NURSING 101.MEDICAL-SURGICAL.[questions and answers with rationale 100% verified ]

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MEDICAL SURGICAL 1. A client with chronic renal failure is to be treated using continuous Ambulatory Peritoneal Dialysis. Which among the following is the correct rationale for this treatment? A. P... rovide continuous contact of dialyzer and blood to clear toxins by ultrafiltration. B. Uses the peritoneum as a semi permeable membrane to clear toxins by osmosis and diffusion. C. Exchange and cleanses blood by correction of serum electrolytes and excretion of creatinine. D. Decreases need for immobility of the client as it clears toxins in short intermittent periods. Answer: B Rationale: Continuous Ambulatory Peritoneal Dialysis (CAPD) is a form of dialysis used for many patients with ESRD. CAPD is performed at home by the patient or a trained caregiver, who is usually a family member; the procedure allows the patient reasonable freedom and control of daily activities. CAPD works on the same principles as other forms or peritoneal dialysis: diffusion and osmosis. Less extreme fluctuations in the patient’s laboratory results occur with CAPD than with intermittent peritoneal dialysis or hemodialysis because the dialysis is constantly in progress. The serum electrolyte levels usually remain in the normal range. 2. Which of the following discharge instructions should the nurse include in the teaching plan of a client with history of renal calculi formation after surgical removal of the calculus has been made? A. Eliminate dairy products from the diet B. Increase daily fluid intake to at least 2-3 L/day C. Follow measure to alkalinize the urine D. Strain urine regularly at home Answer: B Rationale: Because the risk of recurring renal stones is high, the nurse provides education about the causes of kidney stones and ways to prevent their recurrence. One facet of prevention is to maintain a high fluid intake because stones form more readily in concentrated urine. A patient who has shown a tendency to form stones should drink enough fluid to excrete greater than 2000 ml of urine every 24 hours, should adhere to the prescribed diet and should avoid sudden increases in environmental temperatures, which may cause a fall in urinary volume. 3. The nurse is conducting a teaching session to the parent of a child with asthma attacks. Which of the following statements given by the parent indicates a need for further teaching? A. “I need to by hypoallergenic bed pillows” B. “I’ll have my child sleep with the windows open” C. “I’ll dust and vacuum the house frequently” D. “I’ need to stop disinfecting my child’s room with aerosol spray” Answer: B Rationale: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing and dyspnea. Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or allergens also increases the risk for developing asthma. Common allergens can be seasonal (eg. Grass, tree and weed pollens) or perennial (eg. Mold, dust, roaches or animal dander). Common triggers for asthma symptoms and exacerbations in patients with asthma include airway irritants (eg. Air pollutants, cold, heat, weather changes. Strong odors or perfumes, smoke), exercise, stressor emotional upsets, sinusitis with postnasal drip, medications, viral respiratory track infections and GERD.4. For clients who have undergone Pneumonectomy of the right lung, it is most beneficila for the nurse to assist them in which of the following positions? A. Left Sim’s position with the bed elevated 45° B. High fowler’s position C. Flat in bed with the knees flexed slightly D. Right side with the head slightly elevated Answer: D Rationale: Careful positioning of the patient is important. Following pneumonectomy, a client is usually turned every hour from the back to the operative side and should not be completely turned to the unoperated side. This allows the fluid left in the space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. 5. The nurse in creating a discharge plan for a client with tuberculosis about recovery. The nurse should plan to reinforce that the treatment measure with the highest priority is: A. The need for adequate rest B. Consistent adherence to the ordered medications C. Getting plenty of fresh air D. A change in the lifestyle routine Answer: B Rationale: The major goals for the patient include maintenance of a patent airway, increased knowledge about the disease and treatment regimen, increased activity tolerance and absence of complications. The multiple medication regimen that a patient must follow can be quite complex. Understanding the medications, scheduled and side effects is important. The patient must understand that TB is a communicable disease and that taking medications is the most effective means of preventing transmission. 6. A client with emphysema asked the nurse the reason for his Potassium iodide therapy. The nurse can correctly answer the client by stating that Potassium iodide will: A. Decrease bronchial irritation B. Increase blood iodide levels C. Decrease mucous viscosity D. Reduce metabolic needs of the body Answer: C Rationale: Potassium iodide (SSKI) rapidly inhibits thyroid hormone release, reduces thyroid vascularity, and decreased thyroid uptake. Uptake of radioactive iodine after radiation emergencies or administration of radio active iodide isotopes. As an expectorant, it is taught to increase respiratory tract secretions, thereby decreasing mucus viscosity. Potassium iodide also inhibits the growth of bacteria, viruses, molds and yeasts. Since it accumulates in the bronchial secretions, it reduces the number and severity of bronchial infections. 7. The clinic nurse is performing an assessment on a client tells the nurse that he is a cigarette smoker and admits to smoking one pack of cigarette per day for the last ten years. The nurse computes for the pack per years based on the assessment as: A. 20 B. 15 C. 7.5 D. 10Answer: D Rationale: Pack-year is calculated by multiplying the number of packs of cigarettes smoked per day the number of years the client has smoked. In the situation the client admits to smoking 1 pack of cigarette per day for ten years, we therefore compute as 1 pack X 10 years = 10 pack per year 8. After the administration of epinephrine to a child with asthma, which of the following should the nurse monitor as a common side effect of the drug? A. Hypotension B. Flushing C. Tachycardia D. Dyspnea Answer: C Rationale: Epinephrine produces a Sympathomimetic effect. It stimulates alpha and beta-adrenergic receptors, causing relaxation of cardiac and bronchial smooth muscle and dilation of skeletal muscles. Also decreases aqueous outflow, and dilates pupils by contracting dilator muscle. Common side effects include: tachycardia, palpitations, widened pulse pressure, hypertension, urticarial, pallor diaphoresis, necrosis, nausea, vomiting, decrease urinary output, urinary retention, dysuria, dyspnea, pulmonary edema, disorientation, drowsiness, fear, dizziness, anxiety. 9. Mr. Garcia, a client with COPD reports having insomnia and heart racing after starting terbutaline therapy. The nurse recognizes that these symptoms: A. Indicate that the medication is at a therapeutic level B. Will tend to resolve with continued therapy C. Should be reported to the health care provider immediately D. Manifest a toxicity of the drug Answer: B Rationale: Terbutaline sulfate is a selective beta2-adrenergic receptor agonist. It relaxes bronchial smooth muscle by stimulating beta 2 – adrenergic receptors. Tachycardia, heart palpitations and tremors are side effects that have been reported with the use of these medications. Advise client to stablish effective bedtime routine to minimize insomnia. Instruct client to space doses evenly during waking hours to avoid taking drug at bed time. 10. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. Which of the following actions should receive the highest priority? A. Assessment of the client’s airway B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chests wall with a pillow Answer: A Rationale: Blunt chest trauma from sudden compression or positive pressure inflicted to the chest wall. Time is critical in treating chest trauma. Therefore, it is essential to assess the patient immediately to determine the following: when the injury occurred, mechanism of injury, level of responsiveness, specific injuries, estimated blood loss, recent drug or alcohol use and prehospital treatment. The initial assessment of thoracic injuries includes assessment of the patient for airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest and cardiac tamponade. These injuries are life threatening and need immediate treatment. The goals of treatment are to evaluate thepatient’s condition and to initiate aggressive resuscitation. An airway is immediately established with oxygen support and, in some cases, intubation and ventilator support. 11. During a routine physical examination, Mr. Reynold’s chest X-Ray film reveals a lesion in the right upper lobe. When the nurse obtains a history from the client, which of the following information would support the physician’s tentative diagnosis of pulmonary tuberculosis? A. Dry cough and pulmonary congestion B. Night sweats and blood tinged sputum C. Frothy sputum and fever D. Productive cough and engorged neck veins Answer: B Rationale: The signals and symptoms of pulmonary TB are insidious. Most patients have a low-grade fever, cough, night sweats, fatigue and weight loss. The cough maybe non- productive, or mucopurulent sputum may be expectorated. Both the systemic and pulmonary symptoms are usually chronic and may have been present for weeks to months. 12. The nurse is caring for a client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A. Low arterial PaO2 B. Decreased respiratory rate C. Pallor D. Elevated arterial PaO2 Answer: A Rationale: ARDS occur as a result of an inflammatory trigger that initiates the release of cellular and chemical mediators, causing injury to the alveolar capillary membranes. Clinically, the acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs 12-48 hours after the initiating event. A characteristics feature is arterial hypoxemia that does not respond to supplemental oxygen. On chest X-ray, the findings are similar to those with cardiogenic pulmonary edema and present as bilateral infiltrates that quickly worsen. The acute lung injury then progresses to fibrosing alveolitis with persistent severe hypoxemia. The patient also has increased alveolar dead space and decreased pulmonary compliance. 13. A client with emphysema is short of breath and using accessory muscles of respiration. The nurse recognizes that the client’s difficulty in breathing is caused by: A. Difficulty in expelling the air trapped B. An increase in the vital capacity of the lungs C. Spasm of the bronchi that traps the air D. A too rapid expulsion of the air from the alveoli Answer: A Rationale: In emphysema, impaired gas exchange (oxygen, carbon dioxide) results from destruction of the walls of overdistended alveoli, Emphysema is a pathological term that describes an abnormal distention of the air spaces beyond the terminal bronchioles, with destruction of the walls of the alveoli are destroyed, the alveolar surface area in direct contact with the pulmonary capillaries continually decreases, causing an increase in dead space and impaired oxygen diffusion, which leads to hypoxemia. 14. After incurring a motor vehicular accident, the client developed a flail chest. The nurse assesses the client for which most distinctive sign of flail chest? A. HypotensionB. Cyanosis C. Dyspnea, especially on exhalation D. Paradoxical chest movement Answer: D Rationale: Fail chest is frequently a complication of blunt chest trauma from a steering wheel injury. It usually occurs when three or more adjacent ribs (multiple contiguous ribs) are fractured at two or more sites, resulting in free-floating rib segments. During inspiration, as the chest expands, the detached part of the rib segment (flail segments) moves in a paradoxical manner (pendelluft movement) in that is pulled inward during aspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient’s ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance. 15. Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? A. The client will experience chills only once a day B. The patient will cough productively without chest discomfort C. The client will experience less nasal obstruction and discharge D. The client will maintain a fluid intake of 800 ml every 24 hours Answer: C Rationale: The term common cold often is used when referring to an upper respiratory tract infection that is self-limited and caused by various (viral rhinitis). Signs and symptoms of viral rhinitis are nasal congestion, runny nose, sneezing, nasal discharge, nasal itchiness, tearing watery eyes, “scratchy” or sore throat, general malaise, low grade fever, chills and often headache and muscle aches. There is no specific treatment for the common cold of influenza. Management consists of symptomatic therapy. Some measures include providing adequate fluid intake, encouraging rest, preventing chills, increasing intake of vitamin C and using expectorants as needed. 16. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client? A. “Use your nasal decongestant spray regularly to help clear your nasal passages.” B. “Ask the doctor for antibiotics.” C. “It is important to increase your activity. A daily brisk walk will help promote drainage.” D. “keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks.” Answer: D Rationale: Allergic rhinitis (inflammation of nasal mucosa; hay fever, chronic allergic rhinitis, pollinosis) is the most common form of respiratory allergy presumed to be mediated by an immediate (type I hypersensitivity) immunologic reaction. Because allergic rhinitis is induced by airborne pollens or molds it is characterized by the following seasonal occurrences: (1) early spring-tree pollen (2) early summerrose pollen, grass pollen (3) early fall- weed pollen. Sensitization begins by ingestion or inhalation of an antigen. On re-exposure, the nasal mucosa reacts by the slowing of ciliary action, edema formation, and leukocyte (primarily eosinophil) infiltration 17. The client has a history of COPD, but represents with edema of the legs and feet, distended neck vein and large palpable liver. What is the patient most likely suffering from?A. Pulmonary embolus B. Pleurisy C. Atelectasis D. Cor pulmonale Answer: D Rationale: (Pulmonary Heart disease) Cor pulmonale is a condition in which the right ventricle of the heart enlarges (with or without right sided heart failure) as a result of diseases that affect the structure or function of the lung or its vasculature. Any disease affecting the lungs and accompanied by hypoxemia may result in cor pulmonale. The most frequent cause is severe COPD, in which changes in the airway and retained secretions reduce alveolar ventilation. 18. Clients ordered with digoxin preparations should be closely monitored for toxicity when taking: A. Potassium supplements B. Antibiotics C. Furosemide (Lasix) D. Acetylsalicylic acid (Aspirin) Answer: C Rationale: Digoxin increases the force of myocardial contraction and slows conduction through the AV node. It improves contractility, increasing left ventricular output. A serious complication of Digoxin therapy is toxicity. The incidence is high, and toxicity may occur even though the serum digoxin level remains within a normal (0.5 to 2.0 ng/ml). while on this drug, clients especially those receiving both Digoxin and Diuretics should be monitored. An undetected, uncorrected potassium imbalance predisposes patients to digoxin toxicity and dysrhythmias. Furosemide is a potassium wasting diuretic and could therefore led to hypokalemia. 19. Which of the action should be initiated to avoid the development of tolerance to nitroglycerin of clients with angina? A. Use the sublingual form instead of the topical form B. Administer subsequent doses parenterally C. Allow for a daily 8-12-hour nitrate free period D. Store the drug in a dark container, free from light and moisture Answer: C Rationale: nitroglycerin is also available in a lanolin-petrolatum base that is applied to the skin as a paste or a patch. Explain t the client that a long term equally spaced dosing schedule of application of topical nitroglycerin is generally avoided to prevent tolerance. Most physicians prescribe application of topical nitroglycerin paste three or four times daily or every 6-hoours (excluding the midnight dose) and application of the nitroglycerin patch every morning and removed at 10 PM. This dosing regimen allows for a 6 to 8-hour nitrate-free period to prevent the body’s development of tolerance. 20. Daniel is currently receiving Iv heparin therapy. His PT and APTT results indicate his APTT is 90; the laboratory control is 30 seconds. The appropriate nursing intervention is to: A. Assess Daniel for decreased signs and symptoms of sensorium B. Document in the nursing notes that these results are within normal therapeutic range C. Note his RBC count and wait for when the health care provider makes the next round to discuss all laboratory values D. Contact the health care provider with the results via phone Answer: DRationale: Partial thromboplastin time varies so there is a need to compare the value with the control. It measures time elapsed until clot forms. Abnormal value indicates an increased in clotting factor depletion which could promote bleeding. 21. The nurse had administered 20 mg of Furosemide (Lasix) intravenously to a patient with congestive heart failure. You instruct the client to expect diuresis: A. Over 4 hours B. Between 1-3 hours C. Immediately D. Within 5 minutes to 2 hours Answer: D Rationale: Furosemide blocks reabsorption of sodium, chloride and water in kidney. Route Onset Peak Duration PO 30-60 min 1-2 hrs. 6-8 hrs. IM 10-30 min Unknown 4-8 hrs. IV 5 min 30 min 2 hrs. 22. A client’s cardiac monitor shows ventricular fibrillation. The nurse from the coronary care unit should prepare for which of the following? A. Immediate defibrillation B. Elective cardioversion C. An IM injection of digoxin (Lanoxin) D. An IV line for emergency medication Answer: A Rationale: Ventricular Fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles. This dysrhythmia is always characterized by the absence of an audible heartbeat, a pulpable pulse, and respirations. Because there is no coordinated cardiac activity, cardiac arrest and death are imminent if ventricular fibrillation is not corrected. Treatment of choice is immediate defibrillation and activation of emergency services. 23. An asthmatic client has recently been diagnosed with hypertension. Which classification of antihypertensive agents should be avoided by the client knowing his history? A. Angiotensin-converting enzyme (ACE) inhibitors B. Diuretics C. Aldosterone receptor antagonists D. Beta adrenergic agents Answer: D Rationale: Beta blockers such as propranolol (Inderal) appear to reduce myocardial oxygen consumption by blocking the beta-adrenergic sympathetic stimulation to the heart. The result is a reduction in heart rate, slowed conduction of an impulse through the heart, decreased blood pressure and reduced myocardial contractility. Because some beta blockers also affect the beta-adrenergic receptors in the bronchioles, causing bronchoconstriction, they are contraindicated in patients with significant pulmonary constrictive diseases, such as asthma. 24. The nurse is reviewing the ECG rhythm strip obtained on a client with admitting diagnosis of myocardial infarction. The nurse notes that the PR interval is 0 25. 20 seconds. The nurse determines that this is:A. Indicative of impending reinfarction B. Indicative of atrial flutter C. A normal finding D. Indicative of atrial fibrillation so health care provider must be informed immediately Answer: C Rationale: The ECG is composed of wave forms (including the P wave, the QRS complex, the T wave and possibly a U wave) and of segments or intervals (including the PR interval, the ST segment and the QT interval). The PR interval represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. The following are the ECG criteria for normal sinus rhythm: Ventricular and atrial rate: 60-100 in adults, ventricular and atrial rhythm: Regular, QRS shape and duration: usually normal, but may be regularly abnormal, P wave: normal and consistent shape; always in front of the QRS, PR interval: consistent interval between 0.12 and 0.20 seconds, P:QRS ratio: 1:1 26. David is having PVC based on his ECG tracings. As a nurse, you know that the first choice of drug to use to reduce premature ventricular contraction is: A. Procainamide B. Phenytoin C. Digoxin D. Lidocaine Answer: D Rationale: Premature ventricular complex (PVC) is an impulse that starts in a ventricle and is conducted through the ventricles before the nest normal sinus impulse. The patient may feel nothing or may say that the heart is “skipped a beat.” The effect of a PVC depends on its timing in the cardiac cycle and how much blood was in the ventricles when they contracted. Initial treatment is aimed at correcting the cause, if possible. Lidocaine (Xylocaine)is the medication most commonly used for immediate, short term therapy. Long term pharmacotherapy for only PVCs is not indicated. 27. A client who has just begun taking an ECE inhibitor called in the facility and reports to the nurse of feeling very dizzy when standing up and wonders if she should discontinue the medication. How should the nurse respond? A. “Stop taking the medication and report immediately to the facility” B. “Rise to a sitting or standing position slowly and you can feel a relief in your symptoms.” C. I will schedule you to visit the health care provider today.” D. Cut the pill in half and take a reduced dosage.” Answer: B Rationale: Angiotensin-converting Enzyme Inhibitors promote vasodilation and diuresis by decreasing afterload and preload. By doing so, they decrease the workload of the heart. Vasodilation reduces resistance to left ventricular ejection of blood, diminishing the heart’s workload and improving ventricular emptying. Patients receiving ACE-I therapy are monitored for hypotension, hypovolemia, hyponatremia and alterations in renal function, especially if they are also receiving diuretics. Teach patient to change positions gradually and to report signs of dizziness or lethargy. 28. A client experience acute myocardial ischemia. The nurse administers oxygen and sublingual nitroglycerin. When assessing an ECG for evidence that blood flow to the myocardium has improved, the nurse should focus on the? A. Widening of the QRS complexesB. Frequency of ectopic beats C. Return of the ST segment to baseline D. Presence of a significant Q wave Answer: C Rationale: Th ECG provides information that assists in diagnosing acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the emergency department. By monitoring the ECG overtime, the location, evolution and resolution of an MI can be identified and monitored. The classic ECG changes are T-wave inversion, ST-segment elevation, and development of an abnormal Q wave. Ischemia causes inversion of T wave because of altered repolarization. Cardiac muscle injury causes elevation of the ST segment and tall symmetrical T waves. With Q-wave infarction, Q or QS waves develop because of the absence of depolarization current from the necrotic tissue and opposing currents form other parts of the heart. 29. A client has an episode of dysrhythmia, before discharge she should be able to express understanding of the disease and treatment. The nurse’s health teaching is effective when the client verbalizes: A. “I am aware that I will have this problem forever and that medications won’t be able to help me.” B. I will take my medication when there is pain every 5 minutes until pain is resolved.” C. I know that I cannot control another attack.” D. I will make my prescribed medication on time and call immediately if I feel that there is something wrong.” Answer: D Rationale: Dysrhythmia are disorder of the formation or conduction (or both) of the electrical impulse within the heart. These disorders can case disturbances of the heart rate, the heart rhythm, or both. Control of the incidence or the effect of the dysrhythmia, or both, is often achieved by the use of antiarrhythmic medications. The nurse assesses and observes for the beneficial and adverse effects of each of the medications. The nurse also manages medication administration carefully so that a constant serum blood level of the medication is maintained at all times. 30. The nurse should be aware that a child with an iron deficiency may become dizzy during periods of physical activity because of: A. Insufficient cerebral oxygenation B. An inflammation of the inner ear C. A sudden drop in blood pressure D. Decreased levels of serum glucose Answer: A Rationale: Iron Deficiency Anemia typically results when the intake of dietary iron is inadequate for hemoglobin synthesis. The body can store about one fourth to one third of its iron, and it is not until those sores are depleted that iron deficiency anemia actually begins to develop. The diminished iron stores cause small RBCs therefore limiting the capacity of the blood to carry oxygen. 31. A pathophysiologic change underlying the production of symptoms in leukemia is: A. Proliferation and release of immature white blood cells into the circulating blood. B. Excessive destruction of blood cells in liver and spleen C. Progressive replacement of bone marrow with fibrous tissue D. Destruction of red blood cells and platelets by an overproduction of white blood cells Answer: ARationale: Leukemia (white blood) is a neoplastic proliferation of one particular cell type (granulocytes, monocytes, lymphocytes or magakaryotes). The defect originates in the hematopoietic stem cell, the myeloid, or the lymphoid stem cell. The common features of leukemia is an unregulated proliferation of WBCs in the bone marrow. The cause of leukemia is not fully known, but there is some evidence that genetic influence and viral pathogenesis may be involved. 32. One of the priorities for clients with myocardial infraction is to promote adequate tissue perfusion. Among the following activities, which best supports this intervention? A. Promote deep breathing exercise to alleviate pain B. Monitor input and output C. Maintaining the client on bed rest D. Stay with the client Answer: C Rationale: Limiting the client to the bed or chair rest during the initial phase of the treatment is particularly helpful in reducing myocardial oxygen consumption. The limitation should remain until the patient is in pain-free and hemodynamically stable. Checking skin temperature and peripheral pulses frequently is important to ensure adequate tissue infusion. Oxygen may be administered to enrich the supply of circulating oxygen. 33. You are assigned to care for a client who just undergone cardiac catheterization. Immediately after the procedure, which of the following nursing interventions would be most appropriate? A. Monitor for peripheral pulses B. Restricts fluids C. Insert an indwelling catheter D. Assist the client to ambulate to when going to the bathroom Answer: A Rationale: Cardiac catheterization is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into selected blood vessels of right and left sides of the heart. After the procedure, observe the catheter access site for bleeding or hematoma formation, and assess the peripheral pulses in the affected extremity (dorsal pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity)) every 15 minutes for 1 hour, and then every 1-2 hours until the pulses are stable. 34. A client with a diagnosis of Diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding would a nurse expect to not to see as confirming this diagnosis? A. Increased respiration and increase in ph B. Comatose state C. Decreased urine output D. Elevated blood glucose level and low plasma bicarbonate level Answer: A Rationale: DKA is caused by an absence or markedly Inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein and fat. The three main clinical features of DKA are: Hyperglycemia, dehydration and electrolyte loss and acidosis. Acidosis causes a decrease in the blood pH alkalosis causes an increase in the blood ph. 35. A factor learned while obtaining the nursing history that probably predisposed a client to type II Diabetes would be: A. Being 20 pounds overweightB. Having diabetes insipidus C. Eating low cholesterol foods D. Drinking daily alcoholic beverage Answer: A Rationale: Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from defects in insulin secretion, Insulin action, or both. Type II Diabetes is a metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased Insulin resistance Formerly called non- insulin dependent or adult onset. Patients are usually obese at diagnosis. Causes Include obesity, heredity or environmental factors. 36. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms if experienced by the client might indicate tetany? A. Bleeding on the back of the dressing B. Tingling of the fingers C. Pain in hands and feet D. Tension on the suture lines Answer: B Rationale: Occasionally in thyroid surgery the parathyroid glands are injured or removed, producing a disturbance in calcium metabolism. As the blood calcium level falls, hyperirritability of the nerves occur, with spasms of the hands and feet and muscle twitching. This group of symptoms is termed tetany, and the nurse must immediately report its appearance because laryngospasm, although rare, may occur and obstruct the airway. Tetany of this type is usually treated with intravenous calcium gluconate. This calcium abnormality is usually temporary after thyroidectomy. 37. A client with hypothyroidism who experiences trauma, emergency surgery or severe infection is at risk for developing which of the following conditions? A. Hepatitis B B. Malignant hyperthermia C. Myxedema coma D. Thyroid storm Answer: C Rationale: Myxedema com describes the most extreme, severe stage of hypothyroidism, in which the patient is hypothermic and unconscious. Myxedema coma may follow increasing lethargy progressing to stupor and then coma. Undiagnosed hypothyroidism may be precipitated by infection or other systematic disease or by use of sedatives or opioid analgesic agents. The patient's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive CO2 retention, narcosis and coma. These symptoms along with cardiovascular collapse and shock, require aggressive and intensive therapy if the patient is to survive. Even with early vigorous therapy, however, mortality is high. 38. A physician has prescribed propylthiouracil (PTU) for a client with hyperthyroidism and the nurse assigned to this client develops a plan of care for the client. A priority assessment to be included in the plan regarding this medication is to assess for: A. Relief of pain B. Signs of renal toxicity C. Signs and symptoms of hypoglycemia D. Signs and symptoms of hypothyroidismAnswer: D Rationale: Antithyroid agents block the utilization of iodine by interfering with iodination of thyroxine and the coupling of iodothyrosines in the synthesis of thyroid hormones. This prevents the synthesis of thyroid hormone. The most commonly used medications are propylthiouracil or methimazole until the patient euthyroid. These medications block extrathyroidal conversion of T4 to T3. The objective of pharmacotherapy is to inhibit one or more stages in thyroid hormone synthesis or hormone release; another goal may be to reduce the amount of thyroid tissue, with resulting decreased thyroid hormone production. 39. The nurse assesses for the major symptom associated with pheochromocytoma when he: A Takes the client's blood pressure B. Obtains the client's weight E Tests the client’s urine for glucose D. Palpates the skin for its temperature Answer: A Rationale: Pheochromocytoma is a tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. The typical triad of symptoms comprises headache, diaphoresis and palpitations. Hypertension and other cardiovascular disturbances are common. Pheochromocytoma is suspected if signs of sympathetic nervous system overactivity occur in association with marked elevation of blood pressure. These signs can be associated with the Five H'S: hypertension, headache, hyperhidrosis, hypermetabolism and hyperglycemia. 40. Potassium iodide (Lugol's solution) is thyrotoxic crisis. The client calls the clinic and complains of a brassy taste in the mouth. Which of the following is an appropriate instruction to the client? A. Continue with the medication B. Withhold the medication and notify the physician C. Take half of the prescribed dose for the next 24 hours D. Withhold the medication for the next the prescribed does for hours then continue as prescribed Answer: B Rationale: Potassium iodide inhibits thyroid hormone release, reduces thyroid vascularity, and decreases thyroid uptake of radioactive iodine after radiation emergencies and administration of radioactive iodine Isotopes. In long term use, check for signs and symptoms of iodism (lodine toxicity which includes metallic taste (brassy taste), sore teeth and gums, sore throat, burning of mouth and throat cold-like symptoms, severe headache, productive cough, Gl irritation, diarrhea, angioedema, rash, fever and cutaneous or mucosal hemorrhage. Discontinue drug immediately if these occur. 41. Which of the following lab results would be expected in a client suspected of having Cushing's disease? A. Decreased urinary calcium level B. Hypoglycemia C. Hypokalemia D. Hyponatremia Answer: C Rationale: Cushing's syndrome results from excessive adrenocortical activity. The signs and symptoms of the disease are primarily a result of over secretion of glucocorticoids and androgens (sex hormones), although mineralocorticoid secretion also may be affected Indicators of Cushing's syndrome include an increase in serum sodium and blood glucose levels and a decreased serum concentration of potassium, a reduction in the number of blood eosinophils, and disappearance of lymphoid tissue.42. An order of oral glucocorticoid Has bene ordered to a client diagnosed with Addison's disease. Which of the following statements made by the client does not need further teaching? A. “I will take the drug after I have eaten something or with an antacid.” B. “I will take the drug at bedtime to increase absorption” C. “I should take the drug on an empty stomach.” D. “I must remember to take the drug with a full glass of water” Answer: A Rationale: Oral steroids can cause gastric in and ulcers and should be administered with meals, if possible or otherwise an antacid. Glucocorticoids should be taken in the morning not at bedtime. 43. Angelo has been ordered with thiazide diuretic. While on this drug, the nurse should encourage Angelo to eat foods with high amounts of: A. Potassium B. Calcium C. Iron D. Ascorbic acid Answer: A Rationale: Potassium-losing diuretics, such as thiazides (eg. chlorothiazide [Diuril] and polythiazide [Renesel], can induce hypokalemia, particularly when administered in large doses to patients with inadequate potassium intake. 44. Before the procedure, the nurse reviewing the potential complications after hypophysectomy. Which of the following should the nurse teach the complication after the procedure? A. Diabetes mellitus B Acromegaly C. Hypopituitarism D. Cushing's disease Answer: C Rationale: Hypophysectomy is the removal of the pituitary gland, may be performed to treat primary pituitary gland tumors. It is the treatment of choice in patients with Cushing's syndrome due to excessive production of ACTH by a tumor of the pituitary gland. The absence of the pituitary gland alters the function of many body systems. Menstruation ceases and infertility occurs after total or near-total ablation of the pituitary gland. The client should be taught to monitor for change in mental status, energy level, muscle strength and cognitive function. Acromegaly and Cushing's disease are conditions of hypersecretion. 45. For a client diagnosed with diabetes insipidus, which of the following is apriority outcome? A. A serum glucose level within the normal range B. Adequate knowledge regarding dietary restriction C. Maintains normal fluid and electrolyte balance D. Practice proper grooming daily Answer: C Rationale: Diabetes insipidus is disorder of the posterior lobe of the pituitary gland characterized by the of deficiency of antidiuretic hormone (ADH) on the distal nephron of the kidney, an enormous daily output every dilute water like urine with a specific gravity of 1.001 to 1.005 occurs. The objective of therapy are (1) to replace ADH (which is usually a long term therapeutic program. (2) to ensure adequate fluid replacement and (3) to identify and correct underlying intracranial pathology.46. A nurse is preparing a teaching for a client with Diabetes mellitus regarding proper foot care. Which instructions should be included in the plan? A. Soak feet in hot water B. Avoid using mild soap on the feet C. Apply a moisturizing lotion to dry feet but not between the toes D. Always have a podiatrist to cut your toe nails; never cut them yourself Answer: C Rationale: Foot care tips for Diabetic client include: (1) Wash feet in warm, not hot, water (2) Dry feet. well, making sure to dry between the toes (3) Do not soak feet (4) Do not check water temperature with feet; use a thermometer or elbow (4) Rub a thin coat of skin lotion over the tops and bottom of the feet, but not between the toes (5) Use a pumice stone to smooth corns and calluses (6) Trim toenails straight across and file the edges with an emery board or nail file (7) Never walk barefoot. 47. Among the following, a priority nursing diagnosis for a client experiencing Addisonian crisis is: A. Imbalanced Nutrition: more than body requirements related to decrease exercise B. Excess fluid volume relates to reduced urinary excretion of fluid C. Self-care deficit related weakness and fatigue D. Imbalanced Nutrition: more than body requirements related to increase in appetite Answer: C Rationale: Addison’s crisis is an acute adrenocortical insufficiency; characterized by acute hypertension, cyanosis, fever nausea and vomiting, and the classic signs of shock; therefore, physical and psychological stressors must be avoided. These include exposure to cold, overexertion, infection and emotional distress. During acute Addisonian crisis, the patient must avoid exertion; therefore, the nurse anticipates the patients needs and takes measures to meet them. 48. When providing discharge instructions to a client who had a thyroidectomy, the nurse should teach the client to observe for signs of surgically induced hypothyroidism which include: A. Intolerance to heat B. Dry skin and fatigue C. Insomnia and excitability D. Emaciation and weight loss Answer: B Rationale: Hypothyroidism results from suboptimal levels of thyroid hormones. Early symptoms of hypothyroidism are nonspecific, but extreme fatigue makes it difficult to the person to complete a full day’s work or participate in usual activities. Reports of hair loss, brittle nails and dry skin are common, and numbness ang tingling of the fingers may occur. 49. 24 hours after the removal of both adrenal glands, which of the following should receive the highest priority? A. Promoting self-care activities B. Preventing adrenal crisis C. Ambulating in the hallway D. Initiating oral nutrition Answer: BRationale: Adrenalectomy may be used in treating adrenal tumors, primary Cushing’s syndrome, and aldosteronism. If the adrenalectomy is bilateral, replacements of corticosteroids will be lifelong. Nursing management in the postoperative period includes frequent assessment of vital signs to detect early signs and symptoms, of adrenal insufficiency and crisis or hemorrhage. 50. The physician ordered propylthiouracil for a client with hyperthyroidism. The nurse is ware that this drug is beneficial for the client because: A. PTU interferes with the synthesis of thyroid hormone B. PTU increases the uptake of iodine C. PTU decreases the secretion of TSH D. PTU causes atrophy of the thyroid gland Answer: A Rationale: Antithyroid agents blocks the utilization of iodine by interfering with the iodination of thyrosine and the coupling of iodothyronines in the synthesis of thyroid hormones. This prevents the synthesis of thyroid hormone. The most commonly used medications are propylthiouracil (PTU) or methimazole (Tapazole). 1.The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis Answer B is correct. Rationale: The client’s blood gases indicate respiratory alkalosis. Answers A, C, and D are not reflected by the client’s blood gases or present condition; therefore, they are incorrect. 2.A client is diagnosed with emphysema and cor pulmonale. Which finding sare characteristic of cor pulmonale? A. Hypoxia, shortness of breath, and exertional fatigue B. Weight loss, increased RBC, and fever C. Rales, edema, and enlarged spleen D. Edema of the lower extremities and distended neck veins Answer D is correct. Rationale: Cor pulmonale, or right-sided heart failure, is characterized by edema of the legs and feet, enlarged liver, and distended neck veins. Answer A is incorrect because the symptoms are those of leftsided heart failure and pulmonary edema. Answer B is not specific to the question; therefore, it is incorrect. Answer C is incorrect because it does not relate to cor pulmonale 3. A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to: A. Prevent swelling and dysphagia B. Decompress the stomach C. Prevent contamination of the suture line D. Promote healing of the oral mucosaAnswer C is correct. Rationale: The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Answer A is not a true statement; therefore,it is incorrect. Answer B is incorrect because there is no mention of suction. Answer D is incorrect because the oral mucosa was not involved in the laryngectomy. 4. The physician orders the removal of an in-dwelling catheter the second postoperative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that: A. Using warm compresses over the bladder will lessen the discomfort. B. Perineal exercises will be started in a few days to help relieve his symptoms. C. If the symptoms don’t improve, the catheter will have to be reinserted. D. His complaints are common and will improve over the next few days. Answer D is correct. The client’s complaints are due to swelling associated with surgery and catheter placement. Answer A is incorrect because it will not relieve the client’s symptoms of pain and dribbling. Answer B is incorrect because perineal exercises will not help relieve the post-operative pain. Answer C is incorrect because the client’s complaints do not indicate the need for catheter reinsertion. 5. A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client’s chest drainage system: A. Can be disconnected from suction if the chest tube is clamped B. Can be disconnected from suction, but the chest tube should remain unclamped C. Must remain connected by means of a portable suction D. Must be kept even with the client’s shoulders during the transport Answer B is correct. Rationale: The chest-drainage system can be disconnected from suction, but the chest tube should remain unclamped to prevent a tension pneumothorax. Answer A is incorrect because it could result in a tension pneumothorax. Answer C is not a true statement; therefore, it is not correct. Answer D is incorrect because the chest-drainage system should be kept lower than the client’s chest and shoulders. 6. A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is: A. Right ventricular hypertrophy B. Cardiac dysrhythmia C. Left ventricular hypertrophy D. Hyperkalemia Answer B is correct. Rationale: Cardiac dysrhythmias are the most common complication for the client with a myocardial infarction. Answers A and C do not relate to myocardial infarction; therefore, they are incorrect. Answer D is incorrect because it is not the most common complication following a myocardial infarction. 7. A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature: A. Increase cardiac output B. Indicate cardiac tamponade C. Decrease cardiac output D. Indicate graft rejection Answer A is correct.Rationale: Elevations in temperature increase the cardiac output. Answer B is incorrect because temperature elevations are not associated with cardiac tamponade. Answer C is incorrect because temperature elevation does not decrease cardiac output. Answer D is incorrect because elevations in temperature in the client with a coronary artery bypass graft indicate inflammation, not necessarily graft rejection. 8. The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with: A. Speaking and writing B. Comprehending spoken words C. Carrying out purposeful motor activity D. Recognizing and using an object correctly Answer A is correct. Rationale: The client with expressive aphasia has trouble forming words that are understandable. Answer B is incorrect because it describes receptive aphasia. Answer C refers to apraxia and answer D refers to agnosia, so they are incorrect. 9. To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should: A. Tell the client to remain on bed rest until swelling subsides B. Discourage passive range of motion because it will cause further swelling C. Encourage motion of the joint within the limits of pain D. Tell the client she will need joint immobilization for 2–3 weeks Answer C is correct. Rationale: The client with rheumatoid arthritis needs to continue moving affected joints within the limits of pain. Answer A and D are incorrect because they will increase stiffness and joint disuse. Answer B is incorrect because, if done correctly, passive range-of-motion exercises will improve the use of affected joints. 10. A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client? A. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock B. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries C. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries D. Prevent hypovolemic shock, assess for head injuries, establish an airway, and control hemorrhage Answer C is correct. Rationale: Using the ABCD approach to the client with multiple trauma the nurse in the ER would: establish an airway, determine whether the client is breathing, check circulation (control hemorrhage), and check for deficits (head injuries). Answers A, B, and D are incorrect because they are not in the appropriate sequence for maintaining life. 11. A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include: A. Releasing the traction for 5 minutes each shift B. Loosening the pins if the client complains of headache C. Elevating the head of the bed 90° D. Performing sterile pin care as ordered Answer D is correct.Rationale: Nursing care of the client with cervical tongs includes performance of sterile pin care and assessment of the site. Answers A, B, and C alter the traction and could result in serious injury or death of the client therefore, they are incorrect. 12. The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting: A. Chest drainage of 150mL in the past hour B. Confusion and restlessness C. Pallor and coolness of skin D. Urinary output of 40mL per hour Answer A is correct. Rationale: Chest drainage greater than 100mL per hour is excessive, and the doctor should be notified regarding possible hemorrhage. Confusion and restlessness could be in response to pain, changes in oxygenation, or the emergence from anesthesia; therefore, answer B is incorrect. Answer C is incorrect because it is an expected finding in the client recently returning from a CABG. Answer D is within normal limits; therefore, it is incorrect. 13. Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to: A. Record the pulse rate and administer the medication B. Administer the medication and monitor the heart rate C. Withhold the medication and notify the doctor D. Withhold the medication until the heart rate increases Answer C is correct. Rationale: The medication should be withheld and the doctor should be notified. Answers A, B, and D are incorrect because they do not provide for the client’s safety. 14. Which finding is associated with Tay Sachs disease? A. Pallor of the conjunctiva B. Cherry-red spots on the macula C. Blue-tinged sclera D. White flecks in the iris Answer B is correct. Rationale: The child with Tay Sachs disease has cherry-red spots on the macula of the eye. Answer A is incorrect because it is associated with anemia. Answer C is incorrect because it is associated with osteogenesis imperfecta. Answer D is incorrect because it is associated with Down syndrome. 15. A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid: A. Calcium-rich foods B. Canned or frozen vegetables C. Processed meat D. Raw fruits and vegetables Answer D is correct. Rationale: The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers A, B, and C are incorrect because they are permitted in the client’s diet. 16. A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client? A. Sublimaze (fentanyl)B. Pavulon (pancuronium bromide) C. Versed (midazolam) D. Atarax (hydroxyzine) Answer B is correct. Rationale: Pavulon is a neuromuscular blocking agent that paralyzes skeletal muscles, making it impossible for the client to fight the ventilator. Sublimaze is an analgesic used to control operative pain; therefore, answer A is incorrect. Versed is a benzodiazepine used to produce conscious sedation; therefore, answer C is incorrect. Answer D is wrong because Atarax is used to treat post-operative nausea. 17. A client with a history of diverticulitis complains of abdominal pain, fever, and diarrhea. Which food is responsible for the client’s symptoms? A. Mashed potatoes B. Steamed carrots C. Baked fish D. Whole-grain cereal Answer D is correct. Rationale: Symptoms associated with diverticulitis are usually reported after eating foods like popcorn, celery, raw vegetables, whole grains, and nuts. Answers A, B, and C are incorrect because they are allowed in the diet of the client with diverticulitis. 18. The home health nurse is visiting a client with Paget’s disease. An important part of preventive care for the client with Paget’s disease is: A. Keeping the environment free of clutter B. Advising the client to see the dentist regularly C. Encouraging the client to take the influenza vaccine D. Telling the client to take a daily multivitamin Answer A is correct. Rationale: The client with Paget’s disease has problems with mobility. Keeping the environment free of clutter will help prevent falls. Answers B, C, and D will improve the client’s overall health but are not specific to Paget’s disease; therefore, they are incorrect. 19. The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is: A. Preventing addiction B. Alleviating pain C. Facilitating mobility D. Preventing nausea Answer B is correct. Rationale: The nurse should be concerned with alleviating the client’s pain. Answers A, C, and D are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect. 20. A client with emphysema is receiving intravenous aminophylline. Which aminophylline level is associated with signs of toxicity? A. 5 micrograms/mL B. 10 micrograms/mL C. 20 micrograms/mL D. 25 micrograms/mL Answer D is correct.Rationale: The therapeutic range for aminophylline is 10–20 micrograms/mL. Levels greater than 20 micrograms/mL can produce signs of toxicity. Answer A is incorrect because it is too low to be therapeutic. Answers B and C are within the therapeutic range; therefore, they are incorrect. 21. A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices: A. Gastric distress B. Changes in hearing C. Red discoloration of body fluids D. Changes in color vision Answer D is correct. Rationale: An adverse reaction to Myambutol is changes in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer B is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin. 22. The primary cause of anemia in a client with chronic renal failure is: A. Poor iron absorption B. Destruction of red blood cells C. Lack of intrinsic factor D. Insufficient erythropoietin Answer D is correct. Rationale: Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in clients with chronic renal failure; therefore, they are incorrect. 23. A client has ataxia following a cerebral vascular accident. The nurse should: A. Supervise the client’s ambulation B. Measure the client’s intake and output C. Request a consult for speech therapy D. Provide the client with a magic slate Answer A is correct. Rationale: Ataxia affects the client’s mobility, making falls more likely. Answers B, C, and D are incorrect because they do not relate to the problem of ataxia. 24. The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to: A. Prevent headaches B. Boost coagulation C. Prevent cerebral anoxia D. Decrease platelet aggregation Answer D is correct. Rationale: Aspirin decreases platelet aggregation or clumping, thereby preventing clots. Answer A is incorrect because the low-dose aspirin will not prevent headaches. Answers B and C are untrue statements; therefore, they are incorrect. 25. The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should: A. Mix the insulin with Dextrose 5% in Water B. Flush the IV tubing with the insulin solution and discard the first 50mL C. Avoid using a pump or controller with the infusionD. Mix the insulin with Ringer’s lactate Answer B is correct. Rationale: Insulin molecules adhere to glass and plastic; therefore, the IV set and entire tubing should be flushed and 50mL discarded before administering the infusion to the client. Answers A and D are incorrect because insulin is mixed using 0.9% or 0.45% normal saline. Answer C is incorrect because the infusion is given using a pump or controller. 26. While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HB8 AG. The nurse recognizes that the client: A. Has chronic hepatitis B B. Has recovered from hepatitis B infection C. Has immunity to infection with hepatitis C D. Has no chance of spreading the infection to others Answer A is correct. Rationale: A serologic marker of HB8 AG that is present 6 months after acute infection with hepatitis B indicates that the client is a carrier or has chronic hepatitis. Answer B is incorrect because the HB8 AG would normally decline and disappear. Answer C is incorrect because the client can still be infected with hepatitis C. Answer D is incorrect because the client is a carrier. 27. A client with tuberculosis who has been on combined therapy with rifampin and isoniazid asks the nurse how long he will have to take medication. The nurse should tell the client that: A. Medication is rarely needed after 2 weeks. B. He will need to take medication the rest of his life. C. The course of therapy is usually 6 months. D. He will be re-evaluated in 1 month to see if further medication is needed. Answer C is correct. Rationale: The usual course of treatment using combined therapy with isoniazid and rifampin is 6 months. Answers A and D are incorrect because the treatment time is too brief. Answer B is incorrect because the medication is not needed for life. 28. The nurse is caring for a client with irritable bowel syndrome. Irritable bowel syndrome is characterized by: A. Development of pouches in the wall of the intestine B. Alternating bouts of constipation and diarrhea C. Swelling, thickening, and abscess formation D. Hypocalcemia and iron-deficiency anemia Answer B is correct. Rationale: The client with irritable bowel syndrome has bouts of constipation and diarrhea. Answer A is incorrect because it describes changes associated with diverticulosis. Answer C is incorrect because it describes changes associated with Crohn’s disease. Answer D is incorrect because it describes findings associated with ulcerative colitis. 29. A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client’s discharge care plan? A. The medication can cause dental staining. B. The client will need to avoid a high-carbohydrate diet. C. The client will need a regularly scheduled blood work. D. The medication can cause problems with drowsiness. Answer C is correct.Rationale: Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need regularly scheduled blood work. Answer A is incorrect because the medication does not cause dental staining. Answer B is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer D is incorrect because the medication does not cause drowsiness. 30. A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal: A. A weight loss of 2 pounds in 1 day B. A serum creatinine 1.25mg/dL C. Urinary output of 50mL/hr D. Rising blood pressure Answer D is correct. Rationale: Increased blood pressure following a renal transplant is an early sign of transplant failure. Answers A, B, and C are expected with successful renal transplant; therefore, they are incorrect. 31. The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client? A. Take the medication 30 minutes before eating. B. Report changes in appetite and weight. C. Wear sunglasses to prevent cataracts. D. Schedule a time to take the influenza vaccine. Answer D is correct. Rationale: The client taking steroid medication should receive an annual influenza vaccine. Answer A is incorrect because the medication should be taken with food. Answer B is incorrect because increased appetite and weight gain are expected side effects of the medication. Answer C is incorrect because wearing sunglasses will not prevent the development of cataracts in the client taking steroids. 32. The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should: A. Place the client in a prone position 15–30 minutes twice a day B. Keep the foot of the bed elevated on shock blocks C. Place trochanter rolls on either side of the affected leg D. Keep the client’s leg elevated on two pillows Answer A is correct. Rationale: The client with an above-the-knee amputation should be placed in a prone position 15–30 minutes twice a day to prevent contractures. Answers B and D are incorrect choices because elevation of the extremity one day post amputation promotes the development of contractures. Use of a trochanter roll will prevent rotation of the extremity but will not prevent contracture; therefore, answer C is incorrect. 33. A client with an esophageal tamponade develops symptoms of respiratory distress, including inspiratory stridor. The nurse should give priority to: A. Applying oxygen at 4L via nasal cannula B. Removing the tube after deflating the balloons C. Elevating the head of the bed to 45° D. Increasing the pressure in the esophageal balloon Answer B is correct. Rationale: Displacement of the esophageal balloon is the most likely cause of respiratory distress in the client with an esophageal tamponade. The nurse should deflate both the gastric and esophageal balloons before removing the tube. Answers A and C are incorrect because applying nasal oxygen andelevating the head will not relieve airway obstruction. Answer D is incorrect because it would cause further obstruction of the airway. 34. The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at: A. The third intercostal space right of the sternum B. The third intercostal space left of the sternum C. The fourth intercostal space beneath the sternum D. The fourth intercostal space midclavicular line Answer D is correct. Rationale: The mitral valve is heard loudest at the fourth intercostal space midclavicular line, which is the apex of the heart. Answer A is incorrect because it is the location for the aortic valve. Answer B is incorrect because it is the location for the pulmonic valve. Answer C is wrong because it is the location for the tricuspid valve. 35. The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should: A. Tell the client to avoid a tub bath for 48 hours B. Tell the client to expect clay-colored stools C. Tell the client that she can expect lower abdominal pain for the next week D. Tell the client to report pain in the back or shoulders Answer A is correct. Rationale: Following a laparoscopic cholecystectomy, the client should avoid a tub bath for 48 hours. Answer B is incorrect because the stools should not be clay colored. Answer C is incorrect because pain is usually located in the shoulders. Answer D is incorrect because pain in the back and shoulders is expected following laparoscopic surgery. 36. A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client: A. To drink additional fluids throughout the day B. To avoid contact sports for 1–2 months C. To have a snack twice a day to prevent hypoglycemia D. To continue antibiotic therapy for 6 months Answer B is correct. Rationale: The client recovering from mononeucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer A is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer C is incorrect. Answer D is incorrect because antibiotics are not usually indicated in the treatment of mononeucleosis. 37. An adolescent with cystic fibrosis has an order for pancreatic enzyme replacement. The nurse knows that the medication should be given: A. At bedtime B. With meals and snacks C. Twice daily D. Daily in the morning Answer B is correct. Rationale: Pancreatic enzyme replacement is given with meals and snacks. Answers A, C, and D do not specify a relationship to meals; therefore, they are incorrect.38. A client with breast cancer is returned to the room following a right total mastectomy. The nurse should: A. Elevate the client’s right arm on pillows B. Place the client’s right arm in a dependent sling C. Keep the client’s right arm on the bed beside her D. Place the client’s right arm across her body Answer A is correct. Rationale: Following a total mastectomy, the client’s right arm should be elevated on pillows to facilitate lymph drainage. Answers B, C, and D are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity. 39. The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglyerin: A. Slows contractions of the heart B. Dilates coronary blood vessels C. Increases the ventricular fill time D. Strengthens contractions of the heart Answer B is correct. Rationale: Nitroglycerin is used to dilate coronary blood vessels, which provides improved circulation to the myocardium. Answers A, C, and D describe the effects of digoxin, not nitroglycerin; therefore, they are incorrect. 40. A trauma client is admitted to the emergency room following a motor vehicle accident. Examination reveals that the left side of the chest moves inward when the client inhales. The finding is suggestive of: A. Pneumothorax B. Mediastinal shift C. Pulmonary contusion D. Flail chest Answer D is correct. Rationale: The client with flail chest will exhibit paradoxical respirations. (With inspiration, the affected side will move inward; with expiration, the affected side will move outward. Flail chest is frequently associated with high-speed motor vehicle accidents.) Answer A is incorrect because air or blood would be present in the thoracic cavity. Answer B is incorrect because the trachea would be shifted to the affected side. Answer C is incorrect because interstitial edema would be present. 41. The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that: A. The client can have a higher-calorie diet. B. The client has good control of her diabetes. C. The client requires adjustment in her insulin dose. D. The client has poor control of her diabetes. Answer B is correct. Rationale: The client’s diabetes is well under control. Answer A is incorrect because it will lead to elevated glucose levels. Answer C is incorrect because the diet and insulin dose are appropriate for the client. Answer D is incorrect because the desired range for glycosylated hemoglobin in the adult client is 2.5%–5.9%.42. A dexamethasone-suppression test has been ordered for a client with severe depression. The purpose of the dexamethasone suppression test is to: A. Determine which social intervention will be best for the client B. Help diagnose the seriousness of the client’s clinical symptoms C. Determine whether the client will benefit from electroconvulsive therapy D. Reverse the depressive symptoms the client is experiencing Answer C is correct. Rationale: The purpose of the dexamethasone-suppression test is to identify clients who will benefit from therapy with antidepressants and electroconvulsive therapy rather than psychological or social interventions. Answers A, B, and D contain inaccurate statements; therefore, they are incorrect. 43. The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on: A. Ineffective airway clearance B. Impaired gas exchange C. Fluid volume deficit D. Pain Answer C is correct. Rationale: During the emergent phase, the nursing priority for a client with burns confined to the lower body would focus on the risk for fluid volume deficit. Answers A and B are incorrect because there is no indication that the airway is involved. Answer D is incorrect because pain does not take priority over the management of hypovolemia. 44. The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA? A. The nurse leaves the stethoscope in the client’s room for future use. B. The nurse cleans the stethoscope with alcohol and returns it to the exam room. C. The nurse uses the stethoscope to assess the blood pressure of other assigned clients. D. The nurse cleans the stethoscope with water, dries it, and returns it to the nurse’s station. Answer A is correct. Rationale: The stethoscope should be left in the client’s room for future use. The stethoscope should not be returned to the exam room or the nurse’s station; therefore, answers B and D are incorrect. The stethoscope should not be used to assess other clients; therefore, answer C is incorrect 45. The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis? A. Visual disturbances, including diplopia B. Ascending paralysis and loss of motor function C. Cogwheel rigidity and loss of coordination D. Progressive weakness that is worse at the day’s end Answer D is correct. Rationale: The client with myasthenia develops progressive weakness that worsens during the day. Answer A is incorrect because it refers to symptoms of multiple sclerosis. Answer B is incorrect because it refers to symptoms of Guillain Barre syndrome. Answer C is incorrect because it refers to Parkinson’s disease. 46. The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:A. That the infant will need daily calcium supplements B. That it is best to lift the infant by the buttocks when diapering C. That the condition is a temporary one D. That only the bones of the infant are affected by the disease Answer B is correct. Rationale: To prevent fractures, the parents should lift the infant by the buttocks rather than the ankles when diapering. Answer A is incorrect because infants with osteogenesis imperfecta have normal calcium and phosphorus levels. Answer C is incorrect because the condition is not temporary. Answer D is incorrect because the teeth and the sclera are also affected. 47. Physician’s orders for a client with acute pancreatitis include the following: strict NPO and nasogastric tube to low intermittent suction. The nurse recognizes that withholding oral intake will: A. Reduce the secretion of pancreatic enzymes B. Decrease the client’s need for insulin C. Prevent the secretion of gastric acid D. Eliminate the need for pain medication Answer A is correct. Rationale: Withholding oral intake will help stop the inflammatory process by reducing the secretion of pancreatic enzymes. Answer B is incorrect because the client requires exogenous insulin. Answer C is incorrect because it does not prevent the secretion of gastric acid. Answer D is incorrect because it does not eliminate the need for pain medication. 48. A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis? A. Pain in the left lower quadrant B. Board like abdomen C. Low-grade fever D. Abdominal distention Answer B is correct. Rationale: A rigid or boardlike abdomen is suggestive of peritonitis, which is a complication of diverticulitis. Answers A, C, and D are common findings in diverticulitis; therefore, they are incorrect. 49. A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS? A. High calorie, high protein, high fat B. High calorie, high carbohydrate, low protein C. High calorie, low carbohydrate, high fat D. High calorie, high protein, low fat Answer D is correct. Rationale: The suggested diet for the client with AIDS is one that is high calorie, high protein, and low fat. Clients with AIDS have a reduced tolerance to fat because of the disease, as well as side effects from some antiviral medications; therefore, answers A and C are incorrect. Answer B is incorrect because the client needs a high-protein diet. 50. A client with otosderosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve? A. Diminished hearing B. Sensation of fullness in the ear C. Inability to move the tongue side to sideD. Changes in facial sensation Answer D is correct. Rationale: Complications following a stapedectomy include damage to the seventh cranial nerve that results in changes in taste or facial sensation. Answers A and B are incorrect because they are expected immediately following a stapedectomy. Answer C is incorrect because it involves the twelfth cranial nerve (hypoglossal nerve). [Show More]

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