. What gauge needle would be appropriate for a subcutaneous injection? 25 gauge needle is preferred for subcutaneous injections. How should an artificial eye be cleaned? with soap and water. . What is the normal fetal heart rate? 120 and 160 beats per minute.
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. What gauge needle would be appropriate for a subcutaneous injection? 25 gauge needle is preferred for subcutaneous injections.
How should an artificial eye be cleaned? with soap and water.
. What is the normal fetal heart rate? 120 and 160 beats per minute.
. On average, how much weight does a mother gain during pregnancy? 25 and 30 pounds during pregnancy.
What is the best antidote for magnesium sulfate toxicity magnesium sulfate toxicity is calcium glutonate.
. When should a pregnant patient be tested for alpha protein serum levels 18 to 20 weeks into gestation.
. Which of the following is NOT a factor that causes the urine pH to be lessthan 4.5?
A diet high in protein, a fever, and metabolic acidosis can all cause the urinepH to drop below 4.5.
t what age should solids be introduced into an infant's diet? 4 and 6 months
What condition is characterized by involuntary twitching movements of themuscles, particularly rolling of the tongue?
The classic symptom of tardive dyskinesia is involuntary spasms of thefacial muscles, especially rolling of the tongue.
Which foods should be avoided while on MAOI antidepressants?Foods containing tyramine should be avoided while on MAOI
antidepressants.
What kind of antacids are known to cause diarrhea? Magnesium-based antacids are notorious for causing diarrhea
What is the best initial treatment for hypercalcemia?Saline and furomeside should be administered as soon as possible during
cases of hypercalcemia.
What is the most common transfusion reaction? fever
What is another name for primal adrenal insufficiency? Addison's disease is also known as primal adrenal insufficiency.
Pulse pressure (pp) is considered the Difference between the systolic and diastolic pressure.
maternal estrogen has been transfered to the neonate what would the nursesee
enlarged breast tissue
molar pg increased HCG levels
meconium in the amnotic fluid is nl for breach position
restraints should be removed q 2hrs and left off for 5 min for ROM and skin checks
cool mist tent decrease resp tract edema
a kid with celiac how can you monitor the effectivness of tx monitor stools
moro reflex 5 months
impetigo
vacular lesions that ooze and form crust on face and extrimites
direct contact wash hands!
post op cleft lip clean suture line after every feeding w/sterile solution
cf diet high cal high protein
pancrilipase with meals and snacks
iron food PB, green veggies and rasins
fontanels should be closed by 18 months
PDA administer indomethocin
car seat 4 or 40lbs
mo solids till 6 months
to prevent OM place baby in upright position while feeding
preschool child give dolls and medical stuff to play with
fetal heart tones at 11 weeks with doppler
chylamydia tx w/ zithromax
ectopic pg sx abd pain vag pain and positve hcg
false labor contractions felt in abd, irregular and relived by walking
epidural be sure to hydrate before r/t the anestetic can cause hypotension
apgar hr, resp, reflex, irratiblity
going into 2nd stage of labor uncontrolable urge push
common adverse effect of phototherapy watery stools
rooting reflex kid turns head to the side
mag sulfatecns depressant lathargy is s s/e.
Tox = flushing reflex depression , decreased urinary output, depresed rep.
folic acid egg yolks
variable decels change position
external monitor lie any comfy position but try to stay off back
mild preeclampsia htn, edema, proteinurea
placenta previa soft relaxed non tender uterus
rh neg mom rh pos baby give mom rhogam with in 72 hrs
to prepare for amnio asl pt to void, assess fetal heart rate, monitor maternal vs
premature labor provide adequate hydration
hypogycemia in the neonate lathargy is the inital sign
neonate wt loss loose 10 % of birth wt in 3-4 days then nl
breast feed q 1-3 hrs
placenta previa painless vag bleed increase r/f after 35
ace inhibitors inhibit k secretion
DI give vasopressin sub q or intranassaly
mi hypotension rapid pluse and cp
post op cataract don't sleep on effected side
predinsone side effects wt gain hypertension and insomnia
mefanide sulfate topical abx for burns
neostigmine for mg to give 45 60 min before meals to improve chewing
type 1 hypogly event admin 15-20 fast acting CHO
acute viral hepatitis bedrest
bladder spasms and urge to void with foley after turpcheck for clot by ns irrigation at 40-60 gtts q min amount instilled should be
the amount with drawn if patent
nsaids w/food to prevent gi upset
autonomic dysreflexia monitor foley patancy can precipitate condition
asending or transverse colonoscopy liquid or simi liqued stools
myasthenia gravis asses resp system and muscle weakness
long term predinsone osteoporosis
capremeno 1000
post meno 1500 mg q d
rule of 9'strunk post and ant and legs make up 18% . head neck and arms 9%.
perineum 1%
common allergies berries, nuts and eggs
stoma irrigationelevate bsg 18-24 inches above stoma, 500-1000ml lukewarm h20 if
cramping stop irrigation hold breath then resume
hip replacement sitting limit flexion to 90 degrees
tens machine blocks painful stimuli from traveling to small nerve endings
p thyroidectomy tetany may occur monitor for s/s of muscle twitching tingling on numbness
gcs 3 indicates coma
chest tube is disconnected place end in sterile water to prevent air from entering chest tube
crutches all weight on the hands
bed bath water temp 110-115
bacterium responsible for tetnus colstridium tetani
tpn monitor wt q d
positive ppd induration and swelling 5-15mm
iron def anemia sx dyspnea tacycardia pallor and fatigue
hemmacult rules no red meat turnups or pultry or fish for 4 days
laminectomy logroll pt
antacids w. aluminum monitor for constipation
A nursing assessment on a male patient indicates that he is showingevidence of increased intracranial pressure. The first nursing action is to
Answer1.1= Place him in high-Fowler`s position.
= Place him on his side.
= Have him cough and deep breathe.
Attempt to have him deep breathe.As the PaCO2 increases in the cerebral tissues, blood rushes to the area and
this further increases the intracranial pressure. Decreasing the PaCO2,accomplished by breathing deeper and more slowly, will decrease the
intracranial blood flow, thus decreasing intracranial pressure.
Question.2= A 9-year-old patient with cystic fibrosis will take pancreaticenzymes 3 times a day. The nurse will know the child`s mother needs more
education on the purpose and timing of these enzymes if she says
= "The purpose of the enzymes is to help digest the fat in foods."
= "The enzymes should be taken prior to meals."
= "They should be given following breakfast, lunch and dinner."
= "They should be taken at meal times, 3 times a day."
= The purpose of the pancreatic enzymes is to replace the enzymesunavailable in the child`s system that assist with the digestion of fats.
Therefore, they should be taken prior to, not following, the ingestion offood.
= Formulating a care plan for a patient with chronic lymphocytic leukemia,the nurse will expect that his laboratory results will reveal increased
Lymphocytes.= Monocytes.
= Platelets.= Red blood cells.
= White blood cells (lymphocytes) increase in number, although they areimmature. With this condition, there is a decreased number of red blood
cells and platelets.
Question.4= As part of the nursing care plan for a patient with chroniclymphocytic leukemia, the nurse will formulate nursing diagnoses. A
priority Nursing Diagnosis is
= Infection, potential for.
= Alteration in tissue perfusion.
= Impairment of skin integrity.= Fluid volume deficit.
Immature white blood cells predispose the patient to infections, so thisnursing diagnosis is a priority. Fluid volume deficit may also be an
important nursing diagnosis, because the patient may be prone to bleeding.It does not, however, have as high a priority as (1)
The nurse is assigned a patient diagnosed with a left-sidedhemopneumothorax who has a chest tube connected to a water-seal drainagesystem. During the shift change assessment, the nurse observes that fluid in
the suction control chamber is bubbling. The intervention is to
Add water to the water-seal chamber.
= Make sure that there are dependent loops in the system.
= Do nothing, as this is normal.
Sit the patient up to increase suction.
= Bubbling in the suction control chamber is expected. The tubing shouldalways be free of kinks without dependent loops. The patient should beturned side-to-side to promote drainage. While chamber levels must bemaintained, bubbling in the suction control chamber does not indicate a
need for adding water.
= The nurse is assigned to dry and wrap a newborn baby. The nurse will dongloves to complete this task because
It is important to observe universal precautions before the infant`s first bath.
= The infant requires protection from infection.
= It is the nurse`s choice whether or not to wear gloves.
= Gloves are standard procedure for care of normal newborns.
#2
With the high increase in numbers of HIV positive newborns, the Centersfor Disease Control (CDC) guidelines include wearing gloves whenhandling newborns before their first bath. They will be covered with
amniotic fluid and other secretions from the mother, so it is important to beprotected from these body fluids which could harbor the HIV virus.
On the first postpartum day, a mother asks the nurse to bathe and change thebaby. The best response is
Do you remember how you bathed your last baby?"
= "It`s better if you care for the baby."
"How does it feel to have a new baby to care for?"
= "I`d be glad to."
#3
= It is important to find out how the mother feels about baby care. She mayjust be tired, she may be afraid, or she may have some other reason for her
request. The nurse needs to assess further, so this question is the mostrelevant.
= As the nurse is checking on a male patient with dementia, she observesthat he has been incontinent and soiled his clothes. This is the second time
this has happened on this shift. The most appropriate nursing intervention isto
Put the patient in adult diapers to protect him from embarrassment.
= Scold the patient and tell him not to wet his pants again.
= Tell the patient to ask the nurse for assistance the next time he has to go tothe bathroom.
= Tell the patient the nurse will change his pants and establish a 2-hourschedule of taking him to the bathroom.
#4= Even though the nurse may eventually have to place diapers on the
patient, this is not the first intervention. An every 2-hour bathroom schedulemay solve the problem because the patient cannot remember to tell the nurse
when he needs to urinate.
A 50-year-old patient with asthma is to receive Aminophylline. The nursewill evaluate the effectiveness of Aminophylline by observing for decreased
Respiratory distress.
= Rales.
= Mucus production.
=Pulse rate.
#1= Aminophylline causes bronchodilatation and, therefore, increased
oxygenation. The patient is more able to cough up secretions and the breathsounds will become more clear. The CNS is stimulated by this drug and the
pulse rate may increase.
Question.10= A very attractive young man with whom the nurse has had anurse-patient relationship begins to make sexual advances toward her,
making her very uncomfortable. The best approach is to
Ignore the advances, for the nurse knows that lack of reinforcement usuallyextinguishes the behavior.
= Tell his doctor, who should be informed of his inappropriate behavior onthe unit.
= Be direct in communicating the discomfort with his advances and setlimits on his behavior.
= Continue the relationship, for the nurse knows ending it will reinforce hisnegative self-image.
=The patient needs direct feedback and clear delineation of limits to therelationship for example, "This is not acceptable behavior. If you continue, I
will not talk with you."
= The nurse caring for a patient with an ileostomy will carefully assess theskin around the stoma because
It is very difficult to ensure proper fit of the appliance with skin breakdown.= Digestive enzymes may cause skin breakdown.
= The effluent is more solid than watery and may stick to the skin.
= It takes longer to heal than a colostomy stoma.
#2Rational.11= The discharge from an ileostomy is watery and contains manydigestive enzymes that have not been absorbed by the intestinal villi. Theseenzymes may cause skin breakdown. None of the other answers is accurate.
Question.12= Which one of the following treatment plans is mostappropriate in the nursing/medical management of a 10-year-old child with
congestive heart failure?
High concentrations of oxygen, strict bedrest, diuretics.
Answer2.12= Oral fluids, daily weights, high-Fowler`s position.
Answer3.12= High-Fowler`s position, digoxin, diuretics, daily weights.
Answer4.12= Digoxin, diuretics, prophylactic antibiotics.
#3
Rational.12= Digoxin and diuretics are administered in order to increase theforce of systolic contraction and to decrease venous volume/congestion.
High-Fowler`s position is utilized to provide for maximum lung expansion.Daily weights allow for constant monitoring of fluid balance/status.
Antibiotics are not administered prophylactically.
Question.13= The nurse will know that a patient undergoing radiationtherapy understands the side effects of the therapy when he says that he
schedules his meals
Immediately before therapy.
Answer2.13=Two to 3 hours before therapy.
Answer3.13= One hour before therapy.
Answer4.13=Immediately after therapy.
#2
Rational.13= Food and fluids should be taken 2 to 3 hours before or after thetreatments to decrease the nausea experienced as a result of the
radiotherapy.
Question.14= The most appropriate activity or toy for a 4 year oldhospitalized for severe rheumatoid arthritis is
A VCR with a Disney movie or a radio.Answer2.14=An erector set or Legos.
Answer3.14= A dartboard and darts or marbles.
Answer4.14=A wooden puzzle or crayons and coloring book
#4Rational.14= A puzzle or crayons would be appropriate for a 4 year old whois limited in activities by his diagnosis. An erector set is too advanced for his
developmental level. A video movie or radio is too passive and will notencourage intellectual or creative development. Darts are dangerous for a 4year old the dart may accidentally hit someone or something other than the
dartboard.
Question.15= A priority nursing intervention for a patient on total parenteralnutrition (TPN) is to monitor the
Urine specific gravity.Answer2.15=Sodium level.
Answer3.15=Blood sugar levels.Answer4.15=Urine pH.
#3
Rational.15= Because parenteral nutrition solutions are very high indextrose, the pancreatic insulin-secreting ability may not be sufficient tomaintain normal blood glucose levels. The patient may require insulinduring all or part of the TPN course. There should be no change in the
sodium levels, as these solutions are not high in sodium the patient shouldbe in acid-base balance during the therapy.
Question.16= A 42-year-old female patient was admitted to the psychiatricunit with a diagnosis of acute depressive episode. She refuses to get out ofbed, go the dining room, or participate in any of the unit`s programs. The
most appropriate nursing action is to
Allow her to remain in bed until she feels ready to join the other patients.Answer2.16= Suggest she may be hungry later so she had better get out of
bed.Answer3.16= Tell her that the nurse will assist her out of bed and help her to
dress.Answer4.16= Tell her the rules of the unit are that no patient can remain in
bed.
#3Rational.16= Be positive, definite and specific about expectations. Do notgive depressed patients a choice or try to convince them to get out of bed.
Physically assist the patient to get up and dressed. This activity will help tomobilize her which, in turn, will help the depression to lift.
Question.17= A patient is scheduled for laser surgery to correct his retinaldetachment. Before the surgery, the nurse will position him
On total bedrest with the area of detachment dependent.Answer2.17= In bed, in a prone position with his head supported by pillows.
Answer3.17= On his right side with the area of detachment in upwardposition.
Answer4.17= Up ad lib, but not turning his head.
Rational.17=The retinal detachment area must be kept dependent (lowestpart of the eye) in order to keep the separation between the retina and itscirculatory layer, the choroid, minimal. The patient should be on bedrest.
Question.18= Postoperatively on the same day as surgery for a right hipreplacement with a prosthesis, the patient may be positioned on
The patient`s back and left side.Answer2.18=The patient`s back and right side.
Answer3.18= Either side.Answer4.18=The patient`s back only
#4Rational.18= A total hip replacement requires very careful attention to
position. The joint may dislocate in the early postoperative period and thenurse must maintain the affected limb in a position of abduction and
external rotation. Turning to either side in the early postoperative stagewould, therefore, be disallowed.
Question.19= A patient is several days postoperative following a right hipreplacement with a prosthesis. Assisting the patient to sit in a chair, the
nurse will use
he lowest possible chair with the back reclined.Answer2.19=A reclining chair with foot rest elevated.
Answer3.19= A soft chair with arms.Answer4.19=An upright elevated chair.
#2Rational.19= The ball in socket position is maintained by minimizing hipflexion (60 degrees or less). This is done with wheelchair and commode
extenders, high chairs, and proper bed positions.
Question.20= To facilitate breathing in a child with bronchiolitis, thenursing care plan will include establishing an environment of
Humidified oxygen.Answer2.20=Warm mist with oxygen.
Answer3.20= Cool, moist oxygen.Answer4.20=Oxygen therapy with no mist.
#3 Rational.20= Cool, moist oxygen is the supportive therapy of choice forbronchiolitis. If the child is at home, warm mist from the shower may be
administered for croup. Humidified oxygen is administered for pneumonia.
Question.21= A patient has sustained a femoral shaft fracture and is beingtreated with skeletal traction using balanced suspension with a Thomas
splint and Pearson attachment. The goal of maintaining optimum positioningwill be accomplished by
Keeping the affected knee in a position of extension.Answer2.21= Maintaining the lower leg at a 90 degree angle to the upper
leg.Answer3.21= Maintaining the angle between the affected thigh and the bed.
Answer4.21= Not elevating the head of the bed above ten degrees.
#3Rational.21= It is important that the established angle between the affectedthigh and the bed be maintained. The patient can usually have the head ofthe bed flat or elevated and the lower leg can be exercised, then rest in thePearson attachment. If the patient migrates toward the head or foot of thebed, then the angle between the thigh and bed would be altered, so it is
important that adequate countertraction be maintained.
Question.22= While inserting a Foley catheter in a female patient, the nursewill advance the catheter through the urethra a distance of
1 to 1 1/2 inches.Answer2.22=2 to 3 inches.
Answer3.22=Until urine flows.Answer4.22=1 1/2 to 2 inches.
#2Rational.22=The Foley catheter should be advanced 2 to 3 inches into the
female urethra.
Question.23= The nurse is caring for a patient undergoing chemotherapy forcancer. One of the goals of care is to discuss possible side effects of this
therapy, one of which is
Constipation.Answer2.23=Alopecia.
Answer3.23= Increased appetite.Answer4.23=Weight gain.
#3Rational.23= Alopecia, or hair loss, will probably occur caused by damageto the rapidly dwindling cells of hair follicles. Hair loss begins 2 to 3 weeksafter therapy begins and continues through the course of therapy. The other
side effects listed do not occur, as nausea, anorexia and diarrhea arecommon.
Question.24= The nurse will know a diabetic patient understands exerciseand its relation to glucose when the patient tells the nurse that he eats bread
and milk before, or juice or fruit during exercise activity because
Exercise stimulates pancreatic insulin production.Answer2.24= A diabetic`s muscles require more glucose during exercise.Answer3.24= Exercise enhances the passage of glucose into muscle cells.
Answer4.24= The pancreas utilizes more glucose during exercise.
#3Rational.24= Exercise promotes the passage of glucose into muscle cells, soextra complex carbohydrates are essential before or during regular exercise.
To prevent precipitous hypoglycemia, the IDDM patient should injectinsulin into nonactive areas, such as the abdomen.
Question.25= Which of the following behaviors would indicateimprovement in the coping behavior of a patient who has the diagnosis of
depression?
Sleeping frequently during the day.Answer2.25=Going to the dining room to eat.
Answer3.25= Turning off the television to have it quiet.Answer4.25=Initiating interaction with another patient.
#4Rational.25= If a patient initiates interaction with another patient, it
indicates he is not totally absorbed in himself, too depressed to initiate aconversation, or too preoccupied to focus on the television. The other
choices do not necessarily indicate improvement in coping.
Question.26= When a patient`s hallucinations become louder, moredemanding and difficult to ignore, the nurse would judge that his mental
status is
mproving.=Showing more evidence of paranoia.
= Remaining the same.=Deteriorating.
Rational.26=The more demanding and absorbing hallucinations (hearingvoices) becomes, the more the patient`s condition may be deteriorating.
Secondarily, this may indicate increased paranoia, but not necessarily sinceparanoid schizophrenia is only one form of this condition.
Question.27= A 3-day-old infant is admitted to the pediatric floor from thenursery with a diagnosis of esophageal atresia type III. His mother comes tovisit her baby and says to the nurse, "I feel as though I`ve done somethingwrong to make my child sick." The most appropriate response would be to
can understand your feelings, but remember that this is a congenital defectyou did not cause."
"It does no good to feel that way. Your child is sick and needs you. Youshould spend your time caring for him."
= "Don`t be silly, your child was born with this. You`ve done the best youcan."
= "A lot of mothers feel guilty when their child is sick."
#1Rational.27= The nurse acknowledges the mother`s feelings, but tries to
show that they are not based on fact.
Question.28= A 43-year-old female patient had a subtotal gastrectomyseveral weeks ago. She has been readmitted with a diagnosis of perniciousanemia. Taking her nursing history, the nurse expects to find that her diet
has probably not included
Eating enough foods high in iron.Answer2.28=Taking her vitamin B12.
= Eating enough high vitamin B12 foods.
=Taking her iron supplements.
#2Rational.28= Patients who have pernicious anemia following a subtotal
gastrectomy do not have enough intrinsic factor to utilize vitamin B12 infoods and must be given injections or sublingual doses of vitamin B12.
Question.29= A patient who is hospitalized with chronic congestive heartfailure has been placed on telemetry. The nurse should know that the
purpose of this type of monitoring is to
dentify ventricular arrhythmias resulting from hypoxia.= Identify ventricular arrhythmias resulting from hyperkalemia.
= Assess atrial ectopic beats resulting from hypoxia.= Assess ectopic beats resulting from hyperkalemia.
#1Rational.29=When the lungs are filled with fluid, oxygenation is not asefficient as it should be. Hypoxia can cause ventricular arrhythmias, a
dangerous condition. These are identified easily by the use of telemetry.
Question.30= A neighbor asks the nurse to look at her 3-year-old child`srash. Her face, neck and chest are covered with a maculopapular rash. Sheappears feverish and her nose and eyes are "running." There are small red
spots with bluish-white centers on the mucosa of her mouth. The nurserecognizes that these manifestations are most likely caused by
Measles (Rubeola).= Impetigo (Staphylococcus).
= Scarlet fever (Beta hemolytic streptococcus, Group A).= German measles (Rubella).
#1Rational.30= Rubeola is a highly contagious virus. It is more severe than
rubella or roseola because of the complications. The virus is transmitted by acough or sneeze.
Question.31= In each prenatal visit, the assessment technique that evaluatesappropriate fetal growth is
Measurement of fundal height.=A nonstress test.
= Maternal weight gain.=Blood pressure reading.
#1Rational.31= The fundus height changes throughout pregnancy. The height
of the fundus is at the level of the umbilicus by 28 weeks and near thexiphoid process by 38 weeks.
Question.32= A direct Coombs` test is done on the cord blood of a newbornto detect the presence of
Antigens coating the mother`s red blood cells.=Antibodies coating the baby`s red blood cells.
= Maternal red cells in the fetal circulation.=Fetal red cells in the maternal serum.
#2Rational.32= The direct Coombs` test is done on cord blood to detect thepresence of maternal antibodies attached to the neonate`s red blood cells.
Question.33= Persons with personality disorders tend to be manipulators.Which principle is it important for the nurse to know in planning the care of
such a person?
The nurse should allow herself to be manipulated so as to not raise thepatient`s anxiety.
= The establishment of a nurse-patient relationship will decrease thepatient`s manipulations.
= When the patient`s manipulations are not successful, his anxiety willincrease.
= The nurse should appeal to the patient`s sense of loyalty in adhering to therules of the community.
#3Rational.33=Because a person with this disorder tends to manage his or her
life through manipulation of others, when it doesn`t work, their anxiety levelgoes up. The nurse should never allow the patient to manipulate her.
Answers (2) and (4) are not true.
Question.34= A patient is aware that the biopsy report has just returned. Asthe nurse is changing his dressing he says, "Do I have cancer?" The most
appropriate response at this time is
"Would you like to discuss your concerns about the results?"= "Did your physician tell you the results?"
= "I`ll call your doctor and ask him."= "We do not know yet; the report has not returned."
#1Rational.34= This response allows the patient to discuss fears about cancer
and does not close off communication, as the other three responses do.
Question.35= A patient with rheumatoid arthritis has been on aspirin gr. xxTID and prednisone 10 mg BID for the last 2 years. The most important
assessment question related to the patient`s drug therapy is to ask her if sheexperiences
Blurred vision.=Decreased appetite.
= Tarry stools.=Headaches.
#3Rational.35= Aspirin impedes clotting by blocking prostaglandin synthesiswhich can lead to bleeding. A side effect of prednisone is gastric irritation,
also leading to bleeding. Tarry stools indicate bleeding in the upper GIsystem.
Question.36= A 40-year-old male patient has the diagnosis of myastheniagravis; the disease is adequately controlled on Mestinon. The patient tells
the nurse that sometimes he gets very tired when he eats. Nursinginstructions should be to
Eat several small meals each day.=Eat foods rich in vitamin B6.
= Take Mestinon 30 minutes before meals.=Try pureed foods until this symptom decreases.
Rational.36= Myasthenia is a disease characterized by marked weakness andabnormal fatigue of voluntary muscles. A deficiency of acetylcholine results
in a defect in transmission of nerve impulses. Mestinon, ananticholinesterase medication, increases levels of acetylcholine. Taking the
medication before meals will assist in mastication.
Question.37= One afternoon the nurse finds a paraplegic patient sitting inher wheelchair crying. When the nurse asks if she can help, the patient says,
"Go away, no one can help." The best nursing response is
"I understand that you don`t want to talk right now. I will come back andperhaps we can talk."
= "You must be having problems."= "Many people feel sad in the hospital. You`ll be home soon."
= "It`s better if you talk about it. Maybe I can help."
#1Rational.37= The best response is to acknowledge she told the nurse to go
away but to leave communication open for a later time. Other responses putpressure on the patient or close off communication.
Question.38= An adult male patient is being discharged after his peptic ulcerhas been controlled on a medical regimen. One medication he is taking is
sucralfate (Carafate). The nurse asks if he understands when he should takethe medication. The correct answer would be
Just before meals.=One hour before meals and at bedtime.= In early morning.=With every meal.
#2Rational.38= Carafate is a mucosal protective agent with antipepsin activity.
It is taken on an empty stomach, 1 hour before eating, and at bedtime.
Question.39= A new mother is told that on admission to the nursery aninjection of vitamin K is given routinely to normal newborns. The nurse
explains that vitamin K is given because
ewborns have an increased ability to clot blood.= Vitamin K promotes a normal clotting time.
= Vitamin K prevents hypoglycemia.= Newborns need to be protected from hyperbilirubinemia.
#2 Rational.39=Vitamin K is used to promote a normal clotting time untilbacteria, necessary for vitamin K synthesis, is present in the colon. VitaminK does not protect the newborn from hyperbilirubinemia, nor does it play a
role in blood glucose regulation.
Question.40= A 60-year-old male patient has been diagnosed with heartfailure and is started on Digoxin 0.25 mgm PO QD and Lasix 40 mgm PO
BID. After 2 days, he develops an irregular pulse rate of 64. The nursewould expect the physician to order
Calcium gluconate.=Magnesium sulfate.= Atropine sulfate.
=Potassium chloride.
#4 Rational.40=Potassium loss secondary to Lasix administration may causearrhythmias and potentiate the risk of digitalis toxicity. Therefore, potassium
is often ordered when Lasix and digitalis are prescribed.
Question.41= When a patient experiences a severe anaphylactic reaction to amedication, the nurse`s initial action is to
Prepare equipment for intubation.=Start an IV following standard orders.= Place the patient in a supine position.
=Assess the patient`s vital signs.
#3 Rational.41= Initially, the shock position is necessary to maintain vitalsigns. The other interventions may be carried out, but will follow the initial
action.
Question.42= The most appropriate needle used for administering anintramuscular injection into the deltoid muscle of an adult patient is a
25 gauge, 5/8" needle.=22 gauge, 1" needle.
= 25 gauge, 1 1/2" needle.=22 gauge, 1 1/2" needle.
#1Rational.42=A 23 or 25 gauge 5/8" needle is the most appropriate size when
using the deltoid muscle.
Question.43= Which of the following statements best explains whypremature infants are more likely to develop an infection than full term
newborns?
Premature infants receive few antibodies from the mother, becauseantibodies pass across the placenta during the last month of pregnancy.
= Liver enzymes are immature in the premature infant.= Antibody formation does not mature until 6 weeks after birth of a
full-term infant.= The white blood cell defense system is only effective at full term.
#1Rational.43= Antibody formation is immature in the premature infant.Immaturity of the liver is responsible for hyperbilirubinemia but is not
directly related to the infant acquiring an infection. White blood cells maybe ineffective, but that is not necessarily related to full-term birth.
Question.44= A premature infant has the diagnosis of respiratory distresssyndrome (RDS). The nurse understands that this disorder may be caused by
Low concentration of oxygen.=The inability to produce surfactant.
= Cold stress.=A genetic defect.
#2Rational.44=RDS often occurs in premature infants due to decreasedsurfactant production in the lungs. A high concentration of oxygen can also
result in this condition.
Question.45= A 70-year-old female Alzheimer`s patient has been wanderingin and out of other patients` rooms. To deal with this behavior, the most
therapeutic nursing action will be to
Lock the other patients` rooms.=Restrain the patient in her room.
= Confine the patient to the dayroom.=Tell the patient she shouldn`t do tha
#3Rational.45= The most therapeutic action is to keep the patient with others
in the dayroom, not alone in her room. Telling her not to go into others`rooms will not change her behavior because Alzheimer`s patients have littleshort-term memory. Locking rooms may be perceived as punishment by the
other patients.
Question.46= A male patient with bronchospasms has prednisoneprescribed. The nurse`s teaching instructions before he is discharged from
the hospital will include taking prednisone
With milk.=With orange juice.
= Before meals.=After meals.
#1 Rational.46= Prednisone may cause a stress ulcer, so it should be takenwith milk to protect the lining of the stomach. Iron is given with orange
juice to increase assimilation.
Question.47= A patient comes to the walk-in mental health clinic where theLVN is assigned to do intake histories. To determine the presence ofdepression, the primary sign or symptom the nurse will assess for is
Mood with affect of sadness.=Episodic euphoria.
= Loss of reality focus.=Negative behavior.
#1 Rational.47= The distinguishing quality of depression is mood, where theaffect is sadness or gloom. Negative behavior could be present, but also
accompanies other diagnoses. Loss of reality is seen in schizophrenia, andeuphoria is a symptom of manic episode.
Question.48= The physician orders a nasogastric tube for a female patient.As the nurse prepares to insert the NG tube, the patient begins to cry
silently. The best way for the nurse to respond to this behavior is to say
Don`t worry, I will give you pain medicine if you need it."= "It is all right to cry."
= "Can you talk about why you are crying?"= "The insertion of the tube will not be painful."
#3Rational.48= Crying is not a normal response to an NG tube insertion, sothe nurse needs to find out what has occurred in the patient`s past to evoke
such a response.
Question.49= A patient scheduled for surgery has had preoperative teaching.An indication that the teaching was successful would be that the patient
Does not question what the nurse said.= Appears relaxed and can verbalize what the nurse taught.
= Says he understands and wants to be alone now.= Appears to be resting quietly.
#2Rational.49= The person who understands something can explain it tosomeone else. The other responses are typical of stress responses and/or
denial.
Question.50= After a male patient returns from surgery following smallbowel obstruction, he complains of pain and asks for medication. The first
nursing action is to
Determine the location and severity of the pain.=Administer the medication that is ordered.
= Give him half the ordered dosage.=Check with the physician.
#1Rational.50=Because the pain might be caused from his position on theoperating table or the position of his arm with the IV, it may be relieved
without medication by actions such as repositioning or giving a back rub.The patient should receive medication if he needs it, but medication should
not be used in place of good nursing care. The first dose of narcoticfollowing surgery may be only one half the ordered dose, but an assessment
of the pain should be done first.
Question.51= A female patient has been admitted with a diagnosis ofcompulsive disorder. In talking with her one day, she tearfully asks thenurse, "Do you think I`m crazy?" The nurse`s best response would be
That depends on your definition of crazy."="You`re upset. Let`s talk about something else."
= "I think you`re upset, but not crazy."="Are you concerned about being crazy?"
#4 Rational.51=This is the only response that opens communication. Thenurse should encourage the patient to express what she is thinking and
feeling in order to assist her to deal with her fears.
Question.52= The physician has ordered IV fluids at 100 mL/hr. Which oneof the following parameters is the most important indicator of fluid balance?
Adequate intake measurement.=Quality of skin turgor.= Consistent vital signs.=Hourly urine output.
#4 Rational.52= Hourly urine output is the best indicator of fluid balance.Vital signs will change however, they are slower to respond to fluid changes
than alterations in urine output.
Question.53= The nurse assigned to a woman in labor has orders to begin anoxytocin (Pitocin) drip. After 20 minutes of the Pitocin infusion, the nurse
observes a contraction that does not relax after 90 seconds. The nurse`s firstaction is to
Start oxygen by mask.=Stop the Pitocin drip.= Notify the physician.
=Turn the patient on her left side.
#2Rational.53= If a contraction lasts longer than 90 seconds, the safe correctaction is to turn off the Pitocin. Prolonged contractions can result in aruptured uterus. The nurse may then administer oxygen and call the
physician.
Question.54= When the nurse is caring for a patient in labor, which one ofthe following signs indicates that the placenta has detached from the uterine
wall?
The uterus falls below the level of the symphysis pubis. s= There is a noticeable relaxation in the abdominal wall.
= The mother complains of pain low in her back.= The cord lengthens outside of the vagina.
#4Rational.54= As the placenta is expelled and moves toward the cervix, thecord will precede it and appear to get longer.
Question.55= A 48-year-old patient was admitted 2 days ago with thediagnosis of acute interstitial pancreatitis. The nurse will evaluate for the
most common and fatal complication of severe acute pancreatitis, which is
Severe hyperglycemia.=Hypovolemia.
= Electrolyte imbalance.=Infection.
#2Rational.55= This condition causes large amounts of serous fluid to leakfrom the blood channels into the peritoneum, which decreases the
intravascular volume. Hypovolemia can occur. Enzyme release may alsodamage the walls of the blood vessels and precipitate hemorrhage.
Question.56= In counseling a patient, which measure will promote the mostcomfort during a Herpes Simplex Virus, type 2 (HSV-2) outbreak?
Keep the lesions clean and dry.=Apply Acyclovir as ordered.
= Take sitz baths 3 to 4 times a day.=Apply a local anesthetic or systemic analgesia.
#2 Rational.56=Acyclovir applied to the lesion will result in earlierremission and also provide more comfort. There is no known antibiotic forthe virus. Acyclovir applied to the lesions shortens the episode but does not
cure it.
Question.57= A male patient is admitted who is semicomatose, dyspneic,and weak. His admitting diagnosis is HIV immune depression. The
statement that best describes the source of this disease is a/an
Mutated virus that kills helper T-cells.= Autoimmune disease that is caused by the release of an antigen.
= Virus that invades the immune system.= Retrovirus that attaches to the helper T-cells.
HIV is caused by a retrovirus with a different life cycle from that of anormal virus. It may be dormant for years before affecting the helper T-cells
and causing immunosuppression.
Question.58= A female patient, age 58, has been hospitalized for 2 dayswith chronic congestive heart failure. While administering morning care, the
nurse observes that the patient frequently removes her oxygen mask eventhough she is dyspneic. The appropriate nursing intervention is to
Increase the liter flow of O2 to maximum level.=Change from O2 mask to O2 cannula.
= Change O2 administration to a Venturi mask.=Tighten the strap on the O2 mask.
#2Rational.58= Patients often feel that they cannot breathe whenexperiencing pulmonary edema. A mask may increase this feeling. Acannula is often better tolerated and thus should be used in this case.
Question.59= A female patient has been admitted to the coronary care unitwith a diagnosis of myocardial infarction. She is placed on a cardiac monitorand has an IV of D5W at a "keep open" rate. Initially, the nurse will assess
for
Chest pain characteristics.=Apical pulse.
= Blood pressure. D=Heart sounds.
#1 Rational.59= The presence of chest pain may cause the pulse rate toincrease and blood pressure to drop. It can also increase patient anxiety. Thenurse`s priority is to assess the patient for pain. The patient is on a cardiac
monitor therefore, an apical pulse is not the priority action. Once hercomfort has been established, apical pulse, blood pressure, and heart sound
determinations are appropriate.
Question.60= A nurse colleague working on the pediatric unit is newlymarried and wishes to become pregnant. Which of the following tests would
it be important for her to have as soon as possible?
Lipoprotein test.=Papanicolaou (PAP) smear.
= Serologic test for Hepatitis A.=Rubella Viral Serologic test.
#4Rational.60= If the woman is planning to become pregnant, exposure tothe rubella virus is important to detect. If a woman is exposed and she is notimmune, the fetus may have congenital abnormalities at birth. A Pap smear
detects cancer.
Question.61= Of the following interventions, which action should the nursetake first if the cord has prolapsed in a woman in the final stage of labor?
Pushing upward on the presenting part with a sterile-gloved hand.= Reporting the fetal heart rate to the physician immediately.= Replacing the cord very slowly with a sterile-gloved hand.
= Turning the patient onto her left side.
#1Rational.61= The first action is to move the presenting part off the cord toallow oxygen to flow via the cord. Other methods that can be used to
accomplish this are Trendelenburg or knee-chest position. Turning to the leftside (1) will not help (2) and (3) are wasting valuable time.
Question.62= A mother in labor arrives at the emergency room. An initialassessment indicates that crowning is occurring. The first nursing action is
to
sk the patient to push according to the nurse`s instructions.
Apply gentle perineal pressure to prevent rapid expulsion of the head.
= Notify the charge nurse or physician.= Instruct the patient to take short shallow breaths to improve fetal
oxygenation.
#2Rational.62= The first action is to support the perineum to prevent tearsand rapid delivery. The nurse would ask the patient to take short breaths(following instructions) but to prevent pushing the nurse will also send
someone for a physician.
Question.63= A patient in labor is experiencing severe back pain. The bestsource of relief for the mother would be for the nurse to
Divert her attention to the TV.=Apply counterpressure to her sacrum.
= Have her walk around.=Give her a narcotic analgesic.
#2Rational.63=Applying counterpressure will help to release the pain.Moving the patient into knee-chest position is also good for back pain.
Question.64= At the well-baby clinic, a mother tells the nurse she is worriedabout her 1 month old "catching something" before she gets her shots. What
would be the most appropriate response?
Protection from your antibodies will last until she is at least 1 year old."= "She has passive immunity to tetanus and pertussis but not to diphtheria so
she needs to be protected from it by early shots."= "She has active immunity from you so she won`t be affected by any of the
usual childhood diseases."= "The baby is protected for the first few months of life so you need not
worry."
#4Rational.64= The mother can be reassured by knowing that passiveimmunity for diphtheria, tetanus and pertussis are all transferred from
mother to infant during fetal life. There is very little functioning maternalantibody in the infant after age 6 months.
Question.65= Before administering an immunization to an infant, it isimportant that the nurse remember that a primary contraindication for
immunization is
An active infection.=Cystic fibrosis.
= Congenital heart disease.=Failure to thrive.
#1 Rational.65=Children with active infections such as impetigo should notbe immunized until the infection has passed.
Question.66= A 41-year-old male patient has had recurrent sharp flank pain,nausea, and vomiting for 24 hours. He is admitted to the hospital for a
genitourinary work-up. Which of the following orders would be considereda priority?
Temperature every 4 hours.=Strain all urine.
= Administer an antiemetic every 4 hours.=Accurate intake and output records.
#2Rational.66= The patient has symptoms indicative of a urinary calculustherefore, it is important to strain all the urine in order to detect if the stone
has passed.
Question.67= On a home visit to a male patient who has had multiplesclerosis for 20 years, the nurse reinforces the nursing care the wife providesto her husband. Which of the following measures would be most appropriate
to include in the teaching sessions?
Instruction in weight control.= Exercises that promote muscle strengthening and decrease tremors.
= Importance of regular bowel and bladder evacuation.= Side effects of routine medications.
#3Rational.67= Bowel and bladder retention or incontinence is a majorproblem of patients with multiple sclerosis therefore, establishing a good
routine for evacuation is essential.
Question.68= The nurse observes a patient walking down the hall carrying aknife in his hand, and saying in an angry voice, "Get out of my way. Don`t
try to stop me." The nurse`s most appropriate response would be
Move away from him and find an area of safety, or put a piece of furniturebetween herself and the patient while yelling for assistance.
= Hold her ground and quietly ask him to give her the knife while holdingout her hand.
= "You appear angry. Perhaps it would help to talk about it."= "Knives are not allowed on the unit. I want you to give it to me
immediately!"
#1Rational.68= The nurse`s first priority is to give the patient space andprotect herself. Moving in on the patient or showing resistance may agitate
him more. She should not move too close to the patient until there issufficient manpower to swiftly and effectively handle the situation.
Question.82= Collecting physical data on an infant at the well-baby clinic,the nurse will observe which of the following signs in an infant with
congenital hip dysplasia?
Limited adduction of the affected leg.= Symmetrical gluteal folds.
= Femoral pulse when the hip is flexed and the leg is abducted.Limited abduction of the affected leg.
#4 Rational.82= Abduction is limited in the affected leg. Assessment willalso reveal asymmetrical gluteal folds, an absent femoral pulse when the
affected leg is abducted, and a hip "click" on abduction.
Question.83= A male patient is unable to sleep. He is pacing the floor, headdown, and wringing his hands. The nurse recognizes that he is anxious.
What is the most appropriate intervention?
Let him know you are interested and willing to listen.= Explore with him the alternatives to pacing the floor.
= Give him his PRN sleeping medication.= Encourage him to talk about his behavior.
#1 Rational.83= This is a more comprehensive answer and includes theothers. Sleeping medication should be avoided if at all possible or unless
absolutely necessary, because it only temporarily helps suppress thepatient`s feelings.
Question.84= A pregnant patient has been advised to increase her ironintake. The nurse will know she understands the dietary teaching if she says
that she should take the iron supplement
With vitamin C or juice.=With milk.
= With her other prenatal supplements.=At mealtime.
#1 Rational.84= It is most important to take iron with vitamin C, such asorange juice, because this vitamin helps the body assimilate the iron. Iron
should be taken on an empty stomach to increase assimilation. Eggs or milkproducts interfere with assimilation.
Question.85= In a 2 year old with increased intracranial pressure, which oneof the following signs would be cause for alarm?
Diminishing sunset sign.=Absence of nystagmus.
= Equal pupils that react to light.=Increasing lethargy and drowsiness.
Rational.85=Increasing lethargy and drowsiness, although not specific inthemselves, are signs that would lead the nurse to investigate further since
level of consciousness is an excellent indicator of increased intracranialpressure. The other answers-diminishing sunset signs, equal pupils, and
absence of nystagmus-are all normal signs.
Question.86= A patient`s chart states he has a stage III gluteal pressureulcer. When assessing the patient, the nurse would expect to find a(n)
Reddened, nonblanching area of intact skin.=Area of abraded skin.
= Open wound with loss of subcutaneous tissue.=Deep crater with visible muscle tissue.
#3Rational.86= Standardized pressure ulcer staging systems progress fromstage I (red nonblanchable, intact skin) to stage IV (deep crater with visible
underlying structures such as bone, muscle, tendons).
Question.87= When assessing the following patient care situations, whichone would require the nurse to wear goggles?
Changing a dressing.Administering an IM injection.
= Catheterizing the urinary bladder.=Emptying a Foley drainage collection bag.
#4Rational.87=Goggles should be worn when there is a risk of contact withbody fluids through spattering or splashing.
Question.88= The nurse is taking the history of a patient who is scheduledfor diagnostic tests, including an MRI. Which reported condition is of
greatest importance to know about when the nurse is preparing the patientfor an MRI?
Angina.=Iodine allergy.
= Claustrophobia.=Hypertension.
#3
Question.91= Which intervention is most useful when communicating withan aphasic patient?
Use correct medical terminology when teaching or explaining.= Ask open questions to obtain information.
= Repeat the same word until the patient understands.= Provide frequent praise and encouragement.
#4Rational.91= Aphasia leads to feelings of frustration and discouragement.Patients require frequent praise for their efforts and encouragement to
continue to try to communicate. Aphasic patients can best provideinformation by responding to closed questions that require answers such asYes or No. If the patient does not understand a word, use a different wordrather than repeating. Use clear, simple, consistent language to teach or
explain avoid complex medical terminology.
Question.92= Which medication would the nurse expect to be ordered for analert patient who is experiencing severe headache after a head injury
Morphine.=Acetaminophen (Tylenol).
= Ibuprofen (Motrin).=Aspirin.
#2 Rational.92= After a head injury, patients should not receive medicationthat might cause drowsiness or depress the central nervous system (such asmorphine or ibuprofen) or that may interfere with blood clotting (such as
aspirin or ibuprofen). Acetaminophen does not have these undesirableeffects.
Question.94= A patient is NPO and is receiving continuous nasogastric tubefeedings. Select the correct nursing action related to administering
medication through the patient`s nasogastric tube.
Flush the tube with water after each medication.= Stop the tube feeding for 30 minutes before and after medication
instillation.= Add the medications to the tube feeding solution.
= Mix the medications together and slowly instill as a bolus by gravity.
#1 Rational.94= Each medication should be instilled separately andfollowed by 10 mL of water to prevent obstruction of the tube. Medicationsare not added to the feeding solution because of possible incompatibilities,
difficulty maintaining the medication schedule, and delay in medicationabsorption because of the slow flow of continuous tube feedings.
Continuous tube feedings are interrupted only while the medication is beingadministered.
Question.95= The nurse is assigned a patient who is potentially suicidal. Ofthe following nursing objectives, which one is the most important?
Involve the patient in activities with others to mobilize him.= Recognize a continued desire to commit suicide.
= Observe the patient closely at all times.= Provide a safe environment to protect the patient.
#4Rational.95= Because it is unrealistic to observe a patient every minute,the environment must be kept safe for patient protection. Answer (2) is
important, but not the most important.
Question.96= The major advantage of monitoring the fetal heart rateelectronically is that this method
akes less nursing time to use.=Records the actual heart beat.
= Determines beat-to-beat variabilities.=Causes less discomfort to the mother.
#3Rational.96= A continuous record of the fetal heart rate and itsrelationship to uterine contractions is done through fetal monitoring to showbeat-to-beat variability. Fetal monitoring can be done by both internal and
external devices.
Question.97= A male patient has just had a cataract operation without a lensimplant. In doing discharge teaching, the nurse will instruct the patient`s
wife to
Keep the eye dressing on for 1 week.= Allow him to walk upstairs only with assistance.
= Feed him soft foods for several days to prevent facial movement.= Have her husband remain in bed for 3 days.
#2Rational.97= Without a lens, the eye cannot accommodate. It is difficultto judge distance and climb stairs when the eyes cannot accommodate.
Question.98= The nurse has just inserted a nasogastric tube for drainage intoa young male patient and must check placement. The most accurate method
is to
Insert air into the tubing and with a stethoscope, listen for a "whish" sound.= Aspirate the stomach contents and test with litmus paper.
= Place the tip of the nasogastric tube in a glass of water and observe forbubbling.
= Send the patient to x-ray for an abdominal film as ordered.
#2Rational.98= Checking the aspirate with litmus paper indicates tubeplacement. An acidic response means the tube is in the stomach. Manyinstructors continue to teach the air insertion technique however, this isNOT the currently accepted method. An x-ray check will be used if tube
feedings are to be administered.
Question.99= A 23-year-old female patient was in an automobile accidentand is now a paraplegic. The orders are for an intermittent urinary
catheterization program and diet as tolerated. A priority assessment shouldbe to observe for
Urinary retention.Answer2.99=Bowel evacuation.
Answer3.99= Weight gain.Answer4.99=Bladder distention.
#4
Question.101= A female patient has been in the second stage of renal failurefor several months. Her condition has deteriorated to uremia, and she is now
being admitted to the hospital. Checking her lab values, the nurse willexpect to see
BUN 180, Creatinine 18, Urine specific gravity 1.010.Answer2.101= BUN 35, Creatinine 16, Urine specific gravity 1.035.
= BUN 10, Creatinine 12, Urine specific gravity 1.020.= BUN 100, , Urine specific gravity 1.005.
#1Rational.101= While many factors affect the BUN, creatinine is a veryspecific indicator of renal function. Both the BUN and creatinine areelevated in renal failure, frequently with a 10:1 to 20:1 ratio. Specificgravity that stabilizes at 1.010 indicates the kidney has lost ability to
concentrate or dilute urine.
Question.102= A patient with a radioactive implant moves in bed and theimplant becomes dislodged. The priority nursing intervention is to
Put on a lead apron and gloves and place the implant in a covered container.= Wait until a radiation team can be called to recover the implant.
= Leave the room as quickly as possible and report to the head nurse.= Use long-handled tongs and place the implant in a lead box kept in the
patient`s room.
#4
Question.103= A 54-year-old female patient is 3 days postoperativefollowing abdominal surgery. The lab results indicate that her white blood
cell count is 8,000/cu mm. After analyzing this lab report, the nursing actionis to
equest that the lab repeat the test, as results don`t make sense.= Contact her physician so he will be aware of the high abnormal count.
= Do nothing because this is a normal count.= Contact the patient`s physician so he will be aware of the abnormal low
count
Rational.103= This is a normal cell count (the range is 4500 to 11,000/cumm) so the nurse would do nothing except note that it is normal.
Question.108= When evaluating a patient`s understanding of a lowpotassium diet, the nurse knows that he understands if he says that he will
avoid
Pasta.=Dry cereal.
=French bread.=Raw apples.
Rational.108=Raw apples are high in potassium, while white-enriched andFrench bread, dry cereal, and pasta are foods low in potassium.
Question.109= Irrigating a nasogastric tube should be carried out usingwhich one of the following protocols?
Instill 30 mL sterile saline, forcefully if necessary, and allow fluid to flowinto basin for return.
= Gently instill 20 mL normal saline and then allow fluid to flow into basinfor return.
Gently instill 20 mL normal saline and then withdraw solution.= Instill 30 mL sterile water and then withdraw solution.
#2Rational.109= Gentle pressure is necessary when irrigating a nasogastrictube to prevent damage to the stomach wall. Normal saline is recommended
to prevent electrolyte loss through gastric drainage.
Question.110= A patient is scheduled for a voiding cystogram. Severalhours before the test, physician`s orders will instruct the nurse to
Medicate with urinary antiseptics.=Force fluids.
= Maintain NPO =Administer bowel preparation.
#2Rational.110= Forcing fluids ensures a continuous flow of urine toprovide adequate urine output for specimen collection and, also, to prevent
multiplication of bacteria that may be introduced during the procedure.
Question.111= Following a cystoscopy, the nurse will evaluate the patient`scondition for the complication of
Burning on urination.=Difficulty voiding.
Development of cold chills.=Pink-tinged urine.
3 Rational.111= Cold chills could indicate the spread of infectionthroughout the urinary tract. `
Question.114= Collecting growth and development data on the socialdevelopment of a 1-month-old male infant, the nurse knows that it should
include
Responding to "No, no."= Turning his head to a familiar noise.
= Actively following movements of familiar persons with his eyes.= Discriminating between family and strangers.
#3Rational.114= Actively following movements would occur at 1 month.Responding to "No" and turning the head in response to noise begins at 4
months, and discrimination between family and strangers appears at 5months of age. This is considered intellectual or cognitive development.
Question.118= Following dialysis of a patient, the nurse expects to find animprovement in the blood values of
Hypokalemia.=Low hemoglobin.
= High serum creatinine levels.=Hypocalcemia.
#3
Question.119= A 3-month-old infant has unrepaired Tetralogy of Fallot.Which of the following signs and symptoms would the infant be expected to
exhibit?
achycardia, hypertension, decreased femoral pulses.= Hypotension, bradycardia, dyspnea.
= Circumoral cyanosis, hypoxic spells, feeding fatigue.= Cyanosis, tachypnea, hypertension in upper extremities.
#3Rational.119= Cyanosis, hypoxia, and feeding difficulties are classicmanifestations of cyanotic heart disease.
Question.120= An adult patient with a tentative diagnosis of antisocialpersonality refuses to participate in unit activities. When he is on the unit, he
makes fun of the other patients. Considering the patient`s diagnosis andbehavior, which one of the following nursing plans would be most effective
for the nursing staff to follow?
et the patient know the rules on the unit.Answer2.120= Allow the patient to isolate himself so that he does not upset
the other patients.Answer3.120= Confer with the patient, his psychiatrist and the staff about
the patient`s lack of participation on the unit.= Require the patient to participate in activities.
3 Rational.120=In dealing with manipulative behavior, it is important thatall members of the team as well as the patient are clear about expectations.
(1) pits the nurse against the patient (2) is incorrect because it is nottherapeutic to isolate a patient and (4) is nontherapeutic because the patient
is not involved in the treatment.
Question.121= A 56-year-old patient admitted to the hospital with anginapectoris is scheduled to have a cardiac catheterization. While filling out amenu for the following day, the patient says to the nurse, "I always get arash when I eat shellfish." In reading the patient`s chart, the nurse sees nosuch notation. Following safety protocol, the initial nursing intervention
should be to
sk the nurse in charge to communicate the patient`s reaction to shellfish tothe physician.
Answer2.121= Ask the patient if there are any other foods that cause such areaction.
Answer3.121= Notify the dietitian of the patient`s reaction and request a "noshellfish" diet.
Answer4.121= Place a note on the chart regarding the patient`s reaction toshellfish.
#1
Question.122= A few hours after a heart catheterization, the nurse notes thatthe patient`s blood pressure has decreased from 136/72 to 110/64 mmHg.
The patient has been voiding large amounts of urine. The nurse shouldrecognize that this blood pressure change is probably due to
The patient going into cardiac failure.Answer2.122= A reaction to the dye used during the procedure.
Answer3.122= Insufficient fluid intake for the past 12 hours.Answer4.122= Lost fluids because of the diuretic effect of the dye.
#4Rational.122= The dye used during the cardiac catheterization ishyperosmolar and, therefore, acts as a diuretic. As fluid volume drops, the
arterial blood pressure drops.
Question.123= A patient is admitted to the labor room with contractions thatare about 4 to 5 minutes apart and 30 seconds long. The couple have
attended Lamaze childbirth classes. During transition, the nurse shouldsupport a breathing pattern that is
Slow, deep abdominal pattern.Answer2.123= Shallow chest breathing at 20 to 30 times a minute.Answer3.123= Shallow chest breathing at 40 to 60 times a minute.
Answer4.123= Slow, deep chest breathing.
Rational.123=Shallow chest breathing, slightly faster than a normal rate, isthe pattern used most in transition. Slow breathing, while effective for some
women during transition, is usually most effective in earlier labor.Supporting a more rapid rate of 40 to 60 times a minute is not
physiologically sound and could lead to hyperventilation.
= The nurse is assigned to administer two insulin solutions, NPH andregular insulin. The appropriate procedure of combining the insulin
solutions in one syringe is to
Answer1.125= Inject air and withdraw NPH, then withdraw regular insulininto the same syringe.
Answer2.125= Inject air into NPH bottle, then inject air and withdrawregular insulin, then withdraw appropriate amount of NPH into the same
syringe.
Answer3.125= Withdraw NPH and regular insulin into separate syringesand give two injections.
Answer4.125= Inject air and withdraw regular insulin, then inject air andwithdraw appropriate amount of NPH into the same syringe
Rational.125=Regular insulin is withdrawn into the syringe after injectingthe prescribed amount of air into the NPH bottle. The last step is to
withdraw the NPH insulin into the same syringe.
A 21-year-old patient is described as bizarre, withdrawn, talking andlaughing to herself. Orders include chlorpromazine (Thorazine) 200 mg, PO
BID. If refused, 100 mg IM may be administered q 4 hours PRN foragitation. Benztropine mesylate, MSD (Cogentin) 5 mg BID is also
prescribed. Assessing the patient, the nurse finds her screaming and bangingher hands on the wall. She refuses oral medication. The best nursing action
would be to
Answer1.126= Stay with the patient and get assistance to give her the IMinjection of Thorazine.
Answer2.126= Put the patient in restraints until she calms down, thenadminister Thorazine.
Answer3.126= Assign another nurse to administer both Thorazine andCogentin.
Answer4.126= Tell the patient firmly to stop hitting her hands or she willhurt hersel
#1Rational.126=The patient`s behavior indicates that she needs Thorazine. To
decrease the amount of external stimuli, the nurse must provide limitsbecause the patient cannot staying with her will be reassuring.
Question.127= The nurse finds a patient on the psychiatric unit sittingquietly, staring out the window, and laughing inappropriately. The nurse
should recognize that the patient is probably
Getting ready to "act out."
Answer2.127=Laughing instead of crying about the situation.
Answer3.127= Hallucinating.
Answer4.127=Seeing a funny scene.
3Rational.127= Inappropriate laughter in psychotic behavior is generallycaused by visual or auditory hallucinations.
Question.128= In the last few months, a 56-year-old patient has noticed thathe has been "slowing up" in all of his movements and that his speech has
become indistinct. The physician makes a diagnosis of Parkinson`s disease.When teaching the patient about Parkinson`s disease, the nurse should
include encouraging the patient to
aintain employment as long as possible.
Answer2.128=Retire and take part in limited social activities.
Answer3.128= Immediately decrease his work schedule.
Answer4.128=Work only when he feels up to it.
1Rational.128=It is very important to keep patients with Parkinson`s diseaseactively involved in work and social situations. They experience alteredbody images and tend to withdraw from society. When this happens, the
complications of immobility increase. As complications increase, they tendto decrease patients` life spans.
Question.129= A 28-year-old primipara is admitted to the hospital in earlylabor. She is comfortable and visiting with her husband when her water
breaks. Which of the following nursing assessments should be completedfirst?
Monitor the fetal heart rate.
Answer2.129=Attach the external fetal monitor.
Answer3.129= Check for prolapsed cord.
Answer4.129=Note color and quantity of fluid.
3Rational.129=When the water breaks, there is a possibility of prolapsedcord, which must be ruled out immediately. This is the first nursing
assessment. Following this intervention, the nurse would check the fetalheart rate.
Question.135= A postsurgical patient develops bacterial pneumonia. Whenassessing her condition, which of the following signs or symptoms would
the nurse expect to be present
Irregular pulse.
Answer2.135=Hypertension.
Answer3.135= Temperature above 37.7 degrees C (100 degrees F).
Answer4.135=Shallow, irregular respirations.
Rational.135= Bacterial pneumonia causes an increase in temperature, sothe nurse would know that it may be present when the patient`s temperatureis above 37.7 degrees C (100 degrees F). This type of pneumonia would notresult in hypertension, irregular pulse or even shallow, irregular respirations.
The primary symptoms, in addition to a high temperature, are rapid onset,constant cough, pleuritic pain, anxiety and dyspnea.
Question.136= Before a patient who has gout is discharged from thehospital, it is important to evaluate his knowledge of dietary management.Which one of the following diet choices would indicate to the nurse that he
understands his dietary restrictions?
Crab cakes, rice and peas.
Answer2.136=Antipasto salad, rice and asparagus.
Answer3.136= Liver, a potato and spinach.
Answer4.136=Steak, baked potato and green salad.
Rational.136= Steak is the best choice because foods highest in purineinclude shellfish, liver, chicken, beans, and various vegetables. The
appropriate diet will include high carbohydrates with calorie control.
Question.137= A 3-year-old child is brought to an emergency department byhis mother because she could not get him to wake up completely after his
nap. He is semiconscious and has a low-grade fever. The physician suspectslead poisoning. The nurse should expect that the child will be treated with
Calcium disodium edetate (EDTA).
Answer2.137=Syrup of ipecac.
Answer3.137= Activatedcharcoal.
Answer4.137=Erythromycin.
Rational.137=Calcium disodium edetate (EDTA) is a chelating agent whichpromotes the excretion of lead from the body. It is given IV or deep IM for
children who cannot tolerate IV.
Question.138= The nurse should know that if a patient with heart failuredevelops a ventricular arrhythmia, physician`s orders will be to administer
Morphine sulfate, USP.Answer2.138=Lidocaine hydrochloride, USP.
Answer3.138= Digoxin (Lanoxin).
Answer4.138=Propranolol
hydrochloride (Inderal).
Rational.138= Lidocaine hydrochloride, USP, is the medication of choicebecause it depresses ventricular irritability. Inderal is contraindicated, as it is
a beta-adrenergic blocking agent--it also depresses cardiac function. For apatient who already has a compromised cardiac status, this could be fatal.Morphine sulfate, USP, reduces anxiety, but will not prevent arrhythmias.
Digoxin is used to strengthen ventricular contraction.
Question.142= A 26-year-old primigravida who is 27 weeks pregnant isadmitted to the hospital with pre-eclampsia. The physician prescribes
magnesium sulfate therapy. The nurse will place the patient in a privateroom because
A quiet, darkened room is important to reduce external stimuli.
Answer2.142= A rigid regimen is an important aspect of eclamptic care.
Answer3.142= It will allow her husband to be with her.
Answer4.142= She would be disturbed if she were placed in a room withanother woman in active labor.
#1Rational.142= An important aspect of the treatment for pre-eclampsia isabsolute quiet, and only a private room will accomplish this objective.
Question.143= An adult patient with moderate diabetes mellitus, Type I, hasbeen admitted for a work-up for peptic ulcer disease. He is scheduled for anupper GI series at 8:00 AM. The most important nursing intervention related
to his intermediate-acting insulin dose will be to
Administer his usual dose of intermediate-acting insulin before the test.
Answer2.143= Explain that he will not receive his insulin until after the testis completed.
Answer3.143= Administer extra insulin to withstand the stress of the test.
Answer4.143= Administer regular insulin before the test and explain that hisbreakfast will be served after the
Rational.143=The patient is taking intermediate-acting insulin, as he is amoderate diabetic. He will most likely receive insulin and then be fed
breakfast when he returns after the test. Therefore, (1) is the most correct.Extra insulin would not be administered.
Question.144= When completing an assessment on a 9-year-old child, thenurse knows that a primary developmental task of a 9 year old, according to
Erikson, is
Trust.Answer2.144=Initiative.
Answer3.144= Industry.
Answer4.144=Identity.
Rational.144=From age 6 to 12, Erikson has theorized that the maindevelopmental task is industry versus inferiority. Trust (1) is resolved in the
infant stage of development initiative (2) versus guilt is the task ofpreschoolers, age 3 to 6, and identity (4) is the task to be resolved at puberty
and adolescence.
Question.145= The nurse has a full work load and must reassign some of herpatients to the nursing assistant. The most appropriate patient to reassign is
a(n)
Patient just returning from the recovery room following colostomy surgery.
Answer2.145= CVA patient who has been hospitalized for 2 days.
Answer3.145= Newly admitted patient with suspected pancreatitis.
Answer4.145= Oncology patient who is in severe pain controlled byepidural analgesia.
Rational.145=The most appropriate patient would be the one with the CVAdiagnosis. This patient would have been hospitalized for 2 days, so the
initial assessment is completed. This condition does not demand immediateassessment or intervention, as does the colostomy patient (assessing for
hemorrhage, vital signs, etc.), the oncology patient (determining theeffectiveness of the pain protocol), and the new patient with suspected
pancreatitis (who needs a complete assessment).
Question.146= When assessing a 2-month-old infant`s reflexes, the nurseshould understand that at this age the infant should exhibit
negative Babinski`s reflex.
Answer2.146=An absent tonic neck reflex.
Answer3.146= An absent rooting reflex.
Answer4.146=A palmar grasp.
4 Rational.146=The palmar grasp, elicited by placing a finger in the infant`spalm, disappears at about 4 months of age, so it would still be present whileassessing the 2 month old. A positive Babinski`s reflex is present until 12 to
18 months of age. In adults, a positive Babinski`s reflex is indicative ofdisruption of the pyramidal tract. The tonic neck reflex disappears at 4
months, as does the rooting reflex while the infant is awake.
Question.147= A 57-year-old patient is admitted to the nursing unit for anendocrine work-up. The tentative diagnosis is Cushing`s syndrome, etiologyunknown. The patient says to the nurse, "I look so awful! I just can`t stand
having my friends see me like this!" Which of the following responseswould be best?
I know how you feel, but they will get used to it very soon."
Answer2.147= "The way you look is a result of your disease. When it iscontrolled, you will return to your normal appearance."
Answer3.147= "It is best not to worry because the stress will make yoursymptoms worse."
Answer4.147= "That is a problem, and you should ask your physician whatcan be done about it."
Rational.147=The signs and symptoms of Cushing`s syndrome are allcaused by an excessive steroid production. When this condition isnormalized, these signs will disappear. This is a factual, therefore
reassuring, statement.
A nurse is assigned to the oncology unit and understands that serumlaboratory changes are associated with radiation therapy. The nurse will
focus the patient assessment on
Answer1.148= Checking the need for subcutaneous injections of vitamin K.
Answer2.148= Checking lab tests for low hemoglobin.
Answer3.148= Monitoring changes in electrolytes.
Answer4.148= Observing for signs of infection.
Rational.148= Patients undergoing radiotherapy may have a decreased whiteblood cell count and should be observed closely for infections.
Question.149= After 1 month of hospitalization, a schizophrenic patientstates that voices are telling him he will die tonight, and he asks the nurse if
this is true. This question should indicate to the nurse that the patient
Is not improving.
Answer2.149= Will begin to enter the manic phase of his illness.
Answer3.149= Is improving but needs reassurance from the nurse.
Answer4.149= Has a poor prognosis.
3Rational.149=The patient exhibits the awareness to question his symptom,thus he is improving. The nurse can reinforce this strength, then stay withhim and help him discuss his fears. (4) is incorrect as his prognosis cannot
be calculated. (1) and (2) are not substantiated by the data.
Question.150= An adult patient with a gunshot wound to the chest isbrought to the emergency department. A left-sided pneumothorax occurred,and the physician inserted two chest tubes, one into the right anterior lobe
and one into the right lower lobe. The water-seal drainage system isconnected to a walled-in suction. To assist in chest drainage, the nurse
should place the patient in
igh Fowler`s position.
Answer2.150=Semi-Fowler`s position, on his left side.
Answer3.150= Supine position.
Answer4.150=Low-Fowler`s position, on his right side.
Rational.150=Positioning a patient on the left side will assist in drainage andsemi-Fowler`s will assist in breathing. The patient can usually be turned to
both sides and the back.
Question.151= A patient turns abruptly in bed and dislodges his chest tube.The nurse`s first intervention is to
mmediately get a sterile dressing and apply over the opening.
Answer2.151= Obtain a sterile towel and place it over the opening.
Answer3.151= Place a sterile Vaseline gauze over the opening.
Answer4.151= Seal off the opening with the nurse`s hand.
Rational.151=The nurse must seal off the opening immediately therefore, ahand is the closest thing available and should be placed over the opening. If
air is sucked back into the chest cavity, the lung could collapse again.
Question.152= An 11-year-old patient with the diagnosis of acute rheumaticfever will have a care plan that includes the most important nursing measure
of
Sufficient vitamins for tissue repair.
Answer2.152=Adherence to bedrest regimen.
Answer3.152= Breathing exercises to increase oxygen exchange.
Answer4.152=Isolation for prevention of infection.C
Rational.152= The most important nursing care would be to maintainbedrest so that the heart is not overtaxed and the body has sufficient resttime to repair the damage caused by the systemic inflammatory disease.
Warm soaks are given to reduce joint pain, and a good diet is necessary forrepair of any organ, but in this instance they are not the most important
components of nursing care. Normally, isolation is not required.
Question.171= A newborn passes meconium after the first day and themother is concerned. The nurse can explain to the new mother that infant
meconium is normally
Rational.171= Meconium is normally passed during the first 24 hours for allbabies. It is not a transitional stool (3) which is partly meconium and partly
milk, usually passed from the second to the fifth day.
Question.172= If there is a physician`s order to irrigate the bladder, whichone of the following nursing measures will ensure patency?
Answer1.172= Irrigate with 20 mL of normal saline to establish patency.
Question.174= The most important nursing intervention for patients onIPPB therapy is to
Rational.174= The detection of alterations in vital signs could be anindication of nebulizer medication side-effects so this intervention is the
most important.
Question.182= A 29 year old is in the labor room and has been there for 6hours. It is the change of shift and, when the nurse is receiving report, a
nurse`s aide rushes in and says that the patient is delivering. As the nurseenters the room, the baby`s head is crowning. The first nursing action is to
Rational.182= At this stage, the most important action is to support thebaby`s head. The nurse would not try to hold back or stop the delivery, but
allow it to occur naturally. If possible, send someone else to notify thephysician. Instruct the mother to pant, not push, to avoid rapid delivery.
Question.183= Following an emergency delivery, the nurse is alone with themother when the baby is finally born. After suctioning the baby`s mouthwith a bulb syringe, the nurse realizes the newborn has not yet begun to
breathe. The first nursing action is to
nitiate infant CPR.
Answer2.183= Hold the baby upside down by his heels so that mucus willdrain out.
Answer3.183= Gently rub the baby`s back or soles of his feet.
Answer4.183= Sharply slap the baby`s back to stimulate breathing.
#2 Rational.183= The first action is to hold the baby so that the head is in adependent position. This will allow mucus and fluid to drain out. Then, if
the baby does not breathe on his own, action (3) should be done. The nursewould NOT slap the baby on its back.
Question.184= A 21-year-old schizophrenic woman does not relate to staffor other patients on the psychiatric unit. She isolates herself in a part of theday room. The staff nurse wishes to establish communication with her. The
best plan would be to approach the patient
Introduce yourself and ask if you can stay with her.
Answer2.184= Nonverbally because she is nonverbal.
Answer3.184= Introduce yourself and tell her that you are going to sit withher a few moments.
Answer4.184= Use touch to get her attention, and ask her if she would liketo work with you.
3Rational.184= The most therapeutic response would be to introduceyourself and sit quietly a few moments making NO demands on her by
asking questions. A nonverbal approach would be threatening. The nursewould not use touch with a schizophrenic (potentially paranoid) patient.
Question.185= A 25-year-old female with AB negative blood is para 0,gravida 1. She has aborted after 10 weeks and is going to be kept in the
hospital 1 night for observation. Considering her Rh blood type, what actionwould the nurse expect to be performed
85= The patient would be given an injection of RhoGAM within 72 hoursRational.185=RhoGAM must be administered within 72 hours to an
Rh-negative female who has not been sensitized. Because this is her firstpregnancy, this patient should have the RhoGAM within 72 hours.
Question.186= A 50-year-old patient has received the diagnosis ofagranulocytosis. The nurse understands that one of the most serious
consequences of agranulocytosis is
Answer3.186= High susceptibility to infection.
Rational.186= This blood disorder is characterized by profound neutropeniaand can lead to severe infection which could be fatal. The symptoms would
be chills, fever, sore throat, and lethargy.
Question.187= A psychiatric patient rapidly improves and is scheduled to bedischarged tomorrow. Which of the following responses demonstrates that
the nurse has a good understanding of termination of a relationship?
ou`ve done some good work here. I hope you`re able to follow through onit."
Rational.187= Termination is an on-going process, so encouraging thepatient to follow through with what was learned is a good response. The
nurse would NOT encourage the patient to "stop by" because therelationship is terminated.
Question.193= A patient is receiving lithium carbonate for manic behavior.Administration of this medication should be guided by
Answer3.193= Telling the patient that a lag of 7 to 10 days can be expectedbetween the initiation of lithium therapy and the control of manic
symptoms.
Rational.193= There will be 7 to 10 days before the patient will experience adecrease in the manic symptoms. A therapeutic dose is 300 mg TID regularblood studies must be continued throughout drug therapy muscle weakness
is an expected side effect and does not indicate toxicity.
Question.194= A 24-year-old male patient with no feeling or sensation inhis lower extremities is in spinal shock. The nurse will be able to recognize
that his condition is improving when
Answer3.194= Hyperreflexia occurs.
Rational.194= Reflex activity begins to return below the level of injurybecause of automatic activity inherent in nervous tissue.
Question.195= The type of diet that would be indicated for a child withcystic fibrosis is
Answer1.195= High calorie, high protein, low fat.
Rational.195=High calorie and protein intake will support growth andweight gain. A low fat diet is encouraged because the fat is poorly digested.
Pancreatic enzymes are replaced and given with meals to assist with thedigestion and absorption of fat.
Question.198= After a vaginal examination, the patient`s obstetrician tellsher that she is at -1 station. When she asks the nurse what this means, the
nurse tells her that station -1 means the presenting part of the fetus is
1cm above the level of the ischial spines.
Rational.198= Station is the degree to which the presenting part hasdescended into the pelvis-the relationship between the presenting part and
the ischial spine. The fetus moves from above to below the level of theischial spines.
Question.199= In assessing the baby`s position for delivery, the nurseknows that the most favorable position for delivery of an infant is a
Left or right occiput anterior.
Rational.199= Left or right occiput anterior (LOA and ROA) are the mostfavorable positions for delivery. Breech, where the buttocks or lower
extremities are the presenting part, is a difficult delivery position and atransverse lie necessitates delivery by C-section.
Question.204= When measuring a patient for elastic hose, the nurse willmeasure the
Answer4.204= Ankle and calf circumference and leg length after the patienthas been lying down.
Rational.204= The leg length and ankle and calf circumferences should bemeasured after the patient has been lying down. This causes the peripheraledema to be minimal and ensures that the hose fit snugly to offer maximum
support.
Question.207= A patient has physician`s orders to take chemotherapeutichormonal agents. The nurse would prepare the patient to anticipate which of
the following side effects
Fluid retention, mood changes, anxiety.
Rational.207= Fluid retention, mood changes, and anxiety are common sideeffects. They are a direct result of using androgens or estrogens as
chemotherapeutic agents.
Question.209= The physician has just completed a liver biopsy.Immediately following the procedure, the nurse will position the patient
Rational.209=Placing the patient on his right side will allow pressure to beplaced on the puncture site, thus promoting hemostasis and preventing
hemorrhage. The other positions will not be effective in achieving thesegoals.
Question.210= The nurse collects the following information when taking anursing history from a postmenopausal patient. Analyzing the data reveals a
risk factor for the development of osteoporosis when the patient
as been on prednisone (Deltasone) for 3 months.
Rational.210= Glucocorticoids, such as prednisone, promote proteincatabolism and are a known risk factor for the development of osteoporosis.
Question.212= The nurse is at the bedside when a 9 year old has a seizureshortly after admission. The first action during the seizure is to
Answer3.212= Protect the child from injury by removing objects from thebed.
Question.214= While explaining the side effects of oral contraceptives to ateenage patient, the nurse will tell her that
Answer4.214= Side effects may appear but these usually disappear withinthe first to third cycle.
Question.216= A 65-year-old male patient with Parkinson`s disease is beingtreated with L-Dopa. The nurse will know he understands the teaching
principles when he says that he avoids foods rich in
Rational.216= Foods rich in B6 block the desired effects of L-Dopatherefore, they need to be omitted from the diet. Examples of foods to be
avoided include meat, especially organ meats, whole-grain cereals, peanuts,and wheat germ.
Question.220= A 20-year-old patient is admitted to a hospital with adiagnosis of acute schizophrenia. He is becoming more withdrawn and
suspicious of other patients, and he constantly tries to argue with the nursingstaff that several of the patients are "out to get him." The best nursing
approach to this behavior is to
Answer3.220= Avoid disagreeing with him and get him involved with anactivity.
Question.222= A 50-year-old female patient is scheduled for acholecystectomy. Following surgery, she has a T-tube in place and is
returned to the surgical unit. Which position will ensure optimal functioning
Rational.222=Initially a low-Fowler`s position, then a semi-Fowler`sposition is encouraged, but not high-Fowler`s. The objective is to facilitate
drainage, as well as allow a position of comfort for the patient.
Question.223= A patient is admitted with a tentative diagnosis of metabolicacidosis. Assessing for the clinical manifestations most representative of this
condition would include
headache, diarrhea, =Metabolic acidosis results from conditions such asdiabetes mellitus and diarrhea
Question.230= A female patient has orders to take lithium regularly afterbeing discharged from the hospital. Her serum level has been regulated at1.4 mEq/L and she seems to be doing well. Which of the following is the
most important discharge information to impart to the patient and her family
Answer2.230= Drowsiness, tremors and slurred speech are early indicationsof lithium toxicity.
Rational.230= Most important is that the patient and family be aware oflithium toxicity these symptoms are indicators of this condition. Answer
Question.236= The preoperative nursing care plan for a patient scheduledfor an iridectomy will include
Answer1.236= Administering pilocarpine eye drops.
Rational.236=Pilocarpine acts directly on the myoneural junction itconstricts the pupils and forces the iris away from the trabecular, allowing
fluid to escape. Cycloplegic drops are given preoperatively with a cataract toparalyze the ciliary muscle, and postoperatively to relax the ciliary muscle
with an iridectomy.
Question.237= A patient is lying comfortably on her back 30 minutes afterreceiving an epidural injection. The nurse checks fetal heart tones and the
rate is 100 per minute. The first nursing action is to
Answer2.237=Turn the patient onto her left side.
Rational.237= This form of regional anesthesia may cause transitory fetalbradycardia. The first nursing action is to turn the patient onto her left side,shifting the weight of the fetus off the inferior vena cava. If the condition
does not change after repositioning, then administer oxygen, as ordered. Thenext two actions would be to check the fetal heart rate and the mother`s
blood pressure.
Question.239= A 2-month-old female infant develops an ear infection.While administering ear drops, the appropriate technique is to place the
baby
Rational.239=The appropriate technique is to pull the ear auricle down andback so that the ear drops fall into the ear canal. The infant may be on her
side or back with her head turned for this procedure. This question asks fortechnique, so answer (1) is more appropriate. If the nurse is administeringear drops to an adult, the procedure is to pull the ear auricle up and back.
Question.241= One of the primary goals of treatment for a patient withacute glomerulonephritis would be to encourage
Rational.241= Bedrest during the acute phase will protect the kidneys fromadded stress. Activity may increase urinary abnormalities as well asfacilitate diuresis. When the kidneys recover, fluid balance and mild
hypertension will be alleviated. The diet should be low, not high, protein toprotect the kidneys from processing protein waste products.
Question.247= During a typical emergency delivery, which of the followingprinciples best explains why the nurse will not cut the cord
Rational.247= The rationale for not cutting the cord following an emergencydelivery is that lack of sterility could lead to infection. Hemorrhage mightalso occur, but not from the placenta. Answers (1) and (4) are not relevant
principles to explain why the cord should not be cut.
Question.250= A nursing goal to be included in the care plan for a patientwith chest tubes in place will be to
Answer2.250= Keep the bottles below bed level to prevent backflow.
Question.251= A patient has recently been diagnosed with tuberculosis. Thewife of the patient is concerned that she will contract the disease. The nurse
can teach the patient`s wife that the most important preventive methodwould be
Rational.251= Those people infected with the tubercle bacillus without thedisease and those at high risk for developing the disease should receive a
drug regimen of isoniazid and vitamin B6 as prophylaxis. Measures toprevent the spread of the disease should also be implemented but, dependingon the relationship, not living with her husband or keeping him in isolation
are not the usual methods.
Question.252= A 2-year-old patient has a fracture of his right femur.Observing whether Bryant`s traction is properly assembled, the nurse will
expect to see the
Rational.252= Bryant`s traction is a form of skin traction and, therefore,does not require a pin insertion. Moleskin is frequently used as the
stabilizing material for traction application. The weights must hang freelyfrom the crib to maintain alignment and decrease the fracture.
Answer4.252= Weights attached to skin traction and hung freely from thecrib.
Question.254= A patient with the diagnosis of schizophrenia tells the nursethat there is nothing wrong with her-it`s the fault of her family that she is in
the hospital and that they are out to get her. This defense mechanism iscalled
Rational.254= The patient is using projection when she blames her family,saying they are out to get her. Projection is placing the blame for one`s
difficulties on others it is an indicator of paranoia.
Question.255= The nurse observes a schizophrenic female patient sitting,staring into space, occasionally saying something like "Is the world coming
to an end?" The nurse`s understanding of a comment like this is that thepatient is
Answer2.255= Having difficulty telling the difference between her ownwishes and fears and what is real.
Rational.255= A central problem in schizophrenia is difficulty inreality-testing, where the patient often cannot tell the difference betweenwhat is real and what is not. This statement is not necessarily paranoid
ideation, so answer (
Question.259= For a diagnosis of viral pneumonia in a 6 month old, thenursing diagnosis is fluid deficit. The best method of ensuring a proper fluid
balance during the acute stage of the infant`s illness is to administer
Rational.259= One of the dangers of high temperatures in young children isdehydration. It is critical to restore fluid balance, so IV infusion is the
preferred treatment. Dextrose and water is a hypotonic solution that causescells to expand or increase in size. It is the fluid replacement of choice for
diarrhea and dehydration.
Question.261= The nursing staff of a psychiatric unit planned an all-dayouting. Many of the patients were on large doses of phenothiazines. A
nursing action important to implement prior to the outing is to
Rational.261=Patients taking phenothiazines are sensitive to the sun(photophobia). The correct answer is to have these patients put on sunscreen
and wear hats when they are in the sun. Answer
Question.263= A 23-year old female patient, following an automobileaccident, was placed in skeletal traction for a fractured femur. In the
assessment of this patient, one of the nurse`s first concerns will be to assessfor
Rational.263= Proper alignment is critical to maintain skeletal traction incounterbalance or correct pull. It is also important to assess for pressure
points or skin excoriation, but these observations would be continual as longas the traction is in place.
Question.268= Dilantin is ordered to control a 10 year old`s seizures. Whileteaching her mother about the medication, one of the side effects to
emphasize is
Rational.268= The primary side effects of the drug, Dilantin, are bleedinggums and gum hypertrophy, rash and GI symptoms. Answer (3) is the
preferable choice because it will involve teaching the patient to use a softtoothbrush, brush frequently, and eat a diet high in vitamins and minerals to
protect the gums.
Question.274= During the postoperative period following abdominalsurgery, the patient will require airway suctioning. The primary rationale for
keeping the suction catheter in the airway for only 10 to 15 seconds is toprevent
Rational.274= Suctioning longer than this length of time will remove excessoxygen and this may lead to hypoxemia. Another technique of preventing
hypoxemia is to administer oxygen 1 to 2 minutes before suctioning.
Question.276= There is an order to perform the crede procedure on a malepatient every 6 hours. "Crede" is a term used for a
Rational.276= Crede is a French term that refers to the manual expression ofurine, made necessary because of a hypotonic bladder. This method will
help initiate bladder retraining.
Question.277= A patient has a chest tube connected to two-bottle water-sealsuction. The purpose of water in the second bottle is to
Rational.277= The end of the drainage tube is kept under water this waterseals the tube so air cannot enter and be drawn back into the pleural space.
Question.279= Immediate postoperative nursing interventions for anabove-the-knee amputation will include
Rational.279= The possibility exists that the patient could hemorrhage fromthe stump. Therefore, it is safe nursing care to have a tourniquet at the
bedside.
Question.280= The nurse will help a child with acute glomerulonephritisfollow a diet regimen of
Rational.280= A diet with restricted potassium and protein is necessary forall children who demonstrate some degree of renal failure.
Question.282= A child is admitted to the hospital with marked symptoms ofnephrosis. The following information should be included in the admissionnurse`s notes. Which information is most pertinent in terms of the child`s
condition
Rational.282= It is important to note the degree and extent of generalizededema that occurs with nephrosis. The condition is characterized by severeproteinuria which results in hypoalbuminuria leading to the shift of fluid
from the intravascular to the extracellular compartment.
Question.288= The instructions to a patient just learning to use a four-pointcrutch-walking gait would be to move the
Answer3.288= Right crutch, then the left foot.
Question.291= A 1-month-old female infant has been readmitted to thehospital for a cleft lip repair. In planning for her preoperative care, the nurse
will feed her in a/an
Rational.291= An upright or sitting position is important when using a soft,large-holed, cross-cut or special nipple. The nipple should be placed on the
opposite side from the cleft.
Question.294= An adult male patient is admitted to the hospital for a cardiacwork-up. During the initial physical assessment, the nurse listens for
bronchovesicular breath sounds. These sounds can normally be heard overthe
Rational.294= These hollow, muffled breath sounds can be heard over thebronchial area below the clavicle.
Question.296= A male patient has a tracheostomy and requires suctioning.The nurse knows that signs of hypoxia may occur during this procedure. A
nursing action to prevent hypoxia is to
Answer3.296= Hyperinflate the lungs with 100% oxygen prior to andfollowing suctioning.
Rational.296= Hyperinflation of lungs with oxygen before and aftersuctioning prevents potential cardiac complications due to a sudden drop in
blood oxygen levels.
Question.299= A 24-year-old married female suspects that she is pregnant.She states that her last menstrual period started on August 9, 2005. She asks,"If I am pregnant, when will my baby be due?" According to Nagele`s rule,
the due date would be
Rational.299=Nagele`s rule is to count back 3 months from the first day ofthe last menstrual period and add 7 days.
Answer1.299= May 16,2006.
Question.301= A 1 1/2-year-old is brought to the hospital with a diagnosisof pneumonia. His temperature is 38.8C (102F), respiratory rate is 40 and heappears lethargic. A tentative diagnosis of pneumonia is made. Evaluating
his condition, an indication that he is improving is a respiratory rate of
Rational.301=A normal respiratory rate for a 1 1/2 year old is 30breaths/min. This rate would indicate that the child`s respiratory condition isimproving. The usual respiratory rate for a 14 year old is 18 breaths/min. Arespiratory rate of 20 is usual for a 10 year old. A respiratory rate of 50 is
abnormally high.
Question.302= A new mother-to-be asks why her doctor told her todiscontinue taking all unnecessary drugs during pregnancy. Based on theunderstanding of the relationship between drugs and the fetus, the nurse`s
reply would be
Rational.302= All drugs may be expected to cross the placental barrier andare especially damaging during the first 8 weeks, when fetal organogenesisis taking place. Drugs taken later in pregnancy may also affect the fetus, but
their effects may not be known for years. Even drugs taken during labormay have a depressive effect upon the CNS of the fetus and may take
several days to wear off. Nicotine from smoking may cause low birth weightinfants as well as congenital defects.
Question.303= Adequate nutrition is essential during early pregnancy foroptimum fetal development. The nurse recommends a daily diet that would
include
Rational.303= The diet must include at least one fruit or vegetable high invitamin C, and should include a total of four fruits and vegetables.
Pregnancy requires the addition of 300 calories a day over regular caloricintake, and 1500 calories a day would be inadequate. The recommendedcalories for someone aged 28 are 2300 a day. New research indicates that
sodium is essential, so a low sodium diet is not recommended.
Question.306= A cerebral arteriogram is performed on the patient. When hereturns from the operating room, the nurse observes that he may be having areaction to the dye. The sign or symptom that suggests this complication is
Rational.306= Numbness of the extremities is a symptom of delayedreaction to the dye. Respiratory distress is a frequent early sign of
anaphylactic shock. The release of histamine causes major vascular andbronchial symptoms resulting in anaphylaxis.
Question.307= The patient goal for fluid intake following abdominalsurgery for an inguinal hernia would be
Rational.307= 2000 to 3000 mL/day would be fluid maintenancepostsurgery. The body will require additional fluids over the minimum due
to fluid loss and the recovery process after surgery.
Question.309= A 26-year-old primigravida is mildly pre-eclamptic and willbe followed on an outpatient basis. Which of the following signs or
symptoms should the nurse expect to observe if the eclampsia is becomingmore severe
Rational.309=Edema, proteinuria and hypertension are the three cardinalsigns of pre-eclampsia. Normal urine output or oliguria occurs rather than
polyuria.
Question.311= The RN has discussed the baby`s newborn status with themother and asks the practical nurse to reinforce it. She explains to the
mother that the insulin level in newborns of diabetic mothers
Rational.311=Insulin levels are increased in these infants because themother`s glucose readily crosses the placenta and stimulates the fetal
pancreas to secrete increased levels of insulin. The fetal insulin does notcross the placenta.
Question.315= A patient is being prepared for an oral cholecystogram.Before the dinner meal the practical nurse instructs the nursing assistant to
Rational.315= Diarrhea is a very common response to the dye tablets. Adinner of tea and toast is usually given to the patient. Each dye tablet is
given 5 minutes apart, usually with 1 glass of water following each tablet.The number of tablets prescribed will vary, because it is based on the weight
of the patient.
Question.316= A 7-year-old male complains of pain and limited movementin his left hip. The physician suspects Legg-Perthes disease. At this stage of
the disease, the major goal of treatment is aimed at
Rational.316= Legg-Perthes disease affects the femoral epiphysis in whichaseptic necrosis occurs. Pressure on the necrotic femur can cause permanent
damage.
Answer4.316=Preventing pressure on the head of the femur.
Question.318= A 34-year-old male patient with a diagnosis ofschizophrenia, paranoid type, barges into the dayroom yelling, "The
President is on my side. If you bother me, I`ll send him after you!" Thenurse could most effectively respond by saying
Answer3.318= "I understand you are concerned. The staff will see that youare safe."
Rational.318= The patient`s grandiose attacking statements probably reflecthis feelings of fear and his anger at being afraid. Reassurance that he will be
safe is important. His fear should be respected but not necessarilyconfronted since this might increase his anxiety. Confrontation would
probably escalate his aggressiveness and add to his defensiveness. In hispresent state, a probing question would be threatening and inappropriate,
although it might be useful later.
Question.319= A male patient was admitted with a diagnosis of subduralhematoma and transferred to the ICU in a semicomatose state. If the patient
goes into a coma, the nurse would be likely to observe
Rational.319= An indication of a comatose state is increased blood pressureand slowing respirations. Aphasia is also a result of increased pressurehowever, due to a decreased level of consciousness which is sometimes
present, this is not always an accurate indicator.
Question.320= A male patient is taken to surgery for evacuation of asubdural hematoma. Immediately after the evacuation, the priority nursing
assessment is to observe
Rational.320= All of the nursing interventions listed would be carried outfor the patient however, the most important one is to prevent cerebral
hypoxia (which contributes to cerebral edema) by maintaining a patentairway. The acid-base imbalance and hypoxia are often mistaken for signs
of increased intracranial pressure, leading to unnecessary surgicalintervention. A patent airway will establish adequate oxygenation and
prevent carbon dioxide build-up.
Question.323= A female patient has sustained burns of her right arm, rightchest, face, and neck. She has just been admitted to the burn unit. Her
weight on admission is 50 kg. Using the rule of nines, the estimate of theextent of her burns is
Rational.323=The extent of the burns is 27 percent, calculated by adding thehead = 9 percent (face and neck each equal 4 1/2 percent), arm = 9 percent,
and chest = 9 percent.
Question.324= To promote adequate nutrition, a burn patient`s diet after thefirst week of hospitalization should include
Rational.324= A diet high in carbohydrates is essential to allow the proteinto be spared for tissue regeneration. High protein is also needed for tissue
repair.
Question.325= Completing a general assessment on a 6 month year old, thenurse knows that this age infant is able to
Answer1.325= Sit for a short time, look toward sounds, and begin babbling.
Question.327= Each newborn receives an Apgar score shortly after birth.The nurse understands that the purpose of Apgar scoring is to
Rational.327=The purpose of Apgar scoring is to determine the viability ofthe infant. Apgar scoring is the evaluation of five vital signs: heart rate,
respiratory rate, muscle tone, reflex irritability, and color. Scores of 0, 1 or 2are given to each vital sign for a total of 10. A score of 7 to 10 is considered
vigorous.
Question.333= The nurse has completed a postoperative assessment forhypoparathyroidism following a thyroidectomy. If the symptoms of thiscondition are present, the nurse would check with the RN and expect to
administer
Rational.333=Signs of hypoparathyroidism following a thyroidectomy areevident in an acute attack of tetany. The drug of choice is calcium gluconate
to counter the low calcium level.
Question.334= A patient is admitted to the hospital with an obstruction justproximal to the old ileostomy stoma. The nurse will monitor for a major
complication which is most likely to be
Rational.334= Due to the extreme loss of fluids from the high coloninterruption, fluid and electrolyte imbalance is the most common
complication. The lower colon reabsorbs a major portion of the fluid,whereas the upper colon does not have this function. A great potassium loss
also occurs, because it is found in large amounts in the upper colon.
Question.335= The nurse will know that a patient with an ileostomyunderstands dietary restrictions when she indicates that she does not include
which one of the following foods in her diet
Rational.335= Corn may cause obstruction of the ileostomy and thus shouldbe avoided.
Question.338= A 54-year-old male patient with a history of cirrhosis fromalcohol abuse has been admitted for bleeding esophageal varices. While thepatient is on bedrest, he is in a semi-Fowler`s position. The major objective
for using this position is to
Rational.338= Any position that impedes respirations by the pressure ofabdominal contents on the diaphragm should be avoided therefore, the best
position for this patient is semi-Fowler`s position, which increaseseffectiveness of breathing.
Question.339= The nurse is assisting the physician to insert aSengstaken-Blakemore tube. Prior to insertion the nursing action is to
Rational.339= In order to prevent the trauma of reinsertion, the balloonsmust be checked for leaks before insertion. This is done by inflating them
and placing them in water to observe for bubbles.
Question.340= A child with the diagnosis of phenylketonuria (PKU) maynot eat which of the following foods
Rational.340= The accumulation of phenylalanine, an amino acidbreakdown of protein, is toxic to brain tissue. Therefore, any foods high inprotein must be restricted. These include meat, fish, legumes, lima beans,
milk products, etc.
Question.342= A female patient is being treated with intracavitaryirradiation using a Cesium implant. The nursing care plan should include
Rational.342= A low-residue diet helps to prevent frequent bowelmovements, a major side effect of radiation therapy. Absolute bedrest with
logrolling from side-to-side is allowed. The head of the bed can be raised nomore than a 45 degree angle.
Question.343= When a patient with advanced cirrhosis selects a snack, thechoice that indicates understanding of the dietary requirements is
Rational.343= Carbohydrates are one of the mainstays of the cirrhoticpatient`s diet. The liver can metabolize only very small amounts of protein,so usually only 40 to 50 grams of protein is allowed per day (normal diet is
60 to 80 grams per day). The banana is the only nonprotein choice.
Question.346= Which of the following assessments of the patient with anabdominal aortic aneurysm requires immediate reporting to the RN or
physician
Rational.346=The increase in blood pressure could cause a rupture of theaneurysm, so this finding should be reported immediately. Palpation of apulsating mass and a bruit are normal findings. Moderate anxiety over the
surgery is also normal.
Question.347= A patient is having a prolonged labor and there is noprogress past a dilation of 8 cm. Her physician decides to do a cesarean
delivery. The new mother and her partner express their disappointment thatthey will not have a natural childbirth. The best response is to say
Most couples who have an unplanned cesarean birth feel cheated anddisappointed.
Question.354= When using nasotracheal suction to clear a patient`s airwayof excessive secretions, the nurse would
Rational.354= To prevent trauma to the mucous membranes lining theairway, suction should be applied intermittently and only while withdrawing
the catheter. The catheter should be lubricated with a water-solublesubstance to prevent lipoidal pneumonia. Suctioning attempts should be
limited to 10 seconds or less to prevent hypoxia.
Question.356= When a patient has lung cancer that has been classified asStage 1 , NO, MO, the nurse knows that this indicates that the patient has a
tumor
Rational.356= "" means the tumor is less than 3 cm in diameter withoutinvasion proximal to a lobar bronchus. "NO" means there is no
demonstrable metastasis to regional lymph nodes and "MO" indicates nodistant metastasis.
Question.357= The parents of a 4 month old noticed that many bruises wereforming on their son`s knees, buttocks and thighs. The blood tests revealthat he has classic hemophilia. The nurse understands that hemophilia is
Rational.357= Hemophilia is a sex-linked recessive disorder. Theasymptomatic mother transmits the disorder to the son on the X
chromosome.
Question.362= A drug commonly administered to reduce the extrapyramidalside effects of phenothiazines used in the treatment of schizophrenia is
Rational.362=Cogentin or Artane are the antiparkinson drugs usuallyprescribed for reducing extrapyramidal effects caused by phenothiazines.
Benadryl is also commonly used and has fewer side effects. The otheranswers are incorrect-Niamid and Ritalin are antidepressant drugs and
Valium is classified as an antianxiety drug.
Question.363= A 2 year old has eaten half a bottle of his grandmother`sferrous sulfate tablets. When the mother calls the clinic, the nurse will tell
the mother to
Rational.363= Contact either the poison control center or the emergencydepartment first and follow their instructions. In this case they will probablyadvise giving the child water to dilute the ferrous sulfate tablets and syrup of
ipecac to induce vomiting. Because some poisons will be damaging ifvomited, the center would not always advise the mother to give syrup ofipecac. Then the nurse would instruct the mother to bring the child to the
hospital.
Question.364= A 58-year-old patient with a diagnosis of schizophrenia,chronic undifferentiated type is taking 400 mg of chlorpromazine
(Thorazine) TID. The nurse notices on the morning rounds that he isdrooling and flapping when he walks. The best nursing action would be to
Rational.364= The patient is experiencing side effects to phenothiazines, butthese are not life-threatening and can be brought to the attention of the RN
and physician within an appropriate amount of time. (4) is incorrect.Thorazine is effective at certain blood levels, and holding the drug would
lower the blood level. If possible, it is preferable to check with the physicianbefore holding a drug.
Question.365= A 65-year-old female patient has suffered a cerebral vascularaccident (CVA)-left hemisphere lesion. The most appropriate method of
communicating with her is to
Rational.365= For a left hemisphere lesion, the best method ofcommunication is to pantomime what you are communicating while
speaking in a normal tone of voice. Pantomime will confuse a person whohas suffered a right hemisphere lesion. Before communicating, however, the
nurse will assess the patient`s ability to understand speech. It is alsoimportant to give feedback as you communicate.
Question.367= A young patient, following a motorcycle accident, sustainedspinal cord injury with respiratory function impairment. The cord segments
involved with maintaining respiratory function are
Rational.367= Nervous control for the diaphragm (phrenic nerve) exists atthe level of or of the spinal cord.
Question.368= The nurse is assigned a patient with the diagnosis of portalhypertension. The most important assessment with this condition is for the
complication of
Rational.368= GI bleeding is a very common complication associated withportal hypertension. Obstruction of portal circulation leads to increased
collateral circulation which can result in bleeding tendencies.
Question.369= An elderly patient with organic brain syndrome suffers frominsomnia and asks the nurse for something to help him sleep. The physician
will not order barbiturates for this patient because they cause
Rational.369= In organic brain disorder, barbiturates commonly causedelirium, confusion, and paradoxical excitement, thus they should not be
ordered for patients with organic brain disorder.
Question.370= A diabetic patient takes 22 units of NPH insulin at 7:30 AMeach day. Evaluating the effects of insulin, at which time during the day willthe nurse assess her for signs of restlessness, memory lapses and headache
Rational.370= Intermediate insulin peaks from 8 to 12 hours after injection.3:30 PM is the most appropriate time to assess for signs of insulin reaction.
Question.374= A patient is to receive 2500 mL of IV fluid over 24 hours.The IV tubing delivers 15 gtts per 1 mL. How many drops per minute
should the patient receive
Rational.374= First, determine the number of mL to give the patient eachhour by dividing the total volume by the total number of hours: 2500 mL
divided by 24 hours yields a desired hourly amount of 104 mL. One methodfor determining the minute rate uses the formula of: Volume divided by
Minutes multiplied by gtts/mL equals gtts/minute. 104 divided by 60multiplied by 15 gtts/mL equals 26 gtts/ minute.
Question.378= The highest priority goal in the care of a newborn withtracheo-esophageal fistula (TEF) and esophageal atresia is to
Rational.378= The anatomical malformation in this anomaly threatens thenewborn`s airway. Maintaining a patent airway is the highest priority in any
situation in which the airway is threatened.
Question.385= A patient, age 60, is admitted to the hospital for a possiblelow intestinal obstruction. His preoperative work-up indicates vital signs of
BP 100/70, P 88, R 18, and temperature of 96.4(F. Listening to bowelsounds, the nurse would expect to find
Answer3.385= Hyperactive, high-pitched sounds.
Question.386= A patient, age 68, has an external shunt placed in preparationfor hemodialysis. The nursing care plan will include
Rational.386= Shunts should be inspected several times each day forpresence of possible clotting. Dark spots will quickly be followed by
separation of the sera and cells if clotting becomes complete. When darkspots appear, patients should be instructed to immediately seek treatment for
declotting.
Question.387= A patient sustained a fracture 3 days ago. When thefollowing blood studies are returned, they are all elevated. Which elevation
would be considered a normal finding following a fracture
Rational.387=Bone is rich in alkaline phosphatase and blood levelsnormally increase following a fracture and during fracture healing.
Elevation of the other blood studies should alert the nurse to the need forfurther assessment of the patient, because of the probable presence of an
illness.
Question.388= A patient with a fractured right leg has been in Buck`sextension traction for a week. The nurse checking the patient finds that he isnow unable to dorsiflex his right foot. The nurse will notify the charge nurse
because there is a possibility that the
Rational.388= Dorsiflexion of the foot requires an intact peroneal nerve.Compression from any part of the traction apparatus along the lateral surfaceof the leg just below the knee can exert pressure on the peroneal nerve and
impede its function.
Question.389= During visiting hours, a patient the nurse is caring forbecomes very agitated and angry with his visitor. The most effective nursing
approach to this patient is to
Rational.389= This approach would help decrease the patient`s anxiety andassist him in gaining insights.
Question.391= Using Leopold`s maneuvers, the nurse palpates the presenceof a firm round prominence over the pubic symphysis, a smooth convex
structure on the patient`s right side, irregular structures on the left side, anda soft roundness in the fundus. The nurse would conclude that the fetal
position is
Rational.391= The head is down, the back is on the right side, legs on left,and fetus` buttocks in the fundus indicate the position of ROA.
Question.392= A patient who developed cerebral edema following a headinjury is given mannitol (Osmitrol) intravenously. The outcome that most
clearly indicates the drug has achieved its desired therapeutic effect is whenthe
Rational.392= Mannitol is given to reduce cerebral edema by promoting themovement of water from the tissues into the plasma followed by its
excretion through the kidneys. The patient`s level of awareness is the mostsensitive indicator of the effects of increased intracranial pressure.
Improvement in the level of awareness, therefore, indicates a therapeuticresponse to the mannitol. The increased urinary output is simply a meansthrough which the desired therapeutic effect is achieved. The absence ofseizures does not indicate a therapeutic response to mannitol. Slowing of
respirations may indicate increased cerebral edema.
Question.393= When a patient with a diagnosis of manic episode returns tothe clinic to have lithium blood levels checked, her lithium level is only
slightly higher than the previous week but she complains of blurred visionand ataxia. The first intervention is to
Rational.393=These are symptoms of toxicity and the nurse must withholdthe next dose. The nurse would then notify the physician. The patient needsto maintain a normal fluid level to prevent toxicity, but this may not be the
cause of her symptoms.
Question.395= A quadriplegic patient tells the nurse that he believes he isexperiencing an episode of autonomic hyperreflexia (dysreflexia). The first
nursing intervention is to
Rational.395= Blood pressure can become dangerously elevated during anepisode of dysreflexia and can cause cerebral and retinal hemorrhages.
Elevating the head will help prevent these complications and should be thenurse`s first action. Identifying the precipitant is useful in terminating the
episode by removing the noxious stimulus which provoked the exaggeratedautonomic response. A full bladder may precipitate dysreflexia and
emptying the bladder would be appropriate if it was the precipitant. Theblood pressure and pulse should be monitored throughout the episode of
dysreflexia.
Question.396= A 3 month old with a diagnosis of chalasia is admitted to thehospital. He has had severe weight loss because of frequent vomiting. To
minimize vomiting, the nurse would place the infant
Rational.396= The greater curvature of the stomach is toward the left side sothe right side position affords less pressure. Elevation of the head would
lessen the tendency to vomit.
Question.398= Which of the following behaviors would indicateimprovement in coping for a patient
interaction with othes
Rational.398= If a patient can initiate interaction with another patient, itindicates he is not totally absorbed in himself, too depressed to initiate, or
too absorbed in delusions or hallucinations to interact.
Question.400= An elderly patient with the diagnosis of COPD has beenadmitted to the hospital. In teaching the patient about his diet, which dietchoice would indicate that a patient with COPD understands nutritional
needs
Rational.400= Carbohydrate metabolism produces carbon dioxide whichincreases the blood levels of carbon dioxide. High protein prevents muscle
wasting and helps preserve the strength of muscles, including the muscles ofrespiration. Calorie and energy needs are met by increasing the fat intake.
Question.410= A patient has an arteriovenous fistula as an access site forhemodialysis. Which assessment finding indicates that the fistula is patent
Rational.410= The flow of blood through a patent arteriovenous fistulaproduces turbulence manifested by a bruit audible when the fistula is
auscultated.
Question.422= A male patient is becoming increasingly angry and verballyabusive. The first nursing intervention is to
Rational.422= The first intervention would be to calmly set limits to defusethe situation. The nurse would not place the patient in restraints until he is
totally out of control nor would the nurse summon a male staff memberinitially -a sudden involvement of others could escalate the situation. After
the initial intervention, the patient could be sent to his room.
Question.423= Teaching a new mother the principles of breast feeding, thenurse will know the mother understands how to care for her breasts when
she says
Rational.423= The breasts need to be dried after feeding. No soap should beused because it removes natural oils. The baby should not be pulled off thebreast because it will make the breast sore. The baby should not be nursed
more than every 2 hours.
Question.425= The nurse in a well-baby clinic reminds a mother that at 4months of age the infant should receive immunizations that include
Rational.425= At 4 months, most children receive DTaP, (diphtheria,tetanus and pertussis toxoid) inactivated oral polio vaccine hemophilusinfluenzae type b Pneumococcal vaccines and hepatitis B, if not given
earlier. MMR (measles, mumps and rubella) is given at 15 months and 11 to12 years. This is recommended by the Schedule Committee on Infectious
Disease from the American Academy of Pediatrics.
Question.431= The nurse is assigned to a patient who is to have aMiller-Abbott tube inserted. Assisting the physician with this procedure, the
nurse will position the patient in
Rational.431= High-Fowler`s with neck flexed is the position necessary fortube insertion, as it is inserted through the nose into the intestine.
Question.454= When performing naso-oral suctioning, the correct nursingaction is to
Rational.454=Clean, rather than sterile, gloves can be used for naso-oralsuctioning and the nurse would insert the catheter through the nares withoutapplying suction. Suctioning is limited to 10 seconds to prevent excessive
removal of oxygen. Suction on the catheter is released intermittently duringthe procedure and when being withdrawn.
Question.458= A patient makes a suicide attempt on the evening shift. Thestaff intervenes in time to prevent harm. In assessing the situation, the most
important rationale for the staff to discuss regarding the incident is that
Rational.458= Even though all of the reasons are important and should notbe ignored, the most important task for the staff is to assess the patient`sbehavior and to identify cues that might indicate an impending suicide
attempt.
Question.460= A manic patient is on lithium. The nurse will instruct her toreport signs of lithium toxicity, which will not include
Rational.460= Diarrhea is associated with lithium toxicity. Some commonsymptoms of lithium toxicity are diarrhea, vomiting, nausea, drowsiness,
muscle weakness, ataxia, blurred vision, confusion, dizziness, andrestlessness.
Question.462= A baby is born with a myelomeningocele. The best positionfor this baby before surgery is
Rational.462= The prone Trendelenburg position is preferred to minimizetension on the fragile meningeal sac. In addition, feces and urine are less
likely to come into contact with the defect.
Question.463= Assessing for the classic signs of basilar skull fracture, thenurse will observe for blood behind the tympanic membrane and
Rational.463= Cerebrospinal fluid leakage needs to be monitored closely. Ifleakage persists beyond a week, surgical repair may be necessary. Pain in
the back of the head and retinal hemorrhage are not associated with a basilarskull fracture.
Question.465= An infant is hospitalized with a diagnosis of meningitis. Alate sign of meningitis that the nurse should immediately report is
Rational.465= Because the infant`s fontanels are open, opisthotonos, a signof increased intracranial pressure, appears late in the course of the illness.
Hypothermia is a decompensator adaptation to many illnesses. "Sunset" signof the eyes is found in uncorrected hydrocephalus. The fontanels continue to
bulge as the meningitis remains unresolved.
Question.467= When an infant is one day old he has surgery for reduction ofa myelomeningocele. Which nursing intervention is critical during the
postoperative period?
Rational.467= Infants with myelomeningocele are prone to develophydrocephalus, which is sometimes noted before surgery. When surgery isperformed soon after birth, it is a critical nursing responsibility to observe
for signs of increased intracranial pressure. Passive ROM, manualexpression of urine, and observation of stool are important nursing
activities, but the priority is assessment for increasing head circumference.
Question.468= If untreated, a child who has contracted diptheria may diebecause of
Rational.468= In severe cases persons with diptheria may develop amembranous lesion that covers the tonsils and can spread to cover the softand hard palates and the posterior portion of the pharynx. The individual is
unable to exchange air through the membrane and death results.
Question.472= A patient who is 6 weeks pregnant complains of a thick,white vaginal discharge. She denies having any itching of the vulva,blood-tinged mucus, or foul order with the discharge. The nursing
intervention is to
Rational.472= Vaginal secretions during pregnancy are thick, white, andacidic (pH 3.5 to 6.0). The increased acidity is due to the presence ofLactobacillus acidophilus. An increase in leukocytes in the vaginal
discharge results in leukorrhea. No culture or testing is needed.
Question.485= Elements of cause of action in negligence/malpracticeinclude
Rational.485= Breach of duty, foreseeability, causation, injury, and damagesare all constituents of malpractice and negligence. The level of damages isnot related to negligence/malpractice (1). Negligence/malpractice injuriescan be physical or psychological (2). The permanence of an injury doesn`t
dictate negligence/malpractice (4).
Question.493= A female patient experiences swelling from her left shoulderto her fingertips within 24 hours after her left modified radical mastectomywith node dissection. The nurse explains to the patient that this results most
directly from
Rational.493= When axillary nodes are removed and biopsied, thelymphatic system loses important sites of waste and fluid returns to thevenous system. The resultant swelling can resolve without incident, or
become severe and warrant intervention. Elevating her left (operative) armon pillows decreases the swelling gravity assists the flow. Mastectomy is not
usually offered to a woman who has widespread breast cancer. Also thenurse would be stating a medical diagnosis that could severely alarm thepatient. With incisional drains in place postoperatively, it is unlikely thatdrainage from the arm would be impeded enough to allow blood and fluid
collection under the incision. However, the drains should be routinelychecked for patency.
Question.494= During preparation for a cardiac catheterization, instructionsinclude information about contrast medium injections. The nurse will tell the
patient to expect to experience
Rational.494= Nausea, warmth, facial flushing, and a salty taste in themouth are all expected sensations when an iodine-based contrast medium isinjected. Severe dyspnea could indicate a beginning anaphylactic reaction or
perforation of the vessels, heart, and/or lungs by catheter. Generalizeditching often heralds an allergic reaction to the dye. The patient who is cooland clammy may be experiencing hypovolemic shock or neurogenic shock
or anxiety.
Question.507= The nurse observes 210 mL of bloody drainage in the chesttube collection chamber of a patient who underwent cardiac surgery two
days earlier. Which of the following actions should the nurse take?
Rational.507= Bloody chest tube drainage is expected in the postoperativephase of cardiac surgery and no immediate intervention is indicated.
Drainage in excess of 500 mL in the first 24 hours postoperative couldindicate hemorrhage. Suction should never be increased without a
physicians order (1). The chest drainage system should not be elevatedabove the level of the patient`s heart or the insertion site (2). Drainage in
excess of 500 mL for the first 24 hours postoperative should be reported (3).
Question.508= The nurse is caring for a newly hospitalized patientidentified with locked-in syndrome secondary to amyotrophic lateral
sclerosis (ALS). Which of the following interventions would be appropriateto establish a form of communication?
Rational.508= Locked-in syndrome occurs in persons with a paralyzingillness and prevents them from communicating through writing, gestures, orspeech. Because voluntary eye closure is spared, using eye blinks in order to
communicate may prove useful. patients with locked-in-syndrome areunable to write. patients experience paralysis with locked-in-syndrome.
Question.511= When the nurse is caring for a patient with a newendotracheal tube, the most important action is to
Rational.511= Auscultate the patient`s lungs immediately after theendotracheal tube has been inserted and every hour thereafter. Oral hygiene,
repositioning, and arterial blood gas results are not the highest priorities.
Question.512= Which of these assessment findings would indicate a tensionpneumothorax?
Rational.512= A tension pneumothorax occurs when air is trapped withinthe pleural space. Mediastinal shift can develop as pressure increases,
causing the layrnx and trachea to deviate away from the injury. Wheezingon the affected side is not a symptom of pneumothorax, since the lung is
collapsed therefore, lung sounds would be distant or absent
Question.516= Which of the following ECG monitor rhythm-strips wouldindicate the body is compensating for heart failure?
Rational.516= Sinus tachycardia is a hallmark sign of heart failure andresults from sympathetic stimulation. Atrial fibrillation may cause heartfailure (1). Supraventricular tachycardia is an atrial dysrhythmia, not a
common cause of heart failure
Question.517= Nursing care for a 6 month old who had a lumbar punctureperformed to rule out bacterial meningitis should include
Rational.517= Rest, quiet environment, and fluids should be promotedpostprocedure, and the child should be positioned flat or slightly elevated.
Restraints can make the child more agitated and restless.
Question.518= A patient admitted for shortness of breath demonstratesarterial blood gas reults of pH 7.47; PCO2 33; and HCO3 26. A nurse
should recognize these results as indicative ofAnswer3.518= Uncompensated respiratory alkalosis.
Question.519= Interventions in the plan of care for a neonate who isadmitted for sepsis should include
Rational.519= Treatment for neonatal sepsis includes: 1) obtaining blood,urine, and cerebral-spinal fluids for culture 2) initiating antibiotic therapyafter cultures are obtained 3) providing respiratory support after blood gasdeterminations are drawn and 4) instituting measures for fever reduction
which do not influence lab data.
Question.521= When evaluating the reliability of PKU blood test findings,the nurse should be confident with the validity of the results if the blood was
acquired
Rational.521= The Guthrie test should not be done until 24 hours afterfeeding has been started with formula or breast milk. It takes time for themetabolites from feeding to accumulate, hence the need to wait 24 hours.
Question.523= When sending a specimen to the laboratory for ABGanalysis, information that should be on the laboratory slip includes
Answer1.523= O2 running at 3 L/minute when the blood was drawn.
Question.528= A toddler is admitted to the pediatric unit with a diagnosis ofnear drowning. The nurse`s initial plan of care on admission should
primarily focus on
Rational.528= With all near drownings, airway and breathing are the firstpriorities and can lead to subsequent cardiovascular, neurologic, and renal
injuries if oxygenation is not maintained.
Question.529= A toddler is scheduled to receive the measles-mumps-rubella(MMR) and inactivated polio (IPV) vaccines. The nurse should not
administer the MMR vaccine if the child
Rational.529= MMR is a live vaccine which should not be given ifimmunosuppressive therapy is currently being administered. A mild illness
or HIV positivity is not a contraindication for MMR immunization.
Question.531= A patient with a bipolar disorder who is slightly manic is tostart on lithium therapy. The patient and the nurse have discussed the drug`sactions. Which of these statements by the patient indicates he understood the
discussion?
Rational.531= When lithium is used to treat mania, the patient may be awareof a slowing down of the thought processes. Diarrhea is a sign of lithium
toxicity.
Question.532= When a patient taking lithium has a fever, it is extremelyimportant for the nurse to be sure that the patient
Rational.532= Dehydration caused by excessive heat or fever can cause abuildup of lithium due to sodium loss, and toxicity may then occur. Thepriority of care is to prevent lithium toxicity due to sodium and fluid loss
(1). Sunlight is not an issue in the person taking lithium (2). Anonstimulating environment does not address lithium toxicity (4).
Question.534= If a patient who is addicted to a benzodiazepine, such asdiazepam (Valium), were to withdraw abruptly from the drug, the nurse
should expect the patient to have
Rational.534= When a patient becomes addicted and develops a tolerance toValium, the seizure threshold of the brain is raised. Abrupt cessation lowers
the threshold and causes seizures.
Question.535= A patient who has been on long-term antipsychotic drugtherapy shows early signs of tardive dyskinesia. The nurse`s action is based
on the understanding that
Answer2.535= The drug may be discontinued.Rational.535= At this time, the only known treatment for tardive dyskinesia
is to discontinue the antipsychotic drug causing the symptoms.Antiparkinsonian medications are not effective in treating tardive dyskinesia
(1). Increasing the dosage may mask symptoms initially, but they willreemerge
Question.536= A patient who is taking an antipsychotic drug complains ofbeginning symptoms of dystonia. The nurse`s action is to
Answer2.536= Obtain an order for benztropine mesylate (Cogentin).Rational.536= Dystonia requires immediate treatment. It is easily treated
with an antiparkinsonian drug, such as Cogentin.
Question.537= A female patient is started on chlorpromazine (Thorazine)therapy. The patient has received instructions regarding the drug`s side
effects. Which of these comments by the patient indicates that sheunderstood the instructions?
Rational.537= Photosensitivity may occur with Thorazine therapy stayingout of the sun and wearing protective clothing are the best ways to deal withthis problem. Thorazine does not decrease the desire for sex. It may causeimpotence in men, or irregular menses (1). Weight gain is a common side
effect of chlorpromazine (2). Sedation is a common side effect ofchlorpromazine (4).
Question.547= A therapeutic nursing strategy to assist parents whose infanthas just died is to
Rational.547= Alerting all personnel to a patient`s condition can helpminimize pain related to thoughtless remarks. A symbol or a flower placedon the patient`s door alerts other staff to the special needs of the grieving.Parents often feel isolated and health care personnel tend to avoid these
parents due to feelings of awkwardness (1). Health care personnel do notneed to express sadness, only sensitivity to the parents` loss
Question.548= A patient is admitted to the labor and delivery unit in activelabor. She gives birth to a 37-week stillborn baby. Immediately following
the birth, the patient accuses the physician of "making a mistake" and"making a sick joke." She requests the nurse to bring her baby to her
because she can hear him crying. The nurse`s best action is to
Rational.548= Actually seeing and holding the dead infant may help withthe grieving process.
Ask her if she wants to hold the baby
Question.552= Which of the following statements would the nurse use whentrying to get the demented patient, who is angrily arguing about where he is,
to come to dinner?Answer4.552= "You may not want to eat now, but it is dinnertime."
Question.554= When working with a depressed patient, the nurse shouldfocus the initial nurse-patient contacts on
Rational.554= Establishing trust is essential to assist a person withdepression.
Question.560= The rationale for using antipsychotic drugs withschizophrenia is to relieve
Rational.560= Antipsychotic medications work directly to stophallucinations in a schizophrenic patient and are also helpful in eliminating
or minimizing paranoid ideation.
Question.561= A 20-year-old patient on a psychiatric unit tells the nurse,"You are the only one who listens to me. The other nurses on this unit hate
me." This person is attempting to create
Answer3.561= Splitting of the staff.Rational.561= The patient who expresses this is usually trying to manipulatethe nurse in a manner that will put one staff member up against another. The
patient is not attempting to create a fantasy world (1). The patient may betrying to create disorder and confusion, but it is accomplished through
splittinging
When talking with a suicidal patient, it is important to establish does he have a plan
Question.566= A 45-year-old woman is demanding of everyone and showsno concern for anyone but herself. Erickson would note that her stage of
development isAnswer3.566= Generativity versus stagnation.
Question.567= Which of the following interventions is most appropriatewhen one is working with the aggressive, agitated person?
Rational.567= The highest priority of nursing diagnoses for the patient whois agitated and acting aggressively is high risk for injury to self and others.
By creating a calm environment, the patient is provided with the opportunityto regain control. The patient is not violent at this time, so calling in extra
staff isn`t appropriate and may exacerbate the situation (1). Setting limits isappropriate as it helps the patient regain control, but a more important
priority is to remove persons at risk for injury
Question.568= When teaching a patient who is taking lithium to treat abipolar disorder, the nurse would note that a way to prevent lithium toxicity
is to
Rational.568= Lithium is excreted by the kidneys, and increased intake willensure more efficient excretion. Exercise and hygiene aren`t methods to
prevent lithium toxicity
Question.571= An African-American mother asks how to assess forjaundice in her new baby. Which of the following is the MOST appropriate
answer for the nurse to offer?
Rational.571= Jaundice usually begins in the head and moves down thebody and can be detected by blanching the neonate`s nose, palms of the
hands, or soles of the feet. The sclera of the eyes will also be yellow tinted.Neonates of dark skin or olive complexion may appear to be jaundiced when
in actuality they are not.
Question.577= Which of the following assessment findings on a 34 weekgestation infant who is 4 days old would it be a priority to preport to the
physician?
Answer2.577= Distended abdomen.Rational.577= Preterm infants are at risk for necrotizing enterocolitis
(NEC), a condition with 50% mortality. Assessment of increasingabdominal distention or absent bowel sounds, vomiting, blood in the stools,
and signs of infection are vital to report. Treatment includes antibiotics,discontinuation of oral feeding, administration of parenteral nutrition, and
possibly surgery.
Question.579= Which of the following comments by a patient withpregnancy-induced hypertension should alert the nurse to potential
problems?
Rational.579= Preeclampsia may progress to eclampsia, the severe phase ofPIH. In severe cases, patients may experience frontal or occipital headache
that is not relieved by analgesics.
Question.580= As part of the assessment of a patient suspected to havepregnancy-induced hypertension (PIH), the nurse will
Rational.580= Brisk deep tendon reflexes may suggest cerebral irritabilitysecondary to decreased circulation and edema associated with preeclampsia.
Question.581= A patient with preeclampsia complains of epigastric pain.The nursing intervention is to
Rational.581= A sign of impending eclampsia is right upper quadrant orepigastric pain. Early detection and management of preeclampsia are
associated with reducing risks and progression of this condition.
Question.584= During an infant tube feeding the best position for the infantis to
Rational.584= Parents should be encouraged to hold the infant during tubefeedings. If regurgitation has been a problem, the infant may be positioned
on his right side.
Question.586= A postpartal patient is complaining of shortness of breathand chest pain, and exhibiting tachypnea and tachycardia. The priority
nursing intervention is to
Rational.586= Deep vein thrombasis (DVT) and pulmonary embolism arepossible complications occurring in the postpartal period. Signs andsymptoms of pulmonary embolism include sudden, sharp chest pain,
syncope, tachycardia, rales, and tachypnea. Treatment depends upon rapidassessment and notification of the physician of the patient status.
Question.590= A newly married couple have decided to practice naturalfamily planning. They ask the nurse about the Billings method. The nurse
explains that the Billings method is performed by
Rational.590= The Billings method, also called the cervical mucus methodor the ovulation method, depends on the characteristic changes in the
cervical mucus at the time of ovulation.
Question.591= When teaching patients about improving their chances forfertilization, which of the following time periods should be highlighted
postovulation?
Rational.591= The total critical time for fertilization is 24 to 48 hours, 12 to24 hours before ovulation and 12 to 24 hours after ovulation.
Question.592= The nurse is teaching the expectant mother how theproduction of progesterone and estrogen prepare the uterus for implantation
of the fertilized ovum. Which pituitary hormone would the nurseemphasize?
Rational.592= LH is released by the anterior pituitary, stimulating ovulationand the development of the corpus luteum, preparing the endometrium for
implantation.
Question.594= Betamethasone is ordered and given to a patient diagnosedwith preterm labor at 34 weeks. In evaluating the effects of this medication,
the nurse would note that it is given to
Rational.594= Betamethasone may be given to the mother to hasten fetalmaturity by stimulating development of lecithin when membranes are
ruptured and premature labor cannot be arrested. The incidence and severityof respiratory distress syndrome has been found to be reduced if
glucocorticoids (e.g., betamethasone) are administered to the mother at least24 to 48 hours before birth."
Question.601= When performing a physical exam on a newborn infant, thenurse notes a circular swelling with bluish discoloration around the top of
the baby`s head. This is recorded as
Rational.601= Caput succedaneum is a generalized, easily identifiableedematous area of the scalp.
Question.605= When instructing a pregnant patient about average weightgain, the nurse would reinforce that the ideal weight gain during pregnancy
isAnswer4.605= 25 to 35 pounds.
Question.607= Assessing a newly admitted patient to the ER, an early signof shock would be a
Rational.607= A rise in the pulse rate is one of the earliest signs of shock. Ablood pressure of 110/70 and a respiratory rate of 24 are normal and do not
reflect shock (2) (3). The temperature of 101degree F is not associateddirectly with a sign of shock but may indicate many other problems (4).
Question.611= When teaching a patient the proper use of a walker, the nursewould direct the patient to
Rational.611= The walker should be advanced 6 inches (15 cm) in front ofthe patient before the patient moves toward it. Picking the walker up andonly using it periodically would negate the purpose of the walker (2). The
patient should be taught to advance the weaker leg first (3). The arms shouldbe slightly flexed at a 30-degree angle at the elbow. A 90-degree flexion is
unsafe and makes the walker too high for the patient (4).
Question.613= Assuming a normal meal schedule, the patient who takesisophane insulin suspension (NPH) SC at 6 AM is most likely to
demonstrate symptoms of hypoglycemia at
Rational.613= This intermediate-acting insulin has a peak action of 6 to 12hours. If the patient is given this product at 6 AM, the window for a reactionwould be highest between 12 PM and 6 PM. Seven AM is too short a time
period for intermediate insulin (1). Nine AM would be more consistent withthe peak effects of regular insulin (
Question.614= An order reads "Infuse 1000 mL D5W over 10 hours." Thenurse knows that the drop factor is 15gtt/mL. You would infuse
________________________drops per minute.
Rational.614=The answer is 25 drops per minute. To determine the drip rate,first note that 1000 mL administered over 10 hours equals 100 mL per hour.15 gtt/mL x 100 mL = 1500 gtt per hour. 1500 gtt/hour divided by 60 min =
25 gtt/min.
Question.616= A male patient is being treated for ruptured esophagealvarices with a Sengstaken-Blakemore tube. His vital signs have been stable
and the suction port is draining scant amounts of drainage. He suddenlybecomes acutely dyspneic and oximetry reveals an O2 sat of 74%. The
nurse`s immediate action is to
Rational.616= Sudden dyspnea and poor oxygen saturation may be signsthat the esophageal balloon has slipped. If this is the case, the esophagealballoon should be cut immediately, as it is occluding the patient`s airway.
Releasing the gastric balloon will not improve airway function in the personwho is experiencing airway obstruction as a result of movement of the
inflated esphageal balloon (2). Increasing suction or irrigating the gastricballoon will not improve the airway function in the person who is
experiencing airway obstruction as a result of movement of the inflatedesophageal balloon
Question.621= Following the application of skeletal traction, a patientcomplains of "the traction pulling too much." The nurse`s response is to
Rational.621= Continuous or intermittent traction is maintained asprescribed. The patient may realign herself, but the weights must remain inplace. Never lift or remove the weights to care for the patient or to assist the
patient in moving up in bed (2). Caution the patient`s family not to lift orremove the weights. Administering analgesics is appropriate, but the nurse
should assist the patient to realign her body first (3). Do not remove anyweights when caring for a patient in skeletal traction
Question.623= A patient with a fractured tibia is being evaluated in theorthopedic clinic for possible compartmental syndrome. If the patient were
experiencing this complication, she would be likely to complain of
Rational.623= The signs and symptoms of compartment syndrome includepain, pallor, pulselessness, paresthesia, and paralysis.
Question.624= A postoperative patient returns from the PACU with twochest tubes inserted in his right chest. The upper chest tube serves the
purpose of
Rational.624= An upper chest tube is used to remove air. Two chest tubesmay be inserted on one side: an anterior-superior tube for the removal of air,
and a posterior-inferior tube for removal of fluid. The lower chest tube isinserted to remove fluid which may possibly have some clots (1). No chest
tube will prevent clots (2). Milking a chest tube (this procedure is notallowed in many facilities) helps to facilitate patency of the tube, but tube
placement doesn`t facilitate "milking" (4).
Question.626= A nurse is caring for a patient who has a tracheostomy tubeand requires frequent suctioning. When performing tracheal suctioning, the
nurse should limit the procedure to periods ofAnswer4.626= 5 to 10 seconds.
Question.627= The nurse is reviewing with the staff a care plan for a patientwith myasthenia gravis. She explains that the main objective of therapy for a
patient with myasthenia gravis is to
Rational.627= Medical management of the patient with myasthenia gravis isprimarily accomplished by giving anticholinesterase medication to maintain
an effective balance of acetylcholine and cholinesterase at theneuromuscular junction. Stimulating synaptic terminals to produce ACTH orgiving ACTH are not effective treatments (1) (4). Supportive care would be
inadequate, because medication is available to treat this condition (2).
Question.631= After consultation with the physician, a 71-year-old femaleis weaned from mechanical ventilation. After the weaning trial has been inprogress for an hour, the patient`s ABGs and vital signs are blood pressure
140/78, pulse 94 (sinus tachycardia), respiratory rate 22, Sp0 withsubscript((2)) .98, pH 7.23, Pa0 with subscript((2)) 91, PaCo withsubscript((2)) 59, HCO with subscript((3)) 24. Based on the above
information, the nurse interprets the ABGs as indicating
Rational.631= Respiratory acidosis is present when the pH is decreased andthe PaCO with subscript((2)) is increased. No compensation is present
because the kidney hasn`t started to retain HCO with subscript((3)). Thenormal HCO with subscript((3)) does not indicate a compensatory
mechanism (1). Acidosis is present, but not compensatory alkalosis oruncompensated alkalosis (2) (4).
Question.632= A patient receiving radiation therapy complains about thedark black marking placed on her skin. What is the most appropriate
comment by the nurse regarding these markings?
Rational.632= Skin markings are used as a marker for treatment areas andshould not be washed away. They are not permanent or caused by the
radiation
Question.635= A patient with a pituitary tumor is transferred to a surgicalfloor after having a transphenoidal hypophsectomy. The nurse caring for this
patient is aware that which of the following procedures would becontraindicated in the immediate postoperative period?
Rational.635= Frequent mouth care should be given, but the teeth are not tobe brushed, because this may damage the gingival suture line. Advancing
the diet as tolerated, observing for signs of meningitis, and maintaining thebed at a 30-degree angle are appropriate interventions.
Question.637= The nurse is caring for a patient who is admitted forAddisonian crisis. Which of the following symptoms would the nurse expect
the patient to exhibit?
Rational.637= The patient experiencing an Addisonian crisis experiencesthe extremes of hypotension, hyponatremia, dehydration, and hyperkalemia.The other options are not clinical manifestations of a sudden life-threatening
Addisonian crisis.
Question.638= A common complication resulting from bacterial meningitisis
Rational.638= Most complications from meningitis involve damage to thecranial nerves. The most common complication is hearing loss.
Question.641= In children, staring, inattentiveness, or daydreaming may besigns of
Rational.641= Absence seizures result in brief loss of consciousness. Theyare usually very brief (5 to 10 seconds) and do not include the dramaticsymptoms (e.g., falling, rigidity, pallor) characteristic of tonic-clonic
seizures.
Question.647= To decrease neurologic sequelae, children with spinal cordinjuries that result in motor deficits are given
Rational.647= Methylprednisolone is administered in high doses. The drugmust be started within 8 hours of the injury to achieve maximum
anti-inflammatory effect.
Question.648= Digoxin overdose is more common when the child`sRational.648= Digoxin overdose is more common when serum potassium
levels are low. Many children with heart disease receive diuretics that causepotassium to be excreted in higher amounts.
Question.649= Children with Kawasaki may disease often receive aspirinprimarily for
Rational.649= Children with Kawasaki disease develop thrombocytosis,which places them at risk of thromboembolism. Aspirin is given until the
platelet count returns to normal.
Question.651= Recombinant human deoxyribonulease (rhDNase) is anaerosolized medication administered to children with cystic fibrosis for the
purpose of
Rational.651= This medication helps to thin and liquify tenacious mucus inthe bronchioles and maintain airway patency.
Question.654= The nurse checks the young patient in Bryant`s traction.Proper body alignment is being maintained if the legs are perpendicular to
the trunk and the buttocks are
Rational.654= To maintain the prescribed balance of pull andcountertraction in Bryant`s traction, the child`s buttocks must not be allowed
to rest on the mattress. The angle of the hips should be 90 degrees.
Question.658= A characteristic lesion that occurs in children with measles(rubeola) is
Rational.658= Koplik spots appear in the mouth about 2 days before andafter onset of the rash. They are small, irregular, bluish-white spots on a red
background.
Question.661= Which of the following abnormalities is a sex chromosomedefect?
Rational.661= Klinefelter syndrome is the most common of all sexchromosome abnormalities occurring in about 1 in 800 - 1000 live malebirths. It is caused by the presence of one or more extra X chromosomes.
Question.664= When administering IV medications to children, it isrecommended that IV tubing be flushed after an infusion because
Rational.664= A significant amount of the medication may still remain inthe distal tubing. For example, if the tubing held 15 mL and the medicationwere mixed in 30 mL of IV fluid, 50% of the medication would remain in
the tubing if not flushed through.
Question.667= Giving an infant formula that is mixed with too little watercan cause
Rational.667= Improper mixing of the formula introduces a high soluteintake without adequate water, which is a cause of hypernatremia.
Question.670= Neonates are at higher risk than are older children for loss offluid in the urine because
Rational.670= Neonates have a limited ability to concentrate or dilute urinethus they are unable to conserve or excrete fluid in response to fluid shifts.
Question.678= A 37-year-old G VII, P VI gave birth in the LDRP room onehour ago. She was straight catheterized for 950 mL of clear yellow urine
prior to birth. Her labor lasted 8 hours. Since birth, her vital signs have beenstable, fundus firm and 1 cm above the umbilicus with moderate, bright, redvaginal bleeding. Which of the following factors would the nurse assess for
because it would predispose the patient to pospartum hemorrhage?
Rational.678= Postpartum hemorrage is defined as blood loss of 500 mL ormore after birth. Risk factors for early postpartum hemorrhage include
uterine atony, trauma, and lacerations. Grand multiparity (5 or more births)is a predisposing factor for uterine atony as well as previous uterine atony,overdistention of the uterus, and precipitous labor. Postpartum hemorrhage
may also occur later, or 24 hours after birth.
Question.682= A patient requests information about the cause ofmegaloblastic anemia during pregnancy. The nurse should respond
Rational.682= During pregnancy, increased maternal red blood cellproduction and fetal demands can result in folic acid or folacin deficiency.
Folic acid is a co-enzyme necessary for the synthesis of nucleic acids.Nucleic acid and nucleoprotein synthesis are required for the production of
red blood cells.
Question.683= The nurse obtains the following assessment data for afemale, 12 weeks pregnant with her third child: P = 112 (resting), R = 20, T= 99degreeF, profuse sweating, pronounced palmar erythema. Based on this
data, the nurse could anticipate the physician ordering a
Rational.683= Symptoms of hyperthyroidism indicate the need for furtherdiagnostic assessment. These symptoms include tachycardia, weakness,
increased appetite, heat intolerance, sweating, enlarged thyroid,exophthalmos, nervousness, weight loss, and the tremors. She may also
exhibit pronounced palmar erythema and resting pulse rate greater than 100beats per minute.
Question.687= A patient receiving thyroid medication for hypothyroidismasks the nurse whether she can breast-feed. The nurse should respond
Rational.687= A woman receiving thyroid replacement therapy can stillbreast-feed, as only minimal amounts of thyroid hormone are passed to the
infant through the breast milk.
Question.688= A patient is scheduled for a culdocentesis. The nurseexplains that the test
Rational.688= Culdocentesis may be used to confirm ectopic pregnancy,especially when ultrasound is not available. The physician inserts a needle
through the posterior wall into the cul-de-sac and aspirates fluid. Aspirationof nonclotting blood may indicate a ruptured ectopic pregnancy.
Question.691= A new mother asks if amniocentesis can help detect a fetuswith spina bifida (myelomeningocele). The nurse should respond that yes,during the fourth month, assessment of the amniotic fluid would indicate a
nervous system defect if
Rational.691= Between the 14th and 16th weeks of pregnancy, abnormallyhigh levels of a-fetoprotein in the amniotic fluid indicate a neural tube
defect. Although the extent of the defect cannot be determined, anamniocentesis should be performed before the 18th week because, after thistime, a-fetoprotein levels decrease. In addition, there would still be time for
an induced abortion.
Question.692= The nurse assessing a newborn, initiates the Moro reflex by
Rational.692= The Moro, or startle, reflex indicates the newborn`s sense ofbalance. A sudden stimulus such as jarring the infant or making a loud noise
should elicit the reflex. The baby should be lying quietly in the supineposition to provide the best response. Gentle handling of the infant and the
crib will not elicit the reflex.
Question.693= After his arrival from the delivery room, the infant`s initialtemperature is 36degreeC (96.8degreeF). Nursing interventions should
include recording the temperature, dressing and wrapping him, and thenplacing him in a (an)
Rational.693= Immediately after birth the baby`s temperature is the same orslightly higher than the mother`s. Because he is wet, suddenly exposed to a
dry, cool environment, and has a large body surface for weight, he loses heatvia evaporation, conduction, convection, and radiation. His immature
hypothalamus cannot initiate mechanisms such as shivering to raise his bodytemperature. Placing him in a heated crib under a radiant warmer shouldraise his body temperature to 36.6degreeC (97.8degreeF) in 2 - 4 hours.
Question.694= A baby is suspected to have brachial plexus paralysis of theleft arm. Which observation would the nurse make during the newborn
assessment to confirm the diagnosis?
Rational.694= A normal tonic neck reflex should reveal that when the headis turned to one side, the arm on the same side is adducted and extended in afencing position. The infant with brachial plexus palsy has flaccid paralysis
of the affected arm, which does not extend when the tonic neck reflex iselicted. Brachial plexus is not a congenital defect, so the affected arm is not
longer, but may appear that way because of the limpness in that arm (1).There is no resistance of the arm when adducted (3). When the infant has
limited use of the affected arm or asymmetric Moro reflex, a fracturedclavicle is suspected (4).
Question.695= When the nurse elicits a baby Moro reflex, his arms and legsadduct and extend simultaneously. His arms then adduct in an embracingposition, and his legs flex with his soles turned inward as he starts to cry.
The nursing intervention is to
Rational.695= A normal Moro reflex should be symmetrical and complete.An incomplete or absent Moro reflex indicates brain trauma. An
asymmetrical reflex reveals a muscle or peripheral nerve injury, as inErb-Duchenne paralysis. The response was symmetrical and complete (1).
The response was normal, not hyperactive (3). Since the response wassymmetrical, no weakness or paralysis is suggested (4).
Question.698= A 6-year-old child is admitted with a diagnosis of asthma.An early sign of respiratory distress would be
Rational.698= An increased pulse rate indicates respiratory distress and adecrease in the oxygen content of the blood.
Question.700= A young child has a diagnosis of nephrosis. Which of thefollowing medications would the nurse plan to discuss with his parents?
Rational.700= The use of glucocorticoids has been found to have atherapeutic value in treating nephrosis.
Question.702= The clinic nurse is teaching the parents of a newborn aboutthe immunization schedule they will follow. The immunizations that should
be started after the first birthday or at 15 months are
Rational.702= The MMR is recommended to be given at 15 months. Thepresence of the maternal antibody to measles in the infant`s blood is
sufficiently reduced by 12 months, so the vaccine is effective if given afterthe first birthday.
Question.706= When monitoring a 10-year-old child who has undergone acardiac catheterization, which of the following signs would have the highest
priority for continued monitoring?
Rational.706= Cardiac catheterization is a diagnostic procedure but notwithout risks, one of which is transient arrhythmias.
Question.709= A young patient with cyanotic heart disease would presentwith
Rational.709= The child with a cyanotic heart defect is more likely to havefrequent respiratory infections because of lowered resistance and poor
cardiac function.
Question.710= The nursing priority when caring for a child in the earlyphase of Guillain-Barre syndrome is
Rational.710= Guillain-Barre syndrome results in muscle weakness thatbegins in the legs and spreads to the trunk, chest, neck, face, and head. The
child may experience weakness of the respiratory muscles, resulting ininadequate ventilation that may necessitate intubation and mechanical
ventilation.
Question.713= Follow-up evaluation of children who have recovered frommeningitis is important because they
Rational.713= The child is at risk of developing complications frommeningitis. The more common sequelae include hearing loss, attention
deficits, seizures, developmental delay, and septic arthritis.
Question.725= Because drug therapy is often not successful, the treatmentof choice for children with aplastic anemia is
Rational.725= Aplastic anemia results from the failure of the bone marrowto produce adequate numbers of blood cells. A bone marrow transplant from
a compatible sibling or family member donor is the treatment of choice.
Question.729= Discharge instructions for a child who has had rheumaticfever need to emphasize compliance with
Rational.729= On discharge, a daily low-dose antibiotic is prescribed or amonthly long-acting antibiotic injection is given. This prophylactic
treatment may be indefinite, and the family must understand the importanceof preventing future strep infections, and that heart damage can result from
recurrent rheumatic fever.
Question.731= A child with thalassemia minor or thalassemia trait wouldexhibit which of the following symptoms?
Rational.731= Thalassemia minor or thalassemia trait produces a mildmicrocytic anemia.
Question.732= Which of the following locations would place a child withsickle cell anemia at greatest risk for a sickle cell crisis?
Rational.732= Hypoxia resulting from general anesthesia is a major surgicalrisk. Sickle cell crisis could begin during surgery, placing this patient at highrisk. Special precautions must be taken before any surgery. Therefore, it isnecessary that children with sickle cell anemia be appropriately identified
prior to surgery.
Question.742= An infant is 2 months old and had repair to a cleft lip 10hours ago. He is now crying. The most important nursing intervention would
be to
Rational.742= Crying increases tension on the suture line. The nurse shouldanticipate the infant`s needs and provide immediate comfort by having his
mother hold him.
Question.747= A safety precaution when caring for a child with atracheostomy is to
Rational.747= A clean tube of the same size should be immediately readyfor insertion in case the tracheostomy tube should fall out. A second tube of
the next smaller size should also be available in case there is difficultyinserting the same-size tube.
Question.748= A child with cystic fibrosis is at risk for a deficiency inwhich vitamins?
Rational.748= Vitamins A and D are fat soluble. A child with cystic fibrosismay have difficulty digesting fats - so these vitamins will not be assimilated
- because of the absence of pancreatic enzymes. Children are given watersoluble forms of vitamins A, D, E, and K.
Question.750= To determine unresponsiveness in an infant, the nursingaction is to
Rational.750= Unresponsiveness is determined by gently tapping the infantand speaking loudly enough to get a response.
Question.751= Infants develop bronchopulmonary dysplasia as a result ofhigh pressure vent
Rational.751= Bronchopulmonary dysplasia is a condition that results fromthe treatment given to infants with severe respiratory problems.
Question.755= The young patient has just been admitted for evaluation. Thenurse reports that the physical assessment reveals a finding that may indicate
coarctation of the aorta, which is
Rational.755= Coarctation is a narrowing that occurs in the descendingaorta. Blood flow to the legs is decreased, and flow to the arms and head isincreased. The femoral pulses are weak, and the radial pulses are full. The
blood pressure is higher in the arms, lower in the legs.
Question.756= The pediatric nurse is teaching inservice to a new RN staffmember. She knows the RN understands accepted skill procedures when she
says the dorsogluteal muscle can be used for injections for children at theage of
Rational.756= The dorsogluteal muscle develops with walking and shouldnot be used for injections until the child has been walking at least 1 year.
However, because these muscles are poorly developed, they are not the idealchoice for a child younger than 5 years old.
Question.757= A child with cerebral palsy needs a diet
Rational.757= The child with cerebral palsy requires a high-calorie dietbecause of increased muscle activity and feeding problems. Many children
with cerebral palsy have difficulty chewing and swallowing. Offeringhigh-calorie soft foods in small frequent feedings is often helpful.
Question.758= A child has been diagnosed with pulmonary stenosis. Thenurse is teaching the parents about their child`s diagnosis and tells them that
Pulmonic stenosis causes
Rational.758= Stenosis (narrowing) of the pulmonary artery valve makes itmore difficult for blood to enter the pulmonary artery, causing increased
pressure within the right ventricle. This leads to right ventricularhypertrophy, because the ventricle must pump harder to move the blood into
the artery.
r ventricle affected
Question.760= An infant has been diagnosed with patent ductus arteriosus.The nurse teaches the parents that symptoms resulting from this condition
are directly related to the
Rational.760= After birth, blood in the aorta is under higher pressure,causing blood to flow through the ductus into the pulmonary artery. This
extra blood entering the pulmonary system can lead to increased pulmonaryvascular congestion.
Question.768= The needle size that the nurse would use to give anintramuscular (IM) injection to a newborn is a
Rational.768= You would use a thin (25-gauge), short (0.5-inch) needle forgiving an IM injection to a newborn.
Question.786= Which of the following data place a patient at risk fordeveloping pregnancy-induced hypertension (PIH)?
Rational.786= Primigravid women or women pregnant for the first timeafter an abortion are more susceptible to PIH than are multiparous women.
Question.789= A patient with hyperemesis gravidarum is at risk for having a(an)
Answer1.789= Infant who is growth retarded.
Question.792= The nurse should assess the small-for-gestational-age (SGA)neonate for
Rational.792= Small-for-gestational age neonates frequently develophypoglycemia because of low glycogen stores.
Question.798= A male patient is being treated for exacerbation of hischronic obstructive pulmonary disease (COPD). Oxygen would be
administered at 2 liters via nasal cannula because
Rational.798= Precise amounts of oxygen delivered to COPD patients iscritical and depends on the hypoxic drive of the patient. Too much oxygencan depress respirations and cause hypoventilation. The size of the lungs isnot directly related to the hypoxic drive (1). The opposite would occur in
this patient if given high concentrations of oxygen (2). The statement abouthis lungs and chest diamter is true, but does not explain why he responds to
hypoxia (3).
Question.799= Which of the following interventions would the nurse plan todo for the patient demonstrating symptoms of Addisonian crisis?
Rational.799= Addisonian crisis is a life-threatening complication ofAddison`s disease (hypocorticism). Cortisone replacement can be
life-saving. The patient is likely to be severly dehydrated and hypovolemic.IV saline will be run rapidly in bolus amounts (
Question.804= Several days following surgery to remove a thyroid tumor, afemale patient begins to complain of muscle twitching in her legs. The most
likely cause of this is
Rational.804= Accidental parathyroidectomy after removal of the thyroidgland results in a hypocalcemic condition manifested by GI complaints
(vomiting and diarrhea), convulsions, and tetany.
Question.807= While walking with a 79-year-old dementia patient, thenurse shows him a car key. She asks the patient to name the object, but he is
unable to. This inability to describe the key is known as
Rational.807= The failure to recognize previously known objects is calledagnosia. This condition can be seen in several types of nervous system
disorders such as Alzheimer`s dementia and cerebral vascular accidents.Apraxia is the inability to carry out a series of actions (1). Aphasia is adisorder in communication (2). Agraphia is the inability to write (3).
Question.811= Which of the following tests would the nurse employ whenevaluating the hearing of a patient?
Rational.811= The Weber test is conducted by using a tuning fork tomeasure whether the patient is able to hear sound conducted to both ears. Ifthere are conductive or sensorineural losses, it will lateralize to one of theears. The Trendelenburg test is used to check vascular competency in the
lower leg (1). The Snellen test determines vision (3). The Allen test assessesfor radial and ulnar patency at the level of the wrist (4).
Question.816= A patient with carcinoma of the thyroid suddenly developssymptoms of pheochromocytoma. Which of the following symptoms would
the nurse consider a top priority when planning nursing interventions?
Rational.816= Severe, life-threatening hypertension can result from excesscatecholamine secretion.
Question.817= The nurse is caring for a patient with aldosteronism. Thenurse should anticipate which of the following symptoms?
Rational.817= Hypertension and hypokalemia are common signs ofaldosteronism.
Question.831= The nurse is preparing to administer a blood transfusion inthe emergency room. After ordering the blood, the nurse`s first action would
be to
Rational.831= The patient and the family should be supported prior to andduring the procedure, and anxieties should be allayed by the nurse.
Rechecking the order and reviewing the typing and crossmatching are doneby two nurses as part of the pretransfusion checklist (1) (3). It is seldom
necessary to contact the laboratory, because information on the blood baglabel is sufficient to determine that the lab sent the proper unit (4).
Question.836= The patient who has had an MI hopes to resume sexualintercourse with his partner. The nurse determines that the patient
understands the instructions given for resuming sexual intercourse ondischarge from the hospital when he says he will
Rational.836= The strain on the recovering heart should be avoided. After aheavy meal, blood flow is diverted to the GI tract. Increased workload
increases the risk of underperfusion of the coronary arteries. The patientshould lie on his or her back while the partner kneels to take some of the
weight from the patient (1). Answer (2) is not an appropriaterecommendation for this patient. The patient recovering from an MI without
complications may usually resume sexual activity in about 5 to 8 weeks.One index of readiness is the ability to walk up two flights of stairs without
becoming dyspneic (4).
Question.837= While developing a care plan for a patient receivingintermittent pelvic traction (to relieve lower back pain due to sciatica), the
nurse would include
Rational.837= Pelvic traction is skin traction that can be manipulated by thepatient. It can be intermittent and the patient may not require it, except
during specific times. The patient`s pelvis should partially rest on the bedfor support (2). The patient`s knees should be slightly bent to relieve
pressure on the lower back (3). Pelvic traction does not involve pins insertedinto any extremity, as is the case in skeletal traction (4).
Question.838= A 45-year-old male patient comes to the clinic forevaluation. He is receiving continuous ambulatory peritoneal dialysis. Forthe past three cycles, he has retained between 250 and 400 mL with each
cycle. He has no urine output and has not moved his bowels in 3 days. Theeffluent is clear. The nurse should
Rational.838= The physician should be notified When the CAPD patient hasa retention of more than 250 mL of fluid, as glucose absorption may become
a problem. The physician should also be notified if the outflow is 500 mLgreater than the amount that was instilled. Dialysate solution concentrationsshould not be changed without a physician`s order (1). The patient may be
constipated, but the overall priority at this time should be to notify thephysician (3). The next cycle should not be started until after discussing this
problem with the patient`s physician (4).
Question.842= An elderly patient is being transferred to the rehabilitationunit. The nurse explains that the focus of his care will be "tertiary
prevention," or
Rational.842= Tertiary prevention care includes restorative andrehabilitation activities to obtain optimal level of functioning. Screenings
and saftey education are examples of primary prevention. Illness care, suchas first aid, is an example of secondary prevention.
Question.847= A 45-year-old female patient refuses to get out of bed andresists the nurse`s attempts to assist her to sit up in a chair. If the nurse
attempts to remove the patient from her bed without the patient`s approval,the nurse could be charged with
Rational.847= Battery is defined as the offensive touching of the body of anindividual. It is not necessary to have caused harm. Assault is to place
someone in fear of harm. Negligence is conduct that falls below the standardof practice. A tort is a civil wrongdoing.
Question.851= Which of the following disorders would the nurse classify asa disease that is spread through fomite transmission?
Rational.851= Formites are nonliving objects that transmit infection.Examples include the spread of ringworm of the scalp via contaminatedcombs, hats, or the upper back portion of bus seats. Tuberculosis is an
organism spread through airborne droplets. Lyme disease and RockMountain spotted fever are spread through infected ticks.
Question.857= Screening for elevated blood lipid levels is an example ofwhat level of prevention?
Rational.857= Early diagnosis and prompt treatment are part of secondaryprevention. Primary prevention is aimed at health promotion and protectionagainst illness. Tertiary prevention is aimed at rehabilitation and return of
the patient to maximum level of functioning.
Question.859= Conducting a diabetes screening clinic for well adults is anexample of
Rational.859= Secondary prevention includes screening techniques andtreatment of early stages of disease.
Question.863= The method most likely to be used to reduce the heart rate ina child experiencing supraventricular tachycardia is to
Rational.863= Applying ice to face or iced saline solution to the face causesvagal stimulation that may reduce the heart rate. An older child can performthe Valsalba maneuver to increase intrathoracic and venous pressures, thus
slowing the heart rate. Other activities will not reduce the heart rate.
Question.865= When a child is diagnosed with cystic fibrosis, the news isoften met with disbelief by the parents because
Rational.865= Cystic fibrosis is an inherited autosomal recessive disorder,which means that both parents must carry the gene in order for a child to
have the disease. In past generations most children with cystic fibrosis diedvery young, often without ever having been diagnosed. Adults are often
unaware that they are carriers of this disorder.
Question.869= A 4-year-old child has had chronic otitis media. Parenteducation after myringotomy and insertion of tympanostomy tubes would
include
Rational.869= The tubes allow air and fluid to flow from the middle to theouter ear and also allow water to flow in the opposite direction. To avoidintroducing bacteria directly into the middle ear, the child should wear
earplugs when swimming because submerging or diving places the child atincreased risk for otitis media. Noise has no effect on tube placement and
tubes fall out spontaneously.
Question.871= Which of the following symptoms may be an indication ofrespiratory alkalosis in a young child?
Rational.871= Respiratory alkalosis leads to stimulation of the nervoussystem. The clinical signs include nervousness tingling in fingers, toes, and
around the mouth and tetany.
Question.876= In counseling the parents of a child with idiopathicthrombocytopenic purpura (ITP) who has not responded to steroids and
immunoglobulins, the nurse will reinforce the physician`s plan that the nexttreatment would be a
Rational.876= In ITP the platelets are destroyed faster than they areproduced by the bone marrow. The spleen is the organ that destroys theplatelets. Splenectomy is reserved for those patients in whom ITP haspersisted for 1 year or longer. Transfusions and transplantation are not
indicated in the treatment of ITP.
Question.877= To avoid risk of transmission of the humanimmunodeficiency virus (HIV), children with mild hemophilia are often
treated with
Rational.877= DDAVP is a synthetic drug that temporarily increases theactivity for factor VIII two- to threefold. The chance of HIV transmission iseliminated, because the drug is synthetic and thus contains no human blood
components. Factor VIII is not used to treat mild hemophilia andcryoprecipate is no longer recommended.
Question.883= A patient is being assessed for suicidal risk. Which of thesefactors in the patient`s history places the patient at risk for suicide?
Rational.883= Suicide tends to run in families. It may be that because onefamily member committed suicide, suicide can be viewed by other familymembers as an "appropriate" coping mechanism. The other answers do not
place a person at risk for suicide.
Question.885= The nurse and a patient who resides on a psychiatric unit arediscussing the idea of contracting. The patient has a history of violent
behavior. The nurse will know that the patient needs further instructionabout the concept of contracting if the patient makes which of these
statements?
Rational.885= Contracting is a system whereby the nurse, staff, and patienttogether decide how aggressive behavior will be handled.
Question.894= On the psychiatric unit, the nurse is talking to a patient whoconsistently claims that his food is being poisoned. The nurse should
recognize this symptom as
Rational.894= Delusions are fixed beliefs maintained despite experience andevidence to the contrary. Hallucinations are a distorted misrepresentation of
reality, channeled through the patient`s senses (2). Projection is puttingfeelings that are unacceptable to the self onto another person or object (3).
Dissociation describes the abrupt disengagement with the present and loss ofcontact with reality (4).
Question.895= A patient who has been diagnosed as having schizophrenia isreadmitted to the hospital. It is the patient`s third admission in 3 years. Thepatient`s mother says to the nurse, "I don`t understand what my son is doing
wrong. Every year he has to be hospitalized." It is appropriate for thenurse`s response to be based on which of these understandings?
Rational.895= Schizophrenia is a chronic disease and various factors maylead to intermittent hospitalization for acute exacerbation of symptoms.
These admissions should not be viewed as a treatment failure.Noncompliance would lead to repetitive and frequent hospitalization (2).
There is no way to predict the frequency of hospitalization (3). Reevaluatingtreatment options can be done in the outpatient setting as well as in the
hospital (4).
Question.901= A patient is diagnosed as having a schizoid personalitydisorder. The nurse can expect this patient to exhibit a pattern of
Rational.901= Schizoid personality disorder produces a pattern ofdetachment from social relationships and a restricted range of emotional
expression.
Question.903= When the nurse begins to give the patient a prescribedmedication, the patient says, "You`re poisoning me with those pills." Which
of these responses by the nurse is most appropriate?
Answer1.903= "I`ll get a fresh package of pills so you can see me open thesealed package."Rational.903= patients who are having delusions, such as
thinking that their medications are being poisoned, need to be given anappropriate degree of choice, e.g., seeing a closed medication packet andwatching the nurse open the packet. The paranoid thought process isn`t
clarified by attempts to explain or establish logic.
Question.905= A young woman patient on the psychiatric unit has afluctuating mental status. She can be calm and cooperative, and yet an hour
later be paranoid and combative. Her response to environmental stimuliranges from an appropriate response to fleeting illusions. The most
imperative nursing care need for the patient is to
Rational.905= Providing safety for the patient and staff is the primaryconcern on a hierarchy of needs. Encouraging fluid intake, maintaining skin
integrity, and providing reality orientation are less important needs.
Question.908= When the nurse suspects that an individual in crisis may behaving thoughts of suicide, the appropriate intervention is to
Rational.908= Asking directly about a suicide plan will help you determinethe degree of risk for the patient. Not asking, inquiring about moral beliefs,
and trying to persuade the patient that suicide is a poor choice are lesseffective measures.
Question.917= A 50-year-old Asian American woman was admitted to apsychiatric unit. She states that she does not know why she is on apsychiatric floor because she definitely is not crazy. In your initial
interview, you choose an unstructured format in order to
Rational.917= An unstructured format will help establish a trustingrelationship, something that must occur before she can begin to identify and
work on problems. Teaching about psychiatric units will occur after youobtain more information about the patient`s problems (2). Trying to
convince the patient she is in the right place will invalidate her perceptions(3). It`s important to focus on both verbal and and nonverbal behavior (4).
Question.918= As you walk onto a psychiatric unit, a 16-year-old adolescentyells at you, "You are like all the rest. You are full of !@#$!" The best
response to her would beAnswer3.918= "It sounds like you are upset."
Question.924= A young woman is admitted to an acute care psychiatric unitfor having attempted suicide. She is a recent graduate of a nursing programand is employed at a local hospital. You recognize that interaction with her
may be more complicated because she is a nurse. The most obviouspotential problem for you would be
Rational.924= Because the patient is also a nurse, identification may make itdifficult to maintain well-defined boundaries. Because the patient is also anurse does not relate to remaining objective (2). Confidentiality is an issue
with all patients (3). Your relationship with the patient should betherapeutic, not professional (4).
Question.928= The drug of choice for alcohol detoxification usually is
Rational.928= Benzodiazepines are commonly used to decrease the CNSirritability that occurs during alcohol withdrawal. Barbiturates are used forbenzodiazepine or sedative-hypnotic withdrawal (2). Antihistamines areused to combat sleeplessness (3). A neuroleptic would be given to treat
psychotic disorders (4).
Question.929= A patient on lithium believes salt is bad for people, so sheeliminates all sodium from her diet. In counseling her, the nurse should
Rational.929= Deficiency of sodium results in more lithium beingreabsorbed, thus increasing risk of toxicity.
Question.930= A male patient with the diagnosis of depression is given amonoamine oxidase (MAO) inhibitor. The nurse knows that MAO enzymes
destroy
Rational.930= Neurotransmitters are the targets of MAO inhibitors. Normaltransmission with a MAO is partially responsible for keeping synaptic levels
of the neurotransmitter low.
Question.931= A 38-year-old patient who has been diagnosed withschizophrenia comes to the nurse and states that his legs are moving like a
robot. The nurse understands this to be a sign of
Rational.931= Depersonalization is often associated with an alteredperception in which persons feel as if they are having an out-of-body
experience. They report robot-like movements and loss of sensations indifferent body parts. Delusional behavior is seen in examples of delusions of
grandeur ().
Question.932= An elderly gentleman is brought to in the clinic and states,"The radio is sending messages to the police that I am to be interrogated and
arrested." The nurse interprets this communication to be consistent with
Rational.932= Ideas of reference are defined by the patient`s belief thateverything happening around him is related to himself. Delusions of
grandeur represent an exaggerated belief of self-importance (2).Hallucinations are not a delusional experience (3). A disturbance in volition
represents an inability to initiate activities (4).
Question.939= Electroconvulsive therapy has been ordered for a patient,who has severe depression. What is the most important assessment to
complete before the procedure?
Rational.939= patients who are scheduled to undergo ECT should have acomplete history and physical examination to rule out any contraindicationsfor therapy. Diseases such as brain tumors, seizures, and trauma to the head
may be contraindications for ECT. A family history of unremittingdepression does not provide information that would contraindicate ECT (2).
A social history that includes lengthy bouts of sadness is not acontraindication of ECT (
Question.940= A patient is being maintained on lithium therapy for bipolardisorder. Her serum lithium level is 0.9 mEq/L. The nurse assesses this level
as
Rational.940= The therapeutic range for effective ongoing management ofthe patient on lithium carbonate can be as low as 0.6 mEq/L or as high as
1.5 mEq/L. A value of 0.9 mEq/L is within the therapeutic range for lithium.
Question.941= While caring for a 56-year-old patient, the nurse observes anewly developed slight tremor when he is at rest. The patient is taking
prescribed chlorpromazine (thorazine) as part of his management plan fortreating schizophrenia. Which of the following interventions would be most
appropriate?
Rational.941= The development of extrapyramidal symptoms is a side effectof this medication, and tremors are part of the constellation of symptoms.
Medications are frequently prescribed to counteract and relieve thesesymptoms. The patient has begun to develop symptoms of side effects. The
physician should be notified without waiting for other problems to occur (1).Reassurance that his is a normal response is not the correct action (3). The
patient has developed side effects, and it`s important to notify the physician.The nurse should not discontinue the medication without an order (4).
Question.947= Which of the following foods should the patient taking anMAO inhibitor such as isocarboxazid (Marplan) be taught to avoid?
Rational.947= When using this category of medications, the patient shouldbe cautioned against eating foods that contain tyramine. This includes manyfoods that have been fermented in some way, such as yogurt, aged cheese,sour cream, champagne, beer, pickled herring, shrimp, overripe bananas,
and yeast extracts. Spinach, haddock, and tomatoes do not contain tyramineand would not be contraindicated for the person taking an MAO inhibitor.
Question.1612= The intervention that would be contraindicated whenadministering oxygen to a patient with chronic obstructive pulmonary
disease (COPD) is
Rational.1612= Administering oxygen at 5 liters per minute is too muchoxygen for a person who has chronic lung disease. It will create respiratoryarrest potential because these people respond to a hypoxic drive. Oxygen
dries the mucous membranes so moisture to the nose is a comfort measureproperly done by the nurse. Since oxygen is a flammable gas, it is important
for staff and visitors to be aware that it is being used in the room they areentering.
Question.1608= When caring for a patient receiving a sitz bath, theintervention is to
Rational.1608= To maximize healing and relaxation, the sitz bath shouldlast from 10-20 minutes. Water temperature should be about 110 degrees F.
Sitz baths are usually done 3 or 4 times per day to provide cleansing andcomfort.
Question.1607= The causative agent of syphilis isRational.1607= The causative agent of syphilis is Treponema pallidum.Hemophilus ducreyi causes chancroid neisseria causes gonorrhea and
chlamydia trachomatis causes chlamydia.
Question.1603= A patient injects his or her regular insulin at 6 AM everymorning, has breakfast, and then jogs for three miles. This patient should be
taught to
Rational.1603= Exercise increases insulin utilization. The patient should beprepared to treat hypoglycemia as the action of onset of regular insulin is
from 30 minutes to 1 hour.
Question.1600= When administering neomycin sulfate as part of themanagement plan for a patient to prevent hepatic coma, the nurse recognizes
that this medication acts by
Rational.1600= Neomycin works locally on the bowel to decrease oreliminate the normal bacterial flora, which then decreases the amount ofammonia produced. The impaired liver may not be able to metabolize the
ammonia and hepatic failure may result.
Question.1598= Which of the following oxygen-delivery systems would thenurse use to provide the most accurate concentration of oxygen?
venturiRational.1598= This system can deliver oxygen in the 24% to 100% FIOwith subscript((2)) range with flow rates of 4 to 10 L/min. It is the most
accurate of the delivery systems mentioned.
Question.1596= A female patient is recovering from an exacerbation of herchronic bronchitis. Her sputum suddenly changes from a pale-green color toa rusty-brown color. Assessment of her lungs reveals bilateral crackles thatare scattered in both bases and do not clear upon coughing. This change in
sputum is most likely to represent
Pneumococcal pneumonia.
Question.1593= A sudden increase in pain in a patient admitted withduodenal ulcers may indicate that which condition is developing?
Rational.1593= Acute gastric perforation is characterized by sudden, sharp,intolerable pain. Bleeding or extending ulcers do not cause pain. A
pancreatic ulcer is not related to duodenal ulcers.
Question.1592= Cholinergic crisis in myasthenia gravis is due to
Rational.1592= Myasthenia gravis is medically managed with the use ofanticholinesterase medications (or cholinesterase inhibitors). The dose and
medication schedule should be the minimal amount needed to providemaximal improvement in the vital muscles of swallowing and breathing.Side effects of the drug, called cholinergic reactions, result from excess
acetylcholine.
Question.1591= The primary effects of sepsis include
Rational.1591= Sepsis is characterized by hypotension and altered tissueperfusion. Sepsis stems from toxins produced by microorganisms. Once the
organism enters the body, a set of complex humoral, cellular, andbiochemical mediators are released causing epithelial damage, peripheral
vasodilation, and increased capillary permeability. Secondarily, the patientwould become acidotic with decreasing pH and PaO with subscript((2))
levels, followed eventually by loss of consciousness.
Question.1590= A patient is admitted to the intensive care unit with signsand symptoms of ascending paralysis and respiratory failure. The critical
care nurse would investigate for a past history of
Rational.1590= The nurse would suspect Guillain-Barré syndrome, which isan acute, rapidly progressive inflammation and demyelination of nerve
endings of the peripheral nervous system that predominantly affects motorfuntion. Sensory and motor loss usually occur rapidly in an ascending order.
Current research reports that 60-70% of patients with Guillain-Barrésyndrome report a mild febrile illness, usually respiratory or gastrointestinal,1-3 weeks before onset of symptoms. Trauma to the head or spinal cord may
cause paralysis below the area of the injury.
Question.1589= The nurse is administering medications to a patient withacute myelocytic leukemia. One of her medications is allopurinol, and she
questions why she is receiving this. An appropriate nursing response wouldbe
Rational.1589= Chemotherapy may cause hyperuricemia due to rapid tumordestruction. Allopurinol is administered before and during therapy to break
down urates. This is standard treatment and is being done to preventsymptoms of gout.
Question.1588= A 54-year-old man comes to the clinic for evaluation of apainless lump that has been present on the side of his neck for the past 6weeks. Hodgkin`s disease, stage II, was subsequently diagnosed. He is to
begin radiation therapy and is questioning why "an x-ray can kill thiscancer." The nurse`s best response should be
Rational.1588= Therapeutic radiation uses ionizing forms of radiation thatmust produce cell death to be effective. This type of radiation uses
high-energy beams to treat malignant cells. It is not the same as x-rays.There are side effects associated with radiation therapy and the patient will
be informed about those.
Question.1587= A compensated respiratory acidosis would demonstratewhich two blood gas findings?
Rational.1587= The body compensates for respiratory acidosis by increasingthe HCO3 and the PaO2.
Question.1580= Following a gunshot wound to the abdomen, a 27-year-oldmale has a complete colectomy with creation of an ileostomy. Nursing
measures that will be necessary for the patient, considering the fact that thefunction of the large intestine has been eliminated, will include
Rational.1580= Complications following an ileostomy include fluid andelectrolyte imbalance therefore, accurate fluid intake and output recordsmust be maintained at all times. An intact stomach and small intestine
means that the patient does not need tube feedings, enzymes, or emulsifyingagents.
Question.1577= As the nurse is orienting a new nurse to the unit, and sheasks about treatment the patient is receiving for an infection. The new nursetells the nurse she remembers being taught that aminoglycosides (the patient
is receiving gentamicin) can cause renal failure. The patient has a normalurinary output and the following lab values: Na 142, K 4.6, Cl 103, HCO321, creatinine 3.2, BUN 54. She asks if this patient is at risk for developing
renal failure. The nurse would answer
Rational.1577= This patient has elevated creatinine levels (normal is 0.5-1.5mg/dL). Serum creatinine levels do not elevate until half of the nephrons are
not functioning. patients with elevated creatinine are likely to have severerenal impairment. BUN values vary widely according to the dietary intake
of protein, but values elevated to more than 20 mg/dL suggest renalinsufficiency. Renal output is important but the creatinine level denotes
renal impairment (1). The normal range for creatinine is 0.5-1.5 mg/dL (2).
Question.1574= To assess third cranial nerve function, the nurse would testthe patient`s
Rational.1574= The third cranial nerve governs oculomotor responses. Thisincludes pupil response to light. Eye movement is controlled by Cranial
Nerve IV: Trochlear (2). Cranial Nerve I controls olfactory function: smell(3). Cranial Nerve VIII controls vestibulocochlear function (acoustics or
hearing) (4).
Question.1573= A 41-year-old female is admitted to the unit with anexacerbation of chronic lymphocytic leukemia. She states that she has had
small amounts of vaginal bleeding. Ecchymotic areas are noted on her armsand legs. Laboratory data reveal the following:
Rational.1573= A normal platelet count is 15,000-45,000/mm3. A low orbelow normal count places the patient at risk for bleeding. A normal WBC
count is 3400-10,000/mm3. patients with a low or below normal count are atrisk for infection. The other choices are partly correct, but the patient needs
both protective isolation and bleeding precautions.
Question.1572= The rationale for using hypertonic solutions in burnresuscitation is
Rational.1572= Hypertonic solutions will decrease edema because they willpull water out of the cells by osmosis. The hypertonic solution has no
nutritional value (1). The goal of fluid replacement in burn resuscitation is tomaintain a serum sodium concentration of 140 Eq/L
Question.1571= A 72-year-old female is admitted to the unit following a fallat home. Her daughter explains that her mother attempted to stand after
dinner and immediately fell. Currently she is awake but unable to move herleft side. She is able to talk and is alert and oriented. Admission vital signsare blood pressure 176/100, pulse 62, respiratory rate 16, temperature 36.8
degrees C. The patient`s pupils are equal and reactive and her eyemovements are normal. The patient states that she has been healthy and hasnever needed to see a doctor. Based on the preceding information, the nurse
would continue assessing for
Rational.1571= Left-sided weakness (left hemiparesia) or paralysis(hemiplegia) indicates a stroke involving the right cerebral hemisphere,because the motor nerves cross in the medulla before entering the spinalcord and periphery. A left-sided CVA would cause right hemiparesis or
hemiparalysis (1). Hemianopsia is blindness in half the visual field, resultingfrom damage to the optic nerve (2). Hypertonia (spastic paralysis) tends to
cause fixed positions or contractures of extremities (4).
Question.1570= Brudzinski`s sign is best described by which of thefollowing definitions?
Rational.1570= Brudzinski`s sign is positive when the nurse gently flexesthe patient`s head and neck to the chest and flexion of the hips and knees
results. This is an indicator of meningitis.
Question.1569= The critical care nurse should recognize that a majorcomplication of diabetes insipidus could include
Rational.1569= Diabetes insipidus is a condition characterized by impairedrenal conservation of water caused by a deficit of ADH. This causes the
excretion of large volumes of diluted urine, leading to dehydration. Serumsodium levels increase (not decrease), due to decreased or absent ACTH, ifwater replacement does not occur (2). Serum osmolarity is increased, due to
a decrease in ADH and increased water loss (3). Due to dehydration,intravascular volume is low therefore, hypotension occurs. Tachycardia
results as a compensatory response (4).
Question.1567= If a patient develops a grand mal (tonic-clonic) seizure, theinitial nursing action is to
Rational.1567= The first priority is to protect the patient from injuryresulting from environmental hazards, such as siderails, falls, and clothing.Forcing an airway into the patient`s mouth after a seizure has begun should
never be attempted. This is likely to injure the patient`s teeth and riskaspiration on tooth fragments (1). Oxygen therapy may be used, but is notthe initial priority even though cyanosis is common in a grand mal seizure.It generally resolves without treatment (3). A padded tongue blade should
never be inserted after a tonic-clonic seizure has begun, because it mayinjure the patient`s teeth, and tooth fragments may cause aspiration (4).
Question.1566= Which of the following best describes Kernig`s sign?Rational.1566= Kernig`s sign is positive when a patient is unable to extend
his or her leg when the thigh is flexed to the abdomen. This is a positiveassessment for meningitis.
Question.1565= A 36-year-old male is admitted to the nursing unit withrapidly increasing symptoms of generalized weakness following an episodeof "flu." He noticed that the weakness started in his arms and legs and has
progressed to his upper legs, abdomen, and chest. He has difficulty taking adeep breath. Vital signs are normal and he has some complaints of shortnessof breath. Based on the preceding symptoms, which condition is likely to be
developing?
Rational.1565= Guillain-Barr? syndrome is an acute inflammatory processcharacterized by varying degrees of motor weakness and paralysis, plus
sensory and motor disturbances that occur in an ascending, distal toproximal pattern. Respiratory compromise is common. The cause is obscure,but evidence indicates a cell-mediated immunological reaction. Myastheniagravis is a demonstration of progressive paresis that is resolved, in part, byrest. The most common symptoms involve extraocular muscles of the eyes
(2). Multiple sclerosis is a degenerative disease manifested by increasedfatigue, stiffness of the extremities, and flexor spasms (3). ALS
(amyotrophic lateral sclerosis) is a progressive degenerative diseasecharacterized by fatigue while talking, tongue atrophy, dysphagia,
dysarthria, fasciculations of the face, and weakness of the arms and hands(4).
Question.1564= The nurse, assessing a patient with head injuries monitorsfor signs of increasing ICP (intracranial pressure). These signs would be
Bradycardia and hypertension.
Question.1562= Assessing for hypokalemia, the nurse will observe for ECGchanges of
Rational.1562= The cardiovascular effects of hypokalemia includedysrythmias (PVCs), inverted T waves, peaked P waves, and prolonged QT
interval. The other choices are incorrect. A narrowed QT interval isindicative of hypokalemia (4).
Question.1560= Trousseau`s sign is a test for the electrolyte deficiency of
Rational.1560= Tetany resulting from a decrease in serum calcium can beconfirmed by a positive Trousseau`s sign. Hyperphosphatemia may bepresent with a positive Trousseau`s sign (1). Hypercalcemia produces
lethargy and weakness, not signs of carpal spasm seen with Trousseau`s
Question.1559= A nurse in an extended care facility is caring for a patientwith a cuffed endotracheal tube. The nurse understands that the purpose of
inflating the cuff is to
Rational.1559= Inflating the cuff creates a seal between the tube and thepatient`s trachea. This forces air exchange to take place only through the ETtube. Inflating the cuff on the ET does not make suctioning easier (1). The
percentage of oxygen remains the same after the cuff is inflated
Question.1557= A patient is admitted to the intensive care unit aftersustaining a knife wound to the back. Assessment findings include loss of
pain and temperature on the right side and loss of motor function on the left.Vital signs are stable and he is alert and oriented. No other injuries are
noted. Based on this information, which type of neurological syndrome islikely to be developing?
Brown-Séquard syndrome is caused by hemisection of the spinal cord.Clinical manifestations include paralysis below the level of injury on the
same side of the lesion and the perception of pain and temperature isaffected below the level of injury on the opposite side of the lesion. Central
cord syndrome is not a known disease process
Question.1556= The primary symptoms present in cases of autonomichyperreflexia are
Rational.1556= Autonomic hyperreflexia occurs in patients with a spinalcord lesion at or above T6. The response occurs as a result of a noxiousstimulus below the level of the lesion, causing visceral lesion activity
resulting from massive sympathetic response. Symptoms includehypertension, bradycardia, and profuse sweating above the level of the
injury. Autonomic hyperreflexion includes bradycardia and hypertension
Question.1554= For a patient with C-3-4 injury, the nurse should first assessRational.1554= In spinal cord injuries that occur above C-4, the musclesresponsible for respiration are paralyzed. Heart rate, motor ability, and
temperature may be important, but the priority is respiration.
Question.1553= Guillain-Barré syndrome affects the neurologicalcomponent of the
Rational.1553= Guillain-Barré syndrome is an acute, rapidly progressiveinflammation and demyelination of nerve endings of the peripheral nervous
system.
Question.1551= When assessing a patient on the neurological unit, the nurseknows that decerebrate posturing is characterized by
Rational.1551= In decerebrate posturing, the patient has a rigid and possiblyarched spine, rigidly extended and pronated arms with the wrists flexed and
the palms facing backward, and extended legs with plantar flexion. Anabnormal flexion response is decortication (2). Decerbrate posturing does
not include hyperflexion of lower extremities (3). Decerebrate posturing is amotor response (4).
Question.1549= When auscultating a patient`s lungs, which type ofadventitious lung sounds is the nurse most likely to hear with left ventricular
failure?
Rational.1549= Physical signs associated with left ventricular failureinclude bilateral basilar rales. Wheezing is associated with asthmatic or
airway restrictive disease (1). Tinkling sounds aren`t a characteristic of leftventricular failure (2). Increased respiratory breath sounds in the apex is
associated with lung collapse (4).
Question.1548= What is the dominant effect of ADH (antidiuretic hormone)on the kidneys?
Rational.1548= ADH regulates the osmolarity of extracellular fluids byincreasing reabsorption of water from the renal tubules.
Question.1547= A 59-year-old female with a history of alcoholism isadmitted to the unit after being found unresponsive. During the next 24
hours, she develops decreased blood flow to her distal extremities,manifested by discoloration of her hands and feet. The physician believes
that DIC (disseminated intravascular clotting) may be taking place. The testthat will help confirm that DIC is present is the
Rational.1547= A measurement of fibrinogen degradation produces greaterthan 45 ug/mL which helps to confirm DIC. This increased level (normal =
10 ug/mL) indicates that intravascular clots have formed and the body isattempting to dissolve them to restore microcirculation.
Question.1546= A physician orders nitroprusside and dobutamine for apatient with CHF (congestive heart failure). The goal of this type of
medication regimen is to
Rational.1546= Nitroprusside is a vasodilator which dilates arteries andveins. Arterial relaxation reduces afterload, making it easier for the left
ventricle to eject blood. Dobutamine is a synthetic catlecholamine that isprimarily a beta receptor stimulator. Dobutamine increases the force of
contraction by as much as 30-70%. This drug combination reduces afterloadand improves contractility
Question.1544= The priority nursing goal for the patient in status epilepticusis to
Rational.1544= When a patient is in status epilepticus, follow the ABC(airway, breathing, circulation) after calling for help. Do not leave the
patient, maintain a patent airway, and administer oxygen via nasal cannula.Medications are given after the airway and breathing are stabilized.
Question.1541= The nurse is caring for a 37-year-old female admitted withan intracerebral bleed. The nurse on the preceding shift says that a
neurological examination was performed on the patient and that she had anabnormal "doll`s eyes" test. Which of the following descriptions best
describes an abnormal oculocephalic response to the "doll`s eyes" test?
Answer4.1541= The eyes follow the direction of a quick turn of the head.= An injury that stimulates the neurons of the cortical gaze center causes the
patient`s gaze to remain fixed in the direction of head movement. This iscalled a positive "doll`s eyes" test. Normal response is for eyes to move in
the opposite direction of head movement.
Question.1540= Cheyne-Stokes breathing is characterized by which of thefollowing respiratory patterns?
Answer4.1540= Short periods of apnea followed by respirations ofincreasing depth that then slow again to apnea.
Question.1539= The primary function of the cerebellum includes which ofthe following?
Rational.1539= The cerebellum plays an essential role in modifying theforce of contractions of the muscles primarily responsible for movement and
the relaxation of muscles opposing movement. This role is essential forsmooth, coordinated movements. The cerebellum also detects loss ofbalance and restores it by modifying muscle contraction. Thought andpersonality are higher functions and occur in the frontal lobes. Sight is
controlled in the occipital lobe.
Question.1538= Following a head injury sustained in an auto accident, thepatient is admitted. The nurse is assessing the patient`s level of
consciousness, based on her knowledge that maintenance of an awake andalert status is dependent on the proper functioning of which two cerebral
structures?
Rational.1538= Consciousness relies on the active function of the cerebralcortex. This is maintained by continuous stimulation of the cerebral cortexby nerve impulses from a series of nuclei in the brain stem that together are
called the reticular activating system.
Question.1537= A patient in your unit has suffered frontal head injuriesfrom a motor vehicle accident. Which type of impairment may result from
injury to the frontal lobe?
Rational.1537= The frontal lobes make up approximately one-third of themass of the cerebral hemispheres and are thought to be concerned with the
highest cognitive and intellectual functioning, personality, and motorcontrol. Sensation is controlled by the parietal lobes, vision in the occipital
lobe, and hearing in the temporal lobes.
Question.1536= A 20-year-old male is admitted to the unit following asuicide attempt after breaking up with his girlfriend. He ingested an
unknown drug or drugs and is currently combative but with a reduced levelof consciousness. A large-bore nasogastric tube has been inserted in anattempt to lavage his stomach. Which of the following nursing actions
should be initiated at this point?
Rational.1536= patients at greatest risk for aspiration during gastric lavageare those who have an altered level of consciousness, are confused, are
debilitated, or have impaired gag reflexes. Initiation of mechanicalventilation or sedation are physician actions. Maintenance of an airway
takes priority over other possible nursing actions.
Question.1534= Asterixis is regarded as a sign of the developing conditionof
Rational.1534= Asterixis is the irregular flapping movements of the fingersand wrists when the hands are outstretched, with the palms down, wrists
bent up, and fingers spread. Jerking muscle tremors are also seen in the feetand tongue. Also called liver flap or hepatic tremor, this is the most common
and reliable sign that hepatic encephalopathy is developing. Calciumdisturbances and cardiac problems are not manifested in asterixis.
Question.1532= A patient with a C-6 fracture would most likely be able toperform which of the following movements?
Rational.1532= Spinal nerves originating in the cervical disks 5 through 8control the brachial plexus. C-6 function involves good shoulder control,wrist extension, and supinators. Injury above C-5 would have additionalimpairment, while injury below C-6 would determine how much waist or
leg movement was possible.
Question.1531= A 51-year-old female is admitted with hypotension,bradycardia, and decreased level of consciousness. Her core temperature is
35.5degree C. No history is available regarding prior medical problems. Sheappears to be overweight, with dry, scaly skin and puffy face and lips.
Shortly after admission, she has a grand mal seizure. She is intubated andplaced on mechanical ventilation. Based on the preceding information,
which condition is likely to be developing?
Rational.1531= Myxedema coma is a complication associated withhypothyroidism. Signs and symptoms include hypothermia, seizures, and
exacerbations of hypothyroidism. Common CHF symptoms are rales,increased respirations, and tachycardia. ARDS presents with wheezing and
tachycardia. Thyroid crisis has increased heart rate and respirations.
Question.1530= A patient has just been admitted to the unit following anaccident in which he sustained an injury to the temporal lobe. The nurse`s
assessment will focus on disturbances in the patient`s
Rational.1530= The temporal lobes are located on the lateral aspects of thecerebral hemispheres and are primarily concerned with the perception of
verbal material: auditory-receptive and hearing. Spatial orientation and tastearise from the parietal lobes. The occipital lobe is associated with vision.
Question.1529= A 48-year-old female is admitted to the unit. Her diagnosisis a possible syncopal episode. She is currently awake, nervous, and
anxious. Vital signs are as follows: blood pressure 178/108 pulse 129respiratory rate 28 temperature 39degree C (102degree F) During the initialexamination, the nurse notes that she has exophthalmos and that her skin is
warm and wet. Given the preceding information, the nurse will continueassessment for the possible condition of
Rational.1529= Thyroid storm is an extreme exacerbation of severehyperthyroisism. The metabolic rate increases without regard for any bodysystem. Body temperature will rise from as high as 102degree F (39degree
C) to as high as 106degree F (41degree C). Severe tachycardia,hypertension, and tachypnea also are present. Myxedema would present
with opposite symptoms.
Question.1525= The nurse is analyzing data collected from a patient in thefirst 24 hours post acute myocardial infarction (AMI). Which of these data
suggests the onset of cardiogenic shock?
Rational.1525= Extremely close monitoring of a post-MI patient`s vitalsigns is indicated, as hypotension is a cardinal indicator of impending
cardiogenic shock.
Question.1522= A patient has a chest catheter connected to a closed waterseal drainage system. Which nursing action should be included in the plan of
care?
Rational.1522= The documention of the amount, color, and consistency ofthe drainage every shift by the nurse should be included in the plan of care.Any significant change in the amount, color, or consistency is reported tothe physician. Stripping chest tubes is now contraindicated and should not
be included in the plan of care. Continuous bubbling in the water sealchamber indicates an air leak and must be evaluated to maintain proper
function of the system. The collection chamber must be kept below chestlevel to function properly.
Question.1521= A patient with a closed head injury should be monitored forsigns of increased intracranial pressure. A clinical manifestation of this
condition would be
Rational.1521= Increasing systolic blood pressure with widening pulsepressure, bradycardia, and respiratory slowing are part of Cushing`s Triad, a
hallmark of increased intracranial pressure
Question.1520= The assessment finding that indicates a flail chest isRational.1520= A flail chest usually occurs with nonpenetrating trauma and
produces a paradoxical motion of the damaged area so that it moves in adirection opposite to the motion of the uninvolved chest wall.
Question.1519= The nurse evaluates a patient`s arterial blood gases anddetermines that the patient has a low plasma bicarbonate level. This
condition is known as
Rational.1519= Metabolic acidosis occurs when there is either an increase inacids or a deficit in the base (bicarbonate). Acid-base imbalances that are
respiratory in nature result from changes in the CO2 levels.
Question.1518= Which of the following common cardiac medicationsshould the nurse anticipate administering to a patient with a sudden onset of
extreme bradycardia?
Rational.1518= Atropine decreases AV conduction time, thus achieving thedesired outcomes of increasing both heart rate and cardiac output in this
patient. Lidocaine is indicated in the management of ventriculardysrhythmias.
Question.1511= A patient has just been diagnosed with acute pancreatitis.Hypocalcemia is often present in acute pancreatitis. Which of the following
lab findings is associated with hypocalcemia?
Rational.1511= The calcium level is regulated by parathyroid hormone,which maintains an inverse relationship between calcium and phosphorous.
Question.1503= Which of the following ostomies would most need to beirrigated?
Rational.1503= The sigmoid colostomy is most likely to need irrigation,because the stool is similar to the consistancy of normal stool. The other
ostomy types have less formed stool.
Question.1498= When assisting a patient from a bed to a chair for the firsttime postoperatively, the nurse would make sure to place the chair
Rational.1498= Placing the chair at the head of the bed, facing toward thepatient`s feet is a good position for the patient to transfer to and still be able
to observe the activities within the room.,
Question.1496= When planning meals with a patient who is hemodialyzedthree times per week, which of the following food selections would indicate
the patient understands the dietary guidelines?
Rational.1496= Apple juice is low in phosphorus, sodium, potassium, andprotein. The patient in renal failure must avoid these nutrients, because the
damaged kidney cannot clear them. Bananas are high in potassium. Redmeat contains protein and phosphorus. Legumes contain phosphorus.
Question.1483= The nurse practice act is an example of which of thefollowing types of law?
Rational.1483= Individual state legislative bodies enact specific laws forprofessional practice. Each state has its own nurse practice act.
Question.1474= The proper position in which to place a patient immediatelypostop until her gag reflex returns is the
Rational.1474= If the gag reflex has not been regained, place the patient onher side in order to prevent aspiration until she is able to swallow. The prone
position would allow secretions to pool in the airway, predisposing thepatient to aspiration.
Question.1472= Which of the following signs would indicate that a patientis having a severe reaction to the contrast material administered in an
intravenous pyleogram?
Rational.1472= Severe respiratory signs of reaction to the contrast materialinclude laryngospasm, cyanosis, laryngeal edema, and apnea.
Question.1471= An elderly gentlemman patient has a diagnosis of occlusivearterial disease. When instructing the patient regarding proper positioning in
bed, the nurse would advise him to
Rational.1471= Allowing the patient to sleep in a somewhat dependentposition may help prevent pain at rest. Raising the legs would decrease
arterial perfusion and cause more vascular problems.
Question.1467= When assessing the lower extremities of a patient witharterial insufficiency, the nurse notices that they are reddish-blue in color
below the knees. This observation will be recorded as
Rational.1467= Rubor is a reddish-blue color caused by superficialcapillaries that remain dilated after injury. Cyanosis is a blue-gray color,pallor is a white color, and striae are lines that are red, then a silvery tone
over time.
Question.1465= A female patient, age 57, is being evaluated in the GUclinic. Her assessment reveals paradoxical incontinence, which can be
described as
Rational.1465= Overflow or paradoxical incontinence occurs with theleaking of small amounts of urine from a distended bladder in the absence ofeffective contractions. Urinary hesitancy is not associated with paradoxicalincontinence. A decrease in the stream is associated with benign prostate
hypertrophy and frequent urination is associated with an infection.
Question.1463= A patient diagnosed with congestive heart failure (CHF) isnoted to have gained 4 1/2 pounds in the past 24 hours. When considering
the patient is retaining fluid, the nurse would note this weight gain isconsistent with
Rational.1463= The amount of fluid retained can be determined by theweight gain. The accepted ratio, one liter, is equivalent to one kilogram or2.2 pounds. This patient had gained 4 1/2 pounds, or roughly two liters of
fluid.
Question.1454= To assist the left CVA patient out of bed, the nurse wouldplace the wheelchair
Answer1.1454= Facing the patient`s left side.
Question.1451= The proper temperature for administration of a tepid spongebath is
90 degrees F.
Question.1447= A 77-year-old woman suffered a left-sided CVA, resultingin a right hemiparesis. To preserve her skin integrity, the nursing care plan
would include
Rational.1447= The need to encourage high-protein foods is essential forproper maintenance of skin. A lack of protein leads to promotion of skin
breakdown and a lack of healing ability. The position should be changed atleast every two hours. The pressure areas should be massaged with each
turn, at least every two hours. The daily shower would not be recommendedfor a person of this age because it would tend to dry skin, leading to
potential cracking and breaking.
Question.1444= The nurse explains to the patient receiving pertonealdialysis that when the dialysate is removed after the initial peritoneal
dialysis exchange, it often appears
Rational.1444= The dialysate should be clear and pale yellow, althoughafter the first few initial exchanges it may appear bloody or pink tinged. Any
cloudiness or green dialysate may indicate infection.
Question.1443= To eliminate hyperglycemia in the patient who has diabetesand is on peritoneal dialysis, the nurse would
Rational.1443= Diabetics may become hyperglycemic from the dextrose inthe dialysate. Insulin can be added to the dialysate, thereby eliminating theneed to give the patient subcutaneous insulin when performing dialysis.The
dialysate solution must contain dextrose (sugar) in order to create anosmotic gradient. Blood sugar would be tested as symptoms appeared.
Question.1439= When assessing an adult`s ECG, which of the followingfindings would the nurse recognize as being consistent with an MI?
Rational.1439= The area immediately surrounding the infarcted areas hasinjured cells and is called the zone of injury it produces ST segment
elevations. An increase in the PR interval indicates a conduction delaybetween the SA and AV nodes. A widened QRS complex indicates a
conduction delay in the ventricles and may be indicative of ventriculardysrhythmias. U waves are associated with a disturbance in the electrolyte
potassium.
Question.1433= A patient with Type 1 Diabetes Mellitus is given a stat doseof insulin because his blood sugar is 525 mg/dL. After receiving the insulin,the patient begins to demonstrate dysrhythmias on the ECG monitor. Whichof the following disorders would the nurse consider to be the MOST likely
cause of this cardiac irregularity?
Rational.1433= The administration of regular insulin tends to drive thepotassium from the extracellular fluid into the intracellular fluid, causing a
loss of serum potassium. Decreased serum potassium can cause seriousdysrhythmias.
Question.1432= The nurse is completing an admission assessment on a67-year-old male patient who has a long-standing history of emphysema.
Upon percussion of the lungs, the nurse expects to hear
Rational.1432= Hyperresonance is a very loud, low-pitched, boomlikesound produced in air-filled spaces, such as emphysematous lungs. Dullnessis a medium-pitched, thudlike sound heard over a solid structure, such as anorgan. Resonance is a loud, low-pitched, hollow sound normally heard overhealthy lungs. Tympany is a loud, high-pitched, drumlike sound normally
heard over a gastric air bubble.
Question.1429= The staff is developing a care plan for a patient withhypercalcemia. An action the nursing care plan will include to improve
urinary problems is to
Rational.1429= Increased fluids will decrease the incidence of infection andstones both are less likely to develop if the urine is dilute.
Question.1428= Which of the following diets is most likely to berecommended for a patient experiencing hypercalcemia?
Rational.1428= An acid-ash diet will decrease the risk of urinary tractinfection and renal stone development because it helps acidify urine.
Question.1424= Which of the following signs would the nurse assess for ina patient with a suspected diagnosis of Lyme disease?
Rational.1424= Early signs and symptoms of this disorder may includedistinctive flat or raised red lesions, lesions that are hot to the touch, fever,malaise, fatigue, headache, chills, nausea, and lymph node enlargements.
Question.1422= Confabulating and lack of voice control in a patient with aCVA can be attributed to
Rational.1422= A right-hemisphere-damaged CVA patient lacks voicecontrol, talks incessantly, confabulates, and reads aloud fluently without
comprehension.
Question.1415= The nurse in the PACU notes a change in the patient`srespiratory rate from 18 to 36 respirations per minute. The nurse`s first
action would be to
Rational.1415= If the patient has any difficulty in breathing or exhibits achange in the pattern of breathing, notify the anesthesiologist immediately.
Question.1414= A patient has just been informed that she will be started ona CAPD protocol. She wants to know more about CAPD and asks the nurse
how many exchanges she would have to perform per day. The nurseexplains that
Rational.1414= CAPD usually involves 3 to 4 exchanges per day of 2 literseach in a 24-hour period, with dwell times of 4 to 6 hours each. Most
patients who need dialysis can use CAPD.
Question.1411= The wife of a patient on dialysis asks the nurse how chronicrenal failure causes anemia. The nurse explains that
Rational.1411= Anemia in CRF occurs as a result of decreasingerythropoietin and because the uremic environment decreases the life span
of the RBC.
Question.1406= A patient has undergone a transspheniodalhypophysectomy. Procedures contraindicated in the immediate
postoperative period include
Rational.1406= Frequent mouth care should be given, but brushing teethmay damage the gingival suture line. Elevating the head of the bed promotesan open airway. Advancing the diet and monitoring for infection are routine
nursing responsibilities.
Question.1403= The nurse is teaching the wife of a patient with Parkinson`sdisease. She explains that patients with Parkinson`s have difficulty slowing
down once they walk forward, and in fact, they actually speed up. Thisproblem is described as a
Rational.1403= Propulsive gaits are usually exhibited in later diseaseprogression. The patient`s steps become faster and faster and shorter and
shorter.
Question.1397= A male patient has been admitted for treatment of end-stagerenal disease. The nurse understands that the primary cause of renal failure
is
Rational.1397= Diabetes mellitus is the most frequent cause of renal failure,followed by hypertension.
Question.1396= The nurse plans to prevent complications in the diureticstage of a patient`s renal failure. Information that the nurse will use in
developing this plan includes recognizing that
Rational.1396= Although renal healing is occurring during this stage, thetubule system is frequently unable to concentrate urine satisfactorily. Thus,patients may excrete large volumes of urine (but not 25 to 30 liters in a day)
and lose substantial amounts of electrolytes.
Question.1395= Which of the following disorders would be of greatestconcern for a patient in the oliguric stage of acute renal failure?
Rational.1395= Acute uremia results in fluid retention and electrolyteabnormalities, particularly hyperkalemia.
Question.1392= Which of the following would the nurse expect to find onthe urinalysis report of a patient who has a diagnosis of
hyperparathyroidism?
Rational.1392= As a result of hypercalciuria, hyperphosphaturia developsand altered renal tubule function causes unusually alkaline urine. Ketones
and glucose are associated with diabetes mellitus. RBCs are associated withinfection or trauma.
Question.1390= A female patient, age 49, has been admitted to the hospitalwith an exacerbation of rheumatoid arthritis. The nurse understands that this
disease primarily affects adults between 20 and 55 years old and theincidence is
Rational.1390= Rheumatoid arthritis affects women three times as often asmen. It is an autoimmune disease that is not genetically linked and is not as
common in children as in adults.
Question.1388= When percussing a patient`s abdomen, the nurse knows thatfluid will be revealed as a
Rational.1388= Fluid in the abdomen will pool in the flanks and willpercuss with a note that is flat or dull. Tympany or hyperresonant sounds
occur over air. A bruit is a swirling sound.
Question.1387= A patient is diagnosed with a left-sided heart failure. Onemajor goal in the management of congestive heart failure is
Rational.1387= Afterload is a major concern in CHF. Ways to reduce itinclude the administration of vasodilating agents. These agents decreaseperipheral vascular resistance (afterload) and increase cardiac output by
reducing resistance. Contractility is thereby increased. Relief of anxiety isnot an immediate goal of treatment.
Question.1386= To assess the peripheral pulses of a patient`s lowerextremities, which of the following areas would the nurse palpate?
Answer1.1386= The popliteal, dorsalis pedis, and posterior tibial.
Question.1385= To confirm the diagnosis of left-sided CHF, the patient willundergo a cardiac catheterization. Which of the following preprocedure
orders would the nurse question?
Rational.1385= Sodium should be restricted. A reduction of sodium willdecrease the retention of salt and water and therefore reduce vascular
volume.
Question.1378= Which of the following interventions may cause injury in apatient with rheumatoid arthritis experiencing a flare-up (exacerbation) of
the disease?
Rational.1378= During periods of exacerbation, or acute inflammation,active range of motion (especially to the point of pain) can cause significantjoint damage. Consequently, range of motion should be done by the nursebut not to pain or beyond. Splinting of joints and medication are useful in
treating exacerabations of RA.
Question.1374= The aphasia seen in CVA patients is usually caused bydamage to the
Rational.1374= Aphasia, both expressive and receptive, is seen in patientswho have sustained damage to the left cerebral hemisphere. Damage to the
cerebellum usually results in motor deficits.
Question.1371= A 34-year-old female is in the critical care unit with acuterespiratory distress secondary to sepsis following a motor vehicle accident.She currently has a chest tube in place, set at 20 cm H2O suction. There is
no bubbling in the water seal although there is bubbling in the suctioncontrol chamber. While the nurse was at lunch, one of the unit technicianssays he clamped the chest tube to determine if the suction level was still at
20 cm H2O. It is still clamped when the nurse goes into the room. Thepatient does not complain of any symptom change. About the same time, the
patient`s physician comes into the room and notices the clamped tube. Hebecomes very upset and says to get an immediate chest x-ray to see if a
tension pneumothorax has occurred. The nursing action is to
Rational.1371= Fluctuations in the water seal show that there is patencybetween the pleural cavity and drainage bottle. Fluctuations will stop if lung
expansion has occurred or there is kinking of the tube or clots present.Listening to the lungs would indicate if expansion has occurred, in which
case no x-ray will be necessary.
Question.1366= When evaluating the effectiveness of traction, the findingthat would counteract this is
Rational.1366= For traction to be successful, countertraction must bepresent. Weights resting on the bed would not allow for traction. Force anddirection must be maintained with the ropes in the center track of the pulley.
Question.1365= When assessing the breath of a patient with advanced liverdisease, the nurse notes an ammonia-like odor. This most often represents
Rational.1365= Fruity or acetone odor is indicative of ketosis, whereas anammonia smell is associated with uremia.
Question.1361= A young patient is diagnosed with mitral stenosis. Whenassessing the patient, which symptoms are consistent with this condition?
Rational.1361= Mitral stenosis refers to the obstruction of the mitral orificedue to adhesions between the two mitral valve leaflets. The first symptom
observed is exertional dyspnea.
Question.1358= Which of the following assessments would indicatepossible neurovascular compromise in a casted extremity?
Rational.1358= Neurovascular assessment of a casted extremity involvescolor, sensation, and movement. Tingling would indicate a problem. Normalassessment would expect that skin is warm and pink with equally palpable
pulses. Mild pain on passive motion is expected.
Question.1357= A female, age 45, is admitted to a cardiac medical unit forpreoperative care prior to having a possible valve commissurotomy.
Pertinent past history includes her having had a case of rheumatic feverwhen she was 12. She is married and has two children aged 17 and 13. Thepatient seems very anxious and asks the nurse, "How could a sore throat Ihad 30 years ago damage my heart now?" The best reply by the nurse is
Rational.1357= Rheumatic fever is a systemic, inflammatory,nonsuppurative disorder that usually occurs as a sequela to a throat infection
caused by group A beta-hemoloytic streptococci. It is characterized by adiffuse proliferative and exudated inflammatory reaction in connective
tissues, particularly of the heart, joints, and skin.
Question.1353= A patient diagnosed with a hypothalamic disorder is beingadmitted. In her assessment, the nurse will question the patient about
disturbances in
Rational.1353= The hormones of the hypothalmus control many importantfunctions. One of the major functions is temperature control
Question.1352= The nurse is caring for a patient undergoing peritonealdialysis and notes that the dialysate has not drained. To help facilitate
drainage, she will
Rational.1352= Draining problems may occur in peritoneal dialysis due toobstruction of the catheter by the omentum. If this occurs, turning the
patient from side to side will change the position of the catheter.
Question.1347= The nurse continues teaching the patient with AIDS that theagent used to treat pneumocystis carinii pneumonia is
Septra (Bactrim).
Question.1346= The AIDS clinic nurse is teaching a patient about his labprofile. She explains that the cell known as the "helper cell," vital in
activating the immune response, is the
Rational.1346= T4 lymphocytes, known as "helper cells," are vital inactivating the immune response. T8 lymphocytes are suppressor cells and
neutrophils are leukocytes.
Question.1344= The nurse is checking the patient`s pleural drainage system.She recognizes indication of an active pleural leak when she sees
Rational.1344= Constant bubbling in the water seal indicates leakage of airin the drainage system fluctuation is normal with respiration. Bubbling is
expected in the suction control chamber.
Question.1338= In the patient with smoke inhalation, the most likely timeperiod during which pulmonary complications may develop is the
Rational.1338= Any patient with smoke inhalation must be observed for atleast 24 hours for respiratory complications. It may take a full 24 hours for
complications to develop.
Question.1334= A 19-year-old African-American woman presents with anontender, unilateral breast lump in the right breast, which she noticed on abreast self-exam. Her last menstrual period was normal and ended 2 daysago. She denies pain, nipple discharge, or recent trauma. The most likely
diagnosis is fibrocystic breast changes versus
Rational.1334= A mass in an adolescent is almost pathognomonic forfibroadenoma, especially in African-Americans. If breast symptoms are
unilateral or there is a palpable mass, refer the patient for further evaluation.Women with fibrocystic changes usually present with bilateral nodularityand increased tenderness or pain prior to menses. The nodularity may be
generalized or localized in the upper outer region.
Question.1325= A pregnant woman who is not immune to rubella should bevaccinated
Rational.1325= To reduce the risk of acquiring rubella at the beginning of afuture pregnancy, the woman should receive the vaccine after she givesbirth. Caution her to avoid becoming pregnant for at least 3 months after
receiving the vaccine.
Question.1324= The nursing plan for an infant diagnosed with necrotizingenterocolitis (INEC) should include
Rational.1324= Measuring the abdominal girth provides information onwhether or not the gastric distention is resolving.
Question.1323= At what age do term infants usually regain their birthweight after the initial weight loss?
10 days.
Question.1320= When a newborn cries, the right side of his face remainsmotionless. When he sleeps, his right eyelid remains open. The nurse should
interpret this as a
Rational.1320= A facial nerve paralysis results from pressure on the facialnerve during labor or from the use of forceps for delivery. The paralysis isusually unilateral and most apparent when the newborn cries. If the nervehas been injured, the paralysis disappears within a few days or weeks. Itmay take as long as several months. If the nerve has been torn, it requiresneuroplasty. Facial nerve paralysis is an alteration in expected findings ofthe newborn assessment. It is neither a congenital anomaly nor a genetic
defect.
Question.1319= In order to prevent the need for a backup method ofcontraception, the nurse instructs the patient starting oral contraceptives to
take the first pill
Rational.1319= No backup contraceptive method is needed if the OCs arebegun on the first day of menses since ovulation is inhibited for that cycle.The pill works primarily by suppressing ovulation (via suppressing releaseof gonadotropin-releasing hormone [GnRH], which inhibits the pituitaryrelease of FSH and LH), causing thick cervical mucus (which makes it
difficult for sperm to penetrate), and making endometrium or lining of theuterus unfavorable for implantation.
Question.1318= In addition to the current pregnancy Sandra has beenpregnant three times. She lost the first pregnancy at 10 weeks; the secondpregnancy produced twin girls who were born prematurely; and the last
pregnancy was carried to term and her son was born at 39 weeks. All of thechildren are alive and well. Which of the following numeric scores
accurately depicts Sandra`s reproductive history?
Rational.1318= Assessment of pregnancy history is accomplished using thepneumonic GTPAL G (gravida) T (term pregnancy) P (preterm birth) A
(abortion) L (number of living children). Since Sandra has been pregnant 4times, she is gravida 4 . She delivered her last pregnancy at term, making 1
term pregnancy. She had 1 birth (delivery) of twins, making preterm (P)births equal to 1. Her first pregnancy was a miscarriage giving her 1
(spontaneous) abortion. All of her children are currently living (twin girlsand a son). In addition, some pneumonics add "M" (multiple gestations)
making the pneumonic GTPALM, in which case Sandra would be4-1-1-1-3-1.
Question.1316= A patient who is 8 weeks pregnant tells the nurse that hergums have been bleeding with every tooth brushing. The nursing
intervention is to
Rational.1316= Pregnancy gingivitis may result from proliferation oflocalized blood vessels and softening of the gums. A focal hypertrophy ofthe gums, epulis, may present with erythema, swelling, and bleeding when
traumatized as in teeth brushing. The teeth are not affected and thehypertrophy resolves after pregnancy as it is most likely related to elevated
estrogen levels. However, the frequency of bleeding early in pregnancyrequires further assessment before considering this physiologic cause.
Question.1315= Which of the following are probable signs of pregnancythat a patient might experience at some point during her gestation?
Rational.1315= Probable signs, or objective signs, include those which canbe visualized on examination (Chadwick`s sign, uterine enlargements,
ballottement). A positive pregnancy test suggests pregnancy by testing forthe presence of HCG. However, the similarity between HCG and other
hormones (such as LH) may result in cross-reactions resulting in a positivepregnancy test. Therefore, it is considered as a probable sign. Presumptive
signs are subjective signs (including "morning sickness," amenorrhea, breasttenderness, and quickening). Audible fetal heart tones, palpated fetal
movements, and visualization of the fetus on ultrasound are all positivesigns of pregnancy.
Question.1314= A nurse determines that a patient has several presumptiveindicators of pregnancy. They are called "presumptive" because they
Rational.1314= Presumptive signs of pregnancy such as amenorrhea, breasttenderness, nausea, fatigue, and urinary frequency, are subjective and are
not diagnostic, only suggestive of pregnancy.
Question.1313= By the end of 12 weeks the pregnant uterus should bepalpable
Rational.1313= The ascent of the uterus from the pelvis into the abdomenoccurs at approximately 12 weeks. The uterus cannot be palpated when it is
below the level of the symphysis pubis.
Question.1311= A patient who is 12 weeks pregnant reports that her mouthfrequently feels like she has too much saliva. This condition is known as
Rational.1311= Ptyalism is the production of excessive saliva duringpregnancy, characteristically noted during the first trimester. Oral hyperemia(redness) and gingivitis (gum inflammation) may occur also. Hyperemesis is
persistent vomiting during pregnancy, which results in dehydration.
Question.1307= A vaginal exam at eight weeks of pregnancy would revealwhich of the following signs of pregnancy?
Rational.1307= In the early weeks of pregnancy, Goodell`s sign (softeningof the cervix) and Chadwick`s sign (a bluish discoloration of the cervix)
both occur. Ballottement occurs in midpregnancy. The mucus glands form amucus plug, but there is also an increase in white vaginal secretions.
However, in addition the mucus secretions are acidic.
Question.1303= Shortly after entering the room of a patient with PIH, thenurse observes facial twitching followed by a tonic contraction of the
patient`s entire body. The nursing intervention is to
Rational.1303= Eclampsia is marked by the occurrence of tonic-clonicseizures or vascular collapse. In the event of seizures, the following signsare observed: a prodromal facial twitching lasting only a few seconds, a
tonic contraction of the entire body lasting about 20 seconds, and aconvulsion lasting about a minute. Protecting the patient from injury is the
priority intervention.
Question.1302= A pregnant woman is admitted to the ER after having aconvulsion. The diagnosis of eclampsia is made based on the presence of
Rational.1302= Eclampsia is marked by hypertension characterized by theoccurrence of tonic-clonic seizures or vascular collapse.
Question.1301= A patient with mild pre-eclampsia should be encouraged toRational.1301= Left lateral position decreases pressure on the vena cava and
is believed to improve venous return and placental and renal perfusion.
Question.1300= A 2-week-old newborn is brought to the hospital clinic byher mother with a complaint of continuous regurgitation. A barium swallowreveals a diagnosis of gastroesophageal reflux. The nurse will instruct the
mother to
Rational.1300= Prone positioning has been shown to decrease reflux andfacilitate gastric emptying. Some textbooks recommend a prone positionwith the head of the bed elevated. Either position is currently accepted
therapy.
Question.1299= The nurse is caring for a 2-week-old infant with aventricular septal defect. In planning interventions for the nursing diagnosis"alteration in nutrition: less than body requirements related to fatigue," the
nurse will suggest feeding
Rational.1299= A soft nipple helps the infant suck more easily, decreasingthe energy expenditure.
Question.1297= A clinical manifestation of increased intracranial pressurein infants may be observed as
Rational.1297= The early signs and symptoms of increased ICP are oftensubtle and assume many patterns, such as irritability and changes in feeding.
Question.1296= Infants triple their birth weight at age___________________ months.
Rational.1296= The answer if 12 months. During early infancy, the energyrequirements for this period of rapid growth are high. By 1 year of age,
infants weigh approximately 3 times their birth weight.
Question.1295= Assessing an average 2-month-old child, the nurse knowsthat he should be able to
Rational.1295= Although the acquisition of gross motor skills varies in itstiming, infants at 2 months of age can lift their heads up to a 45 degree angle
when prone.
Question.1294= Recommended treatment of children with sickle cellanemia includes which of the following?
Rational.1294= Poor splenic function predisposes the child with sickle celldisease to overwhelming infection from S. pneumoniae and H. influenzae.
Therefore, recommendations for management include oral doses ofprophylactic penicillin to protect from infection.
Question.1293= A 2-year-old African-American child with sickle cellanemia has his immunizations up to date. Now that he is two, which of the
following vaccines should be initiated?
Rational.1293= The pneumococcal vaccine should be administered to allchildren with sickle cell anemia at 2 years of age. These children run a high
risk of developing pneumococcal septicemia or meningitis.
Question.1292= Which of the following is the most common seriouscomplication of sickle cell anemia in children?
Rational.1292= The most common serious complication of children withsickle cell anemia is overwhelming septicemia and meningitis due to
Streptococcus pneumoniae and Haemophilus influenzae type B.
Question.1284= A child who is in a chronic state of hypoxemia would havea physiologic response of
Rational.1284= In chronic hypoxemia, the body compensates by producingmore red blood cells (polycythemia). By producing more red blood cells, theoxygen-carrying capacity of the blood is, in theory, increased. This is only
true if adequate amounts of iron are available for the formation ofhemoglobin.
Question.1283= A 2 month old has hydrocephalis. He has been admitted forinsertion of a ventriculoperitoneal shunt. After surgery the nurse observesthat the baby`s anterior fontanel is elevated. The nursing intervention is to
Rational.1283= An early sign of increased intracranial pressure in an infantis a bulging fontanel when at rest. This is a serious sign after a shunt
operation because it indicates that there is an obstruction to the flow ofcerebrospinal fluid, and corrective surgery may be required.
Question.1282= Which of the following is not a common clinicalpresentation of AIDS in children?
KS
Question.1280= The first sign or symptom of an acyanotic heart defect isoften
murmur
Question.1278= A 32-year-old multipara is pregnant with her third child.She has been in labor for 20 hours, and the fetal position is LOP. The patient
is likely to experience
Rational.1278= Labor with a fetus in an occiput posterior position is longand difficult. Backache is common as the occiput bone presses against the
mother`s sacrum.
Question.1272= A primipara, aged 24 and 39 weeks` gestation, phones theclinic and reports that she is having contractions every 15 minutes. The
nurse will help her distinguish the difference between early and false laborby explaining that it is usually false labor when the patient
Rational.1272= Braxton-Hicks contractions, or false labor, are mild,intermittent, painless contractions which occur throughout the second half ofpregnancy. Women often obtain relief from them by walking or lying down.
Question.1271= A 25-year-old primipara is in labor, having strongcontractions occurring every 2 minutes and lasting 60-90 seconds. She feels
frustrated, starts to tremble, and is afraid she is losing control. The nurseexplains to her that she is moving into the
Rational.1271= The answer is the transition phase these are characteristicfindings of the final or transition phase of the first stage of labor.
Question.1270= A pregnant patient, gravida 2, para 1, is admitted forgeneralized edema, proteinuria of +2, and an elevated blood pressure. She isstarted on magnesium sulfate and is receiving 2 grams/hour IV. Preparing to
mix the next liter of medication, the nurse assesses her, finding absentreflexes and a respiratory rate less than 10 breaths per minute. The first
nursing action is to
Rational.1270= Absent reflexes and a respiratory rate of 10 per minute orless indicate magnesium toxicity and the antidote (calcium gluconate)
should be in the patient`s room ready for administration. The physicianshould also be notified at once.
Question.1269= When caring for a patient with cardiac disease who has justentered the second stage of labor, the nurse understands that the
management of the patient will likely include
Rational.1269= The goal of management with this patient is to shorten thesecond stage of labor. Appropriate management could include 1) spinal
anesthesia, 2) episiotomy, and 3) forceps delivery.
Question.1268= A priority goal for a patient experiencing an incompleteabortion is
maintain vs
Question.1266= A pregnant woman is admitted to the ER. She states thatshe is 16 weeks pregnant and has been bleeding vaginally. The nurse woulddifferentiate between a threatened abortion and an inevitable abortion when
the assessment findings include the
Rational.1266= A threatened abortion is suggested when a womanexperiences vaginal spotting or bleeding early in pregnancy and no cervicaldilation or effacement is present. An inevitable abortion, which cannot be
prevented, is indicated when the cervix has begun to dilate, uterinecontractions are uncomfortable, and vaginal bleeding increases.
Question.1254= The nurse/midwife performs a procedure in the lasttrimester to determine fetal position, lie, and presentation. The nurse would
describe this procedure as
leopold Fetal lie, presentation, position, and engagement can be determinedby abdominal palpation of the mother.
Question.1253= Samantha has been taking an oral contraceptive for 3 years.Since a recent head injury, she is also taking phenytoin (Dilantin) 100 mgthree times a day for seizure control. What information would the nurse
include in the patient teaching?
Rational.1253= Phenytoin can decrease the effectiveness of oralcontraceptives. The oral contraceptive should be supplemented with other
means of birth control.
Question.1249= The nurse in the prenatal clinic is teaching a goup ofpregnant women about self-care. Instructions will include that when lying
down, it is best to lie on the left side in order to
Rational.1249= The growing uterus may press on the inferior vena cavawhen the pregnant woman is supine. This reduces blood flow to the inferiorvena cava when the pregnant woman is supine, and also reduces blood flowto the right atrium. This may lower the blood pressure, causing dizziness.
Question.1244= An elderly patient with pedal edema is admitted to amedical floor with symptoms of vascular disease. The nurse caring for this
patient is aware that edema may result from
Rational.1244= Edema can result from increased capillary pressure or fromthe passage of protein molecules and fluid from blood into interstitial fluid
because of increased capillary permeability. An aneurysm is a localizeddilatation of an artery caused by a weakened arterial wall ). Third spacing
occurs when fluid is filtered from the plasma and then accumulates in otherareas of the body (4).
Question.1241= A patient with cervical cancer enters the hospital to have acesium implant. Before the insertion of the implant, the nurse tells the
patient what to expect while it is in place. Which of the following statementsis accurate?
Rational.1241= It is necessary for staff, family and friends, to havedecreased exposure to the source of radiation. Nursing care is to be
delivered in a timely fashion, with special attention given to physicaldistance. The patient receiving any type of radiation should not be in any
pain as a result of the treatment (1). Bed linens need to be changed asneeded, not because of the radioactive implant (3). patients with radioactive
implants should be able to at least assist with activities of daily living.patients are encouraged to provide self-care measures to decrease the
possibility of complication due to immobility (4).
Question.1239= The nurse caring for a patient with polycythemia vera notesall of the following clinical signs and symptoms. Which of these should be
reported to the physician immediately?
Rational.1239= This is a classic clinical manifestation of thrombophlebitis,a serious complication of this blood disorder.
Question.1217= The physician ordered an enema for a patient to relievegastric distention. The nurse would expect the type of enema ordered would
be a (an)
Carminative enema.Rational.1217= This enema is made up of a solution which is 30 mL of
magnesium, 60 mL of glycerin, and 90 mL of water. A physiologic normalsaline enema is safest for infants and children because of their predispositionto fluid imbalance. A soap suds enema is most frequently used for cleansingthe bowel prior to surgery. An oil retention enema is an oil-based solution. It
permits administration of a small volume, which is absorbed by the stool.The absorption of the oil softens the stool for easier evacuation.
Question.1211= When teaching a patient to use a walker, the nurse wouldinstruct the patient to move the walker
Rational.1211= The proper distance is 6 inches so that the individualmaximizes the safe and effective use of the walker.
coumadin s/e orange urine
50 GRAMS OF DEXTROSE 4 CALS PER GRAM
lactating mothersRestricted fat intake. Lactating mothers need 4 to 5 glasses of milk a day.
They should never be advised to restrict any nutrient or attempt to dietduring lactation.
The nurse can instruct a diabetic patient that blood glucose levels can bemoderated by including more
Dietary fiber decreases the absorption of carbohydrates and may affect therelease of gastrointestinal hormones, which influence insulin and glucagonsecretion. Fiber also increases and prolongs satiety and helps control bloodlipids. Omega 3 fatty acids appear to decrease serum triglycerides, but also
tend to increase fasting plasma glucose levels.
A male client has just returned to the unit after he had an exploratorylaparotomy. His orders include applying a binder to minimize muscular
tension over his incision site. The binder that will be used on this client is a
The straight abdominal binder centers support over abdominal structures. Itprovides continuous wound support and comfort. A stretch net binder is
used for support of dressings or surgical sites over the client`s arms or legs.The T binder is applied to facilitate placement of perineal dressings and
provide support to perineal muscles and organs. A double T binder is usedto support perineal dressings for male patients.
When obtaining a urine sample from a catheter, the period of time forclamping the catheter is
The urinary catheter should be clamped off for short periods of time only, inorder to obtain a small sample of urine. Longer periods of time may causethe urine to back up into the bladder and increase the potential for UTIs.Thirty minutes is sufficient to obtain a specimen in a client with a normal
urine output.
k
The normal potassium level is 3.5-5.0 mEq/L. The patient`s potassium levelis low, and he needs to replenish what has been lost as a result of taking theLasix. In addition to taking potassium supplements, the patient should be
given a list of the appropriate foods that have an average of 7 mEqpotassium per serving. (Fruit, meat, fish, instant coffee, and milk are high in
potassium.
electrolytesnormal electrolyte values for an adult are as follows: sodium of 135-145mEq/L, chloride of 100-106 mEq/L, potassium of 3.5-5.0 mEq/L, and
bicarbonate of 22-29 mEq/L.
sed rateThis is a normal sed rate for a female over age 60. Under age 50, normal is20 mm/hr. If it were increased, it would indicate presence of infection or
inflammation, and surgery might have to be postponed.
PT abnormal
Because the patient is not on anticoagulant therapy, the results are abnormal(normal PT is 11-15 seconds). It is important to notify the head nurse or
physician before the biopsy; bleeding could be life threatening. The patientwill probably be given vitamin K therapy and when the PT results return tothe normal range, the procedure can be done. Liver disease likely caused the
prolonged PT.
lipid agents
to the sun or photosensitization is a risk for patients taking HMG-COAreductase inhibitors (Mevacor). (1) Niacin is usually given with bile acid
sequestrants because they work synergistically. (2) Bleeding from the gumsor rectum is a sign of vitamin K deficiency from bile acid sequestrants
(Questran).
creatine
The normal serum creatinine level for a male is 0.6-0.9 mg/dL. A patientwith a mild degree of renal insufficiency would have a slightly elevated
level, which in this case would be 1.7. Levels of 3.3 (2) and 4.0 (1) may beassociated with acute or chronic renal failure.
labs for pancreatitis
These elevated serum levels (amylase and lipase) are the hallmark of acutepancreatitis. Increased white blood cell count and serum bilirubin level is
also seen with acute pancreatitis. Elevated alkaline phosphatase (4) is foundin chronic pancreatitis.
pyloric stenosis distinctive signs peristalic waves
quickening 17-19 weeks first felt
thrombocytopenia platlet count 50k or below. Sx petechie,purpura and hematuria
Dornase alfa reduces viscosity of sputum with CF
blurred visionadvanced indicatior of
PIH
suction mouth then nose of infant
menstrual cycyle regulated FSH and LH which are produced in the hypothalmus
epiduralvasodilation and blood pooling in extremites. Can lead to hypotension so
monitir BP. Immediate TX elevate legs.
Bucks extension following a hip Fx is to immobalize to relieve muscle spasm at the fx site
pacemaker malfunction weakness and fatigue R/T hypoxia of the tissues
LVN can't take admissions
Denver shuntused for pts with ascites and cirrhosis. diverts fluid from the abd to jugular
or vena cava
shunt should feel warm, hear bruit and feel thrill
chronic hypoxiaR/T copd may stimmulate excessive RBC formation will increase blood
viscosity and risk for thrombus
gentamycin aminoglycide nephrotox!
B12 comes from animal products increase or get b12 shot R/T pernicous anemia
mechanical vent may cause stress ulcers so maintain Ph above 5
lactalose decreases NH3 levels with pt s who have hepatic coma
positioning for pancritits sit up or lean foward to decrease pain
laproscopic shoulder pain after co2 is injected into the abd main cause shoulder pain after surgery
colchine (for gout) sx of toxicity diarrhea
aminoglycides more active when the urine is alkaline so soda bicarb may be given
seconal barbiturate used for sleep. Monitor for sedation
spironolactone decrease urine na then causes diuresis
hypertonic fluids higher in osmotic pressure used for icp because it reduces idema
thiazide diuretics monitor for k loss monitor muscle weakness leg cramps hypotension
start solids 5-6 months
6 months sits with minimal support
sterile technique when skin is broken or STERILE body cavity is entered
surgical asepsis cath to bladder
after surgery immediatly assess pulmonary function first thing post op
critical pathwaymanagment tools developed for particular types of patients . they have
interventions outcomes and progress. they are multidisaplinary.
tens blocks painful stimuli from traveling over small muscle fibers.
osteoarthritis assememt findings joint pain, crepitus, heberdens nodes
at a 4 y/o wc visit the kid is really small. what is the nurses first action inevaluating his growth
compare with siblings
increased vag drainage nl during pg
soap enemanurse should hold about 12 inches above rectum. admin slowly. insert the
tube 3-4 inches in rectum, direct the tip towards the umblicus
hospiceinhances the quality of life for terminal ill pt. helps pt and fam to live life to
the fullest each day
lasixbecause lasix is k wasting the pt needs to eat k foods such as apricots, dates,
and citrus foods
a pt is chocking on his lunch and coughing forcefully what should you doif he is coughing he should be able to dislodge the object if obstruction
occurs then do abd thrusts hemi
intermittent cluadication
chronic perhrial vascular disease that reduces 02 to the feet so do meticulusfoot care. Bath feet in warm water and dry throughly cut toe nails straightacross, wear well fitting shoes, avoid meds unlesed cleared by M.D, stop
smoking not cut back!
rubella iz 12-15 months
if 51/50 and client is feeling better answer is: continue to monitor for suicide
tetany bactrium clostrdium
late sign of hypoxia increased heart rate R/T increased energy demands
fluid overload causes cerebral edema with a pt with meningitis check for icp too
care plan for client in manic state islisten attentivly to pt request, express wilingness and seriously consider the
request, and respond later.
nurse can anticipate a client in the 2nd trimester to be increased intorspection and general sence of well being
dislodge infants airway 5 back blows followed by 5 chest thrusts
chest tube working correctlyflux with fluid level while breathing. Bubbling indicates an air leak. constant
level indicates an obstruction
on g tube first be concerned with aspiration
while collecting data on unresponsive pt. first check responsivness
mao may cause hypotension so nursing dx is r/f injury
group b strep momlow temp in neonate = signof infection. Place mom and baby in seprate
rooms
mom rh neg baby rh pos give rhogam in 72 hrs
hemangiooma vascular tumor in baby
2nd trimester behavior narcissistic and facinated by children
variable decelschange position first action.
then they might do amniofusion or c sec if does not help
hypogly in the neonate lathargic
postpartum perineal discomfort contract your butt before sitting
cna canbottle feed a 24 hr neonate. no first bath, no diaper changes after circ, no
vitals in transitional period
pre term labor nursing intervention provide adequate hydration to halt contractions
cocaine an pgcause increased uterine contractlity, and preterm labor. notify neonatologist
about pts arrival
contraction breathing shallow chest breathing
34 weeks pg and in the er complaning of vag bleed nurses first action is check fhr and maternal bp
vbac incsion lower uterine transverse is the only one allowed with vbac
pg chocking provide chest thrusts
heat loss from evaporation with the neonate drying throughly after bath can prevent this
false labor contractions usually occur in the abd irregular and typically relived by walking
mom with gdm baby is hyperglycemic then is hypoglycemic in the first 24hrs what is a nursing intervention
provide frequent early feeding with formula
high folic acid egg yolks, nuts, seeds and liver
phototheraphy adverse rxn watery stools
lochia 2nd day post op red and scant
embryo third week heart beats
neonate nl resp 30-60
heprin does not cross placenta
gave birth yesterday the fundus should be 1 fb below umbilicus
molar pg use bcp for 1 year
placenta previa softrelaxed non tender uterus
A client with glaucoma has been prescribed Timoptic (timolol) eyedrops.Timoptic should be used with caution in the client with a history of:
Emphysemaeta blockers such as timolol (Timoptic) can cause bronchospasms in the
client with chronic obstructive lung disease
A client being treated with sodium warfarin has an INR of 9.0. Whichintervention would be most important to include in the nursing care plan?
Assess for signs of abnormal bleedingThe normal international normalizing ratio (INR) is 2 - 3. A 9 might indicate
spontaneous bleeding.
An elderly client asks the nurse how often he will need to receiveimmunizations against pneumonia. The nurse should tell the client that she
will need an immunization against pneumonia:
Every 5 yearsImmunization against pneumonia is recommended every 5 years for persons
over age 65, as well as for those with a chronic illness.
A 45-year-old client returned from a colon resection 2 hours ago. Whichvital signs indicate possible hemorrhagic shock?
BP 96/60, heart rate 120
A client is 2 days post-operative colon resection. After a coughing episode,the client's wound eviscerates. Which nursing action is most appropriate?
Cover the wound with a sterile saline-soaked dressingIf the client eviscerates, the abdominal content should be covered with a
sterile saline-soaked dressing.
gathering data on an ocd pt what is most inportant to askdo you have trouble controlling upseting thoughts?
intrusive thoughts repeat over and over
pt is dnr and has cardiac arrest lvn should assess for signs of death
inserting an ng tube wear gloves gown mask and goggles
s/s of fat embolismconfusion, agitation, delirum, coma, increased resp, cp, sob, pallor, htn ,
paetechiae on chest.
liprium antianxiety used to tx etoh w/d
walker pick up move forward 10inches then take a few steps to it!
pt after a cataract removal c/o severe pain what lvn to do next tell RN
dumping syndrome decrease carbs
acute renal faliure decreased urinary output
6-12industry aspires to be best learns social skills, how to finish tasks, sensative
about school.
tube feeding at 100ml hr risdual checked its a 90 what to do?return and turn off feeding.
stop feeding if risdual is 50% of the volume infused in 1 hr
pku testingp a source of protein is injested. pref in the hospital in the first 24 hrs repeat
in 3 weeks
preshoolers need to see and play w/medical equiptment
nl cvp 5-10 cm h20
tx for hyperkalemia decrease k, iv nacl, kayexaltae ,ekg.
tx hypokalemia give KCL no more then 20 qhr observe i/o, ekg
hyponatremia135-145nl
weakness, restless,delirium, confusion
ca 4.3-5.3hypocalcemoa
cramping, tetany
ca 4.3-5.4hypercalcemia
a/n/v lathargy
tx of metabolic acidosisna bicarb, na lactate. watch labs. monitor for hyperkalemia and
dehydration.i/o.
metabolic alkalosis txhigh k high cl foods. i/o. Kcl. ammonium cl to increase hydrogen ions. labs,
monitor for hypokalemia.
resp acidosis tx all resp stuff to promote drainage, breathing etc. give na hc03,RL, and k
resp alkolosis txs/s hyper reflex, muscle twitching, convulsions. use rebreather. monitor k
and hco3
ab compatable w/ all blood groups
bladder irrigation 30-50ml
dvtbed rest 3-4days no pillow under leg . monitor for PE. antiemboletic
stocking to the other leg
fat emboli tx etoh drip, cortisone therapy, deholin to emulsify, lipid lowering drug
mag toxicity first indication extreme thirst
k 3.5-5.5
na 135-145
p mva fat emboli 24-48 hrs p
following removal of ng tube for a pt with pancreatitis diet should be high in carb
diet after cholectomy low residule and no dairy r/t the moucus it can cause
central line usually r subclavian
cl 100-106
bicrb 22-29
high gastric acid indicates duodeal ulcer
sed rate under age 50 20mm/hr
nl PT 11-15 seconds
HMG/COA teach photsensativity
elsa verifies hiv dx
male creatinine 0.6-0.9 elevated with renal insuff
nl bun 10-20
neutrophils first line defense
most common nosocomial infection c diff
removing isolation gown untie front waist strings, remove gloves, untie neck
emergency community wide disaster network who is notified first local health officer commander
rad exposure 1 hr to radiation exposure = 5o RADS
smallpox contraindicated cardiac, leukemia, lymphoma, PG, burns, hiv, shingles, eczema
anthrax standard percautions
pneumonic plague standard and droplet percautions
dm type 1 bg over 250 then check for ketones teach the pt this
high na in milk FYI
phenobarb excreted by the kidneys so good for hepatic coma
pt starts to shiver during a tempid bath stop as the body is attempting to produce heat
dicumarol an anti coag so teach pt about this type of drug
colchacine tox diarrhea first sign
priority assesment for bacterial endocarditis emboli
eartquake in the hospital first thing!!! look for instructions. dont call about pts that need help. weird
kid stong by jellyfish first thing bath in vinigar and apply shaving cream
pt is has severe reaction to meds initial action place pt supine in shock position
with heating pad first sign of thermal injury redness to area
proper depth for infant cpr 1/2 to 1 "
earlisest sx of shock narrowing pluse pressure
radiation beads have follon out of pt you cant find them let the rn know
nl ms dose1mg per//ml
or 5mg/ml on PCA
after masectomy position pt semi fowler with affected arm elevated
radiodermititisavoid all creams or lotions on the area. wash with leukwarm water and mild
soap
early warning ca sign change in bowl habits
wbc nl 5-10k
neomycin preop bowl surg to sterilize the bowl
cesium needle in cervix bed rest until it is removed
malignant melonoma worst prognosis
alkylating chemo drugs work by damaging dna in the cell nuclus fyi
after abortion pt develops dic what is the most critical intervention administer ordered meds (hep)
nst is reactive means that good outcome increased fetal hr w/movment
dm mom ask about breast feeding its encouraged insulin dose not cross to the milk
jaundice appears 2-3 days of life
primipara normally go through effacment before dilation
syphillis may be passed to the fetus after 4 months of pg
lvn care p gen anesthsia monitor bp q 3-5 min until stable
tetany uterus contarcted for more then 1 min= can rupture report to md
mag sulfate assess resp at least 12 per min
dm mom check baby for hypogly, resp. distress and hypocalcemia
baby chocking or resp distress pick it up by the feet and head low
post term babys look small like they have lost wt long nails little subq dry skin
bcp's inhibit fsh production
small for gestational age infants develop hypothermia
pg diet increase iron increase fa and increase cals 300
mastitis apply heat to the breast
american red cross clara barton
elizabeth mahoney first black nurse
managed care 80's to halt rapidly growing health care costs
complemetry care accupuncture, theraputic tuch and imagry
joint commision makes sure hospitals meet rigid standards
inferred consentno consent given by pt but situation is life threating so its inferred the pt
wants it
medical asepsis process to minimize or eliminate organisms that can cause disease
bureaucratic leadership policy minded
extingushier c electcal fire
paradoxical responce opposite effect that you wanted
enteric coated dose not disolve until reaches the intestines
woodslamphigh pressure mercury lamp long wave ultra violet to detect suprafical fungi
and bacterial infx
moist packs applied to the skin for debridment
vitiligo lack melanocytes results in white patchy skin
carbuncle several intr connecting boils in a cluster...yuck
burn types chemical,electrical, rad or thermal
entire back burn 18%
major burn includes second degree over 25% of body and inhilation burn injuries
digestion of carbs begins in the mouth
major fnx of fat provide energy
albumin and globulin blood proteins that help keep fluid were it belongs
electrolytes form acid bases and salts
trace minerals needed in the body in small amounts like zinc
fat soluble vits likely to cause tox cuz they accumulate in the body
k major intracellular electrolyte
basal cell non metasta in whites around the head and neck looks like fleshy nodule
saquamousmay mets red scaly patch second most common face lips mouth and rim of
ears
malignant melonoma danger dark pigmented mole occurs near a mole or other dark spot
endocrin consists of adrenals ovaries testes islets parathyroid pit and thyroid gland
pit gland master gland cuz it stimulates other endocrin glands to secrete
fbg 65-115 nl
cushings syndrome excessive adrenalcortico hormone from the adrenal cortex or brain tumor
adrenal crisis
hypotension, circulatory colapse coma death!Dont stop steroids all at once
or an infx can cause this
emergency tx: iv fluids to increase bv, Iv hydrocortisone , recombantposition with legs up
tyroid storm tx hypothermia blanket antithyroid and antiarrythmic meds
myexdema coma long term untx hypothyroidism
4 main oral anti dm catagories alphaglucaside inhibators, biguanides, sulfono's, thiazolidenedes
glyburide sulfon
regular insulin humulin r short acting
humalog insulin lispro intramediate acting
lipodystrophy change insulin sytes often!
hypogl sxsudden onset of pale moist cool clammy skin w/ sweating shaking and
hungur
hypergly sxSL
Ow onset of flushed dry skin, hot drowsy fruity breath, labored breathing
somongi effect hypogly followed by rebound hyper gly
tx of hyper gly iv fluids antiemetics and low dose insulin
insulin or oral dm meds dont drink cuz etoh can cause extra hypogly effect
glucotrol and etoh disulfaram effect violent, flusshing, throbbing ha, sob and unstable bp
20 grams simple carb = 4 oz OJ
high humidity ant temps 95-100 watch for heat related injuries
muscle cramps, ha, dizzines, weakness and excessive sweating=heat exhustion
tx cool the pt w/o chilling, loosen clothes cold wet compress to the skinwater replacment
heat stroke core temp 105-110 sweatring stops and brain cells FRY!
heat stroke nursing tx remove clothes wrap client in cold wet sheets, place ice axillary and groin
hypothermia
core 94 or lesssx shake clumbsy slow movment arrythmias
tx gradual rewarming cardiac monitor warm bevrages when awake
frost bite blisters some nerve damage increased hypersensativity to cold
anaphlatic SIRES stabilize,identify,reverse,eleminat,support
s/s of anaphlaxis hives cold clammy skin dizzy weak low bp nv itchy watery eyes
nervous sytem communicate and control
frontal lobe written and motor speech
expressive aphasia understand written and verbal but can not write or speak it
can not understand writen and verbal receptive aphasia
nervous sytem aging short term memory loss and thermoreg
206 bones in body FYI
ricketsvit d
bone formation
foramen were stuff goes through
cardiovascular aging results in hematopoiesis
low co2 stimulates breathing for nl adults
aging of the resp system increase r/f infx
aging urinary system nocturia
lens focuses on light rays
frail elderly 85 and over
maoi nardil
maoi on thymine foods
avoid pickles,aged, smoked, fermeted foods, dry sausage and wine
watch for htn crisis sx include occipital ha stiff neck palp sweating dilatedpupils photophobia and n
ect adverse effects ha and myalgia
benzo's xanax and valium
epse akathsia
nms cardinal sign hyperthemia and rigidity
anametadine and cogentin treat adverse effects of antipycotics
autisim sx rituals and lack of social interactions
adhd meds strattera, ritalin and aderall
amniotic fluid cushing
para viable newborn or gestation p 20 weeks
adolsent pg complications pre eclamp, eclamp, spon ab
molar pg early indication uterus enlarging early
iorn rich tofu, fortifed cearl, bread and lean meat
accreta placenta failing to seperate in 20-30 minutes retained placenta
mag sulfate(epson saltsO prevent and control sz
postpartum hemmorage notify md and do external uterine massage
rh neg mom rhpos baby baby will have eretroblastosis fetalis if left untxed
moro reflex startle through out arms draw up legs
post partum 3-10 days post delivery = mild depression usually resolves in 2 weeks
immediatly report jaundice in the newborn esp, in the first 24 hrs cuzindignative of pathologic jaundice results from mother building up ab
against her own fetus
first meconium greenish black
nl newborn axillary temp 97.6-98.6
newborn bp 50/30-80/50
newborn apical for 1 min 120-160 and slightly irregular
newborn resp 30-60
2 months dtap,hib, ipv,pcv
scarlet fever pinpoint reddots and strawberry tongue
chronic renal failure dietavoid high k foods,
Eat high ca and high fe
cushing dietincrease protein
increase kdescrease na and cals
addisons dietincrease nadecrease k
1 L of water= 1kg
1 cup 240 ml's
1 pint 480 ml
1 quart 960ml's
turgur forearm and sternum if wrinkled greater then 20 sec poor
skin breakdown
stage4 full thickness fascia, involves muscle tendon and bone
stage3 full thickness damage and necrosis down to the facia
stage 2 epidermis interrupted abrasion or blister
stage 1 intact skin nonblanching errathemia
trochlear downward and inward eye movment
trigeminal corneal reflex, chewing, face and scalp sensation
vagus gag reflex, swallowing talking,sensations of the throat and larynx
hypoglossal tongue moevemnt
battle sign ecchymosis at mastoid process in basilar skull fx ususally occurs 48hrs p
nystagmus constant involontary eye movment
hippus rythmatic and rapid dilation and constriction of the pupil
decorticate in c sz
generalized absence sz brief of conciouness or posture
myoclonic generalized sz repetative muscle contarctions jerking
tonic clonic stiffness followed by loc and rythmatic contrations of extremites
simple partial sz focal no loc aura usually
complex partial sz focal sz w/alteration in loc
afterload resestance against which the vebtericles must pump when ejecting blood
nl icp 10-15
l side heart failures sx pulmonary edema, sob, orthopnea,
r side heart failure dependent edema, hepatomegaly, abd pain, bloating
ra fatigue anorexia low grade fever joint pain
when is chest tube ready for removal when suction is removed no flucuation is noted in the water seal chamber
elderly client c PNU first symptom altered mental status
chemo before bone marrow transplant cuzto make space for new bone marrow and that all the cancer cells are
removed
nl neutrophil count 2200 to 7000mm3
neupogen colony stimulating factor given p chemo to stim wbc's
nl platlett count 150,000-400,000
s/s of hyponatremia ha lathargy confusion sz
hyper mg loss of deep tendon reflexes
demerol metabolites cause sz's
albumin iv colliod osmotic pressure
cholinergics increase ach in the brain good for Alzheimers
chronotropic change in heart rate
inotropic force of heart rate
dromotropic change w/conduction of electrical inpluses
p ng med administration leave pt sitting for 30 min
IV ntg drip in glass bottle cuz ntg adhers to plastic
iv acess insert needle at 30 degrees
phelbitis remove cath apply warmth moist pack
intr atrial lines for chemo to give close to tumor
when drawing blood from CVAD disgard 10 ml's
disconnected CVAD pt c CP first do turn pt on left side in trendelinburg
Groshong cathether has no clamp just a 3 way valve at the end
needle to access inplanted port 20 gauge noncoring
flushing Groshong 5-10 mls of NS weekly
RH positive can recieve rh neg bloosbut RH neg cant recieve RH pos
If it happens and its admisterd wrong till th eblood back and theMD
type o blood can only recieve type o blood
neutropenic pt usually be transfused with granulocytes
unit of whole blood must be used in 4 hrs
Graft vs. host disease attack on host tissue from lymphocytes. Usually occurs w/comprimised pt
type AB means no antibodies in the blood
amiodarone and dig cause increased dig levels
aldactone k sparing diuretic should not have increase k
electrolyte inbalance w/dig hypokalemia can cause dig tox
glucose6 phosphate dehydrogenase if on asa watch for hemolysis of rbcs. Esp c jews
flagly and etoh = n/v
antacids and dig can decrease absorption of dig!
desmepression acetate for hemophilia and von willebrands releases factor 8
timoptic reduces aqueous humor production
tapazole tx for hyperthyroid
cerebyx tx of sz's
s/e of NTG reflex tachycardia
tetracycline no if less then 8 cuz it stains teeth
phenergen adverse rxn tortacollis neck head tilted to one side
trycyclic adverse rxn= increased temp
body h20 60-70%
main source of energy in a diet carbs
breast feeding increase cals by 500
antabuse and drinking etoh cp, ha, nausea sweating
opioiod w/d sx tachycardia, tacypnea, htn, mydiasos
thrill narrow or buldging blood vessel pluse feels like a vibration
passive immunityadministration of ab produced by other people or animals. the pt is exposed
to the antigen and produces his own ab
2 y/o uses 1-2 word sentances
late fetal heart decels turn on l side give 02
p epidural priority action monitor bp
evaluation for restrant need q4h
haldol s/e hypotension tacycardia
regression pt's use it to elimimate anxiety
ivp be NPO
physiological jaundice on the second or third day decreases by 6th or 7th
renal failure be concerned w/ change in BP
infectious hep enteric percautions
high k foods oj, dried dates, milk
position for hypovolemic shock head on pillow and feet slightly elevated
cobalt implant percationsvisitors 1 hr q day exposure, everyone wears a protective shield, rad tx sign
on door
fetus in posterior position back discomfort
expressive aphasiatheraputically encourage to communicate even though not using correcrt
words
preeclampsia early signs htn, proteinurea, and edema
following a hip replacment during first postop hours observe for hemorrage
infant by 6 months doubles there wt
sengstaaken blakemore tube for espohgeal varices most important safetyintervention
scissors at bedsideresp system can be occluded if balloon slips moves up esophagus and
pressures trach. cut tube if in distress!
newborns usually sleep 20 out of 24 hrs
GDM most hard to control BSearly post partum R/T the [placenta contains the hormone insulinase which
blocks insulin during PG
bethanechol clstimulates PNS increases tone and motility of smooth muscles.
Give to a pt if they cant pee p a TURP..
preemie use soft preemee nip and half strength formula then work to full
nl pluse for a 5 y/o 100
pg be sure to take fe and folacin supplemental
3 month old can focus eyes on stuff
lactalose decreas blood ammonia
hypoglycemia in a infant shrill or high pitched cry
korsakoff syndrome neuro degeneration R/T vit deficiency
pt in er c DT's orders for IV w/vit b6, valium, or check VS. Which one to dofirst?
give IV w/ vit b6 first! wow strange!
baby w/spinal bifida most important assesment measure head circ qd
hirschsprugs diseas sx fails to pass meconium in 24-48 hrs classic sx
apical on a infant left mid clavicular, 3rd and 4th intra costal
interventions for a kid with RA warm comressions and splints at noc
mumps percautions droplet, direct and indirect contact via the resp.system
position for extrophy of the bladder side lying to aid in emptying
bronchiolitis priority assesment flaring nostrils, exp. stridor and wheezing
negativism struggle by a kid between what they can and can not do
one dram 4 ml's
interssusception sudden onset of sx
left side heart failure fatigue, dyspnea, wheezing
menieres disease extreme vertigo, bedrest.
osteoporosis teaching diet high in protein, ca, vit d, wt bearing excercise no etoh
low k skeletal muscle weakness
bucks extension p hip fx relives muscle spasms
pt wants to leave AMA what to do FIRTSnotify MD, then they will try to make her stay, then you can give AMA
form!
breech of duty care did not meet accepted standards
child had cardiac cath monitor peripheral pluses for symetry
child admitted with sickle cell crisis what should nurse do first vs to get a baseline including temp. they are prone to infx
low absolute granulocyte restrict visitors w/active infx's
cytoxan for chemo monitor for hematuria which can indicate hemorragic cystitis which is an adverse effect
subtle signs of resp distress in a child/infant restless, increase resp effort, increase resp,increase pulse, can not calm kid
a child with asthma attack is brought in he has no wheezing! probabley hypoxic or would be wheezing! emergancy
after shunt placment bed flat to prevent subdural hematoma
meningitis droplet spread my resp.
after cleft repair sit upright for feeding
bactrim crystalizes the kidneys drink lots of water
child is a home and has scolding burn immediatly flush site with tempid water to stop progression
glomerulonephritismonotor bp q 4 h
htn major complication
nl urine output for infant 5-10 ml/hr
nephroblastoma surg in 24-48 hrs after dx then chemo and rad to follow up
infant w/ an overdose of thyroid med tachycardia, fever, irratiblity,sweating
neonate w/pyloric stenosis postion on right side
NG tube and complains of nausea check placment then irragate the tube
gluten free diet no malted milk, wheat bread or spaghetti
cleft palate surg delayed till 18 months
cleft lip birth to 3 months
exacerbation of juvenile RA stress and climate
a child w/ duchennes mslow cal high protein high fiber
R/F constipation
absence sz brief loss of responsivness with minimal or no alteration in muscle tone
Ritilin adverse rxn slow growth and ht, sleepy, decreased appitite
do not admin fe with milk it delays absorption
breast feeding natural acquired passive immunity
kid w/ cyanotic heart defect what sx cyanosis, crabby, clubbing, crouching
ultrasound for PG used at 18-40 weeks
what is priority when feeding a neonate wit a cleft frequent small feedings
fetal blood ph shows 7.12 what nursing intervention is called for prep for c section. baby in fetal acidosis
decrement letting down phase of uterine contractions
to halt uterine contractions give brethine/trebutaline
monitor i/o with pitocin because it causes water intoxication leading to sz,coma and death
circulating HCg disapears 8-24 hrs p delivery
letting go phase mom excepts the kid as a separate individual
neonate temp range 96-97.7
phototherapy to reduce unconjugated bili
methergine ergot alkaloid given to stimulate uterine contractions p birth to decrease bleeding
mag sulfate produces smooth muscles depression asses for post partum hemmorage
p amniotomy priority nursing intervention asses fetal heart tones
transitional phase of labor cerv dilation 8-10 contractions 1-2 min apart
hiatal hernia avoid carbonated drinks R/t to esophageal irratation and increased pain
crohns diet needs high cal,protein,carbs and low fat
cytoctec for gastric ulcer monitor for diahrrea
levothroxine can cause tacycardia indicator of thyroid tox
sinemet is working if pt decreases tremors
eccrine gland associated w/body temp regulation
on corticosteriods check blood glucose
partial thickness burn fluid filled vesicles
eswl kindney stones are shattered
a pt w/kidney stones drink 3 l h20 each day
PTH deficiency abnl serum levels ca and phospurus
GTT dx w/Dm if greater then 200
radioactive iodine test increase w/hyperthyroid decrease w/hypo t
levothyroxine inhances coumadin dose!
addisonian crisis hyponatremia needs NS
abd rigidity classic sign of peritonitis
HA after lumbar puncture increase fluids to help restures CSF volume
greatest r/f femoral fx is hypovolemia from hemorrhage
temporal lobe controls speech and hearing
plasmapheresis ab removed from blood
to prevent vasospasms give crystalloids
epitaxis head slightly forward sitting up
breathing w/ emphysema triggered by low 02 levels
TB drugs effectvness can be indicated when sputum results show neg for TB
after a cath there is swelling at site apply firm pressure and have some one call MD
ca channel blocker decrease bp and hr
if BP below 90 systolic delay NTG
The nurse is monitoring a child with hydrocephalus who has aventriculoperitoneal (VP) shunt. What clinical manifestations will the nurse
be most concerned about?
Growth spurt, fever, and irritability changing to lethargy.
he major complications of VP shunts are infection and malfunction.Children can "outgrow" shunts or distal ends can dislodge after growth
spurts. Fever can be a sign of an infected shunt, and irritability deterioratingto lethargy could be due to increased intracranial pressure (ICP) from a
blocked shunt. Appetite usually decreases with increasing ICP;
A 2-year-old toddler was diagnosed with iron-deficiency anemia. Which ofthe following statements best describes the anemias of childhood?
The clinical manifestations of anemia are directly related to the decrease inoxygen-carrying capacity of the blood.
Clinical manifestations of fatigability, anorexia, weakness, and tachycardiaare a result of vitamin B12 and folic acid deficiency. This results in reducedproduction of red blood cells, and a 2-year-old child will manifest symptoms
of this disorder.
When assessing clinical indicators of adequate cardiac output in children,which of the following signs are most important?
Pedal pulses, skin temperature, and capillary refill.
A mother with a 4-month-old infant comes to the clinic for a well-babyexamination. The nurse advises the mother to change the formula she is
feeding the baby to one that contains iron. The nurse explains that the reasonfor this is
The infant`s iron source from the mother is depleted.Between 3 and 5 months, the infant has used the iron provided by the
mother and requires further supplementation if bottle feeding
Which of the following symptoms is the priority assessment because it issuggestive of a complication of a central nervous system infection?
Separation of cranial suturesMeningitis is a common CNS infection of infancy and early childhood.
Increased intracranial pressure, which can accompany meningitis, accountsfor separation of the cranial sutures, bulging not depresse.
What anatomical condition must be present in order for an infant withcomplete transposition of the great vessels to survive at birth?
Large septal defect.Because complete transposition results in two closed blood systems, the
child can survive only if a large septal defect is present
Assessing a child with a possible cardiac condition, the nurse knows that achild with a large patent ductus arteriosus would exhibit which of the
following symptoms?
Is acyanotic but has difficulty breathing after physical activity.PDA isacyanotic.
Following a saline-induced therapeutic abortion, a patient has developeddisseminated intravascular coagulation (DIC). The most critical nursing
intervention for this patient is to
Administer ordered medications.In DIC, the patient begins to hemorrhageafter the initial hypercoagulability uses up the clotting factors in the blood.Administering heparin, therefore, is a critical nursing intervention. Heparin
prevents clot formation and increases available fibrinogen, coagulationfactors, and platelets
A patient`s laboratory results indicate a creatinine level of 7 mg/dL. Thisfinding would lead the nurse to place the highest priority on monitoring the
patient`s
This elevated creatinine suggests impaired renal function. Monitoring intakeand output will provide data related to renal function
A common test used to determine fetal status in the presence ofpreeclampsia is the nonstress test (NST). If this test is "reactive," the nurse
knows that it means
Reactive = good outcome. Increased FHR with movement indicates normalreaction and adequate CNS integration
Which of the following statements is usually true about cervical changes inprimiparas
Primiparas normally go through effacement before dilation of the cervix.Multiparas tend to dilate and efface simultaneously.
A patient is 3 days postpartum. Her vital signs are stable; her fundus is 3fingerbreadths below the umbilicus, and her lochia rubra is moderate. Herbreasts are hard and warm to the touch. The nurse would evaluate that the
patient
Is normal for 3 days postpartumFrom the assessment findings of the lochiaand fundus, the new mother is progressing normally during the postpartum
period. The breast signs indicate normal engorgement, which occurs about 3days after birth. With stable vital signs, infection is not likely to be a
problem. Applying warm packs and wearing a nursing bra will reducediscomfort.
Assessing a patient with eclampsia, the nurse knows that a cardinalsymptom is
High blood pressure is one of the cardinal symptoms of toxemia oreclampsia, along with excessive weight gain, edema, and albumin in the
urine.
An eclamptic patient has been receiving magnesium sulfate IV 2 g/hour.What symptom would indicate that the current dose be continued
A respiratory rate of 16 per minute.The respiratory rate must be maintainedat a rate of at least 12 per minute as a precaution against excessive
depression of impulses at the myoneural junction
A patient is gravida 3 para 2 and is in a labor room. After a vaginal exam, itis determined that the presenting head is at station +3. The appropriate
nursing action is to
Prepare for delivery of the baby.f the head is +3, it is just about crowning,and because the patient is a multipara, it would be reasonable to assume
delivery is imminent.
Counseling a patient who is starting to use oral contraception, the nurseexplains that birth control pills work by the mechanism of
Birth control pills are small doses of estrogen and progesterone thatmaintain sufficient levels in the body to inhibit the pituitary from producing
the follicle-stimulating hormone.
During a physical exam of an infant with congenital hip dysplasia, the nursewould observe for which of the following characteristics?
Abduction is limited in the affected leg. The nurse would also findasymmetrical gluteal folds and an absent femoral pulse when the affected
leg is abducted.
If RhoGAM is given to a mother after giving birth to a healthy baby, thecondition that must be present for the globulin to be effective is that the
RhoGAM will not work if there is any titer in the blood; thus, it is importantto administer it within 72 hours after delivery or abortion if the mothershows no evidence of antibody production. The mother would be Rh
negative and the baby Rh positive for RhoGAM to be needed.
The nurse is doing data collection on a postpartum patient. Suspectinginfection, the nurse would assess for
The major symptoms of infection would be rapid pulse, foul-smelling lochiaor discharge, and discomfort and tenderness of the abdomen
A patient, 36 weeks pregnant, is having a contraction stress test (oxytocinchallenge test). After 35 minutes, her uterus begins to contract, and the nurseobserves three 40-second-long contractions in a 10-minute period. She hastwo contractions within 5 minutes, and her uterus remains contracted after
the second contraction. The first nursing action is to
The first action is to turn the Pitocin off. If the fetal heart rate has dropped inresponse to the prolonged contraction, turning the mother on her side (3) and
administering oxygen (2) may be necessary.
A nurse working in a prenatal clinic recognizes that the physician shouldimmediately see any patient who presents with
Blurred vision is an advanced indicator of pregnancy-induced hypertension(PIH) and the physician should see the patient immediately
The nurse is assessing a 75-year-old patient who is taking digitalis.Assessing for digitalis toxicity, the nurse would identify
Anorexia, nausea, vomiting.
NL wbc 5-10 k
A patient has had a partial colectomy because of a diagnosis of cancer.Surgery began at 7:30 AM. She returned to the unit at 1:30 PM. During a6:00 PM assessment, the nurse observed all of the following. A priority
concern that would require the earliest intervention is a
Inability to void after surgery is a common problem resulting fromanesthesia or pain medication and requires an early intervention. It is
important to be aware of the patient`s output for several reasons: to ensureadequate intake, to detect renal problems, and to assess for blood pressure
problems. Solution to this problem is catheterization, based on a physician`sorder. The dressing (1) should be closely observed but is not presently aproblem. The area on the calf (2) may be developing throbophlebitis and
should be reported to the physician immediatel
Administering care to a patient in hypovolemic shock, the sign that the nursewould expect to observe is
n shock, there is decreased blood volume through the kidneys. This isevidenced by a decrease in the amount of urine excreted. The body hasnumerous compensatory mechanisms that assist in keeping the blood
pressure normal for a short time.
A systolic blood pressure of 60 mm Hg or less would indicate shock inwhich of the following patient age groups?
A systolic blood pressure of 60 mm Hg or less found in children 5 to 12years old would indicate shock.
The nurse has an order to remove a patient`s nasogastric tube. The correctnursing action related to this procedure would be to
Removing the tube quickly while keeping it pinched lessens the risk ofgastric secretions falling into the trachea during removal. Instilling 20-30mL of air, rather than normal saline, into the tube will also help prevent
aspiration of gastric secretions. Unsterile gloves are worn for this procedure.
A patient is about to be discharged on the drug bishydroxycoumarin(Dicumarol).
Dicumarol is an anticoagulant drug and one of the dangers involved isbleeding. Using a safety razor can lead to bleeding through cuts. The drug
should be given at the same time daily but not related to meals. Due todanger of bleeding, missed doses should not be made up. The LVN is
prepared to do this patient teaching.
The nurse is inserting a Foley catheter into a male patient. How far shouldthe catheter be inserted before inflating the balloon?
7-9 inches.
The priority assessment for a patient with acute infective (bacterial)endocarditis is
While all of the symptoms may be present, the major complication with thiscondition is that of emboli. If emboli arise in the right heart chambers, theywill terminate in the lungs; left chamber emboli may travel anywhere in the
arterial tree. The nurse should constantly monitor for this complication.
Basilar crackles are present in a patient`s lungs on auscultation. The nurseknows that these are discrete, noncontinuous sounds that are
Basilar crackles are usually heard during inspiration and are caused bysudden opening of alveoli.
In developing a nursing care plan for a patient with Buerger`s disease, it isimportant to include
Buerger-Allen exercises improve peripheral arterial circulation which isspecific for treatment of Buerger`s disease
The nurse is collecting data on a patient with joint pain. The nurse knowsthat a patient who is in the early stages of rheumatoid arthritis is most likely
to complain of pain, swelling, and limitation of motion in the
Rheumatoid arthritis typically begins with inflammatory changes in thesmall joints of the hands, wrists, and feet.
The nurse would expect to find an improvement in which of the bloodvalues as a result of dialysis treatment?
High creatinine levels will be decreased. Anemia is a result of decreasedproduction of erythropoietin by the kidney and is not affected by
hemodialysis
A 50-year-old patient has a tracheostomy and requires tracheal suctioning.The first intervention in completing this procedure would be to
Before deflating the tracheal cuff, the nurse will apply oral or nasal suctionto the airway to prevent secretions from falling into the lungs
The nurse is teaching a type 1 diabetic patient about her diet, which is basedon the exchange system. The nurse will know the patient has learnedcorrectly when she says that she can have as much as she wants of
Lettuce contains primarily water and fiber, and is considered a "free food" inthe American Dietetic Association exchange lists.
A patient with a bile duct obstruction is jaundiced. The priority interventionto control the itching associated with jaundice is to
Itching is made worse by vasodilation. Tepid water prevents excessivevasodilation
When using nasotracheal suction to clear a patient`s airway of excessivesecretions, a principle of the suctioning procedure is to
To prevent trauma to the mucous membranes lining the airway, suctionshould be applied only while withdrawing the cathete
A patient with an admitting diagnosis of head injury has a Glasgow ComaScore of 3 - 5 - 4. The nurse`s understanding of this test is that the patient
A Glasgow Coma Score of 3 - 5 - 4 means that the patient is able to open hiseyes when spoken to and can localize pain, attempting to remove noxiousstimuli when motor function is tested. He is not able to follow commands
Part of a plan of care for a patient with increased intracranial pressure is tomaintain an adequate airway and to promote gas exchange. To accomplish
these goals, an effective nursing action is to
Hypercapnia leads to vasodilation, thus increasing cerebral blood flow andincreasing intracranial pressure.
Based on nursing knowledge, the nurse is aware that an epidural hematomais characterized by
A short period of unconsciousness followed by a lucid period, followed byrapid deterioration.
Epidural hematomas classically present with a brief period ofunconsciousness, followed by a lucid interval of varying duration, andfinally followed by rapid deterioration of the level of consciousness,
accompanied by complaints of a severe headache.
A patient is admitted following an automobile accident in which hesustained a contusion. The nurse knows that the significance of a contusion
is that
Laceration of the brain may occur.Laceration, a more severe consequence of closed head injury, occurs as the
brain tissue moves across the uneven base of the skull in a contusion.Contusion causes cerebral dysfunction, which results in bruising of the
brain. A concussion causes transient loss of consciousness and retrogradeamnesia, and is generally reversible.
A patient in the early stages of progressive renal failure is admitted to thehospital. The initial assessment will probably reveal
Polyuria, low urine specific gravity, polydipsia.
The nurse will assess for the most significant complication in patientsundergoing chronic peritoneal dialysis, which is
Peritonitis is a grave complication with peritoneal dialysis. Hemodialysismay be necessary until infection clears. Excess fluid and protein effluent
into the peritoneum also complicate care. Use of aseptic technique isessential
The most important teaching the nurse should do for a patient to have wellmanaged intermittent hemodialysis is
It is essential that the end-stage renal patient adhere to all aspects of themedical regimen. Only excess solutes and fluid are removed with dialysis.
Blood pressure management needs to be consistent, not just betweentreatments, aspects of care concerning concomitant anemia, and
phosphate/calcium/vitamin D imbalance, as well as protein restriction andfluid restriction, must be carried out at all times. The dialysis patient
continues to be uremic and has multisystem problems that continue despitedialysis.
A 12-year-old patient has just been returned to the unit following atonsillectomy. A priority nursing intervention during the postoperative
period is to
Apple juice or water is given as soon as the patient is awake and nothemorrhaging. Avoidance of citrus juices will prevent irritation of theoperative site. The patient should be placed on his abdomen or side to
facilitate drainage and prevent aspiration. Ice bags are applied to the neck toprevent edema and bleeding.
A patient with chronic renal failure is on continuous ambulatory peritonealdialysis (CAPD). Which nursing diagnosis would have the highest priority?
Imbalanced nutrition: less than body requirements.There is a high risk of infection in patients receiving CAPD because
microorganisms can enter the body by migrating around, or through, theperitoneal dialysis catheter. They may also enter through contaminated
dialysate solutions. The other diagnoses are not life threatening for a patienton CAPD.
Which of the following statements is true of skeletal traction?
Fractures can be reduced because more weight can be used than with skintraction.Because more weight can be applied with skeletal traction, it can beused to reduce fractures and maintain alignment. It is not used commonly in
the elderly because of prolonged immobilization. It is not preferred forchildren because some displacement of fracture fragments is desirable toprevent growth disturbance. Frequently, patients have more mobility than
they do with skin traction, because balanced suspension is oftenincorporated with skeletal traction.
Russell`s traction is easily recognized because it incorporates aRussell`s traction is a type of skin traction that incorporates a sling under the
knee that is connected by a rope to an overhead bar pulley. It is frequentlyused to treat femoral shaft fractures in the adolescent.
When evaluating all forms of traction, the nurse will check that the directionof pull is controlled by the
Rope/pulley system.
A patient has had a cystectomy and ure-teroileostomy (ileal conduit). Thenurse is assigned this patient in the postoperative period. Which of thefollowing observations indicates an unexpected outcome and requires
priority care?
Feces in the drainage appliance.The ileal conduit procedure incorporates implantation of the ureters into a
portion of the ileum that has been resected from its anatomical position andnow functions as a reservoir or conduit for urine. The proximal and distal
ileal borders can be resumed. Feces should not be draining from the conduit.
A patient requires that a bronchoscopy procedure be done. Due to hisphysical condition, he will be awake during the procedure. As part of the
pretest teaching, the nurse will instruct him that before the scope insertion,his neck will be positioned so that it is
Hyperextension brings the pharynx into alignment with the trachea andallows the scope to be inserted without trauma.
A patient with chronic lymphocytic leukemia is started on chemotherapy.Monitoring the administration of these drugs, the nurse would suggest
dietary guidance to
Consume fluids and foods high in bulk and fiber several hours before thetreatment.
R/T R/F constipation
Which one of the following conditions could lead to an inaccurate pulseoximetry reading if the sensor is attached to the patient`s ear?
Hypothermia or fever may lead to an inaccurate reading. Artificial nails maydistort a reading if a finger probe is used. Vasoconstriction can cause aninaccurate reading of oxygen saturation. Arterial saturations have a close
correlation with the reading from the pulse oximeter as long as the arterialsaturation is above 70 percen
There is a physician`s order to irrigate a patient`s bladder. The prioritynursing measure to ensure patency is to
Irrigate with 20 mL of normal saline to establish patency.
When assessing an ECG, the nurse knows that the P-R interval representsthe time it takes for the
Impulse to travel to the ventricles
When a patient has suffered severe burns all over his body, the mosteffective method of monitoring the cardiovascular system is
Pulmonary artery pressure is the most effective method of monitoring thecardiovascular system for this patient. Patients with a large percentage ofburned body surface often do not have an area where a cuff can be applie
A female patient has orders for an oral cholecystogram. Prior to the test, thenursing intervention would be to
Explain that diarrhea may result from the dye tablets.
Knowing that a patient has the diagnosis of heart failure (HF), whatsymptoms would the nurse assess during data collection?
Cyanosis, crackles, gallop rhythm
The laboratory result that should be monitored regularly in a patient who isreceiving gentamicin (Garamycin) is
Platelets.
A patient with thrombophlebitis should be positioned so that his legs are
Elevating the legs about 30 degrees promotes venous return and reduces legedema. Elevation beyond 45 degrees reduces arterial flow and causes sharpflexion at the hip, thereby reducing venous return. Leaving the legs flat on
the bed or dependent promotes edema formation and venous stasis. Patientswith arterial, rather than venous, insufficiency benefit from a dependent
position.
A hypothyroid patient has orders for all of the following medications. Thenurse would evaluate the patient most closely following administration of
which medication?
Hypothyroidism reduces the metabolic rate and prolongs the sedative effectsof medications. Narcotics are especially dangerous and should be given in
smaller doses. The patient must be closely monitored for signs ofoversedation and respiratory depression.
A patient with COPD has developed secondary polycythemia. Whichnursing diagnosis would be included in the care plan because of the
polycythemia?
Chronic hypoxia associated with COPD may stimulate excessive RBCproduction (polycythemia). This results in increased blood viscosity and the
risk of thrombosis. The other nursing diagnoses are not applicable in thissituation.
The nurse is teaching a patient with a new colostomy how to apply anappliance to a colostomy. How much skin should remain exposed between
the stoma and the ring of the appliance?
A colostomy appliance should be cut to fit the stoma so that there is nopressure placed on the stoma by the appliance and there is a minimum
amount of skin exposed to fecal drainage. Leaving 1/8 inch of skin exposedconforms to these criteria.
Which of the following blood chemistry results would the nurse expect tofind elevated in a patient with right-sided heart failure?
The liver becomes engorged with blood in right-sided heart failure. Liverfunction studies, such as the LDH, an enzyme production test for the liver,will be abnormally elevated in 40 percent of the patients. Serum bilirubin is
also frequently increased
The treatment prescribed for the burned area of skin before skin grafting cantake place will include
In addition to the germicidal soap scrubs, systemic antibiotics areadministered to prevent infection of the wound. Silver nitrate is not a
common treatment today
When a head injury patient has fluid draining from the left ear, the nursewill immediately position the patient with the head of his bed
It is important to decrease intracranial pressure (head of bed elevated) and toallow for drainage (head turned to left)
The patient has arrived in the recovery room following a lobectomy. As thenurse assigned to care for the patient during the immediate postoperative
period, the first intervention will be to
Closed chest drainage is used for lobectomies to reestablish negativepressure in the chest. Because the breathing mechanism operates on the
principle of negative pressure, this is an essential action. The otherinterventions would follow this one.
Connect the Pleur-evac to suction.
A nursing care plan for a patient with a suprapubic cystostomy wouldinclude
Allowing the patient to void naturally will be done prior to removal of thecatheter to ensure adequate emptying of the bladder
A patient admitted for possible bleeding in the cerebrum has vital signstaken every hour to monitor the neurological status. Which of the followingneurological checks will give the nurse the best information about the extent
of bleeding?
Pupillary checks reflect function of the third cranial nerve, which stretchesas it becomes displaced by blood, tumor, etc.
Patient teaching following cataract surgery should include
They must use only one eye at a time to prevent double vision.The function of the lens is that of accommodation, the focusing of nearobjects on the retina by the lens; therefore, only the remaining lens will
function in this capacity, depending on whether a cataract is present.
Preoperative teaching for a patient scheduled for a laryngectomy shouldinclude the fact that
The patient will be able to speak again, but it will not be the same as beforesurgery.
Most of the laryngectomy patients will use esophageal speech or amechanical device for communication. They can usually begin to take oralfluids sometime after 48 hours. They are generally fed by an intravenous or
nasogastric tube prior to oral feedings. Because the larynx is removed, itwill be impossible to breathe through the nose.
he main complication following a nephrostomy that the nurse must assessfor is
While all the other conditions may be complications, bleeding from the siteis the main concern. The procedure is done to achieve relief from infection
caused by urinary stasis, which may have resulted in kidney congestion.
Hemorrhage is a major complication following oral surgery or radical neckdissection. If this condition occurs, the most immediate nursing intervention
would be to
Putting pressure over the vessels in the neck may be lifesaving because asevere blood loss can occur rapidly, leading to shock and death. The surgeon
would be notified as soon as possible.
To achieve the desired outcome of fracture healing, which nursing goalshould receive the highest priority?
Maintaining the prescribed immobilization and body alignment will keep thefracture fragments in close anatomical proximity, thereby promoting
functional fracture healing. This goal should receive the highest priority.The other goals, although applicable in the
The nurse, collecting data for a nursing history from a newly admittedpatient, learns that he has a Denver shunt. This suggests that he has a history
of
The Denver shunt is a type of peritoneovascular shunt used in the treatmentof patients who have cirrhosis with ascites. The shunt diverts ascitic fluid
from the abdomen into the jugular vein or the vena cava
The nurse has been teaching a patient to use crutches. Which statementmade by the patient indicates a need for more teaching?
The hand grips should be placed so that the elbows are flexed at 20-30degrees when standing with the crutches. This placement should not be
changed as long as the patient continues to need crutches. The otherstatements indicate effective learning.
The nurse is preparing a patient for a myelogram using metrizamide(Amipaque), a water-soluble contrast material. The nurse will know the
patient understands the postmyelogram care regimen when she says
The head must be kept elevated because this drug could provoke a seizure ifit reaches the brain in a bolus form. After myelography that uses an
oil-based contrast medium (Pantopaque), patients are kept flat. Forcingfluids helps prevent postmyelogram headache by replacing lost spinal fluid.Itching suggests an allergic reaction, while a stiff neck suggests meningeal
irritation; neither is an expected response to a myelogram.
The precaution protocol necessary to implement for the biohazard ofPneumonic Plague is
Precautions include Standard plus Droplet (eye protection and surgicalmask)■until 48 ■72 hours after antibiotic treatment.
All staff must wear disposable particulate respirators (HEPA filter) when
Staff must wear disposable respirators when there is inadequate roomventilation. If the room has a directional negative-pressure ventilation
system, the staff would not be required to wear a HEPA filter mask, even ifthe patient had TB. These masks are required for droplet
transmission■based conditions.
The nurse is assigned to care for two patients. One patient has just returnedfrom surgery for an abdominal resection. The second patient is hospitalized
with an acute case of tuberculosis. What special precautions should thenurse take when providing care for these two patients?
There are no special precautions; however, the nurse must strictly adhere tobarrier nursing principles and the two patients must be treated separately.
Providing care to the abdominal surgery patient before the TB patient wouldbe appropriate. Proper handwashing is essential (1), but isolation garb is
needed only for the TB patient
When removing an isolation gown, steps the nurse should take would be to Untie front waist strings, remove gloves, and untie neck ties.
Two major factors that influence whether an infection occurs in anindividual are
Inherent health and immunologic status.
Which of the following is a type of transmission-based precaution? droplet
The nurse should explain to a patient who takes Lasix and has a potassiumof 3.2 mEq/L that he should``
The normal potassium level is 3.5-5.0 mEq/L. The patient`s potassium levelis low, and he needs to replenish what has been lost as a result of taking theLasix. In addition to taking potassium supplements, the patient should be
given a list of the appropriate foods that have an average of 7 mEqpotassium per serving. Eat three servings daily of fruits and meat or fish.`
The premenstrual hemoglobin of a 24-year-old patient with no history oftrauma, recent surgery, or hemorrhage is 9.8 g/dL. The nurse interprets that
this value is due to
The normal Hgb for a female is > 12-16 g/dL. With the data given, the nursewould suspect anemia Iron-deficiency anemia.
A patient is scheduled for a carotid endarterectomy in 3 days. Which of thefollowing preadmission lab test results must be immediately reported to the
physician?
Sodium of 151 mEq/L.The normal electrolyte values for an adult are asfollows: sodium of 135-145 mEq/L, chloride of 100-106 mEq/L, potassiumof 3.5-5.0 mEq/L, and bicarbonate of 22-29 mEq/L. The serum sodium is
the only abnormal value.
At the physician`s office, a patient has a random plasma glucose test. Theresults were 250 mg/dL. The patient asked the office nurse why the doctortold him to come back the next day to repeat the test. The best Answer is
"This test requires that it be done at least twice for accurate results."The bestAnsweris to be truthful, but not to frighten the patient by telling him that hemay have diabetes (2) (this is the domain of the physician). Levels of > 200
mg/dL on more than one occasion would, however, be diagnostic ofdiabetes, so the doctor would order at least two tests.
A patient comes to the clinic complaining of a variety of symptomsincluding pain. The patient has a gastric analysis done and results show that
gastric acid is high. This test result would indicate to the nurse that thepatient may receive the diagnosis of
High gastric acid levels may indicate a duodenal ulcer.
A 60-year-old patient is admitted to the surgery unit for removal of fibroidtumors. When the nurse checks the lab results for routine blood chemistry,
she notes that the sedimentation rate is 29 mm/dL. The appropriateintervention is to
This is a normal sed rate for a female over age 60. Under age 50, normal is20 mm/hr. If it were increased, it would indicate presence of infection or
inflammation, and surgery might have to be postponed
A patient is admitted to the hospital for evaluation. His physician writes inthe chart "rule out liver cancer" and schedules a liver biopsy. Before theprocedure, the nurse reviews the PT results just returned from the lab: 24seconds. The nurse also notes that this patient is not on an anticoagulant.
The nursing intervention is to
Because the patient is not on anticoagulant therapy, the results are abnormal(normal PT is 11-15 seconds). It is important to notify the head nurse or
physician before the biopsy; bleeding could be life threatening. The patientwill probably be given vitamin K therapy and when the PT results return tothe normal range, the procedure can be done. Liver disease likely caused the
prolonged PT.
As part of an annual physical exam, a 60-year-old man has had lab workdone. Which of the following serum creatinine levels would indicate that the
patient has a mild degree of renal insufficiency?
The normal serum creatinine level for a male is 0.6-0.9 mg/dL. A patientwith a mild degree of renal insufficiency would have a slightly elevated
level, which in this case would be 1.7. Levels of 3.3 (2) and 4.0 (1) may beassociated with acute or chronic renal failure.
A patient with damaged or impaired lungs cannot remove all of the CO2from the body. When the excess CO2 combines with H2O, it will form
Excess CO2 in the blood, when combined with H2O, forms H2CO3,carbonic acid. Depending on the amount of acid in the blood, the lungs willincrease or decrease ventilation to remove excess CO2 (4). The kidneys can
excrete or retain H+ (3) and HCO3 (2); thus, the equation representinghomeostasis is: CO2 + H2O = H2CO3 = H+ + HCO3.(Lungs) (Kidney)
An 80-year-old patient has been admitted to the hospital with influenza anddehydration. Which of the following blood urea nitrogen (BUN) levelswould indicate to the nurse that the patient has received adequate fluid
volume replacement?
The normal BUN is 10-20 mg/dL
Which group of cells is the first line of defense against bacterial infectionworking primarily through phagocytosis?
Neutrophils are the first line of defense against infection. They live in thecirculation for about 6 hours after bacteria are ingested. The cells die and
become the main component of pus. Monocytes (1) are the second group todefend the body. Platelets (2) are blood components that go to the site of
injury and stem blood loss. Basophils (4) release heparin and histamine inareas that are invaded by antigens.
A 53-year-old patient with Crohn`s disease is placed on total parenteralnutrition (TNA). The fluid in the present TNA bottle should be infused by 8AM. At 7 AM, the nurse observes that it is empty and another TNA bottlehas not yet arrived on the unit. The nursing action is to attach the solution
nearest a TNA solution which is a bottle of
In order that the patient not experience a sudden drop in blood sugar, thesolution nearest most TPN solution concentrations is D10W.
The nurse`s discharge teaching for a patient with acute pancreatitis willinclude advising him to take a dietary supplement of
Because the patient will be on a low-fat diet to decrease pancreatic activity,he will need supplements of the fat-soluble vitamins
The nurse will know that the patient understands presurgical instructions forhemorrhoid surgery if his diet is
A high-fiber diet produces a soft stool without mechanically irritating thehemorrhoidal area. Foods include bran and complex carbohydrates.
The nurse`s diet instructions for a patient with a colostomy will beDiets are individualized and patients are generally able to eat the same foods
they enjoyed preoperatively. Fresh fruits may cause diarrhea in some, butnot all, individuals.
Which of the following statements would be correct when counseling apatient about the postoperative diet he would receive following a simple
surgical procedure?
A daily intake of 2800 calories is required for usual/general tissue repair,whereas 6000 calories may be required for extensive tissue repair. Fluid
intake is 2000 to 3000 mL/day for uncomplicated surgery. Diet progressesfrom nothing by mouth the day of surgery to a general diet within a few
days.
The nurse will know that the diabetic patient understands his diet when hesays that he should obtain the greatest percentage of calories from
The diabetic`s diet should be between 50 and 65 percent carbohydratecalories with only 5 percent of these being simple carbohydrates (sucrose).Fat recommendation is less than 30 percent of calories, and protein should
be 0.8 mg/kg/day.complex carbs
A patient with acute pancreatitis required nasogastric intubation due topersistent vomiting and paralytic ileus. Following NG tube removal, the
feeding schedule would start with a diet that is
Foods that are high in carbohydrate are given, because those with highprotein or fat content stimulate the pancreas. Alcohol is forbidden. There is
no need for the patient to be NPO.
A patient with cirrhosis and ascites is placed on a sodium-restricted diet tohelp control the ascites. In order for this plan to be effective, it is important
that the patient also
It is important that fluids be restricted as well, because unrestricted fluidintake leads to a progressive decrease in serum sodium from dilution.
Electrolyte imbalance with potential neurologic complications could result.
A patient with a history of pancreatitis should avoid which of the followingfoods?
Patients with this condition must not consume foods high in fat contentbecause there are inadequate pancreatic enzymes to digest the fat. High fatcontent also causes pain 2 to 4 hours after ingestion. The suggested diet is
high in carbohydrates.
The nurse questions the dietary department about the lunch delivered for apatient with the diagnosis of cirrhosis when she finds on his tray
Ham is high in sodium and can increase fluid retention, leading to edema.Cirrhosis patients are prone to edema as the osmotic pressures change due to
a decrease in plasma albumin.
The nurse will know that her teaching has been effective when the patientresponds that a low-fiber diet allows the inclusion of
Cooked vegetables and fruits as well as refined breads are included in alow-fiber diet. Bran, fresh fruits, and whole grains and seeds are included in
a high-fiber diet.
Patients with hepatitis may have a regular diet ordered, unless they becomeincreasingly symptomatic. The diet will then be modified to decrease the
amount of
With liver cell damage, the liver cannot break down and eliminate protein.Protein needs to be decreased until symptoms dissipate.
A pregnant patient comes to the clinic, and the nurse is responsible fornutritional counseling. When the patient says that she has eliminated all salt
from her diet, the nurse should respon
Research has indicated that pregnant women require a moderate amount ofsalt, because it is essential in maintaining increased body fluids needed foradequate placental and renal flow as well as tissue requirements. Highly
salted foods should still be avoided
Following surgery, a patient has an IV of D5W to run 50 mL/hr. When thenurse checks his condition for the evening shift, she realizes the IV is 1 hour
behind. The first action would be to
Increase the flow so that the loss is made up over the remaining hours in theday.
Hmmmmm?
One of the duties of the rehabilitative nurse is to teach the activities of dailyliving (ADLs) to a patient about to be discharged. One of the most important
nursing interventions to accomplish these goals is to
One of the most important principles of teaching is to demonstrate theactivity, encourage the patient to perform, and then give positive
reinforcement. It is important that the patient learn to do these activitieshim- or herself
The nurse responsible for administering a thiazide medication to a patientevaluates his recent lab reports, which are K+ 3.0 and NA+ 140. The nurse
would
The appropriate intervention is to withhold the thiazide medication (until thenurse receives further orders) and report the K+ level to the physician.Normal K+ is 3.5-5.5 mEq/L. His NA+ level is normal (range 135-145
mEq/L)
A patient scheduled for surgery is given a spinal anesthetic. Immediatelyfollowing the injection, the nurse will position the patient
Usually, the patient is positioned on the back following the injection. If ahigh level of anesthesia is desired, the head and shoulders can be lowered toslight Trendelenburg`s. After 20 minutes the anesthetic is set, and the patient
can be positioned in any manner.
The nurse is assigned to closely observe a patient for signs of magnesiumtoxicity following an IV of 4 g magnesium sulfate in 250 mL D5W. The
first indication of this condition is
The first sign that the nurse will observe is probably extreme thirst. Therewill also be a loss of the patellar REFLEX
When a person is experiencing severe stress, the nurse would assess forbehaviors such as
Crying and being upset is typical behavior experienced when a person isunder stress. Restlessness and anxiety (1) might be present, but they are not
typical responses
According to Selye`s stress theory, when the individual is in the alarm phaseof the general adaptive syndrome, the body first responds by
Going into shock and countershock.
At which of the following ages would the nurse first expect a child to sitwith no support?
nfants begin to sit with support or leaning forward on both hands at 6months. They sit with minimal or no support between 7 and 8 months. If this
milestone does not occur, the infant should be assessed for retardation.
The patient is age 4 and while in the hospital, he becomes very bored. Thebest activity to implement for this patient is
Fantasy is very active in this stage of development. Puppets would allow forexpression of feelings. Also, this activity is more active than TV (1) or
books (3) and involves the nurse with the child, which is a positive way ofestablishing a relationship.
The ultimate outcome, when the grieving process is successfully completed,will be when the bereaved
When the grieving process is completed, the bereaved will no longer feelemotionally dependent on the person who died. They will always feelemotion (1) when thinking of the loved one, but they will be able to
realistically recall both the good and bad times. There will always be theneed to talk about the loved one (4), even when the grief has been resolved.
In the presence of the RN, a physician asks the LPN to remove the suturesfrom the incision before the patient is discharged. The initial response to the
physician should be"Please write the order and the sutures will be removed."
The LVN observes the nursing assistant (NA) regulating the IV of anoncology patient receiving morphine sulfate for pain. The LVN is
responsible for the patient and has assigned the patient to the NA. Theappropriate intervention is to
Ask the NA to meet with the RN and him/her to discuss the responsibilityparameters that are appropriate for the NA.
The LVN assigns a patient with uremic frost from renal failure to the UAP.The patient is complaining of dry, itchy skin. To alleviate this problem
during bathing, the nurse will instruct the UAP to use
A weak vinegar solution with no soap Vinegar solutions may alleviateitching by dissolving crystal deposits in cutaneous layers and leaving an acid
layer on the skin. .
A state's Nurse Practice Act would not include
Difference between RN and LVN functions.Each state has its own Nurse Practice Act for RNs and LVNs. Separately,they are a series of statutes enacted by a state to regulate the practice of
nursing in that state. It includes all of these plus education.
The nurse is asked to do a TV commercial for hand lotion. In thiscommercial, she will wear her nurse`s uniform and advocate the use of thislotion by nurses in their work setting. In doing this, the nurse is violating
The code of ethics is a set of formal guidelines for governing professionalaction. This situation is not illegal■it is unethical.
The physician wrote a medication order for a patient. The LVN thought thedosage was incorrect. She questioned the physician who said it was all right.Still questioning, she asked the RN, who said it was all right. The LVN gave
the medicine, and the patient died from an overdose. Who is liable?
Both the physician and the nurse who gave the medication.
The primary purpose and criteria of licensure is toThe primary purpose of licensing nurses, both RN and LVN, is to safeguardthe public by determining that the nurse is a safe and competent practitioner.
A nursing assessment on a male patient indicates that he is showingevidence of increased intracranial pressure. The first nursing action is to
As the PaCO2 increases in the cerebral tissues, blood rushes to the area andthis further increases the intracranial pressure. Decreasing the PaCO2,accomplished by breathing deeper and more slowly, will decrease the
intracranial blood flow, thus decreasing intracranial pressure.
The nurse is caring for a patient undergoing chemotherapy for cancer. Oneof the goals of care is to discuss possible side effects of this therapy, one of
which is
Alopecia, or hair loss, will probably occur caused by damage to the rapidlydwindling cells of hair follicles. Hair loss begins 2 to 3 weeks after therapybegins and continues through the course of therapy. The other side effects
listed do not occur, as nausea, anorexia and diarrhea are common.
A neighbor asks the nurse to look at her 3-year-old child`s rash. Her face,neck and chest are covered with a maculopapular rash. She appears feverish
and her nose and eyes are "running." There are small red spots withbluish-white centers on the mucosa of her mouth. The nurse recognizes that
these manifestations are most likely caused by
Rubeola is a highly contagious virus. It is more severe than rubella orroseola because of the complications. The virus is transmitted by a cough or
sneeze.
A patient is several days postoperative following a right hip replacementwith a prosthesis. Assisting the patient to sit in a chair, the nurse will use
The ball in socket position is maintained by minimizing hip flexion (60degrees or less). This is done with wheelchair and commode extenders, high
chairs, and proper bed positions.
A patient has sustained a femoral shaft fracture and is being treated withskeletal traction using balanced suspension with a Thomas splint and
Pearson attachment. The goal of maintaining optimum positioning will beaccomplished by
It is important that the established angle between the affected thigh and thebed be maintained. The patient can usually have the head of the bed flat or
elevated and the lower leg can be exercised, then rest in the Pearsonattachment. If the patient migrates toward the head or foot of the bed, then
the angle between the thigh and bed would be altered, so it is important thatadequate countertraction be maintained.
Which one of the following conditions contraindicates giving morphine?
Morphine causes spasm of the gallbladder and the common bile duct, thusworsening the pain if stones are present. The spasm and resulting
inflammation can also block the pancreatic outlet (ampulla of Vater).Meperidine (Demerol) would be a safe choice for pain relief
A patient has been in a motor vehicle accident and has received cervical andspinal stabilization. He is alert and oriented with no evidence of head injury.
He develops lower extremity paralysis on the same side as the wound andloses pain and temperature sensation on the side opposite the injury. Basedon the preceding information, this type of spinal injury response would be
referred to as
Brown-Séquard syndrome is caused by hemisection of the spinal cord.Clinical manifestations include paralysis below the level of injury on the
same side as the lesion, and the loss of the perception of pain andtemperature below the level of injury on the opposite side of the lesion. A
total transection would lead to paralysis with no sensation
Apnea of prematurity is defined as a pauseApnea of prematurity is defined as: 1. cessation of breathing for 20 secondsor longer. 2. cessation of breathing for less than 20 seconds,but associated
with cyanosis, bradycardia or limpness
The nurse is interviewing a patient who has been addicted to opiates. Thepatient tells the nurse that he cannot understand why his drug screening testwas positive for opiates, as he is not using the drugs now. Which question
would help the nurse understand why the patient`s urine test was positive foropiates?
Ingestion of ibuprofen may cause a false positive on a urine screen foropiates
The father of a 24-hour-old baby boy asks how to hold his son, Christopher,who was circumcised 15 minutes ago. The nurse should respond
"There are a variety of ways to hold a baby. Let me show you a few that Ifind comforting to newborns."
Which of the following data place a patient at risk for developingpregnancy-induced hypertension (PIH)?
Primigravid women or women pregnant for the first time after an abortionare more susceptible to PIH than are multiparous women.
A 54-year-old female patient is 3 days postoperative following abdominalsurgery. The lab results indicate that her white blood cell count is 8,000/cu
mm. After analyzing this lab report, the nursing action is to
Do nothing because this is a normal count.This is a normal cell count (therange is 4500 to 11,000/cu mm) so the nurse would do nothing except note
that it is normal.
When educating the patient about prevention of coronary heart disease andabout risk factors, which of the following would the nurse describe as a
predisposing pathologic factor?
CHD is significantly higher in persons with pathologic conditions such ashypertension, hyperlipidemia, and glucose intolerance (such as diabetesmellitus). Gender is an unmodifiable risk factor. Smoking and stress are
considered modifiable risk factors.
During visiting hours, a patient the nurse is caring for becomes very agitatedand angry with his visitor. The most effective nursing approach to this
patient is to
Approach your patient in a warm, supportive manner and assist him toexplore his feelings
The nurse is teaching the family of a patient with adrenocorticalinsufficiency. It is important to assess coping skills and family functioning
of patients with this condition because
Clinical findings in Addison`s disease reflect involvement in most bodysystems including psychologic and behavioral changes.
When planning meals with a patient who is hemodialyzed three times perweek, which of the following food selections would indicate the patient
understands the dietary guidelines
Apple juice is low in phosphorus, sodium, potassium, and protein. Thepatient in renal failure must avoid these nutrients, because the damaged
kidney cannot clear them. Bananas are high in potassium. Red meat containsprotein and phosphorus. Legumes contain phosphorus.
A quadriplegic patient tells the nurse that he believes he is experiencing anepisode of autonomic hyperreflexia (dysreflexia). The first nursing
intervention is to
Elevate his head as high as possible.Blood pressure can become dangerouslyelevated during an episode of dysreflexia and can cause cerebral and retinalhemorrhages. Elevating the head will help prevent these complications and
should be the nurse`s first action. Identifying the precipitant is useful interminating the episode by removing the noxious stimulus which provoked
the exaggerated autonomic response. A full bladder may precipitatedysreflexia and emptying the bladder would be appropriate if it was the
precipitant. The blood pressure and pulse should be monitored throughoutthe episode of dysreflexia.
Dry heat (AquaK pad) is ordered for a patient with the diagnosis of right legthrombophlebitis. The orders read: apply to patient`s right calf continuously
for 20 hours. The nurse would expect that this treatment would
Because the affected veins are inflamed, the use of heat is indicated to helprelieve the inflammation and venospasm
The most important consideration when working with or teaching olderadult patients is to evaluate their
The developmental stage is very important when developing plans and whenconsidering the health needs of the individual patient. Occupation, socialrelationships, and economic status should also be considered in working
with the elderly, but these factors are not as important.
A patient is admitted to the labor room with contractions that are about 4 to5 minutes apart and 30 seconds long. The couple have attended Lamaze
childbirth classes. During transition, the nurse should support a breathingpattern that is
Shallow chest breathing, slightly faster than a normal rate, is the patternused most in transition. Slow breathing, while effective for some women
during transition, is usually most effective in earlier labor
When catheterization is performed to obtain a urine specimen for culturefrom a young child, the procedure would include
Urinary catheters come in a variety of sizes however infants have urethrasthat are too small even for the smallest urinary catheters. For these infants, 5Fr and 8 Fr feeding tubes are used to obtain a specimen. All catheters must
be sterile and well lubricated.
Infants with sickle cell disease rarely show any symtpoms before 4 monthsof age because
Fetal hemoglobin resists sickling.
The primary purpose for adult patients having executed a valid living will isthat it
Protects health care providers who abide by its provisions against beingcharged with criminal negligence.
A 29 year old is in the labor room and has been there for 6 hours. It is thechange of shift and, when the nurse is receiving report, a nurse`s aide rushesin and says that the patient is delivering. As the nurse enters the room, the
baby`s head is crowning. The first nursing action is to
Support the baby`s head with a clean or sterile towel.
When instructing a group of mothers-to-be, which of the following wouldthe nurse note as the virus that most commonly causes acute diarrhea?
Rotavirus is the most common virus causing diarrhea in young children andaccounts for 50% of the admissions for dehydration and diarrhea.
A nurse is in a medication-oriented group therapy session with patients whoare all on medication therapy. One of the patients says, "I`m sick and tiredof taking these drugs." Many group members express similar feelings. In
addition to discussing the patients` feelings and the importance of andreasons for medication therapy, the group should have a goal that patients
will
Work closely with staff when they discontinue medications.
In a generalized seizure the airway may be compromised during the periodof the
During the tonic phase of a seizure, the individual loses consciousness, andcontinuous muscular contractions occur. If the tonic phase is prolonged, the
person may be unable to breathe because the respiratory muscles arecontracted. This can result in hypoxia. During the clonic phase, there is a
rhythmic jerking of extremities. The postictal phase is the postseizure phasewhen the person is relaxed.
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