Text Mode Text version of the exam B. Carbonic anhydrase inhibitors
Walking to the car on a cold winter
1. The nurse is performing her
admission assessment of a patient.
When grading arterial pulses, a 1+
pulse indicates:
A. Above normal perfusion.
B. Absent perfusion.
C. Normal perfusion.
D. Diminished perfusion.
2. Murmurs that indicate heart
disease are often accompanied by
other symptoms such as:
A. Dyspnea on exertion.
B. Subcutaneous emphysema.
C. Thoracic petechiae.
D. Periorbital edema.
3. Which pregnancy-related
physiologic change would place the
patient with a history of cardiac
disease at the greatest risk of
developing severe cardiac
problems?
A. Decrease heart rate
B. Decreased cardiac output
C. Increased plasma volume
D. Increased blood pressure
4. The priority nursing diagnosis for
the patient with cardiomyopathy is:
A. Anxiety related to risk of declining
health status.
B. Ineffective individual coping related to
fear of debilitating illness
C. Fluid volume excess related to altered
compensatory mechanisms.
D. Decreased cardiac output related to
reduced myocardial contractility.
5. A patient with thrombophlebitis
reached her expected outcomes of
care. Her affected leg appears pink
and warm. Her pedal pulse is
palpable and there is no edema
present. Which step in the nursing
process is described above?
A. Planning
B. Implementation
C. Analysis
D. Evaluation
6. An elderly patient may have
sustained a basilar skull fracture
after slipping and falling on an icy
sidewalk. The nurse knows that
basilar skull factures:
A. Are the least significant type of skull
fracture.
B. May have cause cerebrospinal fluid
(CSF) leaks from the nose or ears.
C. Have no characteristic findings.
D. Are always surgically repaired.
7. Which of the following types of
drugs might be given to control
increased intracranial pressure
(ICP)?
A. Barbiturates
C.
C. Anticholinergics
D. Histamine receptor blockers
8. The nurse is teaching family
members of a patient with a
concussion about the early signs of
increased intracranial pressure
(ICP). Which of the following would
she cite as an early sign of
increased ICP?
A. Decreased systolic blood pressure
B. Headache and vomiting
C. Inability to wake the patient with
noxious stimuli
D. Dilated pupils that dont react to light
9. Jessie James is diagnosed with
retinal detachment. Which
intervention is the most important
for this patient?
A. Admitting him to the hospital on strict
bed rest
B. Patching both of his eyes
C. Referring him to an ophthalmologist
D. Preparing him for surgery
10. Dr. Bruce Owen, a chemist,
sustained a chemical burn to one
eye. Which intervention takes
priority for a patient with a chemical
burn of the eye?
A. Patch the affected eye and call the
ophthalmologist.
B. Administer a cycloplegic agent to
reduce ciliary spasm.
C. Immediately instill a tropical
anesthetic, then irrigate the eye with
saline solution.
D. Administer antibiotics to reduce the
risk of infection
11. The nurse is assessing a
patient and notes a Brudzinskis
sign and Kernigs sign. These are
two classic signs of which of the
following disorders?
A. Cerebrovascular accident (CVA)
B. Meningitis
C. Seizure disorder
D. Parkinsons disease
12. A patient is admitted to the
hospital for a brain biopsy. The
nurse knows that the most
common type of primary brain
tumor is:
A. Meningioma.
B. Angioma.
C. Hemangioblastoma.
D. Glioma.
13. The nurse should instruct the
patient with Parkinsons disease to
avoid which of the following?
A. Walking in an indoor shopping mall
B. Sitting on the deck on a cool summer
evening
day
D. Sitting on the beach in the sun on a
summer day
14. Gary Jordan suffered a
cerebrovascular accident that left
her unable to comprehend speech
and unable to speak. This type of
aphasia is known as:
A. Receptive aphasia
B. Expressive aphasia
C. Global aphasia
D. Conduction aphasia
15. Kelly Smith complains that her
headaches are occurring more
frequently despite medications.
Patients with a history of
headaches should be taught to
avoid:
A. Freshly prepared meats.
B. Citrus fruits.
C. Skim milk
D. Chocolate
16. Immediately following cerebral
aneurysm rupture, the patient
usually complains of:
A. Photophobia
B. Explosive headache
C. Seizures
D. Hemiparesis
17. Which of the following is a
cause of embolic brain injury?
A. Persistent hypertension
B. Subarachnoid hemorrhage
C. Atrial fibrillation
D. Skull fracture
18. Although Ms. Priestly has a
spinal cord injury, she can still have
sexual intercourse. Discharge
teaching should make her aware
that:
A. She must remove indwelling urinary
catheter prior to intercourse.
B. She can no longer achieve orgasm.
C. Positioning may be awkward.
D. She can still get pregnant.
19.Ivy Hopkins, age 25, suffered a
cervical fracture requiring
immobilization with halo traction.
When caring for the patient in halo
traction, the nurse must:
A. Keep a wrench taped to the halo vest
for quick removal if cardiopulmonary
resuscitation is necessary.
B. Remove the brace once a day to allow
the patient to rest.
C. Encourage the patient to use a pillow
under the ring.
D. Remove the brace so that the patient
can shower.
20. The nurse asks a patients
husband if he understands why his
wife is receiving nimodipine
 (Nimotop), since she suffered a
cerebral aneurysm rupture. Which
response by the husband indicates
that he understands the drugs
use?
A. Nimodipine replaces calcium.
B. Nimodipine promotes growth of
blood vessels in the brain.
C. Nimodipine reduces the brains
demand for oxygen.
D. Nimodipine reduces vasospasm in
the brain.
21. Many men who suffer spinal
injuries continue to be sexually
active. The teaching plan for a man
with a spinal cord injury should
include sexually concerns. Which
of the following injuries would most
likely prevent erection and
ejaculation?
A. C5
B. C7
C. T4
D. S4
22. Cathy Bates, age 36, is a
homemaker who frequently forgets
to take her carbamazepine
(Tegretol). As a result, she has
been experiencing seizures. How
can the nurse best help the patient
remember to take her medication?
A. Tell her take her medication at
bedtime.
B. Instruct her to take her medication
after one of her favorite television
shows.
C. Explain that she should take her
medication with breakfast.
D. Tell her to buy an alarm watch to
remind her.
23. Richard Barnes was diagnosed
with pneumococcal meningitis.
What response by the patient
indicates that he understands the
precautions necessary with this
diagnosis?
A. Im so depressed because I cant have
any visitors for a week.
B. Thank goodness, Ill only be in
isolation for 24 hours.
C. The nurse told me that my urine and
stool are also sources of meningitis
bacteria.
D. The doctor is a good friend of mine
and wont keep me in isolation.
24. An early symptom associated
with amyotrophic lateral sclerosis
(ALS) includes:
A. Fatigue while talking
B. Change in mental status
C. Numbness of the hands and feet
D. Spontaneous fractures
25. When caring for a patient with foods by mouth, the preferred
esophageal varices, the nurse method of feeding is:
knows that bleeding in this disorder A. Total parenteral nutrition
usually stems from: B. Peripheral parenteral nutrition
A. Esophageal perforation C. Enteral nutrition
B. Pulmonary hypertension D. Oral liquid supplements
C. Portal hypertension 31. Which type of solution causes
D. Peptic ulcers water to shift from the cells into the
26. Tiffany Black is diagnosed with plasma?
type A hepatitis. What special A. Hypertonic
precautions should the nurse take B. Hypotonic
when caring for this patient? C. Isotonic
A. Put on a mask and gown before D. Alkaline
entering the patients room. 32. Particles move from an area of
B. Wear gloves and a gown when greater osmelarity to one of lesser
removing the patients bedpan. osmolarity through:
C. Prevent the droplet spread of the A. Active transport
organism. B. Osmosis
D. Use caution when bringing food to the C. Diffusion
patient. D. Filtration
27. Discharge instructions for a 33. Which assessment finding
patient who has been operated on indicates dehydration?
for colorectal cancer include A. Tenting of chest skin when pinched
irrigating the colostomy. The nurse B. Rapid filling of hand veins
knows her teaching is effective C. A pulse that isnt easily obliterated
when the patient states hell D. Neck vein distention
contact the doctor if: 34. Which nursing intervention
A. He experiences abdominal cramping would most likely lead to a hypo-
while the irrigant is infusing osmolar state?
B. He has difficulty inserting the A. Performing nasogastric tube irrigation
irrigation tube into the stoma with normal saline solution
C. He expels flatus while the return is B. Weighing the patient daily
running out C. Administering tap water enema until
D. Hes unable to complete the procedure the return is clear
in 1 hour D. Encouraging the patient with excessive
28. The nurse explains to the perspiration to dink broth
patient who has an abdominal 35. Which assessment finding
perineal resection that an would indicate an extracellular fluid
indwelling urinary catheter must be volume deficit?
kept in place for several days A. Bradycardia
afterward because: B. A central venous pressure of 6 mm Hg
A. It prevents urinary tract infection C. Pitting edema
following surgery D. An orthostatic blood pressure change
B. It prevents urine retention and 36. A patient with metabolic
resulting pressure on the perineal acidosis has a preexisting problem
wound with the kidneys. Which other
C. It minimizes the risk of wound organ helps regulate blood pH?
contamination by the urine A. Liver
D. It determines whether the surgery B. Pancreas
caused bladder trauma C. Lungs
29. The first day after, surgery the D. heart
nurse finds no measurable fecal 37. The nurse considers the patient
drainage from a patients anuric if the patient;
colostomy stoma. What is the most A. Voids during the nighttime hours
appropriate nursing intervention? B. Has a urine output of less than 100 ml
A. Call the doctor immediately. in 24 hours
B. Obtain an order to irrigate the stoma. C. Has a urine output of at least 100 ml in
C. Place the patient on bed rest and call 2 hours
the doctor. D. Has pain and burning on urination
D. Continue the current plan of care. 38. Which nursing action is
30. If a patients GI tract is appropriate to prevent infection
functioning but hes unable to take when obtaining a sterile urine
 specimen from an indwelling
urinary catheter?
A. Aspirate urine from the tubing port
using a sterile syringe and needle
B. Disconnect the catheter from the
tubing and obtain urine
C. Open the drainage bag and pour out
some urine
D. Wear sterile gloves when obtaining
urine
39. After undergoing a
transurethral resection of the
prostate to treat benign prostatic
hypertrophy, a patient is retuned to
the room with continuous bladder
irrigation in place. One day later,
the patient reports bladder pain.
What should the nurse do first?
A. Increase the I.V. flow rate
B. Notify the doctor immediately
C. Assess the irrigation catheter for
patency and drainage
D. Administer meperidine (Demerol) as
prescribed
40. A patient comes to the hospital
complaining of sudden onset of
sharp, severe pain originating in
the lumbar region and radiating
around the side and toward the
bladder. The patient also reports
nausea and vomiting and appears
pale, diaphoretic, and anxious. The
doctor tentatively diagnoses renal
calculi and orders flat-plate
abdominal X-rays. Renal calculi
can form anywhere in the urinary
tract. What is their most common
formation site?
A. Kidney
B. Ureter
C. Bladder
D. Urethra
41. A patient comes to the hospital
complaining of severe pain in the
right flank, nausea, and vomiting.
The doctor tentatively diagnoses
right ureter-olithiasis (renal calculi).
When planning this patients care,
the nurse should assign highest
priority to which nursing diagnosis?
A. Pain
B. Risk of infection
C. Altered urinary elimination
D. Altered nutrition: less than body
requirements
42. The nurse is reviewing the
report of a patients routine
urinalysis. Which of the following
values should the nurse consider
abnormal?
A. Specific gravity of 1.002
B. Urine pH of 3
C. Absence of protein
D. Absence of glucose to smoking a pack of cigarettes per
43. A patient with suspected renal day. When developing a teaching
insufficiency is scheduled for a plan, which of the following should
comprehensive diagnostic work-up. receive highest priority to help
After the nurse explains the decrease respiratory
diagnostic tests, the patient asks complications?
which part of the kidney does the A. Weight reduction
work. Which answer is correct? B. Decreasing salt intake
A. The glomerulus C. Smoking cessation
B. Bowmans capsule D. Decreasing caffeine intake
C. The nephron 49. What is the ratio of chest
D. The tubular system compressions to ventilations when
44. During a shock state, the renin- one rescuer performs
angiotensin-aldosterone system cardiopulmonary resuscitation
exerts which of the following effects (CPR) on an adult?
on renal function? A. 15:1
A. Decreased urine output, increased B. 15:2
reabsorption of sodium and water C. 12:1
B. Decreased urine output, decreased D. 12:2
reabsorption of sodium and water 50. When assessing a patient for
C. Increased urine output, increased fluid and electrolyte balance, the
reabsorption of sodium and water nurse is aware that the organs
D. Increased urine output, decreased most important in maintaining this
reabsorption of sodium and water balance are the:
45. While assessing a patient who A. Pituitary gland and pancreas
complained of lower abdominal B. Liver and gallbladder.
pressure, the nurse notes a firm C. Brain stem and heart.
mass extending above the D. Lungs and kidneys.
symphysis pubis. The nurse
suspects:
A. A urinary tract infection
B. Renal calculi
C. An enlarged kidney
D. A distended bladder
46. Gregg Lohan, age 75, is
admitted to the medical-surgical
floor with weakness and left-sided
chest pain. The symptoms have
been present for several weeks
after a viral illness. Which
assessment finding is most
symptomatic of pericarditis?
A. Pericardial friction rub
B. Bilateral crackles auscultated at the
lung bases
C. Pain unrelieved by a change in
position
D. Third heart sound (S3)
47. James King is admitted to the
hospital with right-side-heart
failure. When assessing him for
jugular vein distention, the nurse
should position him:
A. Lying on his side with the head of the
bed flat.
B. Sitting upright.
C. Flat on his back.
D. Lying on his back with the head of the
bed elevated 30 to 45 degrees.
48. The nurse is interviewing a
slightly overweight 43-year-old man
with mild emphysema and
borderline hypertension. He admits
 Answers and Rationales
1. Answer: D. A 1+ pulse indicates weak
pulses and is associated with diminished
perfusion. A 4+ is bounding perfusion, a
3+ is increased perfusion, a 2+ is normal
perfusion, and 0 is absent perfusion.
2. Answer: A.A murmur that indicates
heart disease is often accompanied by
dyspnea on exertion, which is a hallmark
of heart failure. Other indicators are
tachycardia, syncope, and chest pain.
Subcutaneous emphysema, thoracic
petechiae, and perior-bital edema arent
associated with murmurs and heart
disease.
3. Answer: C.Pregnancy increase plasma
volume and expands the uterine vascular
bed, possibly increasing both the heart
rate and cardiac output. These changes
may cause cardiac stress, especially
during the second trimester. Blood
pressure during early pregnancy may
decrease, but it gradually returns to
prepregnancy levels.
4. Answer: D.Decreased cardiac output
related to reduced myocardial
contractility is the greatest threat to the
survival of a patient with
cardiomyopathy. The other options can
be addressed once cardiac output and
myocardial contractility have been
restored.
5. Answer: D.Evaluation assesses the
effectiveness of the treatment plan by
determining if the patient has met the
expected treatment outcome. Planning
refers to designing a plan of action that
will help the nurse deliver quality patient
care. Implementation refers to all of the
nursing interventions directed toward
solving the patients nursing problems.
Analysis is the process of identifying the
patients nursing problems.
6. Answer: B.A basilar skull fracture
carries the risk of complications of dural
tear, causing CSF leakage and damage to
cranial nerves I, II, VII, and VIII. Classic
findings in this type of fracture may
include otorrhea, rhinorrhea, Battles
signs, and raccoon eyes. Surgical
treatment isnt always required.
7. Answer: A. Barbiturates may be used to
induce a coma in a patient with increased
ICP. This decreases cortical activity and
cerebral metabolism, reduces cerebral
blood volume, decreases cerebral edema,
and reduces the brains need for glucose
and oxygen. Carbonic anhydrase
inhibitors are used to decrease ocular
pressure or to decrease the serum pH in a
patient with metabolic alkalosis.
Anticholinergics have many uses
including reducing GI spasms.
Histamine receptor blockers are used to
decrease stomach acidity.
8. Answer: B. Headache and projectile
vomiting are early signs of increased
ICP. Decreased systolic blood pressure,
unconsciousness, and dilated pupils that
dont reac to light are considered late
signs.
9. Answer: A. Immediate bed rest is
necessary to prevent further injury. Both
eyes should be patched to avoid
consensual eye movement and the
patient should receive early referral to an
ophthalmologist should treat the
condition immediately. Retinal
reattachment can be accomplished by
surgery only. If the macula is detached
or threatened, surgery is urgent;
prolonged detachment of the macula
results in permanent loss of central
vision.
10. Answer: C. A chemical burn to the eye
requires immediate instillation of a
topical anesthetic followed by irrigation
with copious amounts of saline solution.
Irrigation should be done for 5 to 10
minutes, and then the pH of the eye
should be checked. Irrigation should be
continued until the pH of the eye is
restored to neutral (pH 7.0): Double
eversion of the eyelids should be
performed to look for and remove ciliary
spasm, and an antibiotic ointment can be
administered to reduce the risk of
infection. Then the eye should be
patched. Parenteral narcotic analgesia is
often required for pain relief. An
ophthalmologist should also be
consulted.
11. Answer: B. A positive response to one
or both tests indicates meningeal
irritation that is present with meningitis.
Brudzinskis and Kernigs signs dont
occur in CVA, seizure disorder, or
Parkinsons disease.
12. Answer: D. Gliomas account for
approximately 45% of all brain tumors.
Meningiomas are the second most
common, with 15%. Angiomas and
hemangioblastomas are types of cerebral
vascular tumors that account for 3% of
brain tumors.
13. Answer: D. The patient with
Parkinsons disease may be
hypersensitive to heat, which increases
the risk of hyperthermia, and he should
be instructed to avoid sun exposure
during hot weather.
14. Answer: C. Global aphasia occurs when
all language functions are affected.
Receptive aphasia, also known as
Wernickes aphasia, affects the ability to
comprehend written or spoken words.
Expressive aphasia, also known as
Brocas aphasia, affected the patients
ability to form language and express
thoughts. Conduction aphasia refers to
abnormalities in speech repetition.
15. Answer: D. Patients with a history of
headaches, especially migraines, should
be taught to keep a food diary to identify
potential food triggers. Typical headache
triggers include alcohol, aged cheeses,
processed meats, and chocolate and
caffeine-containing products.
16. Answer: B. An explosive headache or
the worst headache Ive ever had is
typically the first presenting symptom of
a bleeding cerebral aneurysm.
Photophobia, seizures, and hemiparesis
may occur later.
17. Answer: C. An embolic injury, caused
by a traveling clot, may result from atrial
fibrillation. Blood may pool in the
fibrillating atrium and be released to
travel up the cerebral artery to the brain.
Persistent hypertension may place the
patient at risk for a thrombotic injury to
the brain. Subarachnoid hemorrhage and
skull fractures arent associated with
emboli.
18. Answer: D. Women with spinal cord
injuries who were sexually active may
continue having sexual intercourse and
must be reminded that they can still
become pregnant. She may be fully
capable of achieving orgasm. An
indwelling urinary catheter may be left
in place during sexual intercourse.
Positioning will need to be adjusted to fit
the patients needs.
19. Answer: A. The nurse must have a
wrench taped on the vest at all times for
quick halo removal in emergent
situations. The brace isnt to be removed
for any other reason until the cervical
fracture is healed. Placing a pillow under
the patients head may alter the stability
of the brace.
20. Answer: D. Nimodipine is a calcium
channel blocker that acts on cerebral
blood vessels to reduce vasospasm. The
drug doesnt increase the amount of
calcium, affect cerebral vasculature
growth, or reduce cerebral oxygen
demand.
21. Answer: D. Men with spinal cord injury
should be taught that the higher the level
of the lesion, the better their sexual
function will be. The sacral region is the
lowest area on the spinal column and
injury to this area will cause more
erectile dysfunction.
22. Answer: C. Tegretol should be taken
with food to minimize GI distress.
Taking it at meals will also establish a
regular routine, which should help
compliance.
23. Answer: B. Patient with pneumococcal
meningitis require respiratory isolation
for the first 24 hours after treatment is
initiated.
24. Answer: A. Early symptoms of ALS
include fatigue while talking, dysphagia,
 and weakness of the hands and arms.
ALS doesnt cause a change in mental
status, paresthesia, or fractures.
25. Answer: C. Increased pressure within
the portal veins causes them to bulge,
leading to rupture and bleeding into the
lower esophagus. Bleeding associated
with esophageal varices doesnt stem
from esophageal perforation, pulmonary
hypertension, or peptic ulcers.
26. Answer: B. The nurse should wear
gloves and a gown when removing the
patients bedpan because the type A
hepatitis virus occurs in stools. It may
also occur in blood, nasotracheal
secretions, and urine. Type A hepatitis
isnt transmitted through the air by way
of droplets. Special precautions arent
needed when feeding the patient, but
disposable utensils should be used.
27. Answer: B. The patient should notify
the doctor if he has difficulty inserting
the irrigation tube into the stoma.
Difficulty with insertion may indicate
stenosis of the bowel. Abdominal
cramping and expulsion of flatus may
normally occur with irrigation. The
procedure will often take an hour to
complete.
28. Answer: B. An indwelling urinary
catheter is kept in place several days
after this surgery to prevent urine
retention that could place pressure on the
perineal wound. An indwelling urinary
catheter may be a source of
postoperative urinary tract infection.
Urine wont contaminate the wound. An
indwelling urinary catheter wont
necessarily show bladder trauma.
29. Answer: D. The colostomy may not
function for 2 days or more (48 to 72
hours) after surgery. Therefore, the
normal plan of care can be followed.
Since no fecal drainage is expected for
48 to 72 hours after a colostomy (only
mucous and serosanguineous), the doctor
doesnt have to be notified and the stoma
shouldnt be irrigated at this time.
30. Answer: C. If the patients GI tract is
functioning, enteral nutrition via a
feeding tube is the preferred method.
Peripheral and total parenteral nutrition
places the patient at risk for infection. If
the patient is unable to consume foods
by mouth, oral liquid supplements are
contraindicated.
31. Answer: A. A hypertonic solution
causes water to shift from the cells into
the plasma because the hypertonic
solution has a greater osmotic pressure
than the cells. A hypotonic solution has a
lower osmotic pressure than that of the
cells. It causes fluid to shift into the
cells, possibly resulting in rupture. An
isotonic solution, which has the same
osmotic pressure as the cells, wouldnt
cause any shift. A solutions alkalinity is
related to the hydrogen ion
concentration, not its osmotic effect.
32. Answer: C. Particles move from an area
of greater osmolarity to one of lesser
osmolarity through diffusion. Active
transport is the movement of particles
though energy expenditure from other
sources such as enzymes. Osmosis is the
movement of a pure solvent through a
semipermeable membrane from an area
of greater osmolarity to one of lesser
osmolarity until equalization occurs. The
membrane is impermeable to the solute
but permeable to the solvent. Filtration is
the process by which fluid is forced
through a membrane by a difference in
pressure; small molecules pass through,
but large ones dont.
33. Answer: A. Tenting of chest skin when
pinched indicates decreased skin
elasticity due to dehydration. Hand veins
fill slowly with dehydration, not rapidly.
A pulse that isnt easily obliterated and
neck vein distention indicate fluid
overload, not dehydration.
34. Answer: C. Administering a tap water
enema until return is clear would most
likely contribute to a hypo-osmolar state.
Because tap water is hypotonic, it would
be absorbed by the body, diluting the
body fluid concentration and lowering
osmolarity. Weighing the patient is the
easiest, most accurate method to
determine fluid changes. Therefore, it
helps identify rather than contribute to
fluid imbalance. Nasogastric tube
irrigation with normal saline solution
wouldnt cause a shift in fluid balance.
Drinking broth wouldnt contribute to a
hypo-osmolar state because it doesnt
replace sodium and water lost through
excessive perspiration.
35. Answer: D. An orthostatic blood
pressure indicates an extracellular fluid
volume deficit. (The extracellular
compartment consists of both the
intravascular compartment and
interstitial space.) A fluid volume deficit
within the intravascular compartment
would cause tachycardia, not
bradycardia or orthostatic blood pressure
change. A central venous pressure of 6
mm Hg is in the high normal range,
indicating adequate hydration. Pitting
edema indicates fluid volume overload.
36. Answer: C. The respiratory and renal
systems act as compensatory
mechanisms to counteract-base
imbalances. The lungs alter the carbon
dioxide levels in the blood by increasing
or decreasing the rate and depth of
respirations, thereby increasing or
decreasing carbon dioxide elimination.
The liver, pancreas, and heart play no
part in compensating for acid-base
imbalances.
37. Answer: B. Anuria refers to a urine
output of less than 100 ml in 24 hours.
The baseline for urine output and renal
function is 30 ml of urine per hour. A
urine output of at least 100 ml in 2 hours
is within normal limits. Voiding at night
is called nocturia. Pain and burning on
urination is called dysuria.
38. Answer: A. To obtain urine properly,
the nurse should aspirate it from a port,
using a sterile syringe after cleaning the
port. Opening a closed urine drainage
system increases the risk of urinary tract
infection. Standard precautions specify
the use of gloves during contract with
body fluids; however, sterile gloves
arent necessary.
39. Answer: C. Although postoperative pain
is expected, the nurse should ensure that
other factors, such as an obstructed
irrigation catheter, arent the cause of the
pain. After assessing catheter patency,
the nurse should administer an analgesic
such as meperidine as prescribed.
Increasing the I.V. flow rate may worse
the pain. Notifying the doctor isnt
necessary unless the pain is severe or
unrelieved by the prescribed medication.
40. Answer: A. Renal calculi most
commonly from in the kidney. They may
remain there or become lodged
anywhere along the urinary tract. The
ureter, bladder, and urethra are less
common sites of renal calculi formation.
41. Answer: A. Ureterolithiasis typically
causes such acute, severe pain that the
patient cant rest and becomes
increasingly anxious. Therefore, the
nursing diagnosis of pain takes highest
priority. Risk for infection and altered
urinary elimination are appropriate once
the patients pain is controlled. Altered
nutrition: less than body requirements
isnt appropriate at this time.
42. Answer: B. Normal urine pH is 4.5 to 8;
therefore, a urine pH of 3 is abnormal
and may indicate such conditions as
renal tuberculosis, pyrexia,
phenylketonuria, alkaptonuria, and
acidosis. Urine specific gravity normally
ranges from 1.002 to 1.032, making the
patients value normal. Normally, urine
contains no protein, glucose, ketones,
bilirubin, bacteria, casts, or crystals.
43. Answer: C. The nephron is the kidneys
functioning unit. The glomerulus,
Bowmans capsule, and tubular system
are components of the nephron.
44. Answer: A. As a response to shock, the
renin-angiotensin-aldosterone system
alters renal function by decreasing urine
output and increasing reabsorption of
sodium and water. Reduced renal
perfusion stimulates the renin-
 angiotensin-aldosterone system in an
effort to conserve circulating volume.
45. Answer: D. The bladder isnt usually
palpable unless it is distended. The
feeling of pressure is usually relieved
with urination. Reduced bladder tone due
to general anesthesia is a common
postoperative complication that causes
difficulty in voiding. A urinary tract
infection and renal calculi arent
palpable. The kidneys arent palpable
above the symphysis pubis.
46. Answer: A. A pericardial friction rub
may be present with the pericardial
effusion of pericarditis. The lungs are
typically clear when auscultated. Sitting
up and leaning forward often relieves
pericarditis pain. An S3 indicates left-
sided heart failure and isnt usually
present with pericarditis.
47. Answer: D. Assessing jugular vein
distention should be done when the
patient is in semi-Fowlers position
(head of the bed elevated 30 to 45
degrees). If the patient lies flat, the veins
will be more distended; if he sits upright,
the veins will be flat.
48. Answer: C. Smoking should receive
highest priority when trying to reduce
risk factors for with respiratory
complications. Losing weight and
decreasing salt and caffeine intake can
help to decrease risk factors for
hypertension.
49. Answer: B. The correct ratio of
compressions to ventilations when one
rescuer performs CPR is 15:2
50. Answer: D. The lungs and kidneys are
the bodys regulators of homeostasis.
The lungs are responsible for removing
fluid and carbon dioxide; the kidneys
maintain a balance of fluid and
electrolytes. The other organs play
secondary roles in maintaining
homeostasis.