Text Mode Text version of the following is the most essential A.

Protamine Sulfate
exam. View Answers nursing action? B. Quinidine Sulfate
1. Mrs. Chua a 78 year old client is A. Monitoring urine output frequently C. Vitamin C
admitted with the diagnosis of mild B. Monitoring blood pressure every 4 D. Coumadin
chronic heart failure. The nurse hours 15. In reducing the risk of
expects to hear when listening to C. Obtaining serum potassium levels endocarditis, good dental care is
clients lungs indicative of chronic daily an important measure. To promote
heart failure would be: D. Obtaining infusion pump for the good dental care in client with
A. Stridor medication mitral stenosis in teaching plan
B. Crackles 9. During the second day of should include proper use of
C. Wheezes hospitalization of the client after a A. Dental floss
D. Friction rubs Myocardial Infarction. Which of the B. Electric toothbrush
2. Patrick who is hospitalized following is an expected outcome? C. Manual toothbrush
following a myocardial infarction A. Able to perform self-care activities D. Irrigation device
asks the nurse why he is taking without pain 16. Among the following signs and
morphine. The nurse explains that B. Severe chest pain symptoms, which would most likely
morphine: C. Can recognize the risk factors of be present in a client with mitral
A. Decrease anxiety and restlessness Myocardial Infarction gurgitation?
B. Prevents shock and relieves pain D. Can Participate in cardiac A. Altered level of consciousness
C. Dilates coronary blood vessels rehabilitation walking program B. Exceptional Dyspnea
D. Helps prevent fibrillation of the heart 10. A 68 year old client is C. Increase creatine phospholinase
3. Which of the following should the diagnosed with a right-sided brain concentration
nurse teach the client about the attack and is admitted to the D. Chest pain
signs of digitalis toxicity? hospital. In caring for this client, the 17. Kris with a history of chronic
A. Increased appetite nurse should plan to: infection of the urinary system
B. Elevated blood pressure A. Application of elastic stockings to complains of urinary frequency and
C. Skin rash over the chest and back prevent flaccid by muscle burning sensation. To figure out
D. Visual disturbances such as seeing B. Use hand roll and extend the left upper whether the current problem is in
yellow spots extremity on a pillow to prevent renal origin, the nurse should
4. Nurse Trisha teaches a client contractions assess whether the client has
with heart failure to take oral C. Use a bed cradle to prevent discomfort or pain in the
Furosemide in the morning. The dorsiflexion of feet A. Urinary meatus
reason for this is to help D. Do passive range of motion exercise B. Pain in the Labium
A. Retard rapid drug absorption 11. Nurse Liza is assigned to care C. Suprapubic area
B. Excrete excessive fluids accumulated for a client who has returned to the D. Right or left costovertebral angle
at night nursing unit after left nephrectomy. 18. Nurse Perry is evaluating the
C. Prevents sleep disturbances during Nurse Lizas highest priority would renal function of a male client. After
night be documenting urine volume and
D. Prevention of electrolyte imbalance A. Hourly urine output characteristics, Nurse Perry
5. What would be the primary goal B. Temperature assesses which signs as the best
of therapy for a client with C. Able to turn side to side indicator of renal function.
pulmonary edema and heart D. Able to sips clear liquid A. Blood pressure
failure? 12. A 64 year old male client with a B. Consciousness
A. Enhance comfort long history of cardiovascular C. Distension of the bladder
B. Increase cardiac output problem including hypertension D. Pulse rate
C. Improve respiratory status and angina is to be scheduled for 19. John suddenly experiences a
D. Peripheral edema decreased cardiac catheterization. During pre seizure, and Nurse Gina notice that
6. Nurse Linda is caring for a client cardiac catheterization teaching, John exhibits uncontrollable jerking
with head injury and monitoring the Nurse Cherry should inform the movements. Nurse Gina
client with decerebrate posturing. client that the primary purpose of documents that John experienced
Which of the following is a the procedure is.. which type of seizure?
characteristic of this type of A. To determine the existence of CHD A. Tonic seizure
posturing? B. To visualize the disease process in the B. Absence seizure
A. Upper extremity flexion with lower coronary arteries C. Myoclonic seizure
extremity flexion C. To obtain the heart chambers pressure D. Clonic seizure
B. Upper extremity flexion with lower D. To measure oxygen content of 20. Smoking cessation is critical
extremity extension different heart chambers strategy for the client with
C. Extension of the extremities after a 13. During the first several hours Burghers disease, Nurse Jasmin
stimulus after a cardiac catheterization, it anticipates that the male client will
D. Flexion of the extremities after would be most essential for nurse go home with a prescription for
stimulus Cherry to which medication?
7. A female client is taking Cascara A. Elevate clients bed at 45 A. Paracetamol
Sagrada. Nurse Betty informs the B. Instruct the client to cough and deep B. Ibuprofen
client that the following maybe breathe every 2 hours C. Nitroglycerin
experienced as side effects of this C. Frequently monitor clients apical D. Nicotine (Nicotrol)
medication: pulse and blood pressure 21. Nurse Lilly has been assigned
A. GI bleeding D. Monitor clients temperature every hour to a client with Raynauds disease.
B. Peptic ulcer disease 14. Kate who has undergone mitral Nurse Lilly realizes that the etiology
C. Abdominal cramps valve replacement suddenly of the disease is unknown but it is
D. Partial bowel obstruction experiences continuous bleeding characterized by:
8. Dr. Marquez orders a continuous from the surgical incision during A. Episodic vasospastic disorder of
intravenous nitroglycerin infusion postoperative period. Which of the capillaries
for the client suffering from following pharmaceutical agents B. Episodic vasospastic disorder of small
myocardial infarction. Which of the should Nurse Aiza prepare to veins
administer to Kate?
C. Episodic vasospastic disorder of the 29. George who has undergone C. Sodium bicarbonate
aorta thoracic surgery has chest tube D. Calcium gluconate
D. Episodic vasospastic disorder of the connected to a water-seal drainage 36. Dr. Marquez tells a client that
small arteries system attached to suction. an increase intake of foods that are
22. Nurse Jamie should explain to Presence of excessive bubbling is rich in Vitamin E and beta-carotene
male client with diabetes that self- identified in water-seal chamber, are important for healthier skin.
monitoring of blood glucose is the nurse should The nurse teaches the client that
preferred to urine glucose testing A. Strip the chest tube catheter excellent food sources of both of
because B. Check the system for air leaks these substances are:
A. More accurate C. Recognize the system is functioning A. Fish and fruit jam
B. Can be done by the client correctly B. Oranges and grapefruit
C. It is easy to perform D. Decrease the amount of suction C. Carrots and potatoes
D. It is not influenced by drugs pressure D. Spinach and mangoes
23. Jessie weighed 210 pounds on 30. A client who has been 37. A client has Gastroesophageal
admission to the hospital. After 2 diagnosed of hypertension is being Reflux Disease (GERD). The nurse
days of diuretic therapy, Jessie taught to restrict intake of sodium. should teach the client that after
weighs 205.5 pounds. The nurse The nurse would know that the every meals, the client should
could estimate the amount of fluid teachings are effective if the client A. Rest in sitting position
Jessie has lost states that B. Take a short walk
A. 0.3 L A. I can eat celery sticks and carrots C. Drink plenty of water
B. 1.5 L B. I can eat broiled scallops D. Lie down at least 30 minutes
C. 2.0 L C. I can eat shredded wheat cereal 38. After gastroscopy, an
D. 3.5 L D. I can eat spaghetti on rye bread adaptation that indicates major
24. Nurse Donna is aware that the 31. A male client with a history of complication would be:
shift of body fluids associated with cirrhosis and alcoholism is A. Nausea and vomiting
Intravenous administration of admitted with severe dyspnea B. Abdominal distention
albumin occurs in the process of: resulted to ascites. The nurse C. Increased GI motility
A. Osmosis should be aware that the ascites is D. Difficulty in swallowing
B. Diffusion most likely the result of 39. A client who has undergone a
C. Active transport increased cholecystectomy asks the nurse
D. Filtration A. Pressure in the portal vein whether there are any dietary
25. Myrna a 52 year old client with B. Production of serum albumin restrictions that must be followed.
a fractured left tibia has a long leg C. Secretion of bile salts Nurse Hilary would recognize that
cast and she is using crutches to D. Interstitial osmotic pressure the dietary teaching was well
ambulate. Nurse Joy assesses for 32. A newly admitted client is understood when the client tells a
which sign and symptom that diagnosed with Hodgkins disease family member that:
indicates complication associated undergoes an excisional cervical A. Most people need to eat a high
with crutch walking? lymph node biopsy under local protein diet for 12 months after
A. Left leg discomfort anesthesia. What does the nurse surgery
B. Weak biceps brachii assess first after the procedure? B. I should not eat those foods that upset
C. Triceps muscle spasm A. Vital signs me before the surgery
D. Forearm weakness B. Incision site C. I should avoid fatty foods as long as I
26. Which of the following C. Airway live
statements should the nurse teach D. Level of consciousness D. Most people can tolerate regular diet
the neutropenic client and his 33. A client has 15% blood loss. after this type of surgery
family to avoid? Which of the following nursing 40. Nurse Rachel teaches a client
A. Performing oral hygiene after every assessment findings indicates who has been recently diagnosed
meal hypovolemic shock? with hepatitis A about untoward
B. Using suppositories or enemas A. Systolic blood pressure less than signs and symptoms related to
C. Performing perineal hygiene after each 90mm Hg Hepatitis that may develop. The
bowel movement B. Pupils unequally dilated one that should be reported
D. Using a filter mask C. Respiratory rate of 4 breath/min immediately to the physician is:
27. A female client is experiencing D. Pulse rate less than 60bpm A. Restlessness
painful and rigid abdomen and is 34. Nurse Lucy is planning to give B. Yellow urine
diagnosed with perforated peptic pre operative teaching to a client C. Nausea
ulcer. A surgery has been who will be undergoing rhinoplasty. D. Clay- colored stools
scheduled and a nasogastric tube Which of the following should be 41. Which of the following
is inserted. The nurse should place included? antituberculosis drugs can damage
the client before surgery in A. Results of the surgery will be the 8th cranial nerve?
A. Sims position immediately noticeable A. Isoniazid (INH)
B. Supine position postoperatively B. Paraoaminosalicylic acid (PAS)
C. Semi-fowlers position B. Normal saline nose drops will need to C. Ethambutol hydrochloride
D. Dorsal recumbent position be administered preoperatively (myambutol)
28. Which nursing intervention C. After surgery, nasal packing will be in D. Streptomycin
ensures adequate ventilating place 8 to 10 days 42. The client asks Nurse Annie
exchange after surgery? D. Aspirin containing medications should the causes of peptic ulcer. Nurse
A. Remove the airway only when client is not be taken 14 days before surgery Annie responds that recent
fully conscious 35. Paul is admitted to the hospital research indicates that peptic
B. Assess for hypoventilation by due to metabolic acidosis caused ulcers are the result of which of the
auscultating the lungs by Diabetic ketoacidosis (DKA). following:
C. Position client laterally with the neck The nurse prepares which of the A. Genetic defect in gastric mucosa
extended following medications as an initial B. Stress
D. Maintain humidified oxygen via nasal treatment for this problem? C. Diet high in fat
canula A. Regular insulin D. Helicobacter pylori infection
B. Potassium
 43. Ryan has undergone subtotal 50. Which of the following
gastrectomy. The nurse should symptoms during the icteric phase
expect that nasogastric tube of viral hepatitis should the nurse
drainage will be what color for expect the client to inhibit?
about 12 to 24 hours after surgery? A. Watery stool
A. Bile green B. Yellow sclera
B. Bright red C. Tarry stool
C. Cloudy white D. Shortness of breath
D. Dark brown
44. Nurse Joan is assigned to
come for client who has just
undergone eye surgery. Nurse
Joan plans to teach the client
activities that are permitted during
the post operative period. Which of
the following is best recommended
for the client?
A. Watching circus
B. Bending over
C. Watching TV
D. Lifting objects
45. A client suffered from a lower
leg injury and seeks treatment in
the emergency room. There is a
prominent deformity to the lower
aspect of the leg, and the injured
leg appears shorter that the other
leg. The affected leg is painful,
swollen and beginning to become
ecchymotic. The nurse interprets
that the client is experiencing:
A. Fracture
B. Strain
C. Sprain
D. Contusion
46. Nurse Jenny is instilling an otic
solution into an adult male client
left ear. Nurse Jenny avoids doing
which of the following as part of the
procedure
A. Pulling the auricle backward and
upward
B. Warming the solution to room
temperature
C. Pacing the tip of the dropper on the
edge of ear canal
D. Placing client in side lying position
47. Nurse Bea should instruct the
male client with an ileostomy to
report immediately which of the
following symptom?
A. Absence of drainage from the
ileostomy for 6 or more hours
B. Passage of liquid stool in the stoma
C. Occasional presence of undigested
food
D. A temperature of 37.6 C
48. Jerry has diagnosed with
appendicitis. He develops a fever,
hypotension and tachycardia. The
nurse suspects which of the
following complications?
A. Intestinal obstruction
B. Peritonitis
C. Bowel ischemia
D. Deficient fluid volume
49. Which of the following
compilations should the nurse
carefully monitors a client with
acute pancreatitis.
A. Myocardial Infarction
B. Cirrhosis
C. Peptic ulcer
D. Pneumonia
 20. D. Nicotine (Nicotrol) is given in 40. D. Clay colored stools are indicative of
controlled and decreasing doses for the hepatic obstruction
Answers and Rationales management of nicotine withdrawal 41. D. Streptomycin is an aminoglycoside
1. B. Left sided heart failure causes fluid syndrome. and damage on the 8th cranial nerve
accumulation in the capillary network of 21. D. Raynauds disease is characterized by (ototoxicity) is a common side effect of
the lung. Fluid eventually enters alveolar vasospasms of the small cutaneous aminoglycosides.
spaces and causes crackling sounds at arteries that involves fingers and toes. 42. D. Most peptic ulcer is caused by
the end of inspiration. 22. A. Urine testing provides an indirect Helicopter pylori which is a gram
2. B. Morphine is a central nervous system measure that maybe influenced by negative bacterium.
depressant used to relieve the pain kidney function while blood glucose 43. D. 12 to 24 hours after subtotal
associated with myocardial infarction, it testing is a more direct and accurate gastrectomy gastric drainage is normally
also decreases apprehension and measure. brown, which indicates digested food.
prevents cardiogenic shock. 23. C. One liter of fluid approximately 44. C. Watching TV is permissible because
3. D. Seeing yellow spots and colored weighs 2.2 pounds. A 4.5 pound weight the eye does not need to move rapidly
vision are common symptoms of loss equals to approximately 2L. with this activity, and it does not
digitalis toxicity 24. A. Osmosis is the movement of fluid increase intraocular pressure.
4. C. When diuretics are taken in the from an area of lesser solute 45. A. Common signs and symptoms of
morning, client will void frequently concentration to an area of greater solute fracture include pain, deformity,
during daytime and will not need to void concentration. shortening of the extremity, crepitus and
frequently at night. 25. D. Forearm muscle weakness is a swelling.
5. B. The primary goal of therapy for the probable sign of radial nerve injury 46. C. The dropper should not touch any
client with pulmonary edema or heart caused by crutch pressure on the axillae. object or any part of the clients ear.
failure is increasing cardiac output. 26. B. Neutropenic client is at risk for 47. A. Sudden decrease in drainage or onset
Pulmonary edema is an acute medical infection especially bacterial infection of of severe abdominal pain should be
emergency requiring immediate the gastrointestinal and respiratory tract. reported immediately to the physician
intervention. 27. C. Semi-fowlers position will localize because it could mean that obstruction
6. C. Decerebrate posturing is the extension the spilled stomach contents in the lower has been developed.
of the extremities after a stimulus which part of the abdominal cavity. 48. B. Complications of acute appendicitis
may occur with upper brain stem injury. 28. C. Positioning the client laterally with are peritonitis, perforation and abscess
7. C. The most frequent side effects of the neck extended does not obstruct the development.
Cascara Sagrada (Laxative) is abdominal airway so that drainage of secretions and 49. D. A client with acute pancreatitis is
cramps and nausea. oxygen and carbon dioxide exchange can prone to complications associated with
8. D. Administration of Intravenous occur. respiratory system.
Nitroglycerin infusion requires pump for 29. B. Excessive bubbling indicates an air 50. B. Liver inflammation and obstruction
accurate control of medication. leak which must be eliminated to permit block the normal flow of bile. Excess
9. A. By the 2nd day of hospitalization after lung expansion. bilirubin turns the skin and sclera yellow
suffering a Myocardial Infarction, 30. C. Wheat cereal has a low sodium and the urine dark and frothy.
Clients are able to perform care without content.
chest pain 31. A. Enlarged cirrhotic liver impinges the
10. B. The left side of the body will be portal system causing increased
affected in a right-sided brain attack. hydrostatic pressure resulting to ascites.
11. A. After nephrectomy, it is necessary to 32. C. Assessing for an open airway is the
measure urine output hourly. This is priority. The procedure involves the
done to assess the effectiveness of the neck, the anesthesia may have affected
remaining kidney also to detect renal the swallowing reflex or the
failure early. inflammation may have closed in on the
12. B. The lumen of the arteries can be airway leading to ineffective air
assessed by cardiac catheterization. exchange.
Angina is usually caused by narrowing 33. A. Typical signs and symptoms of
of the coronary arteries. hypovolemic shock includes systolic
13. C. Blood pressure is monitored to detect blood pressure of less than 90 mm Hg.
hypotension which may indicate shock 34. D. Aspirin containing medications
or hemorrhage. Apical pulse is taken to should not be taken 14 days before
detect dysrhythmias related to cardiac surgery to decrease the risk of bleeding.
irritability. 35. A. Metabolic acidosis is anaerobic
14. A. Protamine Sulfate is used to prevent metabolism caused by lack of ability of
continuous bleeding in client who has the body to use circulating glucose.
undergone open heart surgery. Administration of insulin corrects this
15. C. The use of electronic toothbrush, problem.
irrigation device or dental floss may 36. D. Beta-carotene and Vitamin E are
cause bleeding of gums, allowing antioxidants which help to inhibit
bacteria to enter and increasing the risk oxidation. Vitamin E is found in the
of endocarditis. following foods: wheat germ, corn, nuts,
16. B. Weight gain due to retention of fluids seeds, olives, spinach, asparagus and
and worsening heart failure causes other green leafy vegetables. Food
exertional dyspnea in clients with mitral sources of beta-carotene include dark
regurgitation. green vegetables, carrots,mangoes and
17. D. Discomfort or pain is a problem that tomatoes.
originates in the kidney. It is felt at the 37. A. Gravity speeds up digestion and
costovertebral angle on the affected side. prevents reflux of stomach contents into
18. A. Perfusion can be best estimated by the esophagus.
blood pressure, which is an indirect 38. B. Abdominal distension may be
reflection of the adequacy of cardiac associated with pain, may indicate
output. perforation, a complication that could
19. C. Myoclonic seizure is characterized by lead to peritonitis.
sudden uncontrollable jerking 39. D. It may take 4 to 6 months to eat
movements of a single or multiple anything, but most people can eat
muscle group. anything they want.