulation (DIC). Which of the following laboratory findings is

most consistent with DIC?

a. Low platelet count

b. Elevated fibrinogen levels

c. Low levels of fibrin degradation products

d. Reduced prothrombin time

48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained

weight loss over the past 3 months. Physical examination reveals a single enlarged

supraclavicular lymph node. Which of the following is the most probable diagnosis?

a. Influenza

b. Sickle cell anemia

c. Leukemia

d. Hodgkin’s disease

49. A male client with a gunshot wound requires an emergency blood transfusion. His blood

type is AB negative. Which blood type would be the safest for him to receive?

a. AB Rh-positive

b. A Rh-positive

c. A Rh-negative

d. O Rh-positive

Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning

chemotherapy.

50. Stacy is discharged from the hospital following her chemotherapy treatments. Which

statement of Stacy’s mother indicated that she understands when she will contact the

physician?

a. “I should contact the physician if Stacy has difficulty in sleeping”.

b. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.

c. “My physician should be called if Stacy is irritable and unhappy”.

d. “Should Stacy have continued hair loss, I need to call the doctor”.

51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best

response for the nurse is:

a. “Stacy looks very nice wearing a hat”.

b. “You should not worry about her hair, just be glad that she is alive”.

c. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she

may be upset”.

d. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different

in texture”.

52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-

charge should:

a. Provide frequent mouthwash with normal saline.

b. Apply viscous Lidocaine to oral ulcers as needed.

c. Use lemon glycerine swabs every 2 hours.

d. Rinse mouth with Hydrogen Peroxide.

53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV

site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action

to take is:

a. Notify the physician

b. Flush the IV line with saline solution

c. Immediately discontinue the infusion

d. Apply an ice pack to the site, followed by warm compress.

54. The term “blue bloater” refers to a male client which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)

b. Asthma

c. Chronic obstructive bronchitis

d. Emphysema

55. The term “pink puffer” refers to the female client with which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)

b. Asthma

c. Chronic obstructive bronchitis

d. Emphysema

56. Jose is in danger of respiratory arrest following the administration of a narcotic

analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to

be which of the following values?

a. 15 mm Hg

b. 30 mm Hg

c. 40 mm Hg

d. 80 mm Hg

57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg;

Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the

following conditions?

a. Metabolic acidosis

b. Metabolic alkalosis

c. Respiratory acidosis

d. Respirator y alkalosis

58. Norma has started a new drug for hypertension. Thirty minutes after she takes the

drug, she develops chest tightness and becomes short of breath and tachypneic. She has a

decreased level of consciousness. These signs indicate which of the following conditions?

a. Asthma attack

b. Pulmonary embolism

c. Respiratory failure

d. Rheumatoid arthritis

Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out

cirrhosis of the liver:

59. Which laboratory test indicates liver cirrhosis?

a. Decreased red blood cell count

b. Decreased serum acid phosphate level

c. Elevated white blood cell count

d. Elevated serum aminotransferase

60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at

increased risk for excessive bleeding primarily because of:

a. Impaired clotting mechanism

b. Varix formation

c. Inadequate nutrition

d. Trauma of invasive procedure

61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most

common with this condition?

a. Increased urine output

b. Altered level of consciousness

c. Decreased tendon reflex

d. Hypotension

62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o.

every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:

a. “I’ll see if your physician is in the hospital”.

b. “Maybe your reacting to the drug; I will withhold the next dose”.

c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.

d. “Frequently, bowel movements are needed to reduce sodium level”.

63. Which of the following groups of symptoms indicates a ruptured abdominal aortic

aneurysm?

a. Lower back pain, increased blood pressure, decreased re blood cell (RBC) count,

increased white blood (WBC) count.

b. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC

count.

c. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC

count, decreased WBC count.

d. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased

WBC count.

64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his

buttocks. Which of the following steps should the nurse take first?

a. Call for help.

b. Obtain vital signs

c. Ask the client to “lift up”

d. Apply gloves and assess the groin site

65. Which of the following treatment is a suitable surgical intervention for a client with

unstable angina?

a. Cardiac catheterization

b. Echocardiogram

c. Nitroglycerin

d. Percutaneous transluminal coronary angioplasty (PTCA)

66. The nurse is aware that the following terms used to describe reduced cardiac output and

perfusion impairment due to ineffective pumping of the heart is:

a. Anaphylactic shock

b. Cardiogenic shock

c. Distributive shock

d. Myocardial infarction (MI)

67. A client with hypertension ask the nurse which factors can cause blood pressure to drop

to normal levels?

a. Kidneys’ excretion to sodium only.

b. Kidneys’ retention of sodium and water

c. Kidneys’ excretion of sodium and water

d. Kidneys’ retention of sodium and excretion of water

68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is

administered to treat hypertension is:

a. It dilates peripheral blood vessels.

b. It decreases sympathetic cardioacceleration.

c. It inhibits the angiotensin-coverting enzymes

d. It inhibits reabsorption of sodium and water in the loop of Henle.

69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus

erythematosus (SLE) is:

a. Elavated serum complement level

b. Thrombocytosis, elevated sedimentation rate

c. Pancytopenia, elevated antinuclear antibody (ANA) titer

d. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels

70. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency

department. Before discharge, he complains of a headache. When offered acetaminophen,

his mother tells the nurse the headache is severe and she would like her son to have

something stronger. Which of the following responses by the nurse is appropriate?

a. “Your son had a mild concussion, acetaminophen is strong enough.”

b. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young

adults.”

c. “Narcotics are avoided after a head injury because they may hide a worsening condition.”

d. Stronger medications may lead to vomiting, which increases the intracarnial pressure

(ICP).”

71. When evaluating an arterial blood gas from a male client with a subdural hematoma, the

nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the

result?

a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)

b. Emergent; the client is poorly oxygenated

c. Normal

d. Significant; the client has alveolar hypoventilation

72. When prioritizing care, which of the following clients should the nurse Olivia assess first?

a. A 17-year-old clients 24-hours postappendectomy

b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome

c. A 50-year-old client 3 days postmyocardial infarction

d. A 50-year-old client with diverticulitis

73. JP has been diagnosed with gout and wants to know why colchicine is used in the

treatment of gout. Which of the following actions of colchicines explains why it’s effective for

gout?

a. Replaces estrogen

b. Decreases infection

c. Decreases inflammation

d. Decreases bone demineralization

74. Norma asks for information about osteoarthritis. Which of the following statements

about osteoarthritis is correct?

a. Osteoarthritis is rarely debilitating

b. Osteoarthritis is a rare form of arthritis

c. Osteoarthritis is the most common form of arthritis

d. Osteoarthritis afflicts people over 60

75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her

thyroid replacement medicine. The nurse understands that skipping this medication will put

the client at risk for developing which of the following lifethreatening complications?

a. Exophthalmos

b. Thyroid storm

c. Myxedema coma

d. Tibial myxedema

76. Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should

the nurse report to the physician immediately?

a. Pitting edema of the legs

b. An irregular apical pulse

c. Dry mucous membranes

d. Frequent urination

77. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive

care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour,

leading the nurse to suspect diabetes insipidus. Which laboratory findings support the

nurse's suspicion of diabetes insipidus?

a. Above-normal urine and serum osmolality levels

b. Below-normal urine and serum osmolality levels

c. Above-normal urine osmolality level, below-normal serum osmolality level

d. Below-normal urine osmolality level, above-normal serum osmolality level

78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is

stabilized and prepared for discharge. When preparing the client for discharge and home

management, which of the following statements indicates that the client understands her

condition and how to control it?

a. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need

to urinate, drink, or eat more than usual."

b. "If I experience trembling, weakness, and headache, I should drink a glass of soda that

contains sugar."

c. "I will have to monitor my blood glucose level closely and notify the physician if it's

constantly elevated."

d. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."

79. A 66-year-old client has been complaining of sleeping more, increased urination,

anorexia, weakness, irritability, depression, and bone pain that interferes with her going

outdoors. Based on these assessment findings, the nurse would suspect which of the

following disorders?

a. Diabetes mellitus

b. Diabetes insipidus

c. Hypoparathyroidism

d. Hyperparathyroidism

80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to

take fludrocortisone acetate and hydrocortisone at home. Which statement by the client

indicates an understanding of the instructions?

a. "I'll take my hydrocortisone in the late afternoon, before dinner."

b. "I'll take all of my hydrocortisone in the morning, right after I wake up."

c. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon."

d. "I'll take the entire dose at bedtime."

81. Which of the following laboratory test results would suggest to the nurse Len that a

client has a corticotropin-secreting pituitary adenoma?

a. High corticotropin and low cortisol levels

b. Low corticotropin and high cortisol levels

c. High corticotropin and high cortisol levels

d. Low corticotropin and low cortisol levels

82. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary

tumor. Preoperatively, the nurse should assess for potential complications by doing which

of the following?

a. Testing for ketones in the urine

b. Testing urine specific gravity

c. Checking temperature every 4 hours

d. Performing capillary glucose testing every 4 hours

83. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed

with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according

to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which

he receives 8 U of regular insulin. Nurse Mariner should expect the dose's:

a. onset to be at 2 p.m. and its peak to be at 3 p.m.

b. onset to be at 2:15 p.m. and its peak to be at 3 p.m.

c. onset to be at 2:30 p.m. and its peak to be at 4 p.m.

d. onset to be at 4 p.m. and its peak to be at 6 p.m.

84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with

classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

a. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the

TSH stimulation test

b. A decreased TSH level

c. An increase in the TSH level after 30 minutes during the TSH stimulation test

d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected

by radioimmunoassay

85. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has

prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension

(NPH) to be taken before breakfast. When teaching the client how to select and rotate

insulin injection sites, the nurse should provide which instruction?

a. "Inject insulin into healthy tissue with large blood vessels and nerves."

b. "Rotate injection sites within the same anatomic region, not among different regions."

c. "Administer insulin into areas of scar tissue or hypotrophy whenever possible."

d. "Administer insulin into sites above muscles that you plan to exercise heavily later that

day."

86. Nurse Sarah expects to note an elevated serum glucose level in a client with

hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding

should the nurse anticipate?

a. Elevated serum acetone level

b. Serum ketone bodies

c. Serum alkalosis

d. Below-normal serum potassium level

87. For a client with Graves' disease, which nursing intervention promotes comfort?

a. Restricting intake of oral fluids

b. Placing extra blankets on the client's bed

c. Limiting intake of high-carbohydrate foods

d. Maintaining room temperature in the low-normal range

88. Patrick is treated in the emergency department for a Colles' fracture sustained during a

fall. What is a Colles' fracture?

a. Fracture of the distal radius

b. Fracture of the olecranon

c. Fracture of the humerus

d. Fracture of the carpal scaphoid

89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development

of this disorder?

a. Calcium and sodium

b. Calcium and phosphorous

c. Phosphorous and potassium

d. Potassium and sodium

90. Johnny a firefighter was involved in extinguishing a house fire and is being treated to

smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring

intubation and mechanical ventilation. He most likely has developed which of the following

conditions?

a. Adult respiratory distress syndrome (ARDS)

b. Atelectasis

c. Bronchitis

d. Pneumonia

91. A 67-year-old client develops acute shortness of breath and progressive hypoxia

requiring right femur. The hypoxia was probably caused by which of the following

conditions?

a. Asthma attack

b. Atelectasis

c. Bronchitis

d. Fat embolism

92. A client with shortness of breath has decreased to absent breath sounds on the right

side, from the apex to the base. Which of the following conditions would best explain this?

a. Acute asthma

b. Chronic bronchitis

c. Pneumonia

d. Spontaneous pneumothorax

93. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver.

He’s now in the emergency department complaining of difficulty of breathing and chest pain.

On auscultation of his lung field, no breath sounds are present in the upper lobe. This client

may have which of the following conditions?

a. Bronchitis

b. Pneumonia

c. Pneumothorax

d. Tuberculosis (TB)

94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?

a. The space remains filled with air only

b. The surgeon fills the space with a gel

c. Serous fluids fills the space and consolidates the region

d. The tissue from the other lung grows over to the other side

95. Hemoptysis may be present in the client with a pulmonary embolism because of which

of the following reasons?

a. Alveolar damage in the infracted area

b. Involvement of major blood vessels in the occluded area

c. Loss of lung parenchyma

d. Loss of lung tissue

96. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis

performed to determine the extent of hypoxia. The acid-base disorder that may be present

is?

a. Metabolic acidosis

b. Metabolic alkalosis

c. Respiratory acidosis

d. Respiratory alkalosis

97. After a motor vehicle accident, Armand an 22-year-old client is admitted with a

pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system.

Bubbling soon appears in the water seal chamber. Which of the following is the most likely

cause of the bubbling?

a. Air leak

b. Adequate suction

c. Inadequate suction

d. Kinked chest tube

98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives

3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop

factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how

many drops per minute?

a. 18

b. 21

c. 35

d. 40

99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive

heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin

contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to

the child?

a. 1.2 ml

b. 2.4 ml

c. 3.5 ml

d. 4.2 ml

100. Nurse Alexandra teaches a client about elastic stockings. Which of the following

statements, if made by the client, indicates to the nurse that the teaching was successful?

a. “I will wear the stockings until the physician tells me to remove them.”

b. “I should wear the stockings even when I am sleep.”

c. “Every four hours I should remove the stockings for a half hour.”

d. “I should put on the stockings before getting out of bed in the morning.”

ANSWER AND RATIONALE

1. Answer: (C) Hypertension

Rationale: Hypertension, along with fever, and tenderness over the grafted kidney, reflects

acute rejection.

2. Answer: (A) Pain

Rationale: Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused

by uretheral distention and smooth muscle spasm; relief form pain is the priority.

3. Answer: (D) Decrease the size and vascularity of the thyroid gland.

Rationale: Lugol’s solution provides iodine, which aids in decreasing the vascularity of the

thyroid gland, which limits the risk of hemorrhage when surgery is performed.

4. Answer: (A) Liver Disease

Rationale: The client with liver disease has a decreased ability to metabolize carbohydrates

because of a decreased ability to form glycogen (glycogenesis) and to form glucose from

glycogen.

5. Answer: (C) Leukopenia

Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a

result of myelosuppression.

6. Answer: (C) Avoid foods that in the past caused flatus.

Rationale: Foods that bothered a person preoperatively will continue to do so after a

colostomy.

7. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.”

Rationale: This height permits the solution to flow slowly with little force so that excessive

peristalsis is not immediately precipitated.

8. Answer: (A) Administer Kayexalate

Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for

potassium in the intestine, reducing the serum potassium level.

9. Answer:(B) 28 gtt/min

Rationale: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the

drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60

minutes)

10. Answer: (D) Upper trunk

Rationale: The percentage designated for each burned part of the body using the rule of

nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior

trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%;

Perineum 1%.

11. Answer: (C) Bleeding from ears

Rationale: The nurse needs to perform a thorough assessment that could indicate

alterations in cerebral function, increased intracranial pressures, fractures and bleeding.

Bleeding from the ears occurs only with basal skull fractures that can easily contribute to

increased intracranial pressure and brain herniation.

12. Answer: (D) may engage in contact sports

Rationale: The client should be advised by the nurse to avoid contact sports. This will

prevent trauma to the area of the pacemaker generator.

13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for

breathing.

Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the

CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for

breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic

drive.

14. Answer: (B) Facilitate ventilation of the left lung.

Rationale: Since only a partial pneumonectomy is done, there is a need to promote

expansion of this remaining Left lung by positioning the client on the opposite unoperated

side.

15. Answer: (A) Food and fluids will be withheld for at least 2 hours.

Rationale: Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic

to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the

client food and drink after the procedure without checking on the return of the gag reflex

can cause the client to aspirate. The gag reflex usually returns after two hours.

16. Answer: (C) hyperkalemia.

Rationale: Hyperkalemia is a common complication of acute renal failure. It's life-

threatening if immediate action isn't taken to reverse it. The administration of glucose and

regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest

by moving potassium into the cells and temporarily reducing serum potassium

levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal

failure and aren't treated with glucose, insulin, or sodium bicarbonate.

17. Answer: (A) This condition puts her at a higher risk for cervical cancer; therefore, she

should have a Papanicolaou (Pap) smear annually.

Rationale: Women with condylomata acuminata are at risk for cancer of the cervix and

vulva. Yearly Pap smears are very important for early detection. Because condylomata

acuminata is a virus, there is no permanent cure. Because condylomata acuminata can

occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to

other parts of the body, such as the mouth, oropharynx, and larynx.

18. Answer: (A) The left kidney usually is slightly higher than the right one.

Rationale: The left kidney usually is slightly higher than the right one. An adrenal gland lies

atop each kidney. The average kidney measures approximately 11 cm (4-3/8") long, 5 to

5.8 cm (2" to 2¼") wide, and 2.5 cm (1") thick. The kidneys are located retroperitoneally,

in the posterior aspect of the abdomen, on either side of the vertebral column. They

lie between the 12th thoracic and 3rd lumbar vertebrae.

19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl.

Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level

ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated,

reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from

the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF

also increases serum levels of potassium, magnesium, and phosphorous, and decreases

serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of

2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.

20. Answer: (D) Alteration in the size, shape, and organization of differentiated cells

Rationale: Dysplasia refers to an alteration in the size, shape, and organization of

differentiated cells. The presence of completely undifferentiated tumor cells that don't

resemble cells of the tissues of their origin is called anaplasia. An increase in the number of

normal cells in a normal arrangement in a tissue or an organ is called

hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where

the second type normally isn't found is called metaplasia.

21. Answer: (D) Kaposi's sarcoma

Rationale: Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous

cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated

specifically with AIDS.

22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage

Rationale: The client receiving a subarachnoid block requires special positioning to prevent

CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning

doesn't help prevent confusion, seizures, or cardiac arrhythmias.

23. Answer: (A) Auscultate bowel sounds.

Rationale: If abdominal distention is accompanied by nausea, the nurse must first

auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or

small intestine dilation and these findings must be reported to the physician. Palpation

should be avoided postoperatively with abdominal distention. If peristalsis is absent,

changing positions and inserting a rectal tube won't relieve the client's discomfort.

24. Answer: (B) Lying on the left side with knees bent

Rationale: For a colonoscopy, the nurse initially should position the client on the left side

with knees bent. Placing the client on the right side with legs straight, prone with the torso

elevated, or bent over with hands touching the floor wouldn't allow proper visualization of

the large intestine.

25. Answer: (A) Blood supply to the stoma has been interrupted

Rationale: An ileostomy stoma forms as the ileum is brought through the abdominal wall to

the surface skin, creating an artificial opening for waste elimination. The stoma should

appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests

decreased perfusion, which may result from interruption of the stoma's blood supply and

may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting the

ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An

intestinal obstruction also wouldn't change stoma color.

26. Answer: (A) Applying knee splints

Rationale: Applying knee splints prevents leg contractures by holding the joints in a position

of function. Elevating the foot of the bed can't prevent contractures because this action

doesn't hold the joints in a position of function. Hyperextending a body part for an extended

time is inappropriate because it can cause contractures. Performing shoulder range-of-

motion exercises can prevent contractures in the shoulders, but not in the legs.

27. Answer: (B) Urine output of 20 ml/hour.

Rationale: A urine output of less than 40 ml/hour in a client with burns indicates a fluid

volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg).

White pulmonary secretions also are normal. The client's rectal temperature isn't

significantly elevated and probably results from the fluid volume deficit.

28. Answer: (A) Turn him frequently.

Rationale: The most important intervention to prevent pressure ulcers is frequent position

changes, which relieve pressure on the skin and underlying tissues. If pressure isn't

relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues

and resulting in cell death and ulcer formation. During passive ROM exercises, the

nurse moves each joint through its range of movement, which improves joint mobility and

circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is

necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar

flexion and footdrop by maintaining the foot in a dorsiflexed position.

29. Answer: (C) In long, even, outward, and downward strokes in the direction of hair

growth

Rationale: When applying a topical agent, the nurse should begin at the midline and use

long, even, outward, and downward strokes in the direction of hair growth. This application

pattern reduces the risk of follicle irritation and skin inflammation.

30. Answer: (A) Beta -adrenergic blockers

Rationale: Beta-adrenergic blockers work by blocking beta receptors in the myocardium,

reducing the response to catecholamines and sympathetic nerve stimulation. They protect

the myocardium, helping to reduce the risk of another infraction by decreasing myocardial

oxygen demand. Calcium channel blockers reduce the workload of the heart by

decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote

vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt

decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance

(afterload).

31. Answer: (C) Raised 30 degrees

Rationale: Jugular venous pressure is measured with a centimeter ruler to obtain the

vertical distance between the sternal angle and the point of highest pulsation with the head

of the bed inclined between 15 to 30 degrees. Increased pressure can’t be seen when the

client is supine or when the head of the bed is raised 10 degrees because the point

that marks the pressure level is above the jaw (therefore, not visible). In high Fowler’s

position, the veins would be barely discernible above the clavicle.

32. Answer: (D) Inotropic agents

Rationale: Inotropic agents are administered to increase the force of the heart’s

contractions, thereby increasing ventricular contractility and ultimately increasing cardiac

output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and

ultimately decreased the workload of the heart. Diuretics are administered to decrease the

overall vascular volume, also decreasing the workload of the heart.

33. Answer: (B) Less than 30% of calories form fat

Rationale: A client with low serum HDL and high serum LDL levels should get less than 30%

of daily calories from fat. The other modifications are appropriate for this client.

34. Answer: (C) The emergency department nurse calls up the latest electrocardiogram

results to check the client’s progress

Rationale: The emergency department nurse is no longer directly involved with the client’s

care and thus has no legal right to information about his present condition. Anyone directly

involved in his care (such as the telemetry nurse and the on-call physician) has the right to

information about his condition. Because the client requested that the nurse update his wife

on his condition, doing so doesn’t breach confidentiality.

35. Answer: (B) Check endotracheal tube placement.

Rationale: ET tube placement should be confirmed as soon as the client arrives in the

emergency department. Once the airways is secured, oxygenation and ventilation should be

confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse

should make sure L.V. access is established. If the client experiences

symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to

5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s

arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia,

ventricular fibrillation and atrial flutter – not symptomatic bradycardia.

36. Answer: (C) 95 mm Hg

Rationale: Use the following formula to calculate MAP

MAP = systolic + 2 (diastolic)

3

MAP=126 mm Hg + 2 (80 mm Hg)

3

MAP=286 mm HG

3

MAP=95 mm Hg

37. Answer: (C) Electrocardiogram, complete blood count, testing for occult blood,

comprehensive serum metabolic panel.

Rationale: An electrocardiogram evaluates the complaints of chest pain, laboratory tests

determines anemia, and the stool test for occult blood determines blood in the stool.

Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are

appropriate for a cardiac primary problem. A basic metabolic panel and alkaline

phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin

time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify

bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.

38. Answer: (D) Heparin-associated thrombosis and thrombocytopenia (HATT)

Rationale: HATT may occur after CABG surgery due to heparin use during surgery. Although

DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after

revascularization surgery. Pancytopenia is a reduction in all blood cells.

39. Answer: (B) Corticosteroids

Rationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the

antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause

thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin

overload, and ASA decreases platelet aggregation.

40. Answer: (D) Xenogeneic

Rationale: An xenogeneic transplant is between is between human and another species. A

syngeneic transplant is between identical twins, allogeneic transplant is between two

humans, and autologous is a transplant from the same individual.

41. Answer: (B)

Rationale: Tissue thromboplastin is released when damaged tissue comes in contact with

clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion

of factors XII to XIIa and VIII to VIII a are part of the intrinsic pathway.

42. Answer: (C) Essential thrombocytopenia

Rationale: Essential thrombocytopenia is linked to immunologic disorders, such as SLE and

human immunodeficiency vitus. The disorder known as von Willebrand’s disease is a type of

hemophilia and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not

polycythermia. Dressler’s syndrome is pericarditis that occurs after a myocardial

infarction and isn’t linked to SLE.

43. Answer: (B) Night sweat

Rationale: In stage 1, symptoms include a single enlarged lymph node (usually),

unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly

may be present in some clients, night sweats are generally more prevalent. Pericarditis isn’t

associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly

and pericarditis aren’t symptoms. Persistent hypothermia is associated with Hodgkin’s but

isn’t an early sign of the disease.

44. Answer: (D) Breath sounds

Rationale: Pneumonia, both viral and fungal, is a common cause of death in clients with

neutropenia, so frequent assessment of respiratory rate and breath sounds is required.

Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t

help detect pneumonia.

45. Answer: (B) Muscle spasm

Rationale: Back pain or paresthesia in the lower extremities may indicate impending spinal

cord compression from a spinal tumor. This should be recognized and treated promptly as

progression of the tumor may result in paraplegia. The other options, which reflect parts of

the nervous system, aren’t usually affected by MM.

46. Answer: (C)10 years

Rationale: Epidermiologic studies show the average time from initial contact with HIV to the

development of AIDS is 10 years.

47. Answer: (A) Low platelet count

Rationale: In DIC, platelets and clotting factors are consumed, resulting in microthrombi

and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time

increases. Fibrin degeneration products increase as fibrinolysis takes places.

48. Answer: (D) Hodgkin’s disease

Rationale: Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph

mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia

manifest signs and symptoms of chronic anemia with pallor of the mucous membrane,

fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight

loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.

49. Answer: (C) A Rh-negative

Rationale: Human blood can sometimes contain an inherited D antigen. Persons with the D

antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s

important that a person with Rhnegative blood receives Rh-negative blood. If Rh-positive

blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins,

and sub sequent transfusions with Rh-positive blood may cause serious reactions with

clumping and hemolysis of red blood cells.

50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting and diarrhea”.

Rationale: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of

toxicity and the patient should stop the medication and notify the health care provider. The

other manifestations are expected side effects of chemotherapy.

51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6 months, but

may be different in texture”.

Rationale: This is the appropriate response. The nurse should help the mother how to cope

with her own feelings regarding the child’s disease so as not to affect the child negatively.

When the hair grows back, it is still of the same color and texture.

52. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed.

Rationale: Stomatitis can cause pain and this can be relieved by applying topical anesthetics

such as lidocaine before mouth care. When the patient is already comfortable, the nurse can

proceed with providing the patient with oral rinses of saline solution mixed with equal part

of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene.

Every 2-4 hours.

53. Answer: (C) Immediately discontinue the infusion

Rationale: Edema or swelling at the IV site is a sign that the needle has been dislodged and

the IV solution is leaking into the tissues causing the edema. The patient feels pain as the

nerves are irritated by pressure and the IV solution. The first action of the nurse would be

to discontinue the infusion right away to prevent further edema and other complication.

54. Answer: (C) Chronic obstructive bronchitis

Rationale: Clients with chronic obstructive bronchitis appear bloated; they have large barrel

chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients

with ARDS are acutely short of breath and frequently need intubation for mechanical

ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics

of chronic disease, and clients with emphysema appear pink and cachectic.

55. Answer: (D) Emphysema

Rationale: Because of the large amount of energy it takes to breathe, clients with

emphysema are usually cachectic. They’re pink and usually breathe through pursed lips,

hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with

asthma don’t have any particular characteristics, and clients with chronic obstructive

bronchitis are bloated and cyanotic in appearance.

56. Answer: D 80 mm Hg

Rationale: A client about to go into respiratory arrest will have inefficient ventilation and will

be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other

values are lower than expected.

57. Answer: (C) Respiratory acidosis

Rationale: Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is

normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which

eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22

mEq/L the client would have metabolic acidosis.

58. Answer: (C) Respiratory failure

Rationale: The client was reacting to the drug with respiratory signs of impending

anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also

related to an asthma attack or a pulmonary embolism, consider the new drug first.

Rheumatoid arthritis doesn’t manifest these signs.

59. Answer: (D) Elevated serum aminotransferase

Rationale: Hepatic cell death causes release of liver enzymes alanine aminotransferase

(ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the

circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by

generalized inflammation and fibrosis of the liver tissues.

60. Answer: (A) Impaired clotting mechanism

Rationale: Cirrhosis of the liver results in decreased Vitamin K absorption and formation of

clotting factors resulting in impaired clotting mechanism.

61. Answer: (B) Altered level of consciousness

Rationale: Changes in behavior and level of consciousness are the first sins of hepatic

encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the

liver is unable to convert protein metabolic product ammonia to urea. This results in

accumulation of ammonia and other toxic in the blood that damages the cells.

62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a

day”.

Rationale: Lactulose is given to a patients with hepatic encephalopathy to reduce absorption

of ammonia in the intestines by binding with ammonia and promoting more frequent bowel

movements. If the patient experience diarrhea, it indicates over dosage and the nurse must

reduce the amount of medication given to the patient. The stool will be mashy or

soft. Lactulose is also very sweet and may cause cramping and bloating.

63. Answer: (B) Severe lower back pain, decreased blood pressure, decreased RBC count,

increased WBC count.

Rationale: Severe lower back pain indicates an aneurysm rupture, secondary to pressure

being applied within the abdominal cavity. When ruptured occurs, the pain is constant

because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due

to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood

volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is

decreased – not increased. The WBC count increases as cell migrate to the site of injury.

64. Answer: (D) Apply gloves and assess the groin site

Rationale: Observing standard precautions is the first priority when dealing with any blood

fluid. Assessment of the groin site is the second priority. This establishes where the blood is

coming from and determineshow much blood has been lost. The goal in this situation is to

stop the bleeding. The nurse would call for help if it were warranted after the

assessment of the situation. After determining the extent of the bleeding, vital signs

assessment is important. The nurse should never move the client, in case a clot has formed.

Moving can disturb the clot and cause rebleeding.

65. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA)

Rationale: PTCA can alleviate the blockage and restore blood flow and oxygenation. An

echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual

medication. Cardiac catheterization is a diagnostic tool – not a treatment.

66. Answer: (B) Cardiogenic shock

Rationale: Cardiogenic shock is shock related to ineffective pumping of the heart.

Anaphylactic shock results from an allergic reaction. Distributive shock results from changes

in the intravascular volume distribution and is usually associated with increased cardiac

output. MI isn’t a shock state, though a severe MI can lead to shock.

67. Answer: (C) Kidneys’ excretion of sodium and water

Rationale: The kidneys respond to rise in blood pressure by excreting sodium and excess

water. This response ultimately affects sysmolic blood pressure by regulating blood volume.

Sodium or water retention would only further increase blood pressure. Sodium and water

travel together across the membrane in the kidneys; one can’t travel without the other.

68. Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle.

Rationale: Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the

loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of

peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood

pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood

pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their

action on angiotensin.

69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer

Rationale: Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA

titer, and decreased serum complement levels. Clients may have elevated BUN and

creatinine levels from nephritis, but the increase does not indicate SLE.

70. Answer: (C) Narcotics are avoided after a head injury because they may hide a

worsening condition.

Rationale: Narcotics may mask changes in the level of consciousness that indicate increased

ICP and shouldn’t acetaminophen is strong enough ignores the mother’s question and

therefore isn’t appropriate. Aspirin is contraindicated in conditions that may have bleeding,

such as trauma, and for children or young adults with viral illnesses due to the danger of

Reye’s syndrome. Stronger medications may not necessarily lead to vomiting but will sedate

the client, thereby masking changes in his level of consciousness.

71. Answer: (A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure

(ICP)

Rationale: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties;

therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral

vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar

hypoventilation would be reflected in an increased Paco2.

72. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome

Rationale: Guillain-Barre syndrome is characterized by ascending paralysis and potential

respiratory failure. The order of client assessment should follow client priorities, with

disorder of airways, breathing, and then circulation. There’s no information to suggest the

postmyocardial infarction client has an arrhythmia or other complication. There’s no

evidence to suggest hemorrhage or perforation for the remaining clients as a priority

of care.

73. Answer: (C) Decreases inflammation

Rationale: Then action of colchicines is to decrease inflammation by reducing the migration

of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or

decrease bone demineralization.

74. Answer: (C) Osteoarthritis is the most common form of arthritis

Rationale: Osteoarthritis is the most common form of arthritis and can be extremely

debilitating. It can afflict people of any age, although most are elderly.

75. Answer: (C) Myxedema coma

Rationale: Myxedema coma, severe hypothyroidism, is a life-threatening condition that may

develop if thyroid replacement medication isn't taken. Exophthalmos, protrusion of the

eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by

severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower

leg, is associated with hypothyroidism but isn't life-threatening.

76. Answer: (B) An irregular apical pulse

Rationale: Because Cushing's syndrome causes aldosterone overproduction, which increases

urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should

immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse,

to the physician. Edema is an expected finding because aldosterone overproduction causes

sodium and fluid retention. Dry mucous membranes and frequent urination signal

dehydration, which isn't associated with Cushing's syndrome.

77. Answer: (D) Below-normal urine osmolality level, above-normal serum osmolality level

Rationale: In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-

normal urine osmolality level. At the same time, polyuria depletes the body of water,

causing dehydration that leads to an above-normal serum osmolality level. For the same

reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-

normal serum osmolality levels.

78. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by paying

attention to my need to urinate, drink, or eat more than usual."

Rationale: Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By

recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing

fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be

appropriate for hypoglycemia. A client whose diabetes is controlled with oral

antidiabetic agents usually doesn't need to monitor blood glucose levels. A

highcarbohydrate diet would exacerbate the client's condition, particularly if fluid intake is

low.

79. Answer: (D) Hyperparathyroidism

Rationale: Hyperparathyroidism is most common in older women and is characterized by

bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit

hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus

also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism

is characterized by urinary frequency rather than polyuria.

80. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third in the late

afternoon."

Rationale: Hydrocortisone, a glucocorticoid, should be administered according to a schedule

that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the

dose of hydrocortisone should be taken in the morning and one-third in the late afternoon.

This dosage schedule reduces adverse effects.

81. Answer: (C) High corticotropin and high cortisol levels

Rationale: A corticotropin-secreting pituitary tumor would cause high corticotropin and high

cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level

with a low cortisol level would be associated with hypocortisolism. Low corticotropin and

high cortisol levels would be seen if there was a primary defect in the adrenal glands.

82. Answer: (D) Performing capillary glucose testing every 4 hours

Rationale: The nurse should perform capillary glucose testing every 4 hours because excess

cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine

ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at

risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be

compromised, it usually isn't dangerously imbalanced. Temperature regulation may be

affected by excess cortisol and isn't an accurate indicator of infection.

83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.

Rationale: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes

and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected

onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after 30

minutes during the TSH stimulation test

Rationale: In the TSH test, failure of the TSH level to rise after 30 minutes confirms

hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone.

Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal

hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and

may result from administration of phenytoin and certain other drugs.

85. Answer: (B) "Rotate injection sites within the same anatomic region, not among

different regions."

Rationale: The nurse should instruct the client to rotate injection sites within the same

anatomic region. Rotating sites among different regions may cause excessive day-to-day

variations in the blood glucose level; also, insulin absorption differs from one region to the

next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves,

or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay

absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as

hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites

systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into

sites above muscles that will be exercised heavily.

86. Answer: (D) Below-normal serum potassium level

Rationale: A client with HHNS has an overall body deficit of potassium resulting from

diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the

relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are

characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in

HHNS.

87. Answer: (D) Maintaining room temperature in the low-normal range

Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat

intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat

intolerance and diaphoresis, the nurse should keep the client's room temperature in

the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage,

not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat

intolerance would cause discomfort. To provide needed energy and calories, the nurse

should encourage the client to eat high-carbohydrate foods.

88. Answer: (A) Fracture of the distal radius

Rationale: Colles' fracture is a fracture of the distal radius, such as from a fall on an

outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture

of the olecranon, humerus, or carpal scaphoid.

89. Answer: (B) Calcium and phosphorous

Rationale: In osteoporosis, bones lose calcium and phosphate salts, becoming porous,

brittle, and abnormally vulnerable to fracture. Sodium and potassium aren't involved in the

development of osteoporosis.

90. Answer: (A) Adult respiratory distress syndrome (ARDS)

Rationale: Severe hypoxia after smoke inhalation is typically related to ARDS. The other

conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.

91. Answer: (D) Fat embolism

Rationale: Long bone fractures are correlated with fat emboli, whichcause shortness of

breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a

previous history. He could develop atelectasis but it typically doesn’t produce progressive

hypoxia.

92. Answer: (D) Spontaneous pneumothorax

Rationale: A spontaneous pneumothorax occurs when the client’s lung collapses, causing an

acute decreased in the amount of functional lung used in oxygenation. The sudden collapse

was the cause of his chest pain and shortness of breath. An asthma attack would show

wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would

have bronchial breath sounds over the area of consolidation.

93. Answer: (C) Pneumothorax

Rationale: From the trauma the client experienced, it’s unlikely he has bronchitis,

pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.

94. Answer: (C) Serous fluids fills the space and consolidates the region

Rationale: Serous fluid fills the space and eventually consolidates, preventing extensive

mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no

gel that can be placed in the pleural space. The tissue from the other lung can’t cross the

mediastinum, although a temporary mediastinal shift exits until the space is filled.

95. Answer: (A) Alveolar damage in the infracted area

Rationale: The infracted area produces alveolar damage that can lead to the production of

bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs.

There’s a loss of lung parenchyma and subsequent scar tissue formation.

96. Answer: (D) Respiratory alkalosis

Rationale: A client with massive pulmonary embolism will have a large region and blow off

large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane

more readily than does oxygen and results in respiratory alkalosis.

97. Answer: (A) Air leak

Rationale: Bubbling in the water seal chamber of a chest drainage system stems from an air

leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling

doesn’t normally occur with either adequate or inadequate suction or any preexisting

bubbling in the water seal chamber.

98. Answer: (B) 21

Rationale: 3000 x 10 divided by 24 x 60.

99. Answer: (B) 2.4 ml

Rationale: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.

100. Answer: (D) “I should put on the stockings before getting out of bed in the morning.

Rationale: Promote venous return by applying external pressure on veins.