NURSING PRACTICE IV CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART B

1. A client is hospitalized for treatment of a fractured femur. Suddenly, he becomes pale, confused and very short of breath. He complains of pain to his chest. The nurse also notes petechial hemorrhages on his legs and stomach. The nurse suspects that this clients. a. Is having an acute anxiety attack c. May have a wound infection b. May have a fat embolism d. Is having a myocardial infarction Rationale: B Because involvement of the long bone with shortness of breath involving respiration and petechia this occur within 24 to 48 which not mention. What make (A) wrong because it is psychosocial and (C, D) it didnt answer the question. 2. The nurse is the first professional to arrive at the scene of a multi vehicle accident. Mr. R. was riding a motorcycle. Upon impact, he fell off the bike and it fell back on his legs. Priority care for Mr. R. should be directed toward: a. assessing blood loss c. obtaining vital signs b. monitoring respiratory status d. organizing lay people on the scene Rationale: B In the presence of multiple trauma, maintenance of a patent airway must always be the priority in the sequence of care delivery. Assessing blood loss would be the second priority of care. Obtaining vital signs would be the next action. Organizing lay people on the scene would be a later action. 3. A client involved in a motor vehicle accidents is brought to the emergency department with head and chest injuries. The client is unresponsive and is unable to give informed consent for surgery. Which of the following actions is most appropriate for the nurse to take? a. Have the physician and anesthesiologist sign the consent form. b. Witness the consent form along with another nurse. c. Prepare the client for surgery and omit the form since the client cannot consent. d. Request that the nursing supervisor witness the consent form. Rationale: C Informed consent for adults is not needed when delay of treatment to obtain consent would be harmful or lethal to the client or when the client waives the right to informed consent. In this situation, the first circumstance applies, and the nurse should prepare the client for surgery. Option A is incorrect; these two individuals do not sign the consent form. Options B and D are incorrect because there is no client signature to witness. 4. What is the most important aspect to include when developing a home care plan for a client with severe arthritis? a. Maintaining and preserving function c. Supporting coping with limitations b. Anticipating side effects of therapy Rationale: A d. Ensuring compliance with medications

To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture and active and passive range of motion exercises important interventions for maintaining function of affected joints. 5. An adult client sustained a fractured tibia three hours ago. A long leg cast was applied. Now the client is complaining of increasing pain. The pain is more intense with passive flexion of the toes. The nurse suspects the client is developing compartment syndrome. Which initial action should the nurse take? a. Prepare for emergency fasciotomy. b. Administer the ordered narcotic IV, then reassess the clients pain in 15 minutes. c. Raise the casted leg above the heart, apply ice and notify the physician. d. Raise the casted leg to the level of the heart, notify the physician, and prepare to split the cast. Rationale: D To decrease the pressure within the compartment, raise the affected extremity only to the level of the heart and remove any constructive dressing or cast. If this does not work to decrease the pressure, a fasciotomy may be necessary Option A - Fasciotomy is performed if compartment pressure cannot be relieved Option B Pain from compartment syndrome does not respond well to pain medicine Option C Placing the extremely above the level of the heart increases compartment pressure and should be avoided. 6. Mrs. Susan has a fractured right hip with 5 lb of Bucks traction. The bed that Mrs. F. is in is broken. How should the nurse best direct the team to move Mrs. F. to the new bed? a. Slowly lift the traction to release the weight, support the right leg, and lift Mrs. F. to the new bed b. Slowly lift the 5 lb weight from the traction set up, and apply 10 lb of manual traction during the move c. It is not safe to move Mrs. F. with Bucks traction. Support her position changes with pillows until traction is no longer needed. d. Decrease the weight of traction over a two hour period; then discontinue the traction and move Mrs. F. into the new bed. Rationale: A 5-8 lbs of traction is applied temporarily to provide immobilization prior to surgery. Bucks traction should be removed every eight hours to assess the skin under the traction device. Skeletal traction should not be released unless there is a life-threatening emergency. Option B - it is not necessary to maintain manual traction, especially at twice the weight, to move a person in Bucks traction. Option C - it is safe to move persons with Bucks traction and would be uncomfortable to use pillow support for position changes. Option D - Once the weight of traction has been established as effective, the weight should be maintained until it is no longer needed. 7. A nurse is training a client for a swing-to gait. What is the most specific direction you can give to your client? a. Move both crutches forward, then lift and swing your body past the crutches. b. Place the two crutches forward, immediately follow your weak leg in lined to them, them lift swing your other leg. c. Look down at your feet before moving the crutches to ensure you wont fall, then raise your head as you sways away. d. Move both crutches forward, then lift and swing your body in conjunction with crutches.

Rationale: D This is the procedure for using the swing-to gait. Clients are instructed to look straight ahead when walking with crutches. Looking down can lead to falls and uneven gait. Option A is swing-through. Option B is 3-point gait. Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 311. 8. On the second postoperative day after the hip surgery for a fractured left hip, you are going to help your client ambulate. The best thing that you can do is: a. Allow minimal amount of weight on the hips when getting him up. b. Let the client get up by having him flex the hips for about degrees to maintain proper bodily contour. c. Use a walker for balance when getting up the client. d. Let the client dangle first his legs before moving up. Rationale: C Postoperatively hip replacement clients may get up the first day, but need to use a walker for balance. They should not bear any weight on the affected side, dangle or sit in a chair, flexing their hips. Positions with 60-90 degree flexion should be avoided. Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 51. 9. A nursing student is problematic about her upcoming NCLEX exam, she tells you If only my skull can move! I think I can get an extra enlargement of my ideas too. The skull is functionally classified as what type of joint? a. Syndesmosis c. Synarthrosis b. Amphiarthrosis d. Diarthrosis Rationale : C Functional classification depends on the degree of movement the joint allows. A diarthrosis, such as the knee, moves freely. A synarthrosis cant move like the pelvis and skull. Amphiarthrosis can move only slightly like the coccyx and sacrum. A syndesmosis like the tibiofibular or radioulnar joint, is a type of amphiarthrosis with intervening connective tissue forming an interosseous membrane or ligament. Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 96. 10. Which among the following could be the best health teaching to a client who had sprained her ankle and the toes? a. Place a lukewarm compress to the site. b. Try to exercise the site a little to prevent loss of function and gangrene formation. c. Place your toes and ankle in lined with your hips to prevent much blood loss. d. You can try frozen water to the affected areas. Rationale: D Treatment of a sprained muscle includes resting the affected leg and applying an elastic or compression bandage to a sprained muscle to control swelling. Elevating the legs and applying ice area also included. Option D is just the reword ICE! (RICE: rest, ice, compress, elevate) Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 121. 11. After change-of-shift report, which patient should the nurse assist first? a. A client with fracture complaining that the cast is tight b. A client with right leg amputation complaining of phantom pain

c. A client with hyperthyroidism who tells you that he feels depressed d. A client with carpal tunnel syndrome complaining of pain Rationale: A The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage. While all of the other patients concerns are important and the nurse will want to see them as soon as possible, none of their concerns is urgent. Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62. 12. A client with Pagets disease is admitted in your unit. After thorough assessment, which finding indicates that the physician should be notified? a. The patient is 411 and weighs 110 pounds. b. The patients skull is soft and larger than normal. c. The base of the patients skull is invaginated. d. The patient has bowing legs Rationale: C Platybasia (basilar skull invagination) causes brain stem manifestations that threaten life. Patients with Pagets disease are usually short and often have bowing of the long bones that results in asymmetric knees or elbow deformities. Their skull is typically soft, thick, and enlarged. Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62. 13. A 1year-old boy is admitted to the hospital with a fractured femur. Which of the following lunches would be the most appropriate? a. String beans b. Strained beans c. French fries d. Infant formula Rationale: A The finger foods appeal to a 1-year-old and offer appropriate nutrition as well. A fractured femur does not require a special diet. Option B, this may be a nutritious meal, but offers little variety in texture, and the child cannot easily feed herself. Option C, it is best to avoid fried foods when possible. Foods should be broiled, poached, or baked rather than fried. Option D, solids should be introduced to the child at around six months of age. Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 65. 14. Which of the following assessment findings would a nurse expect in a client with gouty arthritis? a. Pruritus and increased calcium in the blood b. Positive blood culture results and increased ESR c. Abnormal ABG results and petechiae in the chest d. Bone pain and increased WBC Rationale: A Hyperuricemia and pruritus are associated with gouty arthritis. Osteomyelitis causes localized bone pain, tenderness, heat and swelling at affected area, high fever, increased WBC count and ESR and positive blood culture results. Petechiae over the chest and abnormal ABG results suggest fat embolism. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 433.

15. A 16-year-old client is admitted for scoliosis repair with a Harrington Rod insertion. The Nurse should not fail in giving this information to the client before the postoperative care: a. Take a soft diet b. Elevate legs 5 times every 2 hours c. Get off and on the bedpan by lifting hips d. Take 10 deep breaths every 2 hours Rationale: D These clients must be monitored closely for the first 48-72 hours for respiratory problems. Bowel and urinary problems need to be assessed along with neurological problems in the extremities. Option A, incorrect because the client may have a nasogastric tube to low suction. Option C, incorrect because the client will have a catheter. Option B, is not appropriate for the situation. Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 28. 16. Client Morazella wrathfully goes to you for some advices. She yells to you, Whats the fact about being obese?! a. Obese people have a lower percentage of water than lean people. b. Obese people have a higher percentage of water than lean people. c. Girls have a higher percentage of water than boys. d. You are not obese, you are sexy! We are sexy Rationale: A The proportion of body water varies inversely with the bodys fat content because fat contains no water. Therefore, an obese person has a lower percentage of water than a lean person. Most women have a lower percentage of water than men because their bodies normally have a higher percentage of body fat. (Option D is the best answer nyahaha!) Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 341. 17. The nurse made her diagnosis for a client who is having a shock, Fluid Volume Deficit related to decreased plasma volume. Which of the following supports her diagnosis? a. Shallow respirations with some bubbling crackling sounds. b. Some pitting edema found in the ankles. c. Bounding post-tibial pulses d. Flattened neck veins, which are obvious upon lying in. Rationale: D Normally, check veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristics of Fluid Volume Excess. Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 23. 18. If a client had a diagnosis of Syndrome of Inappropriate Anti-diuretic Hormone (SIADH), which of the following electrolyte should a nurse watchful for? a. Decreased sodium c. Increased potassium b. Increased sodium d. Decreased potassium Rationale: A SIADH causes a relative sodium deficit due to excessive retention of water. Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 24.

19. Which of the following would the nurse suspect if the clients ECG waveform is tall-tented T waves? a. Hyperkalemia c. Hypokalemia b. Hypercalcemia d. Hypocalcemia Rationale: A An ECG waveform showing a shortened QT interval and bradycardia suggests hypercalcemia. The ECG pattern typically associated with hyperkalemia reveals tall-tented T waves, a prolonged PR interval and QRS duration, absent P waves, and ST depression. The ECG associated with hypocalcemia typically shows a prolonged QT interval. With hypokalemia, the ECG reveals a flattened T wave, prominent U wave, depressed ST segment, and prolonged PR interval. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed., 2001. p. 66. 20. Which of the following clinical manifestations signifies hyperphosphatemia? a. Increased respiratory rate b. Diaphoresis, flushed skin c. Hyperreflexia d. Rhabdomyolysis and muscle pain Rationale: C Soft tissue calcification and hyperreflexia are indicative of hypermagnesemia. Increased RR and depth are associated with metabolic acidosis. Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed., 2001. p. 66. 21. Foods high in potassium should be avoided in which of the following anomalies? a. Renal disease c. Ileostomy b. Colostomy d. Metabolic alkalosis Rationale: A Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic alkalosis may be hypokalemic and should be encouraged to eat foods high in potassium. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 65. 22. When assessing a client in the oliguric-anuric stage of acute renal failure, the nurse notices a respiratory rate of 28, and the client complains of nausea, a dull headache, and general malaise. The priority nursing action should be? a. Provide oxygen at 2 L by nasal cannula. b. Administer analgesic and antiemetic as ordered. c. Check the chart for her latest electrolyte values. d. Notify the physician Rationale: C The nurse should look for the clients latest potassium level, since these symptoms indicate hyperkalemia, which can lead to death. Option A, the client is not in respiratory distress. Option B, this is not a priority since the client is exhibiting symptoms of an increased potassium level, which can lead to death. Option D, the physician will want a complete assessment before being notified, and will require

the nurse to relate the potassium level. Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159. 23. ICF as opposed to ECF has higher concentration of which of the following electrolyes? a. Magnesium and potassium c. Calcium and potassium b. Sodium and calcium d. Chloride and potassium Rationale: A ICF has higher concentrations of magnesium, potassium, protein, phosphate, and sulfate, and lower concentrations of sodium, calcium, chloride and bicarbonate. Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 341. 24. A client, admitted with aspirin intoxication, has the following results: pH=7.50, PaCO2=32, HCO3=24. This clients blood gas values indicate which of the following acid-base disturbances? a. Respiratory Alkalosis c. Respiratory Alkalosis, compensated b. Metabolic Alkalosis d. Metabolic Alkalosis, uncompensated Rationale: A This is common due hyperventilation, which causes blowing off CO2 and hence a decrease in plasma carbonic acid content. This should be uncompensated because the bicarbonate is normal. Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159. 25. The laboratory technician just handed to you the electrolyte profile. It is known that the major cation of the body is a. Bicarbonate b. Phosphate c. Magnesium d. Choride Rationale: C Major cations (positively charged) include Na, potassium, calcium, and magnesium. Major anions (negatively charged) include chloride, bicarbonate and phosphate. Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 341. 26. Twelve hours post lumbar laminectomy a client complains of discomfort and the inability to void. Which is the best action for the nurse to take? a. Assist the client to the bathroom b. Palpate for fullness of the bladder c. Apply manual pressure to the bladder as the client attempts to void d. Insert an indwelling catheter Rationale: B After surgery, urinary retention may occur for may occur for many reasons: anesthesia depresses the micturition reflex arch, voluntary micturition is impeded when the bladder is distended, or the supine position reduces the ability to relax the perineal muscles and external sphincter. If the bladder is distended and conservative measures have not induced voiding, an order for catheterization should be obtained. 27. A normal sign of aging in the renal system is: a. incontinence c. microscopic hematuria b. concentrated urine d. a decreased glomerular filtration rate

Rationale : D The glomerular filtration rate is decreased dramatically in the elderly because of changes in the renal tubles. The person loses the ability to concentrate urine as aging occurs. Microscopic hematuria is a symptom of pathology, not normal aging. Incontinence is not an expected outcome of aging. 28. The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment? a. High serum creatinine levels c. Hypocalcemia b. Low hemoglobin welve d. Hypokalemia Rationale: A High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients. 29. There is a physicians order to irrigate a clients bladder. Which one of the following nursing measures will ensure patency? a. Use a solution of sterile water for the irrigation b. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to remain for 10 hour, and then siphon it out d. Irrigate with 20mL's of normal saline to establish patency Rationale: D Normal saline is the fluid of choice for irrigation. It is never advisable to force fluids into a tubing to check for patency. Sterile water and aqueous Zephiran will affect the pH of the bladder as well as cause irritation. 30. Nurse Joyce is putting a retention catheter for a male client. She is confused where to tape the catheter. You are helping her if you suggested her to tape it where? a. On the inner thigh c. Under the thigh b. On the navel area d. On the upper thigh Rationale: D The catheter should be taped on the lower abdomen or upper thigh to prevent a penoscrotal angle that can cause a fistula development. Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 291. 31. Grandpa Daddy is ordered by the physician to take Finasteride (Proscar) for the treatment of benign prostatic hyperthrophy (BPH). Which statement if made by him will you give him a two thumbs up? a. Im glad that this medication can have its effect within 6 months. b. I should maintain proper hygiene because I know I will be catheterized for months. c. Grandma will have some lonely nights, but I know I can express my love in some other ways. d. This drug does not give the guarantee that surgery will be another thing to be done. Rationale: C Finasteride is an androgen inhibitor that may promote a reductionof prostatic hypertrophy, thereby improving bladder emptying. It may take 6-12 months to become effective and it does not

work for all clients. Some clients, therefore, will need surgery to relieve the obstructive symptoms of BPH. One of the side effects of the drug is decreased libido. Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 293. 32. Mrs. Hilary arrived in the emergency room because she made an overheated argument with Obaman regarding the issue about sex change. Your blood pressure reading is 220/150. Upon further assessments done by the primary physician, he decided to give her a loop diuretic. What is the purpose of this medication? a. This medication acts on the loop of Henle to control the flow of water and electrolytes. b. Hydrogen ions and potassium are secreted and reabsorbed c. Water is removed from the filtrate and returned to the interstitial fluid. d. Solutes are reabsorbed from the glomerular filtrate back into the blood. Rationale: A Sodium and chloride are removed to maintain osmolality by ascending tubule of loop of Henle Option B refers to the function of nephrons distal tubule. Option C, refers to descending tubule of the loop of Henle. Option D, refers to proximal tubule.. Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 324. 33. A client put his call light on and tells the nurse that she has to urinate. The client has had a Foley catheter in place since her surgery 3 days ago. What is the most appropriate nursing action? a. Checking the catheter and tubing for kinks, note also for the urine output in the drainage bag. b. Explain to him that the urge to void is a common occurrence for clients who have urinary catheters. c. Replace the Foley catheter with a new catheter. d. Remind the client that she has a Foley catheter in place and does not need to go to the bathroom. Rationale: A Checking the equipment is the best nursing action, since data will be obtained which will assist the nurse with problem solving. This is a nursing process question, and assessment is always the first nursing action in this type of question. Option B - The urge to void usually occurs upon initial insertion of the Foley catheter, not 2 days afterwards. There are several possible reasons for the client having urgency, and the nurse must attempt to discover the cause in order to meet the clients needs. Option C - a new catheter might be necessary to meet the clients needs, but the nurse must assess the situation further to determine the cause of the clients urge to void. Option D - although a Foley catheter is in place, it may not be patent, which can result in distention of the bladder and cause the patient to feel the urge to void. This action does not meet the clients needs. Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 54. 34. Which among the following statements made by the client would be the cause of his impotence problem? a. I have never had an intimate sexual relationship for 2 years now. b. I have urinary frequency and dribbling. c. I have had diabetes for the last 5 years. d. I dont buy Mens magazine anymore.

Rationale: C Impotence may result from psychogenic and organic causes. Endocrine conditions such as diabetes, pituitary tumors, and hypogonadism are possible organic causes of impotence. Options A & D are the result or effects of this impotence. Option B, are signs and symptoms of BPH. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 279. 35. A three-way bladder irrigation is used after TURP to prevent which of the following inconsistencies? a. Hemorrhage b. Urinary retention c. Infection d. Clot formation Rationale: A After TURP, 3-way bladder irrigation provides continuous normal saline in the bladder to prevent hemorrhaging. Typically, the urine output should be light pink. Infection, urinary retention, and thrombosis are complications after the TURP, but bladder irrigation cannot prevent them. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 278. 36. A common management for a client having chronic renal failure is which of the following? a. Weighing the client before each meal and drinking 500 ml of fluid about 5 times each day. b. Subtracting 500 ml to the previous days urine and limiting intake of coffee. c. Adding 500 ml to the previous days urine and dividing that amount over the next 24 hours. d. Maintain the intake of fluid in the morning rather than the afternoon to prevent nighttime bladder distention. Rationale: C Insensible losses (500 ml) plus urine output determines intake in the renal failure. Fluid intake should be divided over a 24-hour period. Drinking 500 ml of fluid 5X each day far exceeds the recommended allotment. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 488. 37. A nurse is caring for clients having a common theme of knowledge deficit related to the needs for teaching to prevent pyelonephritis. This concept is not commonly related to which of the following? a. A bedridden grandmother, with an indwelling catheter. b. A toddler with a history of vesicourethral reflux. c. A 28-year-old, sexually active man. d. A woman who has been treated for urinary tract infection and retention. Rationale: C Kidney infections are caused by immobility, reflux, stasis and debilitation. Women are more prone to UTI. The other options are more prone to UTI. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 488. 38. A client has an order for a sterile urine specimen to be obtained. What is the best nursing action in obtaining specimen from the retention collector? a. Clamp the drainage tube, when fresh urine collects, open the tubing and drain in into a sterile container. b. Disconnect the tubing between the catheter and the drainage bag and drain urine into sterile

container. c. Disconnect the drain at the bottom of the drainage bag and drain urine into a sterile container. d. Use sterile syringe and needle to obtain urine from the porthole. Rationale: D This represents the appropriate process in collecting a sterile urine specimen. The other options open a closed system which allows bacteria to be introduced. Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 25. 39. A client has lower flank pain due to possible renal calculi. On completion of an ultrasound of the kidney and ureters, the priority nursing intervention should be: a. Straining urine c. Administer a laxative b. Restricting fluids d. Obtaining vital signs Rationale: A With complaint of flank pain and the possibility of renal calculi, straining urine is appropriate. Option B, would not be done, as a client with possible renal calculi needs to increase fluids to promote the flushing out of the stone. Option C, is unnecessary. Option D, is not as high a priority since this is not an invasive procedure. Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 64. 40. During peritoneal dialysis, the nurse notes that the outflow is less than the inflow. What should the nurse do? a. Notify the physician c. Reposition the dialysis catheter b. Change the clients position d. Irrigate the catheter with 30 ml of saline Rationale: B The outflow should always be greater than the inflow. After the dwell time the dialysate should be diffusing out the extra fluid and waste products. By changing a clients position you can affect the drainage. If after changing the clients position there is not an increased amount of drainage, the doctor should be notified (Option A). Sometimes problems with outflow are related to a full colon. Peritoneal catheters are surgically placed and are usually not irrigated (options C&D). Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 67. 41. The nurse finds her client who has myxedema having some crackles in the right lower lung lobe, decreased breath sound and a respiratory rate of 11/min. The client does not appear to be dyspneic. The best nursing action that you can institute upon seeing this condition is: a. Initiate postural drainage. b. Increase turning in bed and some deep breathing exercises. c. Maintain enough rest and sleep. d. Increase fluid intake Rationale: B Clients with myexedema often experience a decreased respiratory rate and chest excursion, so they require extra care to prevent atelectasis. Encouraging moving, turning, and coughing exercises will open the alveoli, thus decreasing the risk of atelectasis. Postural drainage and increase fluid intake will not prevent atelectasis because the treatment does not expand the alveoli. Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 363. 42. Client Nenita has a hyperparathyroidism. When her papa comes she yells for some comfort.

a. b. c. d.

Nenita loves to be thrown in the air. Upon seeing this, you think of giving him this teaching that Nenitas extremities, especially the arms, should be held with care because of Edema causes tissue to seepage easily and may tore easily. It can suppress her energy stores and depletes her calcium and phosphate bone deposits. Decreased calcium bone deposits can lead to fractures. Hypercalcemia leads to bone resorption.

Rationale: C The parathyroid glands regulate calcium in the body. Excessive activity results in calcium leaving the bones and teeth to enter the bloodstream. This makes the bones more brittle and susceptible to fracture. Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 362. 43. After several sessions of health teaching about proper care of the bodily systems in the community hospital, you try asking one client for what is the possible cause of myxedema. You and the group of patients will clap your hands when she says: a. It is caused by overproduction of FSH. b. Give me another day to confirm this, but as I remember it, it is caused by decreased secretion of adrenocorticotropin hormone c. It is caused by too little TSH. d. It is caused by too much secretion of adrenocorticotropin. Rationale: C Hyposecretion of TSH causes myxedema, which is characterized by slow speech, slow metabolism, hand and facial swelling, and coarse, edematous skin. Too much FSH leadsto precocious puberty. Hyposecretion of adrenocorticotropin hormone results in Addisons disease, which is marked by hypotension, anorexia, increased skin pigmentation, hypoglycemia, nausea and hypotension. Hypersecretion of adrenocorticotropin results in Cushings disease, which is characterized by fatigue, weakness, and adiposity of the face, neck, and trunk. Reference: Bates, Rita. Straight As in Anatomy and Physiology. 2007. p. 364. 44. A client is a type I diabetes mellitus client. He is scheduled for a gall bladder X-ray in the outpatient department. He was given medication to take as a preparation for this test. Which of the following nursing actions is most important when preparing the client for this test? a. Give the client directions to the Outpatient Department and the parking lot. b. Tell the client to take his insulin and eat breakfast before leaving home. c. Explain to the client that he should not take his insulin before the X-ray. d. Explain the procedure to the client, and ask if he has any question. Rationale: C IF the client takes his insulin before the test but remains PO as required for procedure, hypoglycemia may result and potentially life-threatening. Maintaining the glucose level is a physiological need which should receive highest priority based on Maslows Hierarchy of Needs. Option B, the client should not eat breakfast. The test for which he is scheduled requires that he remain NPO. It is also very important that the client not take his insulin, because taking his insulin without eating breakfast may cause a potentially life-threatening hypoglycemia. Option A, the client should be given directions to the outpatient department and information about whereto park. However, this is not the most important nursing action in preparing him for the test. Option D, any client scheduled for a test should be given an explanation and opportunity to ask questions. Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 60.

45. Which among the following would be included in the fluid management for the client diagnosed with SIADH? a. Increased fluid intake c. Fluid restriction b. D10W as ordered d. NSS and IVF as ordered Rationale: C SIADH involves the oversecretion of ADH, resulting in excessive water conservation. Fluid management involves fluid restriction, because the client already has an excess amount of fluid in the body. Rapid administration of IVF, IFI, and dextrose would exacerbate the clients water-intoxicated state. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 246. 46. A client is manifesting some addisonian crisis. Which of the following are common with this disorder? a. Rapid respirations, pallor and hypotension b. Chvostek sign, numbness c. Tremors, heached, increased heart rate d. Increased urine output, increase fang Rationale: A The signs and symptoms of an addisonian (adrenal) crisis are the clinical manifestations of shock such as hypotension, rapid respirations, and pallor. Polyuria, polydipsia, and polyphagia are signs and symptoms of DM. Tremors, tachycardia and headache are associated with hypoglycemia. A positive Chvostek sign, photophobia and numbness are signs and symptoms of hypoparathyroidism. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 247. 47. A nurse is caring for a diabetic client. The client has been managed by giving regular and NPH insulin in the morning and evening. The result of the blood glucose-monitoring test is hyperglycemic before the morning meal. Which of the following doses of insulin would the nurse suspect to be the cause? a. Evening dose of NPH insulin b. Morning dose of regular insulin c. Evening dose of regular insulin d. Morning dose of NPH insulin Rationale: A The NPH insulin taken at supper exerts its greatest effect during the night. The peak action of regular insulin occurs at 2-4 hours, so neither the morning nor evening dose could affect breakfast-time blood glucose level. The morning dose of NPH dissipates long before breakfast the next morning. Reference: Huttel, Ray. Lippincotts Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 247. 48. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: a. In 10-20 minutes c. In 60 120 minutes b. In 30-60 minutes d. In 40-100 minutes

Answer: B Rationale: The onset for regular insulin is 30-60 minutes. Reference: Exam Cram, 1st Edition 2006. Pearson Education Ltd. 49. The result of the stimulation of calcitonin is which of the following? a. High serum calcium level b. Low serum calcium level c. High sodium level d. Low sodium level Rationale: Calcitonin promotes calcium absorption in the bone decreasing serum calcium levels. Reference: Mastering Fundamentals of Nursing, 2004. Josie Udan, RN. 50. When the nurse tested an unconscious client for noxious stimuli, the client responded with decorticate rigidity or posturing. This is best described as: a. Flexion of the upper and lower extremities into a fetal-like position b. Rigid extension of the upper and lower extremities and hyperextension of the neck c. Complete flaccidity of both upper and lower extremities and hyperextension of the neck d. Flexion of the upper extremities, extension of the lower extremities, and plantar flexion Rationale: D Decorticate rigidity or posturing is best described as an abnormal flexor response in the arm with extension and plantar flexion in the lower extremities. Decerebrate rigidity involves rigid extension of the arms and legs with plantar flexion. Flexion of the upper and lower extremities into a fetal-like position is a complication of bed rest. 51. Which of the following reduces cerebral edema by constricting cerebral veins? a. Dexamethasone (Decadron) c. Mannitol (Osmitrol) b. Mechanical hyperventilation d. Ventriculostomy Rationale: B Mechanical hyperventilation to reduce CO2 levels to 25 mmHg produces cerebral vasoconstriction and thereby decreases ICP. Dexamethasone is an anti-inflammatory agent. Mannitol is an osmotic diuretic. While the actions of both drugs will reduce cerebral edema, neither constricts cerebral veins. Ventriculostomy is a surgical procedure where a catheter is placed into a cerebral ventricle to drain excess cerebrospinal fluid. 52. The nurse is caring for an adult client who was admitted unconcious. The initial assessment utilized the Glasgow Coma Scale. The nurse knows that the Glasgow Coma Scale is a systemic neurological assessment tool that evaluates all of the following EXCEPT a. Eye opening c. Pupillary reaction b. Motor response d. Verbal performance Rationale: C The Glasgow Coma Scale is a practical scale that independently evaluates three features: eye opening, motor response, and verbal performance. It does not evaluate pupillary reaction. 53. An adults Glasgow Coma Scale score is indicative of coma. Her score is: a. Zero b. Two c. Six d. Ten

Rationale: C Without even thinking about it the answer must be #3 due to the fact that the lowest score possible is a 3 and the top being a 15. The score obtained with this scale is used to the assess Coma and impaired consciousness # Mild is 13 through 15 points # Moderate is 9 to 12 points # Severe 3 through 8 points # Patients with score less than 8 are in Coma 54. An adult has the medical diagnosis of increased intracranial pressure and is being cared for on the neurology unit. The nursing care plan includes elevating the head of the bed and positioning the clients head in proper alignment. The nurse recognizes that these actions are effective because they act by a. making it easier for the client to breathe c. promoting venous drainage b. preventing a Valsalva maneuver d. reducing pain Rationale: C It has been demonstrated that positioning the client with the head elevated to 30 degrees decreases ICP. Gravity aids in venous drainage from the head. Pronounced angulation of the neck can obstruct venous return. Pain, airway problems, and a Valvalsa maneuver will all increase ICP and will not directly benefit from proper head alignment. 55. An elderly woman reports that she has been using more salt on her food than she used to. This is because: a. Her taste buds are dulled b. She is confused because of her advancing age c. Sodium is needed to ensure adequate renal function d. Her body is attempting to compensate for lost fluids Rationale: A The taste buds begin to atrophy at age 40 and insensitivity to taste qualities occurs after 60. Studies related to diminished taste indicate that there are changes in the salt threshold for some elderly individuals. People lose the ability to compensate for fluid losses as they age. Extra sodium is not needed for renal function. Confusion can cause a wide variety of behaviors but most elderly individuals do not experience confusion. 56. A 24 year old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours Rationale: B The halo or "bull's eye" sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result. 57. A 24 year old male is admitted with a possible head injury. His arterial blood gases show

a. b. c. d.

that his ph is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his Pa CO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that: Edema has resulted from a low pH state Acidosis has caused vasoconstriction of cerebral arterioles Cerebral edema has resulted from a low oxygen state Cerebral blood flow has decreased

Rationale: C Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg. 58. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is a. That it is reversible c. Amnesia will occur b. Loss of consciousness may be transient d. Laceration of the brain may occur Rationale: D Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible. 59. Mrs. Cuneta is an 80-year-old client admitted to your nursing unit with a diagnosis of weakness, status post fall. The admission face sheet indicates that she is widowed and lives alone. As you work through your nursing admission assessment, which of the following would be the least priority concern? a. Ask Mrs. T about the details of her fall. b. Does Mrs. T like to read? c. Ask Mrs. T about her ability to shop and cook for herself. d. What medications has she been taking?

Rationale: B Mrs. Cunetas reason for admission is weakness and a fall. Priority concerns in assessment would be to identify any intrinsic or extrinsic factors that lead to her fall. Her interest in reading, although it be important in determining possible activities to incorporate into her care plan while in the hospital, is a lesser priority. 60. You are the emergency nurse on duty when a young man is brought in after an auto accident with massive head injuries. You know that if he is judged to be brain dead, organ donation is suggested. Which of the following statement is true about organ donation? a. The family of a donor is not changed for the cost of organ donation b. Organ donation disfigures the donor and potentially alters the funeral arrangements c. The family is not asked for organ donation when a client has massive head inujuries d. The donors name and personal information is given to the organ recipient to facilitate communications after the transplant. Rationale: A The family or donor's estate is not charged for organ donation. Organ donation does not disfigure

the donor. Funeral arrangements, such as open caskets, do not have to be altered because of donation. Often families of clients with massive head injuries who become brain dead are given the opportunity to donate organs because the other organs are still functional. The donor's information is confidential and not communicated to the recipient under normal circumstances. 61. A 24 year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours Rationale: B The halo or "bull's eye" sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result. 62. A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that a. Edema has resulted from a low pH state b. Acidosis has caused vasoconstriction of cerebral arterioles c. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased Rationale: C Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg 63. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is a. That it is reversible c. Loss of consciousness may be transient b. Amnesia will occur d. Laceration of the brain may occur Rationale: D Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible. 64. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to : a. Blindness b. Myopia c. Retrolental fibroplasias d. Uveitis Rationale: A The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic

nerve, and leads eventually to blindness. 65. A nurse is caring for a burn client who has sustained thoracic burns and smoke inhalation and is risk for impaired gas exchange. The nurse avoids which action in caring for this client? a. repositioning the client from side to side every 2 hours b. maintaining the client in a supine position with the head of the bed elevated c. suctioning the airway as needed d. providing humidified oxygen as prescribed Rationale: A Aggressive pulmonary measures are used to prevent respiratory complications in the client who has impaired gas exchange as a result of a burn injury. These include turning and repositioning, positioning for comfort, using humidified oxygen, providing incentive spirometry, and suctioning the client on an as needed basis. The nurse would avoid maintaining the client in one position. This will ultimately lead to atelectasis and possible pneumonia. 66. A client sustains a burn injury to the entire right arm, entire right leg, and anterior thorax. According to the rule of nines the nurse determines that what body percent was injured? a. 45% b. 40% c. 35% d. 55% Rationale: A According to the Rule of Nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is 1%. If the anterior thorax (18%), entire right leg (18%), and entire right arm (9%) were burned, according to the Rule of Nines, this would equal 45%. 67. A nurse assesses a burn injury and determines that the client sustained a full-thickness fourth-degree burn if which of the following is noted at the site of injury? a. a wet shiny weeping wound surface c. charring at the wound site b. a dry wound surface d. blisters Rationale: C In a full-thickness fourth-degree burn injury, charring is visible. Extremity movement is limited and wound sensation is absent. Blisters and a wet shiny weeping surface would be noted in a partial-thickness second-degree burn injury. A dry wound surface would be noted in a full-thickness third-degree burn injury. 68. A client is brought to the emergency room following a burn injury. In assessment the nurse notes that the clients eyebrow and nasal hairs are singed. The nurse would identify this type of burn as: a. thermal b. electrical c. radiation d. chemical Rationale: A Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes facial burns or singed eyebrow or nasal hairs, the victim likely experienced the burn in an enclosed smoke filled space such as in a residential fire. Electrical burns are caused by heat that is generated by the electrical energy as it passes through the body.

Radiation burns are caused by exposure to a radioactive source. Chemical burns are caused by tissue contact with strong acids, alkalis, or organic compounds. 69. A nurse assesses the carbon monoxide level of a client following a burn injury and notes that the level is 8%. Based on this level, which finding would the nurse expect to note during the assessment of the client? a. tachycardia b. tachypnea c. coma d. impaired visual acuity Rationale: D Clinical manifestations of carbon monoxide poisoning are related to the levels of carbon monoxide saturation. A level between 5 to 10% would cause impaired visual acuity; 11 to 20% flushing and headache; 21 to 30% nausea and impaired dexterity; 31 to 40% vomiting, dizziness, and syncope; 41 to 50% tachypnea and tachycardia; and greater than 50% coma and death. 70. A nurse assesses the clients burn injury and determines that the client sustained a partialthickness superficial burn. Based on this determination, which finding did the nurse note? a. a wet, shiny, weeping wound c. charring at the wound site b. a dry wound surface d. absence of wound sensation Rationale: A A partial-thickness superficial burn appears wet, shiny, and weeping, or may contain blisters. The wound blanches with pressure, is painful, and very sensitive to touch or air currents. Charring would occur in a deep full-thickness burn. Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns. 71. A nurse assesses the clients burn injury and determines that the client sustained a partialthickness deep burn. Based on this determination, which finding did the nurse note? a. a wet, shiny, weeping wound surface c. charring at the wound site b. a dry wound surface d. total absence of wound sensation Rationale: B A partial-thickness deep burn appears dry and may be red or white in appearance. No blanching occurs and thrombosed vessels may be visible. Decreased wound sensation will be present. Blisters and a wet shiny weeping surface occur in partial-thickness superficial burns. Charring would occur in deep full-thickness burns. Total absence of wound sensation would occur in deep full-thickness burns. 72. On assessment of a child, the nurse notes the presence of white patches on the childs tongue and determines that they may be indicative of candidiasis (thrush). The nurse understands that the white patches of candidiasis (thrush): a. adhere to the tongue even when scraped with tongue blade b. cause the tongue to bleed continuously around the patch c. produce a red circle in the center of the white lesion d. will occur only in the tongue Rationale: A Candidiasis, a fungal infection, adheres firmly to the tongue and/or mucous membranes of the mouth and throat. Bleeding may occur after the trauma of trying to remove the patches. A red circle on the skin may be associated with other disorders such as Lyme disease but is not seen in candidiasis. Candidiasis can occur on the oral mucous membranes as well as on the tongue.

73. On assessment, a nurse notes a flat brown circular nevi on the skin of a client that measures less than one centimeter. The client asks, "Is this cancer?" The nurse makes which response to the client? a. "These are likely to be benign moles." b. "These require immediate attention because they are probably cancer." c. "These indicate malignancy." d. "These are probably verrucae." Rationale: A A flat brown circular nevi is a description of a classic benign mole. Therefore option 1 is correct. If the color changes or varies, if the size is greater than 1 cm, or if the mole was raised or itchy, it should be considered suspicious. The description in the question indicates that the lesions are nevi (moles) and thus are not verrucae (warts). 74. A nurse is performing a skin assessment on a client. The nurse understands that moles with variegated color, irregular borders, and/or an irregular surface should be considered: a. suspicious b. normal c. common d. benign Rationale: A The data identified in the question suggest the possibility of malignant melanoma; therefore, moles with these characteristics should be considered suspicious. Options b, c, and d are incorrect. 75. A client is diagnosed with herpes zoster (shingles). Which pharmacological therapy would the nurse expect to be prescribed to treat this disorder? a. tetracycline hydrochloride (achromycin) c. acyclovir (zovirax) b. erythromycin base (e-mycin) d. indomethacin (indocin) Rationale: C The goals of treatment for herpes zoster are to relieve pain, to prevent infection and scarring, and to reduce the possibility of postherpetic neuralgia. Oral analgesics are prescribed to reduce the incidence of persistent pain. The lesions may also be injected with corticosteroids. Acyclovir, if started early, may reduce the severity of herpes zoster. Options a and b identify antibiotics that are not normally prescribed for this condition. Option d is a nonsteroidal antiinflammatory medication. 76. A nurse reviews the record of a client diagnosed with pemphigus and notes that the physician has documented the presence of Nikolskys sign. Based on this documentation, which of the following would the nurse expect to note? a. client complains of discomfort behind the knee on forced dorsiflexion of the foot b. a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland c. carpal spasm elicited by compressing the upper arm d. the epidermis of the clients skin can be rubbed off by slight friction or injury Rationale: D A hallmark sign of pemphigus is Nikolskys sign, which occurs when the epidermis can be rubbed off by slight friction or injury. Other characteristics of pemphigus include flaccid bullae that rupture easily and emit a foul smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, groin and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Trousseaus sign is a sign for tetany in which carpal spasm can be

elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvosteks sign seen in tetany is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans' sign, a sign of thrombosis in the leg, is discomfort behind the knee on forced dorsiflexion of the foot. 77. A hospitalized client is diagnosed with scabies. Which of the following would a nurse expect to note on inspection of the clients skin? a. the appearance of vesicles or pustules b. the presence of white patches scattered about the trunk c. multiple straight or wavy threadlike lines beneath the skin d. patchy hair loss and round, red macules with scales Rationale: C Scabies can be identified by the presence of multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by a female mite, which burrows beneath the skin and lays its eggs. Options a, b, and d are not characteristics of scabies. 78. A client is seen in the health care clinic and the physician suspects herpes zoster. The nurse prepares the items needed to perform the diagnostic test to confirm this diagnosis. Which item will the nurse obtain? a. a biopsy kit c. a culture swab and tube b. a woods light d. a patch test kit Rationale: C Herpes zoster is caused by a reactivation of the varicella zoster virus, the cause of the virus for chicken pox. With classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. In a Woods light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A patch test is a skin test that involves the administration of an allergen to the skins surface to identify specific allergies. A biopsy will determine tissue type.

79. A nurse reviews the health care record of a client diagnosed with herpes zoster. Which finding would the nurse expect to note as characteristic of this disorder? a. a generalized red body rash that causes pruritus b. small blue-white spots with a red base noted on the extremities c. a fiery red edematous rash on the cheeks and neck d. clustered and grouped skin vesicles Rationale: D The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the bodys midline. Options a, b, and c are not characteristics of herpes zoster. 80. 43 years old women is undergoing chemotherapy treatment for uterine cancer. She asks the nurse how chemotherapeutic drugs work. The most accurate explanation would include which statement? a. They affect all rapidly dividing cells. b. Molecular structure of the DNA segment is altered. c. Chemotherapy stimulates cancer cells to divide.

d. The cancer cells are sensitive to drug toxins. Rationale: A There are numerous mechanisms of action for chemotherapeutic drugs, but most affect rapidly dividing cells. Cancer cells are characterized by rapid division. Some, but not all, chemotherapeutic drugs affect molecular structure. Chemotherapy slows, not stimulates, cell division. All cells are sensitive to drug toxins, but not all chemotherapeutic drugs are toxins, there are several different mechanisms of action. 81. A woman loses most of her hair as a result of cancer chemotherapy. The nurse understands that which of the following is true about chemotherapy-induced alopecia? a. New hair will be gray. c. The hair loss is temporary b. Avoid the use of wigs. d. Pre-chemo hair texture will return Rationale: C Alopecia from chemotherapy is only temporary. While hair color and texture may change following loss due to chemotherapy, the returning color will not necessarily be grey. Hair loss is a serious threat to self-esteem in the client receiving chemotherapeutic drugs. Clients who will be receiving medications known to cause hair loss should be encouraged to purchase a wig while they still have hair to allow for matching. 82. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? a. A young adult with a history of Downs syndrome b. A teenager who reads at a 4th grade level c. An elderly client with numerous arthritic nodules on the hands d. A preschooler with intermittent episodes of alertness Rationale: D A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This child without a normal level of consciousness would not benefit from the use of a PCA pump. 83. What protective mechanism prevents drug overdose with PCA? a. The nurse controls the amount administered. b. Extensive client teaching precedes its use. c. The client can stop drug administration but not initiate it. d. After a bolus is administered, there is a mandatory waiting period. Rationale: D Immediately after a bolus dose of medication is administered, the device enters the mandatory lock-out mode where no other boluses of medication can be delivered. The nurse may program the amount of medication administered but it is the mandatory lock-out that prevents overdose. The client chooses whether or not to initiate the administration or abstain from using the drug. Pre-op teaching is always important but it is not the protective device to prevent drug overdose. 84. Pre operative teaching for an adult who is to have patient controlled analgesia following surgery includes telling her: a. You will not be drowsy. b. You will experience no pain c. Pain control will be adequate d. You will not have incisional pain but you may have muscle pain

Rationale: C Clients should be told that they will be able to control their pain. They should not be told that there will be no pain. The client receiving PCA will have few side effects. Incisional and muscle pain may both be present to some degree following surgery. 85. A 48 year old woman has just returned to her room after having had a hysterectomy. She has patient-controlled analgesia (PCA). To reduce anxiety regarding receiving adequate pain relief, the client was most likely told that a. PCA is almost always effective. b. Comfort will be assessed frequently. c. Additional IM medication will be available. d. Most therapies are better than frequent IM injections. Rationale: C Pain is an individual experience. It is important to reassure the client that assessments will be made on a frequent basis and that drug dosages will be adjusted according to the amount of pain the client is perceiving. IM boosts are generally not needed when PCA is in use. PCA is effective when used with clients who are able to follow the directions for use. 86. Ibuprofen (Motrin) is prescribed for an adult with chronic pain. The nurse must teach the client to observe which dietary precaution while taking ibuprofen? a. Eat a high fiber diet b. Drink citrus juices daily c. Take the medication with milk d. Omit spinach and other green leafy vegetables from her diet Rationale: C NSAIDs are very irritating to the GI tract and should always be taken with milk or food to minimize the possibility of bleeding. It is not necessary to add or eliminate food from the diet unless the individual is experiencing some specific food intolerances. Spinach may be omitted from the diet of a person taking Coumadin. 87. An adult has been taking acetylsalicyclic acid (ASA) 650 mg four times a day for choric back pain. The nurse assessing this client knows that a common side effect of high doses of ASA is a. renal failure c. gastrointestinal bleeding b. paralytic ileus d. retinal detachment Rationale: C High doses of aspirin are associated with GI bleeding. Renal failure, paralytic ileus, and retinal detachment are not complications associated with aspirin therapy. 88. Acetylsalicylic acid is being administered to an adult client. The nurse understands that the most common mechanism of action for non-narcotic analgesics is their ability to a. inhibit prostaglandin synthesis b. after pain perception in the cerebellum c. directly affect the central nervous system d. target the pain producing effects of kinins Rationale: A

Non -narcotic analgesics inhibit prostaglandin synthesis. Prostaglandins increase the sensitivity of peripheral pain receptors to endogenous pain-producing substances. There is no direct action on the central nervous system or change in pain perception. 89. A risk factor for prostate cancer is: a. a history of infertility c. poverty b. being over age 40 d. too many girlfriends Rationale: B Prostate cancer seldom develops in men under age 40. Socioeconomic status and infertility dont appear to affect the risk for prostate cancer. 90. Multiple myeloma is related to the immunity factor: a. Histamine b. Serotonin c. IgG

d. IgA

Rationale: C In multiple myeloma, plasma cells secrete an unusually large amount of IgG. 91. A change in the shape, color and texture of a nevus may indicate: a. Multiple myeloma c. Healing of the nevus b. Malignant melanoma d. Ulcerative colitis Rationale: B An obvious change in a wart or mole is a sign of malignant melanoma and is one of the seven warning signs of cancer identified by the American Cancer Society. 92. Lymphedema occurs in the patient with breast cancer because the: a. Breast tissue causes the patient to retain fluid. b. Lymphatic system is swollen with immune-response factors to fight the cancer. c. Area is traumatized, which causes it to swell. d. Breast was touched frequently. Rationale: B The lymphatic system brings immune response factors to the area to fight the cancer, which causes lymphedema. 93. The following are signs and symptoms seen in a client with syndrome of inappropriate diuretic hormone (SIADH) secretion, except: a. Dilute urine b. Confusion c. Weakness d. Muscle cramps Rationale: A The syndrome of inappropriate anti-diuretic hormone (SIADH) secretion includes excessive ADH secretion from the pituitary gland even in the face of subnormal serum osmolality. Clients with this disorder cannot excrete dilute urine. They retain fluids and develop a sodium deficiency known as dilutional hyponatremia. Anorexia, nausea, and malaise are the earliest findings, followed by headache, irritability, confusion, muscle cramps, weakness, obtundation, seizures, and coma. These occur as osmotic fluid shifts result in cerebral edema and increased intracranial pressure. Dilute urine is seen in clients with Diabetes insipidus. Key feature: concentrated urine and hyponatremia Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1212

94. Nursing management for a client with SIADH include all of the following, except: a. Close monitoring of daily weight b. Increasing fluid intake c. Close monitoring of intake and output d. Monitoring neurologic status Rationale: B Eliminating the underlying cause if possible and restricting fluid intake (not increasing) are typical interventions for managing this syndrome. Diuretics may be used along with fluid restriction if severe hyponatremia is present. Close monitoring of intake and output, daily weight, urine and blood chemistries and neurologic status is indicated for the client with SIADH. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1212 95. The nurse prepares discharge instructions for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH). Which statement indicates that the patient understands these instructions? a. Ill check all food labels to make sure that I restrict my sodium intake. b. Ill keep a log of my daily weight and call the doctor if I gain 2 lb (0.90 kg) or more in a day without changing my eating habits. c. Ill check my pulse every morning and will contact my doctor if its irregular or rapid d. III measure my urine and check the specific gravity with a refractometer. If it begins to gradually rise, Ill tell my doctor Rationale: B Daily weight measurement is the most accurate means of monitoring hydration status at home. The patient should be encouraged to increase dietary intake of both sodium and potassium, particularly if diuretics are prescribed. Pulse checks and urine specific gravity measurements are unnecessary in a patient with chronic SIADH. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1212 SITUATION: Gabby is a 48-year-old overweight man who was seen for a routine check-up. His fasting blood glucose is 135 mg/dl, so hes scheduled for a repeat test. 96. Gabby asks the nurse, why he has to return for another test. The nurses best response would be: a. Your fasting blood glucose level was normal, but we need a confirmation of that result. b. Fasting blood glucose level tests are always repeated. c. You have type 2 diabetes mellitus, so the test must be repeated. d. Your fasting blood glucose was abnormal and needed to be tested again. Rationale: D Type 2 diabetes is diagnosed with two fasting blood glucose levels> 126 mg/dl or a casual plasma glucose level > 200 mg/dl and symptoms. Because his first fasting blood glucose level was > 126 mg/dl, it must be repeated to make the diagnosis of type 2 diabetes. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1154 97. The second fasting blood glucose level was 131 mg/dl, and Miguel asks what caused his diabetes, the nurse should reply that type 2 diabetes is:

a. b. c. d.

An autoimmune disease Caused by decreased insulin levels Caused by insulin resistance Caused by eating too many sweets

Rationale: C June 2009 NLE Question (Etiology of Type I and Type II diabetes) The pathophysiology of type 2 diabetes involves insulin resistance, impaired insulin secretion, and inappropriate hepatic glucose production. Type 2 diabetes isnt an autoimmune disease. Although type 2 diabetes is characterized by elevated insulin levels, because of insulin resistance, that insulin isnt effective. Eating sweets doesnt cause diabetes. However, it may contribute to the development of diabetes if eating sweets causes obesity. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1153 98. Which of the following statements about insulin is incorrect? a. It is secreted by the alpha cells of the Islet of Langerhans in the pancreas b. It inhibits the breakdown of stored glucose, insulin and fat c. It transports and metabolizes glucose for energy d. It enhances the storage of dietary fat in the tissue Rationale: A Option b, c and d are correct about insulin. Option A should be the beta cells of the Islets of Langerhans in the pancreas, Insulin is an anabolic or storage hormone. It is glucagon that is produced by the alpha cells. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1151 99. The initial treatment for Miguel is meal plan change, with a goal of modest weight loss and exercise. Modest weight loss and exercise are used to treat type 2 diabetes because each will: a. Enhance insulin sensitivity b. Enhance insulin secretion c. Make patients feel better d. Prevent the progression of diabetes Rationale: A Modest weight loss (5% to 10% of body weight) and exercise both decrease insulin resistance, which improves insulin sensitivity. These management modalities dont enhance insulin secretion, but the insulin thats secreted is more effective. Although modest weight loss and exercise generally help patients feel better, this isnt the major reason these modalities are prescribed. The natural history of type 2 diabetes is a gradual inability of the pancreas to maintain the required insulin secretion. Therefore, its unlikely that modest weight loss and exercise will prevent the progression of diabetes for the rest of the patients life, although they will delay the progression as long as the patient maintains euglycemia. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1156 100. Blood glucose monitoring is a cornerstone of diabetes management. The nurse is teaching the client on self-monitoring of blood glucose. She should recommend that it should be done how many times daily?

a. Once a day c. Anytime the client wants to b. Two to four times d. Before and after meals and at bedtime

Rationale: B SMBG is recommended two to four times daily, usually before meals and at bedtime. For patients taking insulin before each meal, SMBG is required at least three times daily before meals to determine each dose. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 1162

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