Silvestri1901-2000

PN~CD~Questions~1901-2000 PN~CD~Questions~1901-2000 -

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Comprehensive Review CD Questions 1901-2000 {COMP: Equations/Formulas: 1963; questions: 1901, 1907, 1919, 1922, 1925, 1957; note multiple figures/figure credits for Question 1919.} {PLACE FIGURE HERE (Fig. 20) for Q#1901} Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. W.B. Saunders, p. 693. 1901. A nurse is checking the apical heart rate of a client with angina. The nurse places the stethoscope in which anatomical area? Answer: 4 Rationale: The apical heart rate is best assessed by placing the stethoscope in the mitral mitral area, which is located in the fifth intercostal space on the left side of the chest at the apex of the heart. Erb’s Erb’s point is located in the third intercostal space just left of the sternum. The aortic area is located in the second intercostal space just right of the sternum. sternum. The pulmonic area is located in the second intercostal space just left of the sternum. Test-Taking est-Taking Strategy: Recalling that the apical heart rate is best assessed at the apex of the heart and knowledge that this area is located in the fifth intercostal space to the left of the sternum will direct you to option 4. Review the procedure for taking the apical heart rate if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Cardiovascular References: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 693. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 561. {PLACE FIGURE HERE (Fig. 20) for Q#1901} Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. W.B. Saunders, p. 693.

1902. A nurse is collecting collectin g data from a client with varicose veins. veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? 1. Legs are unsightly in appearance and distress the client 2. The client complains of of aching and feelings of heaviness in the the legs 3. The physician finds that the legs become distended when the tourniquet is released during the Trendelenburg test 4. The client complains of of leg edema, and skin breakdown has started Answer: 4 Rationale: Complications of varicose varicose veins include leg leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic chron ic insufficiency. insuffici ency. The client with varicose veins may be distressed distressed about the unsightly unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are are common.


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Option 3 describes the Trendelenburg test findings, which are indicative of varicose veins. In the test, the physician has the the client lie down and elevate the legs to empty the veins. veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow. backflow. potential Test-T Test-Taking aking Strategy: Strategy: Use the process proce ss of elimination elimina tion and note the key words words potential complication. complication. Noting the words “skin breakdown” in option option 4 will direct you to this option. option. If you had difficulty with this question, review the complications associated with varicose veins. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Cardiovascular Health/Cardiovascular Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 343. 343 . 1903. A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and had an arterial blood gas test performed. Which of the following results would the nurse expect to note? n ote? 1. pO2 of 70 mm Hg and pCO2 of 50 mm Hg 2. pO2 of 68 mm Hg and pCO2 of 40 mm Hg 3. pO2 of 62 mm Hg and pCO2 of 40 mm Hg 4. pO2 of 60 mm Hg and pCO2 of 50 mm Hg Answer: 4 Rationale: During an acute exacerbation of COPD, the arterial blood gases deteriorate deteriorate with a decreasing pO2 and an increasing pCO2. In the early stages of COPD, COPD, arterial blood blood gases demonstrate a mild to moderate hypoxemia with the pO2 in the high 60’s to high 70’s and normal arterial pCO2. As the condition advances, hypoxemia increases and hypercapnia may result. Test-Taking est-Taking Strategy: Use the process of elimination and note the key words acute exacerbation. exacerbation. This will direct you to option 4. This is the the option that indicates the lowest pO2 level. If you had difficulty difficulty with this question, review the physiological alterations that occur in COPD and the associated blood gas values. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 497-499. 1904. A client client scheduled for a thyroidectomy says to the nurse, “I am so scared scared to get cut in my neck.” Based on the client’s client’s statement, the nurse suggests including which nursing diagnosis in the plan of care? 1. Anxiety related to inadequate knowledge knowledge about the surgical procedure 2. Ineffective Coping related to fear about impending surgery


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3. Situational Low Self Self Esteem related related to changes in personal appearance 4. Impaired Home Maintenance related to the surgical procedure Answer: 2 Rationale: The client is having a difficult difficult time coping with the scheduled surgery. surgery. The client is able to express fears but is frightened. frightened. There are no data in the question question to support options 1, 3, and 4. Test-Taking est-Taking Strategy: Use the process of elimination. Focusing specifically on the client’s statement in the question will direct you to option 2. Also note the relation between the words “scared” in the question and “fear” in the correct correct option. Review the defining characteristics for Ineffective Coping if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. p p. 1124-1127. 1905. A client client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client client indicates the best understanding understanding of this stress reduction measure? 1. “This works for me only if I am alone in a quiet area.” 2. “This will help only if I play music music at the same time.” 3. “I need to do this only when I lie down in case I fall asleep.” 4. “The best thing about this is that I can use it anywhere, anytime.” Answer: 4 Rationale: Guided imagery involves the client’s client’s creation of an image in the mind, concentrating on the image, and gradually become less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it. Test-Taking est-Taking Strategy: Use the process of elimination and note the key words best understanding . Eliminate options 1, 2, and 3 because of the absolute word “only.” “only.” Review guided imagery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 914. 1906. A client client who is 36-hours post-myocardial infarction has ambulated for the first first time. The nurse determines that the client client best tolerated the activity if which observation was made? 1. Skin cool but slightly slightly diaphoretic 2. Dyspnea noted only at the end of the exercise 3. Preactivity pulse rate rate 86 beats per minute, postactivity pulse rate 94 beats per minute 4. Preactivity blood pressure (BP) 140/84 mm Hg, postactivity BP 110/72 110/72 mm Hg


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Answer: 3 Rationale: The nurse checks vital vital signs and the level of fatigue with each activity. activity. The client is not tolerating the activity if there is a d rop in systolic BP greater than 20 mm Hg, changes in pulse rate of greater than 20 beats per minute, dyspnea, dyspnea, or chest pain. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise. Test-Taking est-Taking Strategy: Use the process of elimination. The question asks about activity tolerance, which tells you that you are looking for normal data. Look for the option that identifies normal values or the least degree of variation. Options 1 and 2 clearly identify abnormal data. Option 4 identifies a significant drop in BP, BP, indicating an abnormal condition. An increase in pulse rate as reflected in option 3 is a normal expectation after exercise. Review the effects of exercise on the cardiovascular system system if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1474. nursing (4th ed.). St. Louis: Mosby, Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th p 316. {PLACE FIGURE HERE (Fig. 21). For Q#1907} Wilson, S., & Giddens, J. (2005). Health (2005). Health assessment for nursing practice (3rd ed.). St. Louis: Mosby, Mosby, p. 489. 489 . 1907. A nurse is preparing to auscultate bowel sounds on a postoperative client. The nurse places the stethoscope in which quadrant first? Answer: 3 Rationale: To auscultate bowel sounds, the nurse should begin at the ileocecal valve area in the right lower quadrant, because bowel sounds are normally present in this area. The diaphragm end piece is used because bowel sounds are relatively high-pitched. The stethoscope is held lightly against the skin because pushing too hard may stimulate more bowel sounds. Test-Taking est-Taking Strategy: Knowledge regarding the anatomy and physiology of the gastrointestinal tract and the procedure for assessing bowel sounds is required to answer this question. Remember, begin at the ileocecal ileocecal valve area in the right lower lower quadrant. If you are unfamiliar with the auscultation of bowel sounds, review this procedure. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal References: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 655. Wilson, S., & Giddens, J. (2005). Health (2005). Health assessment for nursing practice (3rd ed.). St. Louis: Mosby, Mosby, p. 489. 489 . {PLACE FIGURE HERE (Fig. 21). For Q#1907}


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Wilson, S., & Giddens, J. (2005). Health (2005). Health assessment for nursing practice (3rd ed.). St. Louis: Mosby, Mosby, p. 489. 489 . 1908. A nurse nurse observes that a client’s client’s nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube is still not draining. The nurse analyzes this problem as: 1. Channels of gastric secretions may be bypassing the holes in the tube, and turning the client will promote stomach emptying 2. Thick gastric secretions may may be blocking the tube, and removing this tube and reinserting a new tube will correct the problem 3. It is a normal occurrence occurrence for a nasogastric tube to stop draining; no action is required 4. This is a potentially serious complication, and the physician physician must be notified immediately Answer: 1 Rationale: The nurse must check nasogastric tubes regularly to maintain maintain the tube’s tube’s patency and ensure that it is draining properly. properly. Nasogastric tubes are used to decompress the stomach. The gastric distention distention will be relieved only if the tube drains properly. properly. One cause of improper tube drainage results from channels of gastric secretions forming along the walls of the stomach stomach and bypassing the holes in the the nasogastric tube. Turning the client regularly helps to collapse the channels and promotes gastric gastric emptying. The tube has already been flushed, so it is unlikely u nlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a potentially serious complication. Test-Taking est-Taking Strategy: Use the process of elimination. Option 2 can be eliminated because the tube has just been flushed. Option 3 can be eliminated because it is is not acceptable to ignore a tube that has suddenly suddenly stopped draining. Option 4 can be eliminated because there are nursing options available to reestablish nasogastric tube patency before notifying the physician. If you you had difficulty difficulty with with this question, review nursing care to the client with a nasogastric tube. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 705. Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 1408. 1909. A nurse is performing performing nasotracheal suctioning of the secretions of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? 1. Secretions are becoming bloody bloody 2. Heart rate decreases from 78 to 54 beats per minute 3. Coughing occurs with suctioning


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4. Skin color becomes cyanotic Answer: 3 Rationale: The nurse monitors for adverse effects of suctioning, suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning, and reports these signs to the physician immediately. immediately. Coughing is a normal response to to suctioning for the client with an intact cough reflex, and does not indicate that the client cannot tolerate the procedure. Test-Taking est-Taking Strategy: Use the process of elimination. The wording of the question asks you to select an option that would be a normal or expected finding while suctioning the secretions of a client. Cyanosis (option 4) and bradycardia bradycardia (option 2) are abnormal findings, and are eliminated first. first. From the remaining options, options, the use of the word “becoming” in association with bloody secretions in option 1 tells you that this has not been an ongoing problem, making this an incorrect option also. Because the cough reflex is normally present, and suction triggers coughing, this is the preferable option of those remaining. Review the expected and unexpected findings during nasotracheal suctioning if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Health/Respiratory Reference: deWit, S. (2005). Fundamental (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 511. 1910. The nurse is is caring for a client receiving digoxin (Lanoxin). The nurse monitors the client for which early manifestation of digoxin toxicity? 1. Photophobia 2. Anorexia 3. Yellow color perception 4. Facial pain Answer: 2 Rationale: Digoxin is a cardiac glycoside glycoside that is used to manage manage and treat heart failure and to control ventricular rates in clients with atrial atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities can also occur early and include fatigue, headache, depression, weakness, drowsiness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity but are not early signs. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first first because they are similar and both relate to eye disturbances. disturbances. From the remaining options, focus on the key word early to direct you to option 2. Review the early signs of digoxin toxicity if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation


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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. W.B. Saunders, p. 310. 1911. A nurse nurse is planning a dietary menu for a client with congestive heart failure (CHF) being treated with digoxin (Lanoxin) and furosemide furosemide (Lasix). Which of the following would be the best dinner choice from the daily menu? 1. Beef vegetable soup, macaroni and cheese, and a dinner roll 2. Beef ravioli, spinach soufflé, and Italian bread 3. Baked pollack, mashed potatoes, and carrot-raisin carrot-raisin salad salad 4. Roasted chicken breast, brown rice, and stewed stewed tomatoes Answer: 3 Rationale: Furosemide depletes potassium potassium levels, and a client taking digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia may make the client more more susceptible to digoxin toxicity. toxicity. The recommended daily intake for potassium potassium is 2000 mg. Option 1 is not the best best choice because beef vegetable soup contains 1002 mg of sodium and only 76 mg of potassium. Macaroni and cheese has 1029 mg of sodium and no potassium. Option 2 is not the best choice because beef ravioli has 1150 1150 mg of sodium and no potassium. potassium. Spinach soufflé is is a good source of potassium (345 mg) but also contains 820 mg of sodium. Option 4 is not the best choice because roasted chicken breast contains only 218 mg of potassium and very little sodium (63 (63 mg). Stewed tomatoes contain 125 mg of potassium and 230 mg of sodium. Brown rice contains only 42 mg of potassium. Option 3 is is the best choice because all three foods are high in potassium: potato (314 mg), pollack (388 mg), and raisins (600 mg) and low in sodium. Test-Taking est-Taking Strategy: Use the process of elimination. Focusing on the client’s client’s condition will assist in determining that the client requires a high potassium and low sodium intake. Next, review the foods in each option to direct you to option 3. If you had difficulty difficulty with this question, review those foods that are high in potassium and low in sodium. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Nix, S. (2005). Williams’ basic Williams’ basic nutrition & diet therapy (12th ed.). St. Louis: Mosby, Mosby, p. 137. 1912. A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knew to report which of the following items? 1. Warm, flushed feeling 2. Pressure at the insertion site 3. Chest pain 4. Urge to cough Answer: 3 Rationale: The client is instructed instructed before cardiac catheterization to immediately immediately report chest pain or any unusual sensations. sensations. The client is informed that a warm, flushed feeling feeling


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may accompany dye injection, and occasional palpitations and the urge to cough may occur as the catheter tip touches the the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site. Test-Taking est-Taking Strategy: Use the process of elimination, noting the key words best understanding . Focus on the issue—what the client should report. This indicates that you are looking looking for an adverse consequence. This should direct you to option 3. Review client teaching points regarding the cardiac ca rdiac catheterization procedure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1592. Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 328. 3 28. 1913. A nurse is caring for a client with Buerger’s disease. Which finding finding would the nurse determine is a potential complication associated with w ith this disease? 1. Discomfort in one digit 2. Cramping in the the foot while resting 3. Pain with diaphoresis 4. Numbness and tingling tingling in the legs Answer: 4 Rationale: Buerger’s disease (thromboangiitis obliterans), obliterans), which affects affects men between 20 and 40 years of age, has an unknown etiology. etiology. It is a recurring inflammation inflammation of the smallsized and medium-sized arteries and veins v eins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. vessels. Options 1, 2, and 3 are not complications of this disorder. disorder. The finding that can be interpreted as a complication complication of the disorder is numbness and tingling in the legs. Test-T Test-Taking aking Strategy: Use the process pro cess of eliminatio el imination n and the ABCs—airway ABCs—airway,, breathing, and circulation—to answer this question. This will direct you to option option 4. If you had difficulty with this question, review the complications associated with Buerger’s disease. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 628. 1914. A client client with respiratory failure has a nursing diagnosis of Imbalanced Imbalanced Nutrition: Less than Body Requirements, related to ano rexia secondary to fatigue and dyspnea d yspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if the client: 1. Selected foods that are very dry


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2. Ate the largest meal of the day at a time when most hungry 3. Increased the use use of milk products 4. Increased the use of stimulants, such as caffeine caffeine Answer: 2 Rationale: The client is taught to to plan the largest meal of the day at a time when the client is most likely to be hungry. hungry. It is also beneficial to eat four to six small meals per day if needed. The client avoids dry foods, which are hard to chew and swallow. swallow. The client also avoids milk and chocolate, which have a tendency to thicken saliva and secretions. Finally, Finally, the client should avoid the use of caffeine, which contributes to dehydration by promoting diuresis. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate option 1 first because dry foods are hard to chew and swallow. swallow. Options 3 and 4 are eliminated eliminated next because they thicken secretions and have a dehydrating dehydrating effect, respectively. respectively. Review dietary suggestions for the client with a respiratory disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Respiratory Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1826. 1915. A client client has undergone fluoroscopy-assisted aspiration biopsy of a chest lesion. The nurse determines that the client is experiencing e xperiencing complications from the procedure if the nurse notes which of the following? 1. Pulse rate of 80 beats per minute, up from 74 beats per minute 2. Skin pink, warm, and dry 3. Absence of breath sounds in the right upper lobe 4. Oxygen saturation 97% by pulse oximetry Answer: 3 Rationale: Pneumothorax and bleeding are possible complications of this procedure. The client is observed for signs of respiratory difficulty, difficulty, such as dyspnea, change in breath sounds, change in vital signs, pallor, pallor, and diaphoresis. Observation of the sputum for for traces of blood or hemoptysis hemoptysis is also indicated. The absence of breath sounds in the right upper lobe indicates a potential pneumothorax. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the issue—a complication. Begin to answer this question by eliminating options 2 and 4 first, because they indicate normal data. Option 1 identifies a slight slight change in pulse rate, and may be expected with this procedure. Absence of breath sounds is always an abnormal finding. Review postprocedure complications co mplications following fluoroscopy-assisted aspiration biopsy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory References: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic


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procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 238. Mosby’s diagnostic and laboratory test reference (6th Pagana, K., & Pagana, T. T. (2003). Mosby’s ed.). St. Louis: Mosby, p. 586. 1916. A client client with acquired immunodeficiency syndrome (AIDS) has difficulty difficulty swallowing, and the nurse has given the the client suggestions to minimize minimize the problem. The nurse determines that the client has understood und erstood the instructions if the client verbalized to increase intake of foods such as: 1. Raw fruits fruits and vegetables 2. Hot soup 3. Peanut butter 4. Puddings Answer: 4 Rationale: The client is instructed to avoid spicy, spicy, sticky, sticky, or excessively hot or cold foods. The client is also instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to consume foods that are mild, nonabrasive, and easy to swallow. swallow. Examples of these include baked fish, fish, noodle dishes, well-cooked eggs, and desserts such as ice ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating. Test-Taking est-Taking Strategy: Use the process of elimination and focus on the issue—difficulty issue—difficulty swallowing. Evaluate each of the foods listed listed in terms of how easily they are swallowed. swallowed. The rough, hot, and sticky foods in options 1, 2, and 3, respectively, respectively, help you to choose choo se option 4 as the correct option. Review nutritional concepts and the AIDS client if you you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Immune Health/Immune Reference: Peckenpaugh, N. (2003). Nutrition (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. W.B. Saunders, p. 164. 1917. The nurse prepares to care for a client with inflamed inflamed joints and plans to use which item to maintain proper positioning for rest of the inflamed joints? 1. Large pillows 2. Footboards 3. Small pillows 4. Soft mattress Answer: 3 Rationale: Small pillows, trochanter trochanter rolls, and splints will properly and safely safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft soft mattress and footboards will not be helpful to inflamed joints and should be avoided. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate option 2 first because there is no direct relation relation between this item and resting resting joints. In general, soft mattresses mattresses are not beneficial, so eliminate option 4. From the remaining options, visualize each. Small pillows will be most effective effective in positioning inflamed joints. If you had difficulty


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with this question, review care to the client with inflamed joints. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, pp. 17231724. 1918. A client has received instructions on self-management of peritoneal peritoneal dialysis. The nurse determines that the client needs further instruction if the client states to: 1. Use a strong strong adhesive tape to anchor the catheter dressing dressing 2. Use meticulous aseptic aseptic technique for dialysate dialysate bag changes 3. Take own vital signs daily 4. Monitor own weight daily Answer: 1 Rationale: The client is at risk risk for impairment of skin integrity because of the presence of the catheter, exposure to to moisture, and irritation irritation from tape and cleansing solutions. solutions. The client should be instructed to use paper pape r tape or nonallergenic tape to prevent preven t skin irritation and breakdown. It is proper procedure for the client to use aseptic technique, and to self-monitor vital signs and weight on a daily basis. Test-Taking est-Taking Strategy: Use the process of elimination, noting the key words needs further instruction. instruction. These words indicate a false false response question and that you you need to select the incorrect client statement. Knowing that self-monitoring self-monitoring of weight and vital signs signs is important guides you to eliminate eliminate options 3 and 4. To choose correctly between options 1 and 2, you should know either that meticulous aseptic technique is used to prevent the occurrence of peritonitis or that the skin needs n eeds to be protected from maceration using a variety of methods. Review the procedure for peritoneal dialysis dialysis if you you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Renal Health/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 966. {PLACE FIGUREs HERE (Figs. 22-25). For Q#1919} {Fig. 22} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th nursing (5th ed.). St. Louis: Mosby,, pp. 1462. Mosby {Fig. 23} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th nursing (5th ed.). St. Louis: Mosby,, pp. 1463. Mosby nursing (5th ed.). St. Louis: {Fig. 24} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th Mosby,, pp. 1464. Mosby {Fig. 25} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th nursing (5th ed.). St. Louis: Mosby,, pp. 1465. Mosby 1919. A nurse is preparing to administer a soapsuds enema to a client. Which


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position does the nurse place the client to administer the enema? Answer: 3 Rationale: To administer an enema, the nurse assists the client into the left side-lying side-lying (Sims) position with with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural na tural curve of the sigmoid colon and rectum, thus improving the retention of solution. Option 1 is a supine position. Option 2 is a prone position. Option 4 is a right side-lying side-lying (semiprone) position. Test-Taking est-Taking Strategy: Focus on the issue—administering an enema. Think about the anatomy of the gastrointestinal gastrointestinal tract to assist assist in directing you to option 3. If you had difficulty with this question, review the procedure for administering an enema. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Fundamental Skills Skills Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th nursing (5th ed.). St. Louis: Mosby, Mosby, pp. 1462-1465. {PLACE FIGUREs HERE (Figs. 22-25). For Q#1919} nursing (5th ed.). St. Louis: {Fig. 22} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th Mosby,, pp. 1462. Mosby {Fig. 23} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th nursing (5th ed.). St. Louis: Mosby,, pp. 1463. Mosby nursing (5th ed.). St. Louis: {Fig. 24} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th Mosby,, pp. 1464. Mosby nursing (5th ed.). St. Louis: {Fig. 25} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (5th Mosby,, pp. 1465. Mosby

1920. A nurse has completed nutritional counseling counseling with an overweight client about weight reduction to modify the the risk for coronary artery disease. The nurse would determine the teaching as most successful if the client stated that a safe weight loss goal is: 1. One half pound per day 2. Two pounds per week 3. Four pounds per week 4. Six pounds per week Answer: 2 Rationale: Most people, including the mildly and moderately obese, can only lose about 2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due to protein and water loss alone. Test-Taking est-Taking Strategy: Use the process of elimination. Options 1 and 3 are similar similar and may be eliminated. The word “safe” before weight loss implies an optimum optimum value. Two pounds of weight loss per week is safer than six. six. Therefore option 2 is the best best option. Review the components of a weight loss program if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation


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Content Area: Adult Health/Cardiovascular Reference: Peckenpaugh, N. (2003). Nutrition (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. W.B. Saunders, p. 211.

1921. A postgastrectomy postgastrectomy client is at high risk for hyperglycemia hyperglycemia related to uncontrolled gastric emptying of fluid fluid and food into small intestine intestine (dumping syndrome). Because of this risk, the nurse plans to monitor the: 1. Fasting blood glucose readings 2. Postprandial blood glucose readings 3. Client’s Client’s daily weight 4. Calorie counts from the dietary department Answer: 2 Rationale: Late manifestations of dumping syndrome syndrome following a gastrectomy occur 2 to 3 hours after eating and result from a rapid entry of increased carbohydrate food into the jejunum, a rise in blood glucose levels, and excessive insulin secretion. To monitor this, the nurse checks the blood glucose level 2 hours after meals. Options 3 and 4 are unrelated to the issue of the question. A fasting fasting blood glucose level would not accurately determine hyperglycemia. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the key words postgastrectomy and hyperglycemia. hyperglycemia. Recalling that manifestations of dumping syndrome following a gastrectomy occur 2 to 3 hours after eating will direct you to option 2. Review the manifestations of dumping syndrome if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 664. {PLACE FIGURE HERE (FIG. 26) for Q#1922} Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. W.B. Saunders, p. 201. 1922. A nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 7:00 AM. The IV is to infuse at 100 mL per hour, and the nurse places a time tape on the IV bag. At noon the nurse would expect that the infusion line on the IV bag would be at which point? Answer: 2 Rationale: If an IV is to infuse at 100 mL per hour, in a 5-hour period (7:00 AM to noon) a total of 500 mL would have infused. Therefore the infusion line would be at the 500 mL point. Test-Taking est-Taking Strategy: Focus on the issue of the question—the amount of IV solution to infuse in a 5-hour period. Note that the IV bag contains 1000 mL: 1000 mL minus 500 mL equals 500 mL. Review the procedure for monitoring IV IV infusions if you had difficulty with this question. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Physiological Integrity


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Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Fundamental Skills Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. W.B. Saunders, p. 201. {PLACE FIGURE HERE (FIG. 26) for Q#1922} Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. W.B. Saunders, p. 201.

1923. A nurse has finished finished suctioning the secretions secretions of a client. The nurse would use which of the following parameters to best determine d etermine the effectiveness of suctioning? 1. SaO2 is 98% by pulse oximetry 2. Clear breath sounds 3. Client statement statement of comfort 4. Client’s Client’s color is pink Answer: 2 Rationale: The nurse evaluates the effectiveness effectiveness of the suctioning procedure procedure by auscultating breath sounds. This helps to determine if the respiratory tract tract is clear of secretions. Options 1, 3, and 4 do not determine determine the effectiveness of suctioning. Test-Taking est-Taking Strategy: Use the process of elimination, noting the key words best determine the effectiveness. effectiveness. Focusing on the purpose of suctioning—to suctioning—to clear secretions —will direct you to option 2. Review the purpose of suctioning if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Health/Respiratory Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, p. 1108. 1924. A client who underwent bronchoscopy was returned returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes: 1. Breath sounds greater on the right right side than the left side 2. Respiratory rate of 22 breaths per minute 3. Oxygen saturation saturation of 95% 4. Weak gag and cough reflex Answer: 1 Rationale: Asymmetrical breath sounds sounds could indicate pneumothorax, and this should should be reported to the physician. A weak cough and gag reflex 1-hour postprocedure is an expected finding, due to residual effects effects of intravenous sedation and local anesthesia. A respiratory rate of 22 breaths per minute and oxygen saturation of 95% are acceptable acceptab le measurements. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the issue—a complication. Therefore look for the abnormal piece of data. Begin to answer this


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question by eliminating options 2 and 3, which are acceptable data. From the remaining options, recall that the client is premedicated before this procedure, which would cause a weak gag and cough reflex. Remember, unequal breath sounds are always abnormal. Review postbronchoscopy complications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Health/Respiratory References: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 297. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 461. {PLACE FIGURE HERE (Fig. 27) for Q#1925} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby Mosby,, p. 483. 1925. A nurse nurse is reading a physician’s order and notes that a client is to receive a medication at 1:00 PM. Using the military time clock, the nurse administers the medication at which military time? Answer: 1 Rationale: Many health care agencies use military military time, which is a 24-hour system that avoids misinterpretation of AM and PM times. Instead of two 12-hour cycles in in standard time, the military clock is one 24-hour time cycle. cycle. Therefore 1:00 PM is 1300 military time. Test-Taking est-Taking Strategy: Specific knowledge regarding the military time clock is required to answer this question. Recalling that the military time clock is one 24-hour time time cycle will direct you to option 1. If you are unfamiliar with military time, review this information. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Fundamental Skills Skills Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 483. {PLACE FIGURE HERE (Fig. 27) for Q#1925} Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby Mosby,, p. 483.

1926. A nurse is monitoring the respiratory status of a client following insertion of a tracheostomy tube. The nurse understands that oxygen saturation saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems? 1. Hypotension 2. Fever 3. Respiratory failure


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4. Epilepsy Answer: 1 Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings because of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure would also not affect the accuracy of measurement, although the readings may be abnormally low. low. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the key word inaccurate. inaccurate. Recall that pulse oximetry measures oxygen saturation in blood flowing through the blood vessels in the periphery of the body. body. Inaccurate measurement may result from any factor that impairs blood flow through through the periphery. periphery. Evaluating each of the options from this viewpoint helps you to select select hypotension as the answer. answer. Review the procedure for measuring pulse oximetry if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, pp. 361-362. 36 1-362. 1927. A nurse nurse is caring for a client with pneumonia who has a history of bleeding esophageal varices. Based on this information, the the nurse plans care knowing that it is important to prevent: 1. Nausea 2. Diarrhea 3. Pain 4. Constipation Answer: 4 Rationale: Increased intrathoracic pressure contributes contributes to rupturing of varices. Straining during defecating, coughing, and vomiting vomiting all increase intrathoracic pressure. The nurse needs to implement measures that that will prevent increased intrathoracic pressure. Options 1, 2, and 3 will not increase intrathoracic pressure. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the client’s client’s diagnosis and noting the key word prevent word prevent . Recalling that activities that increase intrathoracic pressure can cause rupture will direct you to option 4. If you had difficulty difficulty with this this question, review the measures to prevent the rupturing of esophageal varices. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal Reference: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1346. 1928. An adult client has been defibrillated defibrillated three times unsuccessfully unsuccessfully for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is ongoing by two health care workers. The best indicator that CPR CPR is being performed effectively effectively is if: if:


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1. The chest compressions are given given at a depth of 1.5 to 2 inches inches 2. The ratio of compressions to ventilations given is 15:2 3. Respirations are given after 15 compressions 4. The carotid pulse is palpable with with each compression Answer: 4 Rationale: Correct procedure for basic life life support with two rescuers rescuers includes a compression to ventilation ratio of 15:2. With adults, compressions are performed performed at a depth of 1.5 to 2 inches. With With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal normal cardiac output, so correct technique is vital. Test-Taking est-Taking Strategy: Use the process of elimination noting the key words best indicator and the issue—that CPR is being performed effectively. effectively. Eliminate options 2 and 3 first because they are similar. similar. Also note that options 1, 2, and 3 are procedural and do not reflect an outcome. The issue of the question guides you to look for an end result of the procedure, which then directs you to option option 4. Review the findings that determine determine the effectiveness of CPR if you had ha d difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular References: Harkreader, H., & Hogan, M. A. (2004). Fundamentals (2004). Fundamentals of nursing: Caring and clinical judgment (2nd judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 912. nursing (3rd ed.). Linton, A. & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd Philadelphia: W.B. W.B. Saunders, p. 190. 1929. A nurse nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which of the following? 1. An air leak is present 2. The tubing is kinked 3. The lung has re-expanded re-expanded 4. The system is functioning as expected Answer: 4 Rationale: Fluctuations (tidaling) in in the water seal chamber are normal normal during inhalation and exhalation. Fluctuations of 5 to 10 cm (2 to 4 inches) during normal breathing are common. The absence of fluctuations could mean that that the tubing is obstructed by a kink, the client is lying lying on the tubing, or dependent fluid has filled filled a loop of tubing. Expanded lung tissue can also block the chest tube eyelets during expiration. The absence of fluctuations could also mean that air is no longer leaking into the pleural space. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge of the functioning of the chest tube drainage system system to answer the question. Focusing on the issue— fluctuations in the water seal chamber—and recalling the purpose of this chamber will direct you to option 4. Review the expected and unexpected findings in a closed chest drainage system if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity


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Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Health/Respiratory nursing (6th ed.). St. Louis: Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th Mosby, pp. 1117, 1121. 1930. A client client who is scheduled for surgery to be placed in skeletal traction says to to the nurse, “I’m not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture.” Based on the client’s statement, statement, the nurse should make which response to the client? 1. “Your “Your fracture is very unstable. You You will die if you don’t have this surgery performed.” 2. “There is no reason to to be concerned. I have seen seen lots of these procedures.” 3. “Skeletal traction is much more effective than than skin traction in your your situation.” 4. “You “You have concerns about skeletal versus skin traction for your type of fracture?” Answer: 4 Rationale: Option 4 identifies the therapeutic communication technique technique of paraphrasing. Paraphrasing is restating the client’s client’s message in the nurse’s nurse’s own words. Option 1 identifies a communication block that reflects a lack of the client’s client’s right to an opinion. It will also cause fear in the client. In option 2, the nurse is offering a false reassurance reassurance and this type of response will block communication. Option 3 is also a communication block and reflects a lack of the client’s client’s right to an opinion. Test-Taking est-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Select the option that enhances communication and addresses the client’s client’s feelings and concerns. Review therapeutic communication techniques techniques if you you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Process: Communication and Documentation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 437. 1931. The nurse is collecting data on a client with Parkinson’s Parkinson’s disease. Which finding indicates a serious complication of this disorder? 1. Congested cough and coarse rhonchi heard on auscultation auscultation 2. Last bowel movement was 48 hours ago 3. Resting and pill-rolling tremors 4. Shuffling and propulsive gait Answer: 1 Rationale: Clients with Parkinson’s Parkinson’s disease are at risk risk for aspiration. A congested cough and coarse rhonchi may be present after after a client aspirates. Although constipation is a problem for clients with Parkinson’s disease, the concern is greater if the client has not had a bowel movement by the third day. day. Resting and pill-rolling tremors and a shuffling, shuffling, propulsive gait are characteristic findings in Parkinson’s disease. Test-Taking est-Taking Strategy: Use the process of elimination noting the key word serious word serious.. Use the ABCs—airway ABCs—airway,, breathing, and circulation. Aspiration presents a serious risk risk to the client and may be suspected if the client with Parkinson’s develops a congested cough


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and coarse rhonchi. Review the signs of aspiration and the serious complications complications of Parkinson’s Parkinson’s disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Neurological Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2174. 1932. The client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis to Pneumocystis jiroveci pneumonia. Which measure should the nurse suggest including in the plan of care to assist the client in performing activities of daily living? 1. Provide supportive care with hygiene needs 2. Provide meals and snacks with high protein, high calorie, and high nutritional nutritional value 3. Provide small, small, frequent frequent meals meals 4. Offer low microbial food Answer: 1 Rationale: Providing supportive care with hygiene needs reduces the client’s client’s physical and emotional energy demands and conserves co nserves energy resources for other functions such as breathing. Options 2, 3, and 4 are important interventions for the client with AIDS, but do not address the issue of activities of daily living. Option 2 will assist the client in maintaining appropriate weight and proper nutrition. nutrition. Option 3 will assist assist the client in tolerating meals better. better. Option 4 will decrease the client’s client’s risk of infection. Test-Taking est-Taking Strategy: Focus on the issue—performing activities activities of daily living. Options 2, 3, and 4 are all important interventions for the client with AIDS, but do not address the issue. Option 1 is the only option that addresses the issue of the question. Also, note that options 2, 3, and 4 are similar similar and relate to nutrition. nutrition. Review care to the client with with AIDS if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Immune Health/Immune Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 23872388, 2397-2398. 1933. While doing discharge planning for for a female teenager with anorexia nervosa, the nurse suggests that the teenager attend a meeting of the local chapter of Anorexia Nervosa and Associated Associated Disorders. Which response by the teenager indicates that she will most likely be compliant with this suggestion? 1. “I’ll go once, but if I don’t like it I won’t go back.” 2. “I’ll think about it.” 3. “I’ll do whatever I have to do to get out of this place.” 4. “I’m going to do whatever it takes to get better.” better.” Answer: 4


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Rationale: Self-help groups serve to to reduce the possibilities of further emotional distress, distress, leading to pathology and necessary treatment. treatment. Option 1 indicates that the client client already has doubts about participation and has given herself permission to terminate participation in a self-help group. Option 2 identifies an ambivalent ambivalent attitude that promises nothing. Option 3 indicates that the client’s client’s thinking is limited to short-term short-term goals. Option 4 indicates that the client is a proactive participant in her plan of care. Test-Taking est-Taking Strategy: Use the process of elimination and focus on the key words most likely be compliant . The option that demonstrates the most positive client response response in terms of participation is is option 4. Review care to the client with with anorexia nervosa if you you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostro, C. (2003). Psychiatric Psychiatric nursing (4th nursing (4th ed.). St. Louis: Mosby, pp. 506, 512. 1934. A nurse nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. excessively. The best way for the nurse to explore issues with the client regarding this behavior is to: 1. Conduct a group discussion discussion with the client’s client’s family 2. Have the client express express the feelings in writing 3. Have the physician physician speak to the client 4. Ignore the behavior since it is is expected in clients with trigeminal neuralgia Answer: 2 Rationale: Speaking can exacerbate the pain pain that occurs with with trigeminal neuralgia. Having the client record feelings in writing will help the nurse to gain an understanding of the client’s client’s concerns without increasing the client’s client’s pain. Discussing the issue with the family will not provide insight into the client’s client’s feelings. It is not in the client’s client’s best interest to refer the matter to the physician or to ignore the behavior. behavior. The nurse should explore the client’s concerns and offer support. Test-Taking est-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Identifying the client in the question will assist assist in eliminating options options 1 and 3. From the remaining options, recall that ignoring the behavior blocks communication and places the client’s issues issues on hold. Remember to address the client’s client’s feelings first. Review therapeutic communication techniques and care to the client with trigeminal neuralgia if you had difficulty with this question. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Process: Communication and Documentation Content Area: Adult Health/Neurological Health/Neurological Reference: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1604. 1935. A client is scheduled scheduled to have electroconvulsive therapy (ECT). The nurse tells the client that:


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1. There are no expected side effects associated with ECT 2. Amnesia of events occurring near the period of the therapy is common 3. Many clients experience long-term memory loss 4. The client will receive no medications during during the procedure Answer: 2 Rationale: The most common side effects effects of ECT include include amnesia of events occurring near the period of the therapy and the potential for transient confusion as a result of the seizure and barbiturate barbiturate anesthetic. Option 1 is incorrect. Option 3 is incorrect because in most cases clients experience little little long-term memory loss. Option 4 is incorrect because general anesthesia and a muscle relaxant (often succinylcholine) are usually administered. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first first because of the absolute word “no.” From the remaining options recalling that most clients experience little long-term memory loss will direct you to option 2. Review the side effects related to ECT if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostro, C. (2003). Psychiatric Psychiatric nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 528. 1936. A client client with a burn injury begins to cry and states to the nurse, “I don’t don’t want anyone seeing me. I look awful.” The nurse determines that the client is at risk risk for which of the following? 1. Disturbed Body Image 2. Anxiety 3. Situational Low Self Self Esteem Esteem 4. Powerlessness Answer: 1 Rationale: The client with a burn injury injury experiences structural and functional changes of the integumentary system changes as a result of this injury injury.. The nursing diagnosis of Disturbed Body Image refers to a disruption in the way one perceives one’s body image. A verbal or nonverbal response to an actual or p erceived change in structure or function of the body must be present present to justify this this nursing diagnosis. Options 2, 3, and 4 do not relate to the client’s client’s statement. Test-Taking est-Taking Strategy: Use the process of elimination and focus on the data in the question. Noting the client’s client’s statement “I look awful” will direct you you to option 1. Review the defining characteristics for Disturbed Body Image if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Integumentary Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1043.


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1937. A client client had thoracic surgery 2 days ago and has a chest tube in place connected to a Pleur-Evac drainage system. system. The nurse notes that there is is continuous bubbling in the water seal chamber. chamber. The nurse determines that: 1. The client has a large large amount of fluid that is being evacuated by the system 2. This is a result of the suction applied to the system, system, which is set at 20 mm Hgof suction pressure 3. There is a leak in the the system, which requires immediate investigation and correction 4. This is normal on the second postoperative day Answer: 3 Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates that there is a leak somewhere in the system, and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action, which may include notifying the physician. Bubbling may occur intermittently intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. earlier. Hemothorax results in accumulation of drainage in the collection chamber, chamber, but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber, but not the water seal chamber. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge of the function and normal findings for each of the chambers of the Pleur-Evac closed chest drainage system. Remember that continuous bubbling in the water seal chamber indicates leakage of air into the system, while intermittent bubbling indicates drainage of pneumothorax. If you had difficulty with this question or are unfamiliar with the care of the chest tube drainage system, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 384. 384 . 1938. A client scheduled for pulmonary angiography is fearful about the procedure procedure and asks the nurse if the procedure involves significant pain and radiation radiation exposure. The nurse gives a response to the client that provides reassurance, based on the understanding that: 1. The procedure is somewhat painful, but there is minimal exposure to radiation 2. Discomfort may occur with with needle insertion, and there is minimal exposure to radiation 3. There is absolutely no pain, although a moderate amount of radiation radiation must be used to get accurate results 4. There is no pain from the procedure, and the exposure to radiation is negligible Answer: 2 Rationale: Pulmonary angiography involves minimal exposure to radiation. radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. Options 1, 3, and 4 are incorrect. incorrect. Test-Taking est-Taking Strategy: Use the process of elimination. Recalling that radiation radiation exposure


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is minimal helps to eliminate option 3 first. To select from the remaining options, it is necessary to know that the discomfort discomfort occurs only with with needle insertion. If you had difficulty with this question, review the description and procedure for pulmonary angiography. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Health/Respiratory Mosby’s diagnostic and an d laboratory test tes t Reference: Pagana, K., & Pagana, T. T. (2003). Mosby’s reference (6th ed.). St. Louis: Mosby, Mosby, p. 735. 7 35. 1939. A nurse enters a client’s client’s room and finds the client client slumped in the chair. chair. Breathing is shallow and a pulse is is present. Based on these data, the nurse determines that the priority would be to: 1. Call the the doctor immediately 2. Check the vital signs signs and level of consciousness 3. Have the secretary secretary call a Code Blue 4. Ask the unit clerk to to call the family immediately Answer: 2 Rationale: The client is breathing and has a pulse; therefore further further data are needed before any other action. The vital signs and level of consciousness should be checked. Once that assessment is made, the physician is notified, who will then contact the family. Code Blue is not indicated at the present time. Test-Taking est-Taking Strategy: Focus on the data in the question and use the steps of the nursing process. Option 2 is the only option that addresses data collection. Also, use of the ABCs—airway, ABCs—airway, breathing, and circulation—will direct you to option 2. Review emergency care measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2024. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. pp . 371-372. 1940. A nurse nurse has given instructions to the family of an older client who seems anxious about being discharged after cardiac surgery surgery.. The nurse would need to reinforce the the teaching if a family member made which of the following statements? 1. “Fatigue, discomfort, and lack of appetite occur more commonly with with older people, and may last for 2 to 5 weeks.” 2. “A daily half-mile long long brisk walk generally helps people bounce back more quickly and provides more of a sense of control.” 3. “Recuperation after cardiac surgery surgery is generally slower slower for older people.” 4. “It’s “It’s important to get out of bed every day, day, even if tired or weak at first.” Answer: 2


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Rationale: Clients generally increase activity activity by beginning a simple simple walking program, starting with distances of 400 feet twice daily and gradually increasing distance until able to walk ¼ mile (usually (usually at the end of the the second week). Exercise has physiological and psychological benefits. The statements made in options 1, 3, and 4 are correct. Test-Taking est-Taking Strategy: Use the process of elimination noting the key words need to reinforce the teaching . These words indicate a false false response question and that you you need to select the incorrect statement. statement. Noting that the client is older and recalling that activity is resumed gradually after surgery will direct you to option 2. Review home care instructions for the client who had cardiac surgery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 16481649. 1941. A nurse nurse monitors the laboratory data on a client at risk for coronary artery disease. disease. A fasting fasting blood glucose reading of 200 mg/dl is recorded on the chart. The nurse analyzes this result as: 1. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease 2. Decreased, indicating a decreased risk of coronary artery disease 3. Normal, indicating adequate blood glucose control with with no risk for coronary coronary artery disease 4. Elevated, but would not present a risk risk for coronary artery disease Answer: 1 Rationale: A fasting fasting blood glucose level of 200 mg/dl signals the presence of diabetes mellitus. Diabetes mellitus predisposes a client to coronary artery disease. Options 2, 3, and 4 are inaccurate interpretations. Test-Taking est-Taking Strategy: Use the process of elimination. Recalling the normal blood glucose level and recalling the association between diabetes mellitus and the risk for coronary artery disease will direct you you to option 1. If you had difficulty with this this question, review the normal blood glucose level and the risk factors associated with coronary artery disease. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Cardiovascular References: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, pp. 804805. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 903. 1942. After 5 days in the psychiatric unit, a manic client is able to tolerate tolerate short periods


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of time in the dayroom. dayroom. The nurse overhears the client telling telling another client that he is is a journalist posing as a client in order to write an article for a magazine. The nurse’s nurse’s best response/action is to: 1. Ignore the delusion 2. Confront the client with with reality 3. Take the client to a quiet room 4. Support the client’s client’s denial of illness Answer: 2 Rationale: When dealing with a delusional client, it is important to clearly state state that you do not share his or her perceptions. Options 1, 3, and 4 do not focus focus on reality and ignore the issue. Option 2 focuses on reality orientation. Test-Taking est-Taking Strategy: Use the process of elimination with the knowledge that reality orientation is the priority. priority. Options 1 and 4 are nontherapeutic and can be eliminated. eliminated. Option 3 takes the client out of the setting. Option 2, the correct answer, answer, provides reality orientation for the client. Review care of the delusional client client if you had difficulty difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, Morrison-Valfre, M. (2005). Foundations (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, Mosby, p. 331. 331 . 1943. A 4-year-old 4-year-old child is reluctant to take deep breaths following abdominal surgery. surgery. The most effective measure to encourage deep breathing is to: 1. Have the child pretend he is the the big, bad wolf blowing the little little pig’s pig’s house down 2. Give the child colorful latex balloons to blow up 3. Tell the child to exhale forcefully forcefully through the peak flow meter meter 4. Administer chest percussion percussion in several postural drainage drainage positions Answer: 1 Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flow meter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth o f respiration. Test-Taking est-Taking Strategy: Note the age of the child. Eliminate option 2 first for safety reasons. Next eliminate option 3 because the language language is too advanced for the age of the child. From the remaining options, note that option 4 does not relate relate directly to the outcome of deep breathing. Review the stages of growth and development and the relation to the hospitalized child if you had ha d difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Implementation Content Area: Child Health Reference: James, S., Ashwill, J., & Droske, Droske, S. (2002). Nursing (2002). Nursing care of children: Principles & practice (2nd ed.). Philadelphia: W.B. W.B. Saunders, p. 311.


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1944. The nurse’s nurse’s teaching plan for a client with a family history of breast cancer should include which most important item? 1. Teaching the breast self-exam technique to be done every month 2. Teaching the importance of weight-bearing exercises 3. Monitoring for grief reactions reactions 4. Implementing measures to prevent cancer Answer: 1 Rationale: Monthly breast self-examination is recommended for all adult women. It is especially important for those with a familial history history of breast cancer. cancer. Weight-bearing exercises are specifically important in preventing osteoporosis, osteoporosis, not breast cancer. cancer. There are no data in the question that indicate that assessing for grief reactions is necessary. Implementing measures to prevent cancer are important, but option 1 relates to the issue of breast cancer. Test-Taking est-Taking Strategy: Use the process of elimination and note the key words most important . The only option that directly directly relates to the data in the question is option 1. Note the relation of the words “family history of breast cancer” in the question and the words “breast self-exam technique” in option 1. Review health promotion measures for breast cancer if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Oncology Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p.353. 1945. A nurse is caring for a client with Addison’s Addison’s disease. The nurse checks the vital signs and determines that the client has orthostatic hypotension. hypotension. The nurse determines that this finding relates to which of the following? 1. A decrease in cortisol cortisol release 2. A decreased secretion of aldosterone 3. An increase in epinephrine secretion secretion 4. Increased levels of androgens Answer: 2 Rationale: A decreased decreased secretion of aldosterone results in a limited reabsorption of sodium and water; therefore the client experiences exp eriences fluid volume deficit and resultant orthostatic hypotension. A decrease in cortisol, an increase in epinephrine, and an increase in androgen secretion do not result in orthostatic hypotension. Test-Taking est-Taking Strategy: Use the process of elimination. Recalling the action of aldosterone in the regulation of intravascular volume and an d blood pressure will assist in answering this question. Determine the relationship relationship between blood pressure pressure control and aldosterone secretion when selecting the correct option. option. If you had difficulty difficulty with this question, review the action of aldosterone. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection


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Content Area: Adult Health/Endocrine Health/Endocrine nursing (4th ed.). St. References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 474. 474 . Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 645. 1946. Which nursing measure would be most most effective in preventing preventing complications in a client with Addison’s disease? 1. Restricting fluid intake 2. Offering foods high in potassium 3. Checking family support systems 4. Monitoring the blood glucose level Answer: 4 Rationale: The decrease in cortisol secretion that characterizes Addison’s Addison’s disease can result in hypoglycemia. hypoglycemia. Fluid intake should be encouraged to compensate for dehydration. Potassium intake intake should be restricted because of hyperkalemia. Option 3 is not a priority for this client in the question as stated. Test-Taking est-Taking Strategy: Use the steps of the nursing process remembering that data collection is first. first. This will assist in eliminating options 1 and 2. From the remaining remaining options, note that both options 3 and 4 address data collection; however, option 4 addresses the physiological need. According to Maslow’s Maslow’s Hierarchy of Needs theory, theory, physiological needs come first. Review the pathophysiology associated with Addison’s Addison’s disease and the nursing care involved if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 12191220. 1947. An older client with advanced Alzheimer’s disease disease is placed in balanced suspension traction, and the physician ph ysician expects to internally fixate the client’s client’s femur in 1 week. Based on this information, the nurse determines that the first first priority relates to addressing which of the following nursing diagnoses? 1. Risk for Constipation 2. Risk for Activity Intolerance Intolerance 3. Impaired Tissue Integrity 4. Disturbed Thought Process Process Answer: 1 Rationale: While all of these these nursing diagnoses may apply to this client, lying lying supine, being older, and having cognitive impairment place the client at extreme risk for constipation and possibly impaction. While the client likely does have disturbed thought processes because of Alzheimer’s disease and impaired tissue integrity as a result of the fracture, activity is restricted and tolerance therefore is unknown. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the data in the question.


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Recalling the effects of cognitive impairment, skeletal traction, analgesics, an algesics, immobility, immobility, and aging on the gastrointestinal tract will assist in answering this question. Also, note the length of time before the surgical surgical procedure. Review care to the older, older, immobile client with advanced Alzheimer’s disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2165. Wold, G. (2004). Basic (2004). Basic geriatric nursing (3rd nursing (3rd ed.). St. Louis: Mosby, Mosby, p. 141. 1948. A nurse nurse is reading the results of the Mantoux skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. ecchymosis. The nurse interprets that the result is: 1. Positive 2. Negative 3. Uncertain 4. Borderline Answer: 2 Rationale: A positive positive Mantoux skin test reading has an induration measuring 15 mm or more in clients at low risk, and is considered abnormal. An area of ecchymosis is insignificant, and is probably related to the injection technique. A Mantoux Mantoux skin test result that shows no induration is negative. Test-Taking est-Taking Strategy: To answer this question accurately, it is necessary to know that induration is necessary for a positive result. Because the client in this question has no induration, the result can only be negative. Review the procedures for reading the the results of a Mantoux skin test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 766. 1949. A nurse is collecting collecting data on a client with a diagnosis of hypothyroidism. hypothyroidism. Which of these behaviors, if present in the client’s client’s history, history, would the nurse determine as being most likely related to the manifestations of this disorder? 1. Depression 2. Nervousness 3. Irritability 4. Anxiety Answer: 1 Rationale: Hypothyroid clients experience a slow slow metabolic rate, and its manifestation includes apathy, apathy, fatigue, sleepiness, and depression. depression. Options 2, 3, and 4 identify the clinical manifestations of hyperthyroidism.


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Test-Taking est-Taking Strategy: Use the process of elimination and knowledge of the differences between hypothyroidism and hyperthyroidism hyperthyroidism to answer this question. Remember, “hypo” means “down” and “hyper” means means “up.” This may assist you in remembering the symptoms that occur in each condition. condition. If you had difficulty difficulty with this question, review the differences between each of these disorders. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Endocrine Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 890. 1950. An older client is transferred to the nursing unit following following a graft to a stage 4 decubitus ulcer. ulcer. Which combination of dietary items items would the nurse encourage the client to eat to promote wound healing? 1. Chicken breast, broccoli, broccoli, strawberries, strawberries, milk 2. Salad, watermelon, tea 3. Baked potatoes, Jell-O, water 4. Spaghetti, bread, cola Answer: 1 Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Options 2, 3, and 4 do not provide protein or vitamin C. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge of nutrition related to wound healing to answer the question. question. Recalling that protein and vitamin C are necessary for wound healing will direct you to option 1. Also, remember that when an option contains more than one item, be sure that all items in the option relate to what the question is asking. Review nutrition related to wound healing if you had difficulty difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 234. 1951. A client is admitted admitted to the hospital with a diagnosis of acute pancreatitis. The nurse plans care knowing that which problem occurs with this disorder? 1. Excess fluid volume related to sodium retention 2. Alteration in fluid and electrolyte balance related to hyperkalemia hyperkalemia 3. Alteration in comfort related to to abdominal pain 4. Potential for hypoglycemia hypoglycemia related to a low blood glucose level secondary to increased insulin secretion Answer: 3 Rationale: Abdominal pain is the predominant symptom of acute pancreatitis. pancreatitis. Shock and hypovolemia may occur from hemorrhage, toxemia, or loss of fluid into the peritoneal


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space. Potassium and sodium may may be lost from gastric suction and frequent vomiting. vomiting. Hyperglycemia may result from impaired carbohydrate metabolism. Test-Taking est-Taking Strategy: Use the process of elimination. Recalling that the predominant symptom of acute pancreatitis is abdominal pain will direct direct you to option 3. If you had difficulty with this question, review the signs and symptoms associated with acute pancreatitis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 742. 1952. What equipment should the nurse plan to have at the bedside when initiating initiating a clear liquid diet in a postoperative po stoperative client who has had general anesthesia? 1. Oxygen via nasal nasal cannula 2. Suction equipment 3. Cardiac monitor 4. A straw and a Styrofoam Styrofoam cup Answer: 2 Rationale: General anesthesia depresses the gag reflex that, in turn, increases the risk for aspiration. Suction equipment must be available in the event the the client aspirates. aspirates. Oxygen may be administered postoperatively and a cardiac monitor may be present, but these options have nothing to do with initiation of postoperative diet intake. A straw straw may help the client sip fluids, but is not necessary. necessary. Use of a Styrofoam cup is unnecessary. unnecessary. Test-Taking est-Taking Strategy: Focus on the issue of the question—the risk for aspiration aspiration and airway clearance. Option 2 addresses and maintains airway clearance. Review care to the postoperative client if you had difficulty d ifficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Planning Content Area: Fundamental Skills Skills Reference: Refere nce: Potter, P., P., & Perry, Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 1638. 1953. While collecting data on a client being prepared for an adrenalectomy, adrenalectomy, the nurse obtains a temperature reading of 100.8°F 100.8° F. The nurse analyzes this temperature temperature reading as: 1. Within Within normal limits 2. A finding that needs to be reported reported immediately 3. An expected finding caused by the operative operative stress response 4. Slightly abnormal but an insignificant finding finding Answer: 2 Rationale: An adrenalectomy is performed performed because of excess adrenal gland function. Excess cortisol production impairs the immune response, making the client at risk for infection. Because of this, the client needs to be protected from infection, infection, and minor


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variations in normal vital sign values need to be reported so that infections are detected d etected early and before they become overwhelming. Options 1, 3, and 4 are not correct interpretations. Test-Taking est-Taking Strategy: Use the process of elimination noting that the temperature is elevated and that the client is being prepared to undergo an adrenalectomy. adrenalectomy. Knowing that a temperature is an indication of infection and keeping in mind that the adrenal glands are needed to fight infection will direct you to option 2. If you had difficulty difficulty with this question, review preoperative nursing care of the client undergoing adrenalectomy. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Health/Endocrine References: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877. Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 1599. 1954. A nurse is working working in a tuberculosis tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB? 1. Persons admitted to the hospital for same-day surgery 2. Children over 6 years of age in a summer school program 3. Residents of a long-term care facility 4. A family family who has recently emigrated from Australia Answer: 3 Rationale: Residents of long-term care facilities are considered high-risk high-risk candidates for TB. Children under 4 years of age would also be considered a high-risk high-risk group. Persons admitted for same-day surgery surgery are not high-risk high-risk candidates. Foreign immigrants (especially from Mexico, the Philippines, and Vietnam) are considered high risk, but persons from Australia are not. Test-Taking est-Taking Strategy: Use the process of elimination. Recall that the very young and very old are often susceptible to infection, as are persons with chronic or debilitating diseases. Persons residing in a long-term care facility may fall into the category of being older and/or having chronic health problems. If you had difficulty difficulty with this question, review the high-risk populations for TB. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 374. 374 . 1955. A client client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) (CSF) protein level is 750 mg/dl. The nurse analyzes these results as: 1. Normal 2. Lower than normal, normal, ruling out Guillain-Barré Guillain-Barré


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3. Higher than normal, supporting the diagnosis of Guillain-Barré 4. Not significant and unrelated to Guillain-Barré Answer: 3 Rationale: Approximately 7 to 10 days following the onset of symptoms of GuillainBarré, the spinal fluid protein protein levels become extremely high. Normal CSF protein level level is 15 to 45 mg/dl. A value of 750 mg/dl is higher than normal, supporting supporting the diagnosis of Guillain- Barré. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge regarding the diagnostic results associated with with Guillain-Barré to answer answer the question. Recalling the normal level of CSF protein will direct you you to option 3. Also, note that options 1, 2, and 4 are similar in that they indicate that there is no relationship between the protein value identified in the question and Guillain-Barré Guillain-Barré syndrome. If you had difficulty difficulty with this question, review the diagnostic results associated with Guillain-Barré and the normal level of CSF protein. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Neurological Health/Neurological nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 609. 609 . 1956. The client is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the the client? 1. Administer enemas the evening before before and the morning of the procedure 2. After the procedure, keep the client client NPO until the gag reflex reflex returns 3. Keep the client on clear liquids for 24 hours before the the procedure 4. Tell the client that the substances used for the test contain only traces of radioactivity Answer: 2 Rationale: An ERCP requires that that a client is NPO for 12 hours before the procedure. Since an endoscope is inserted through the oral cavity, the throat will be sprayed with an anesthetic and the client will be kept NPO until the gag reflex reflex returns. Enemas are not needed. Radioactive isotopes are not used for this test. Contrast dye is is injected via a catheter into the pancreatic or bile ductal systems. Test-Taking est-Taking Strategy: Focus on the name of the diagnostic diagnostic procedure. Recalling that ERCP involves endoscopic insertion through the throat will direct you to option 2 . Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 501. {PLACE FIGURE HERE (Fig. 28). For Q#1957} Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1190.


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1957. A mother of a 5-year-old child brings the c hild to the emergency e mergency department and tells the nurse that the child fell. A fracture is suspected, and an x-ray x-ray is taken. The results indicate that the child child has a comminuted fracture of the right humerus. The mother asks the nurse to describe this type of fracture and the nurse draws a picture for the mother. Which picture identifies this type of fracture? Answer: 2 Rationale: When small fragments of bone are broken from the fracture fracture shaft and lie in the surrounding tissues, the fracture is called comminuted. An open or compound fracture (option 1) is a fracture with an open wound from which the bone is or has protruded. In an oblique fracture fracture (option 3), a diagonal line across across the bone is noted. In a greenstick fracture (option 4), the bone is partially bent and partially broken. Test-Taking est-Taking Strategy: Note the issue issue of the question—a question—a comminuted fracture. Recalling the definition of comminuted (fragmented) will assist in directing you to the correct option. If you had difficulty difficulty with this question, review the descriptions of the various types of fractures. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health References: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1190. nursing (3rd ed.). Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd Philadelphia: W.B. W.B. Saunders, pp. pp . 821-822. {PLACE FIGURE HERE (Fig. 28). For Q#1957} Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1190.

1958. A visitor brings a suicidal client a brightly packaged gift. gift. The nurse accompanies the visitor to the client’s room and takes which action? 1. Lets the visitor visitor spend time alone with the client client 2. Tells the client what a beautiful package this is 3. Suggests that the client open the gift 4. Reinforces the safety policies with the client Answer: 3 Rationale: The nurse must be concerned with the safety of the client. The visitor may or may not be aware of the client’s suicidal thoughts or the hospital safety policies. The client should open the gift in the presence of the nurse so that sharp or unsafe objects could be locked in the client’s client’s safety box. Leaving the package unattended in the room with the client is hazardous. Options 1, 2, and 4 are incorrect and unsafe. Test-Taking est-Taking Strategy: Note the key words suicidal words suicidal client . Because the client’s client’s safety is the priority, priority, the only option that assures that the gift is not dangerous for the suicidal client is for the nurse to ask the client to open the gift in the nurse’s nurse’s presence. Review care to the suicidal client if you had difficulty with this question. Level of Cognitive Ability: Application


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Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, Morrison-Valfre, M. (2005). Foundations (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, Mosby, p. 288. 288 . 1959. A client client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin megavitamin and diet therapy, therapy, since the original surgery did not provide provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which of the the following concepts? 1. The client’s client’s right to justice, and the nurse’s nurse’s obligation to protect this right 2. The client’s client’s right to privacy, privacy, and the nurse’s obligation to uphold the law 3. The client’s client’s right to freedom of speech, and the nurse’s nurse’s obligation to support the client 4. The client’s client’s right to autonomy, autonomy, and the nurse’s obligation obligation to behave ethically Answer: 4 Rationale: The client has the right to to autonomy, autonomy, or the exercise exercise of personal choice. At the same time, the nurse has the obligation to behave ethically. ethically. Some unconventional cancer treatments have not been proven to be effective, may be toxic to the client, and may be extremely expensive. The nurse balances the client’s client’s right to self-determination self-determination with the obligation to share with the client knowledge about the ineffectiveness of these methods. Privacy is the right right of a client to be free from intrusion by someone into their own personal affairs. Justice is the ethical principle of treating people fairly. fairly. Test-Taking est-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 1 and 2, because they are unrelated to the issue issue of the question. From the remaining options, select option 4 knowing that the nurse must behave ethically, ethically, and that the client ultimately has the right to exercise exercise personal choice. Review these ethical issues if you had difficulty with this question. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Fundamental Skills Skills Reference: deWit, S. (2005). Fundamental (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. pp . 39-40. 1960. The anticipated intended effect of fludrocortisone acetate (Florinef) (Florinef) for the treatment of Addison’s Addison’s disease is to: 1. Stimulate the immune immune response 2. Promote electrolyte balance 3. Stimulate thyroid production 4. Stimulate thyrotropin production Answer: 2 Rationale: Florinef is a long-acting long-acting oral medication with mineralocorticoid mineralocorticoid and moderate glucocorticoid activity that is used for long-term management of Addison’s Addison’s disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium potassium and hydrogen ions. In small doses,


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fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. The client can rapidly develop hypotension hypotension and fluid and electrolyte electrolyte imbalance if the medication is discontinued abruptly. abruptly. Options 1, 3, and 4 are not associated with the effects of this medication. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 because they are similar. From the remaining options, recall that Addison’s Addison’s disease is not related to the immune system and that Addison’s Addison’s disease produces deficiencies of glucocorticoids, mineralocorticoids, and androgens. This will direct you you to option 2. Review the action of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Health/Endocrine Reference: Hodgson, B., & Kizior, Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. W.B. Saunders, p. 418. 1961. This morning a client sustained sustained a right proximal fibula fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines determines that the client’s symptoms are indicative of: 1. Fat embolism 2. Volkmann’s olkmann ’s contracture contra cture 3. Venous thrombosis thrombo sis 4. Compartment syndrome Answer: 4 Rationale: In this situation, the the edema and the cast are compressing compressing the structures within the leg. As pressure within within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain, known as compartment syndrome. Fat embolism may result from a fracture, fracture, but the client is not experiencing any signs or symptoms of this complication. Venous thrombosis may occur after fractures, but would not affect sensation. Volkmann’s contracture is a result of compartment syndrome in an upper extremity following a fractured humerus. Test-Taking est-Taking Strategy: Specific knowledge of the complications associated with lower extremity fractures and with with casting is needed to answer this question. Focusing on the data in the question and noting the relation of these data to option 4 will direct you to this option. If you had difficulty difficulty with this question, review the complications associated associated with a fracture. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 143. 143 .


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1962. A client client has a newly fractured fibula, which is plaster casted in the emergency department. Because the client will need to to use crutches, the nurse plans to teach the client which crutch walking gait before be fore discharge? 1. Four-point alternate gait 2. Three-point gait 3. Two-point gait 4. Swing-through gait Answer: 2 Rationale: The client with a new fracture fracture that is casted with with a plaster cast needs to avoid weight-bearing movements. Option 2 is the only option that identifies a gait that allows non–weight-bearing movement on the affected extremity extremity.. The client should not bear weight on the affected extremity until the physician ph ysician evaluates the client on the follow-up examination. Test-Taking est-Taking Strategy: Use the process of elimination and visualize each of the gaits identified in the options. Recalling the different crutch crutch walking gaits and the amount of weight-bearing necessary for each gait will direct you you to the correct option. Remember that plaster casts are weak until they dry in a bout 48 to 72 hours, ho urs, so non–weight-bearing movement is essential until follow-up by the physician. If you had difficulty with with this question and are unfamiliar with the different types of crutch walking gaits, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: deWit, deWit, S. (2005). Fundamental (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. pp . 805-806. Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Mosby, Mosby, p. 950. {PLACE FIGURE HERE (Fig. 29). For Q#1963} Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed). Philadelphia: W.B. W.B. Saunders, p. 175. 1963. A physician physician has prescribed prochlorperazine (Compazine) 4 mg intramuscularly for a client who is vomiting. The nurse reads the label on the medication vial and administers how many milliliters to the client? 1. 0.8 mL 2. 1.2 mL 3. 4.0 mL 4. 5.0 mL Answer: 1 Rationale: Use the following formula for calculating medication dose: Desired _________ × Volume = mL per dose Available 4 mg _____ × 1 mL = 0.8 mL


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5 mg Test-Taking est-Taking Strategy: Follow the formula formula for the calculation of the correct dose. Use a calculator to verify the answer answer and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Fundamental Skills Skills References: Harkreader, H. (2000). Fundamentals (2000). Fundamentals of nursing: Caring and clinical judgment. Philadelphia: W.B. W.B. Saunders, p. 548. Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed). Philadelphia: W.B. W.B. Saunders, pp. 80, 175. {PLACE FIGURE HERE (Fig. 29). For Q#1963} Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed). Philadelphia: W.B. W.B. Saunders, p. 175.

1964. A client client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia dysreflexia (hypereflexia). Which finding is indicative of this this complication? 1. Knee jerk reaction is absent bilaterally 2. The client complains of a headache and the blood blood pressure is elevated 3. 100 mL of residual residual urine remains after the client voids 4. Pupil responses are brisk bilaterally Answer: 2 Rationale: Autonomic dysreflexia, also known as autonomic hyperreflexia, is a lifethreatening syndrome. It is a cluster cluster of clinical manifestations manifestations that results when when multiple spinal cord autonomic responses discharge discharge simultaneously. simultaneously. Exaggerated autonomic nervous system reactions to stimuli result in sudden hypertensive episodes with severe headache. The client may sweat profusely profusely above the level of the cord cord lesion and complain of a stuffy stuffy nose. Pupil and knee jerk jerk responses are not affected. While a distended bladder is often the precipitating event, not all clients with bladder distention exhibit dysreflexia. Test-Taking est-Taking Strategy: Note the key word autonomic, autonomic, which indicates that involuntary organ function is involved. Because knee jerk reactions involve skeletal muscles, muscles, eliminate option 1. Eliminate option 3 because catheterization (checking residual residual urine) is a treatment for dysreflexia, dysreflexia, not an assessment technique. Eliminate option 4 because the pupils are above the level of the injury, injury, so are unlikely to be affected. Because blood pressure is an autonomic function and headache can result from hypertension, option 2 is correct. If you had difficulty difficulty with this question, review the manifestations manifestations of autonomic dysreflexia (hyperreflexia). Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Neurological Health/Neurological nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 650. 650 .


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1965. A nurse nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which of the following is indicative of this complication of a spinal cord injury? 1. Hypertension 2. Tachycardia 3. Profuse diaphoresis 4. Areflexia below the level of injury Answer: 4 Rationale: Spinal shock represents a temporary temporary but profound disruption of spinal cord function, which occurs immediately after injury, and is clinically evident within 30 to 60 minutes. It is a state state of areflexia characterized by the the loss of all neurological function below the level of injury. injury. Flaccid paralysis occurs along with bradycardia, and hypotension. The body is unable to use either shivering or perspiring perspiring as a means of controlling body temperature. Test-Taking est-Taking Strategy: Focus on the issue—spinal shock. Recalling that this complication is characterized by a state of areflexia will direct you to the correct option. If you had difficulty with this question, review the signs and symptoms of spinal shock. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Neurological Health/Neurological Reference: Phipps, W., W., Monahan, F., F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, Mosby, p. 1409. 1966. A client client with quadriplegia complains bitterly about the nurse’s nurse’s slow response to the call bell and the rigidity of the therapy schedule. Which interpretation of this this behavior would serve as a basis for planning nursing care? 1. The client is reacting to loss of control 2. The client’s client’s complaints indicate indicate depression 3. The client must adjust to institutional institutional schedules 4. Limits must be set set on staff response response time to call bells bells Answer: 1 Rationale: Clients who feel a sense of control over their situation situation will adapt to their their limitations more readily that those who think that they have lost control. Both of the client’s complaints indicate a need for greater greater control. Clients should be offered offered an opportunity for input into scheduling scheduling and planning for staff staff response to their needs. For this reason, options 2, 3, and 4 are incorrect interpretations of the client’s behavior. behavior. Test-Taking est-Taking Strategy: Use the process of elimination focusing on the data in the question. There are not sufficient sufficient data to indicate depression. Since self-care is usually usually a desired outcome, interventions that limit client control, such as option 3, should be avoided. Option 4 addresses only one of the client’s client’s complaints without a focus on the real problem. It would not serve as the basis for for a plan of care. Review psychosocial behaviors that occur in a quadriplegia client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity


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Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Neurological Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2231 1967. The client diagnosed with with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. therapy. The nurse determines that the client is using the defense mechanisms of denial and projection and takes which initial action? 1. Collects information information to develop a database 2. Determines the client’s client’s past experiences with acting out 3. Explains to the client that nothing is wrong and accepts the behavior 4. Recognizes the level of client anxiety and sets limits limits Answer: 4 Rationale: Denial is a failure to to recognize what is occurring in a situation and generates inappropriate behavior. Projection is the disowning disowning and attributing process that enables a person to remain blind to aspects of self and distant to to the perception of others. Setting firm limits on unacceptable and inappropriate beh aviors in a nondefensive manner is the initial nursing action in this this situation. Because the client’s client’s behavior is inappropriate, option 3 is incorrect. Options 1 and 2 may be appropriate at some point but not initially. initially. Test-Taking est-Taking Strategy: Note the key words initial action. action. Also note the the behaviors of the client identified in the question. question. These types of behaviors require intervention by the nurse. This should direct you you to option 4, because this option is is the only one that specifically provides client intervention. intervention. Review interventions for the client with paranoid schizophrenia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Mental Health Reference: Stuart, G., & Laraia, M. M. (2005). Principles (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, Mosby, p. 414. 414 . 1968. A client client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several several days. On data collection the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address the client’s need for: 1. Physiological care 2. Safety and security 3. Self-esteem 4. Love and belonging Answer: 2 Rationale: An important consideration when working working with clients who have delusions delusions is the maintenance of safety. safety. Positive symptoms such as delusions may compel a client to take risks. Because the client shows no evidence of dehydration dehydration and malnutrition at this this time, safety and security is the priority need. Psychosocial needs (options 3 and 4) are not immediate client needs.


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Test-Taking est-Taking Strategy: Note the key words no evidence of dehydration and malnutrition at this time and focus on the issue—the issue—the immediate nursing action. Use Maslow’s Maslow’s Hierarchy of Needs theory. theory. Since a physiological need is not present, then safety and security needs take take priority. priority. This will direct you to to option 2. Review care to the client with delusions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostro, C. (2003). Psychiatric Psychiatric nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 107. 1969. The nurse is caring for a client with hypothyroidism hypothyroidism who has a nursing nursing diagnosis of Imbalanced Nutrition. Which food items would the nurse suggest to include in the plan? 1. Peanut butter, butter, avocado, and red red meat 2. Skim milk, apples, and whole-grain bread and cereal 3. Organ meat, carrots, and skim milk 4. Seafood, spinach, spinach, and cream cheese Answer: 2 Rationale: Clients with hypothyroidism hypothyroidism have a diagnosis of Imbalanced Imbalanced Nutrition: More than body requirements because of their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, however, the foods should be low in in calories. Option 2 is the only option that identifies food items that are low in calories. Test-Taking est-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis, diagnosis, recalling that the client with with hypothyroidism has a decreased decreased metabolic need. In options 1, 3, and 4, at least one of the food items is high in fat content; therefore eliminate these options. In option 2 all foods listed listed are low in fat. Review dietary needs for the client with hypothyroidism if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. p . 1197. 1970. A client client with Parkinson’s Parkinson’s disease quickly develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Stand erect and use a cane to ambulate 2. Keep the feet close close together while ambulating and use a walker 3. Consciously think about walking over imaginary lines on the floor 4. Use a wheelchair to move around Answer: 3 Rationale: Clients with Parkinson’s Parkinson’s disease can develop bradykinesia (slow movement)


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or akinesia (freezing or no movement). movement). Having these individuals imagine lines lines on the floor to step over can keep them moving forward. While standing erect and using using a cane can help prevent falls, these measures will not help a person with akinesia move forward. Clients with Parkinson’s Parkinson’s disease should walk with a wide gait, g ait, not with the feet close together. A wheelchair should should be used only when the client can no longer ambulate with assistive devices such as canes or walkers. Test-Taking Strategy: Focus on the issue—akinesia. Recalling the manifestations associated with this condition will direct you to option 3. Option 3 encourages forward movement while ambulating. Review ambulation measures associated associated with Parkinson’s Parkinson’s disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Health/Neurological References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2172. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby Mosb y, p. 1573. 15 73. 1971. A nurse has completed counseling about smoking cessation cessation with a client with with coronary artery disease. The nurse determines that the the client has understood the material material best if the client states that: 1. “A smoker smoker has twice the risk of having a heart attack than a nonsmoker.” 2. “I may try just cutting down first, first, since most of the damage has already been done.” 3. “I’m never going to start start again, since I can cut my risk of cardiovascular disease to zero within a year.” year.” 4. “I don’t think I want to quit, since none of the effects effects are reversible anyway.” anyway.” Answer: 1 Rationale: Cigarette smokers have twice the the risk of having a myocardial myocardial infarction than a nonsmoker and have two to four times the risk of having sudden sudden cardiac death. Smoking cessation will reduce its damaging effects on the cardiovascular system. Test-Taking est-Taking Strategy: Use the process of elimination. The words “zero” and “none” in options 3 and 4 are absolute words, and these options are eliminated eliminated first. From the remaining options focus on the issue (smoking cessation) and note the key word best in best in the stem of the question to to direct you to option 1. Review the relation of smoking cessation and the risk of cardiovascular disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 315. 315 . 1972. A nurse nurse has given a client with a myocardial infarction simple instructions on preventing some of the complications of bed rest. The nurse would intervene if the the client was performing which of these activities, which would be contraindicated?


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1. Repositioning self from side to side 2. Deep breathing breathing and coughing 3. Isometric exercises of the arms and legs 4. Ankle circles, plantar plantar flexion and dorsiflexion dorsiflexion exercises Answer: 3 Rationale: The client with myocardial myocardial infarction should avoid activities that tense the muscles, such as isometric exercises. These increase intraabdominal and intrathoracic intrathoracic pressures and can decrease the cardiac output. They can also trigger vagal stimulation, stimulation, causing bradycardia. The exercises in options 1, 2, and 4 are acceptable. Test-Taking est-Taking Strategy: Focus on the client’s client’s diagnosis. Note that the question is addressing a cardiac client and note the key word contraindicated . This word indicates a false response question and that you need to select the incorrect exercise. Eliminate options 1, 2, and 4 because they are basic basic and nonstressful exercises. exercises. Review activities related to the cardiac client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 316. 316 . 1973. A nurse nurse is preparing a client for skin grafting and notes that the physician has documented that the client is scheduled for for heterograft. The nurse understands that heterograft used for the burn client is skin from: 1. Another species 2. A cadaver 3. The burned client 4. A skin bank Answer: 1 Rationale: Biological dressings are obtained from from living or deceased humans (homograft (homograft or allograft) or animals (heterograft or xenograft). Heterograft is skin skin from another species. The most commonly used type type of heterograft is pig skin because of its relative relative compatibility with human skin. skin. Homograft is skin from from another human, which is usually usually obtained from a cadaver and is provided through a skin bank. Test-Taking est-Taking Strategy: Use the process of elimination. Note that options 2, 3, and 4 are similar and all refer to donor skin from the the human species. Option 1, the correct option, identifies skin from a different different species. If you had difficulty with with this question, review the types of skin grafting. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Integumentary Health/Integumentary References: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, pp. 1641-1642. 1974. A nurse nurse is caring for a client that is comatose and notes in the client’s client’s chart that the


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client is exhibiting decerebrate posturing. The nurse understands that decerebrate posturing is characterized by: 1. The extension of the extremities and pronation of the the arms 2. The flexion of the extremities and pronation of the arms 3. Upper extremity flexion with lower extremity extension 4. Upper extremity extension with lower extremity flexion Answer: 1 Rationale: Posturing is a late sign of deterioration in the client’s client’s neurological status and warrants immediate physician physician notification. Decerebrate posturing (abnormal (abnormal extension), which is associated with dysfunction in the brainstem area, is the extension of the extremities and the pronation of the arms. Options 2, 3, and 4 are incorrect incorrect descriptions of decerebrate posturing. Test-Taking est-Taking Strategy: Knowledge regarding the characteristics of posturing is required to answer the question. Remembering that decerebrate posturing posturing indicates abnormal extension will assist in answering questions similar similar to this one. If you had difficulty with with this question, review assessment data related to posturing. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Neurological Health/Neurological Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 617. 617 . 1975. A postgastrectomy postgastrectomy client who is being discharged from the hospital tells tells the nurse, “I hope my stomach problems are over. over. I need to get back to work right away. I’ve missed a lot of work and I’m really behind. If I don’t get my act together, together, I may lose my job.” Based on the client’s statement, the nurse determines that at this time it is most most appropriate to discuss: 1. Reducing stressors stressors in life 2. The postgastrectomy diet 3. An exercise program 4. Wound care Answer: 1 Rationale: Some clients need help reducing stressors in their lives. This may be extremely important for recovery recovery.. Clients may expect a rapid rapid recovery and are disappointed when this does not occur. The client’s client’s statement provides an opportunity for the nurse to discuss stress and its relationship relationship to gastrointestinal disorders. The data in the question are unrelated to options 2, 3, and 4. Test-Taking est-Taking Strategy: Use the process of elimination noting the key words most appropriate. appropriate. Focusing on the client’s client’s statement in the question question and noting that it relates relates to a psychosocial issue will direct you to option 1. Review the indicators of stress if you you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal


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Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. p . 1121. 1976. A client recovering from a craniotomy complains of a “runny “runny nose.” Based on the interpretation of the client’s complaint, the best nursing action is to: 1. Provide the client with with tissues tissues 2. Tell the client not to blow blow the nose 3. Monitor the client for signs of a cold 4. Notify the registered nurse nurse (RN) Answer: 4 Rationale: If the client has sustained sustained a craniocerebral injury or is recovering from a craniotomy, craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its its presence is indicative of a serious breach of cranial integrity. integrity. The nurse would check the drainage for the presence of glucose, which would be indicative of the presence of cerebrospinal fluid, and would also report the presence of any suspicious drainage to the RN, who will then contact the physician. Test-Taking est-Taking Strategy: Use the process of elimination noting the key words best nursing action. action. Remember, in a client with cranial trauma and injury, injury, the nurse should suspect cerebrospinal fluid leakage if drainage is noted no ted from the eyes, ears, nose, or traumatic area. Review care to the client following following craniotomy if you you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Health/Neurological References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 649. 649 . Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby Mosb y, p. 1517. 15 17. 1977. The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe and effective effective delivery of the oxygen, oxygen, the nurse avoids which of the following? 1. Secures the oxygen tubing to the the client’s client’s bottom sheet 2. Keeps the humidification jar filled with distilled water 3. Observes the client’s client’s nares frequently for for skin breakdown 4. Checks the oxygen flow rate and physician’ physician’ss orders every shift shift Answer: 1 Rationale: If the tubing is attached attached to the client’s client’s bed linen, it will become dislodged from the nares whenever the client moves. The tubing should have sufficient sufficient slack and be secured to the client’s client’s clothes. Keeping the humidification jar filled will help prevent the client from breathing dehumidified oxygen. oxygen. The nares should be checked frequently because oxygen will dry the nasal mucosa. Oxygen is a medication and its its order should be verified every shift to ensure the correct c orrect rate. avoids. This word indicates a false response Test-Taking est-Taking Strategy: Note the key word avoids. response


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question and that you need to select the incorrect intervention. Options 2, 3, and 4 will promote the safe delivery of oxygen. Option 1 could disrupt the flow flow of oxygen for the client. If you had difficulty difficulty with this this question, review the safety procedures associated with the use of oxygen. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Fundamental Skills Skills References: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, pp. 666667. nursing (6th ed.). St. Louis: Mosby, Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th Mosby, p. 1122. 1978. A nurse nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse interprets that: 1. The client must also have a high blood alcohol level 2. The client probably suffers from alcoholism 3. The carbon monoxide has caused the blood glucose level to decrease 4. The behavior is most likely likely the result of hypoxia Answer: 4 Rationale: The client with carbon monoxide poisoning may appear intoxicated. intoxicated. This is the end result of hypoxia on the the central nervous system (CNS). With carbon monoxide poisoning, oxygen cannot easily bind onto the hemoglobin, which is carrying strongly bound carbon monoxide. Since cerebral tissue has a critical need for oxygen, sustained sustained hypoxia may yield this typical finding. For this reason, options options 1, 2, and 3 are incorrect interpretations. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first first because they are similar and both address the issue of alcohol. From the remaining options, recalling that carbon monoxide displaces oxygen on the hemoglobin molecule will direct you to option 4. Additionally, Additionally, option 4 addresses add resses oxygen, the highest priority. priority. Review the manifestations associated with carbon monoxide poisoning if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory nursing (4th ed.). St. References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, p. 359. 359 . Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby Mosb y, p. 516. 51 6. 1979. A client client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse interprets that this result is: 1. Unexpected, and indicates a concurrent history of renal insufficiency insufficiency


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2. Unexpected, and indicates a deficit of hydrogen hydrogen ions in the bloodstream 3. Expected, and indicates the result of massive hemolysis hemolysis 4. Expected, and indicates that acidosis has driven hydrogen ions into the cell, cell, forcing potassium out Answer: 4 Rationale: With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell, forcing intracellular potassium out. This is an expected finding in this situation. Options 1, 2, and 3 are incorrect interpretations. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge regarding the effects of acidosis on the body. body. Note the relation between “acidosis” in the question and in the correct option. Also note that the potassium level is elevated and the relation relation between this elevated level and the issue of forcing potassium out of the cells in option 4. Review the effects of acidosis on the bod y if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, Mosby, pp. 360-361. 36 0-361. 1980. A nurse nurse gathers data from a client admitted to the hospital with gastrointestinal reflux disease (GERD) who is scheduled for a Nissen Nissen fundoplication. Based on an understanding of this disease, the nurse determines that the client may be at risk for which complication? 1. Diarrhea 2. Belching 3. Aspiration 4. Abdominal pain Answer: 3 Rationale: The primary symptom symptom of GERD is heartburn, also called pyrosis. Another symptom is regurgitation. regurgitation. The client reports the feeling feeling of warm fluid traveling traveling up the throat. If the fluid reaches the the level of the pharynx, the client client notes a sour or bitter bitter taste in the mouth. This effortless effortless regurgitation frequently occurs when the client is in the upright position. If regurgitation regurgitation occurs when the client is recumbent, the client is at risk for aspiration. Belching may be a symptom symptom of the disease. Diarrhea and abdominal pain are not specifically associated with the disease. Test-Taking est-Taking Strategy: Use the process of elimination and the ABCs—airway, ABCs—airway, breathing, and circulation—in answering the question. Note the key word complication and that option 3 identifies the priority priority concern because it relates to airway. airway. Review the complications of GERD if you had difficulty d ifficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th


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Louis: Mosby, Mosby, p. 184. 184 . 1981. A client has a blood glucose level drawn drawn for suspected hyperglycemia. After interviewing the client, the nurse determines that the client ate lunch approximately 2 hours before the blood specimen was drawn. The laboratory reports that the blood glucose level is 180 mg/dl, and an d the nurse analyzes this result to be: 1. Normal 2. Lower than the normal value 3. Elevated from the normal value 4. A dangerously high value requiring immediate immediate physician notification Answer: 3 Rationale: Normal fasting blood blood glucose values range range from 70 to 120 mg/dl. A 2-hour postprandial blood glucose level should be less less than 140 mg/dl. In this situation, situation, the blood glucose value was 180 mg/dl 2 hours after the client ate, which is an elevated value as compared to normal. Although the result may be reported to the physician, it is not a dangerously high one. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge regarding the normal blood glucose value to answer this this question. This will direct you you to option 3. Review the normal blood glucose g lucose value if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Endocrine Health/Endocrine Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 599. 1982. In planning nutrition for the client with hypoparathyroidism, hypoparathyroidism, which diet would be appropriate? 1. High in calcium and low in phosphorus 2. Low in vitamins A, D, E, and K 3. High in sodium with no fluid fluid restriction 4. Low in water water and insoluble insoluble fiber Answer: 1 Rationale: Hypocalcemia is the end result of hypoparathyroidism due either to a lack of parathyroid hormone (PTH) secretion secretion or to ineffective ineffective PTH influence on tissue. tissue. Calcium is the major controlling factor factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus, since these two electrolytes must exist in inverse proportions in the body. body. The other options are not dietary dietary interventions with hypoparathyroidism. Test-Taking est-Taking Strategy: Focus on the client’s client’s diagnosis. Recalling that hypocalcemia is the the end result of hypoparathyroidism will direct you you to option 1. The diets identified in options 2, 3, and 4 do not correct hypocalcemia. Review these concepts related to hypoparathyroidism if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Planning


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Content Area: Adult Health/Endocrine Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 1215. 1983. The nurse is planning care for a client with Bell’s Bell’s palsy. palsy. Which measure should be included in the plan? 1. Apply cold packs to the affected side four times a day 2. Ensure that the client client avoids wearing dark glasses glasses 3. Instill artificial artificial tears and a patch over the affected affected eye at night 4. Ensure that the client avoids touching the affected affected side Answer: 3 Rationale: Instilling artificial tears and patching the affected eye at night protect the e ye from corneal abrasions. Warm packs, not cold, will alleviate discomfort. Wearing dark glasses is recommended, as is gentle massage of the affected side. Test-Taking est-Taking Strategy: Focus on the client’ client’ss diagnosis. Recalling the pathophysiology associated with this disorder will direct you you to option 3. If this question was difficult, difficult, review this disorder and the nursing care. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Neurological Health/Neurological Reference: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1606. 1984. A nurse nurse analyzes the results of laboratory studies performed on a client with with peptic ulcer disease. Which laboratory value would indicate a complication associated with the disease? 1. White blood cell count of 5000 cells/mm3 2. Hemoglobin level of 10.2 g/dl 3. Platelet count of 400,000 cells/mm3 4. Creatinine level of 1 mg/dl Answer: 2 Rationale: The most common complications of peptic ulcer disease are hemorrhage, perforation, pyloric obstruction, and intractable disease. A low low hemoglobin and hematocrit level will indicate bleeding. The normal hemoglobin range in females is 12 to 16 g/dl and in males 14 to 18 g/dl. A white white blood cell count is performed to indicate the presence of infection or inflammation. inflammation. The normal white blood cell count is is 5000 to 3 10,000 cells/mm . The normal platelet range is 150,000 to 400,000 cells/mm3. The creatinine level measures renal function. function. The normal value is 0.6 to 1.3 mg/dl. mg/dl. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge regarding the complications associated with peptic ulcer ulcer disease and normal laboratory values. The only abnormal laboratory value in the options o ptions is the hemoglobin level, which is low, indicating bleeding. If you had difficulty difficulty with this question, review both the complications of peptic ulcer disease and these normal laboratory values. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity


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Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Gastrointestinal Health/Gastrointestinal References: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1032. Phipps, W., W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1035. 1985. A client has had a set of arterial blood gases drawn. The results are: are: pH 7.34, PaCO2 of 37, PaO2 of 79, HCO3 of 19. The nurse interprets that the client is experiencing: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Answer: 3 Rationale: Metabolic acidosis occurs when the the pH falls below 7.35 and the bicarbonate level falls below 22 mEq/L. With respiratory respiratory acidosis, the pH drops below 7.35 and the carbon dioxide level rises above 45 mm Hg. With respiratory respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic metabolic alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 26 mEq/L. Test-Taking est-Taking Strategy: Knowing that a pH of 7.34 is acidotic allows you to eliminate options 2 and 4 first. From the remaining options, knowing knowing that a metabolic condition exists when the bicarbonate follows the same up or down pattern as the pH, helps you to choose option 3 over option 1. Review the procedure for interpreting interpreting arterial blood gases if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Respiratory Health/Respiratory Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 245. 1986. A client client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff feels that the client is ve ry discouraged about her condition. It is important for the nurse to include which of the following information information in discussions with the client? 1. Maximum paralysis occurs within 48 hours following diagnosis 2. Paralysis occurs proximally to distally 3. With maximum rehabilitation, function is regained within 3 months 4. Generally, Generally, the vast majority of people recover from this condition Answer: 4 Rationale: The vast majority of clients with Guillain-Barré syndrome recover from the paralysis because it affects peripheral nerves that have the cap acity to remyelinate. Maximum paralysis can take up to 4 weeks to develop. Paralysis progresses progresses distally to to proximally. proximally. Rehabilitation can take from 6 months months to 2 years. Test-Taking est-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they present very restricted restricted time frames. From the remaining options, eliminate


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option 2 because paralysis progresses distally to proximally proximally.. One way to remember the Barré is that it moves from the “G progression of paralysis with Guillain- Barré “Ground to the Brain.” Brain.” Review the characteristics associated associated with this syndrome syndrome if you had difficulty difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2182. 1987. A client client with myasthenia gravis is being discharged on pyridostigmine pyridostigmine bromide (Mestinon). The nurse provides the client with with medication instructions and makes makes which statement to the client? 1. “Take “Take the medication on an empty stomach.” stomach.” 2. “Take “Take the medication before activities such as eating or work.” 3. “Tonic “Tonic water with quinine and the use of antacids improve the effect of the medication.” 4. “It is not important when you take the medication, as long as you take the exact amount prescribed.” Answer: 2 Rationale: Pyridostigmine bromide (Mestinon) (Mestinon) is an anticholinesterase anticholinesterase that is used to improve muscle strength in the client with myasthenia gravis. Taking the medication before activities such as working or eating helps lessen fatigue and dysphagia and improves muscle strength. The medication should should be taken with food. Clients should avoid quinine, antacids, magnesium, and morphine sulfate and its derivatives, because these medications can reverse the action ac tion of the pyridostigmine bromide and increase weakness. The medication should be taken regularly and on time to prevent fluctuating blood levels, which can cause weakness. Test-Taking est-Taking Strategy: Use the process of elimination. Using general guidelines related to medication administration will assist in eliminating eliminating options 3 and 4. From the remaining options, recalling that muscle weakness is a major proble m with the disease will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, Kizior, R. (2004). Saunders nursing drug handbook 2004. 2004. Philadelphia: W.B. W.B. Saunders, pp. 857, 859. 1988. A nurse nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic. hyperglycemic. Which nursing diagnosis noted on the plan of care would the nurse consider first, when planning care for this client? 1. Deficient Knowledge 2. Potential for Impaired Urinary Elimination 3. Potential for Imbalanced Nutrition Nutrition


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4. Deficient Deficie nt Fluid Volume Answer: 4 Rationale: Hyperglycemia can develop into ketoacidosis in the client with with type 1 diabetes mellitus. Polyuria develops as the the body attempts to get rid rid of the excess glucose, and the client will lose large large amounts of fluid. fluid. Because glucose is hyperosmotic, fluid fluid is pulled from the tissue. Nausea and vomiting can occur as a result result of hyperglycemia hyperglycemia and can lead to a loss of sodium and water. Water is also lost from the lungs in an attempt to get rid of excess carbon dioxide. The severe dehydration that occurs can lead to hypovolemic shock. Of the nursing diagnoses listed, listed, fluid volume deficit is considered first. Test-Taking est-Taking Strategy: Use the process of elimination and Maslow’s Hierarchy of Needs theory. theory. Eliminate options 2 and 3 first first because they are potential potential rather than actual problems. From the remaining options, select option 4 because it addresses addresses a physiological problem. Review care to the client with with type 1 diabetes mellitus mellitus and hyperglycemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 487. 487 . 1989. When planning care for a woman with pregnancy-induced hypertension, the nurse plans to encourage which maternal behavior? 1. Expression of hope for a positive outcome 2. Delaying preparations for for finishing the the nursery at home 3. Walking 1 to 2 miles daily 4. Anticipatory grieving Answer: 1 Rationale: Hoping for a positive outcome is an appropriate coping mechanism. It is important to support an expression of hope by a client with a high-risk pregnancy as long as the hope is realistic (e.g., fetus is viable). Anticipatory grieving is not a positive adaptation for this client. Grieving should begin when a loss occurs. Delaying nursery preparations at home reflects an “expecting the worse” situation. Walking 1 to 2 miles daily is contraindicated for a woman with pregnancy-induced hypertension. Test-Taking est-Taking Strategy: Focus on the client’s client’s diagnosis. Eliminate option 3 because walking 1 to 2 miles daily is much too strenuous. Next eliminate options 2 and 4 because they indicate a negative outcome. Review the plan of care for a client with pregnancyinduced hypertension if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Murray, Murray, S., McKinney, McKinney, E., & Gorrie, T. T. (2002). Foundations (2002). Foundations of maternalnewborn nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 686.


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1990. A woman with type type 1 diabetes mellitus mellitus is in in labor. labor. Based on the knowledge knowledge of insulin and diabetes and pregnancy pregna ncy,, the nurse will be prepared to care for a newborn newbo rn infant who is most likely to have which complication? 1. Macrosomia 2. Hyperglycemia 3. Postmaturity syndrome 4. Anemia Answer: 1 Rationale: Typically Typically,, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore excessive body growth (macrosomia) results from high maternal glucose levels. After birth, hypoglycemia may be a problem because the infant’s infant’s pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant’s infant’s glucose supply. supply. Infants of diabetic mothers are usually delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks. Polycythemia, not anemia, is commonly associated with infants of diabetic women. Test-Taking est-Taking Strategy: Use the process of elimination and recall that typically infants infants of diabetic mothers are large for gestational age. This will direct you to to option 1. Review diabetes and pregnancy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Planning Content Area: Maternity/Postpartum Maternity/Postpartum Reference: Murray, Murray, S., McKinney, McKinney, E., & Gorrie, T. T. (2002). Foundations (2002). Foundations of maternalnewborn nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 855. 1991. A nurse nurse is reviewing the medical record of a young young female client who is suspected of having systemic lupus erythematosus erythematosus (SLE). Which of the following would the nurse nurse expect to note documented in the record that is related to this diagnosis? 1. Presence of two hemoglobin S genes in the blood cell report report 2. Ascites noted in the abdomen 3. Recurrent emboli 4. Butterfly rash on cheeks and bridge of nose Answer: 4 Rationale: SLE primarily occurs in females 10 to 35 years of age, and is a chronic chronic inflammatory disease that affects affects multiple body systems. A butterfly butterfly rash on the cheeks and the bridge of the nose is a characteristic characteristic sign of SLE. Option 1 is found in sickle cell anemia. Options 2 and 3 are found in many conditions, but are not usually usually noted in SLE. Test-T Test-Taking aking Strategy: Strategy: Focus on the issue—a manifestation manifest ation of SLE. Recalling that a butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE will direct you to option 4. Review the signs and symptoms symptoms of systemic lupus erythematosus erythematosus (SLE) (SLE) if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection


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Content Area: Adult Health/Immune Health/Immune nursing (4th ed.). St. Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Louis: Mosby, p. 80. 1992. A client with with a diagnosis of congestive heart failure is preparing for discharge to home from the hospital. The nurse determines that the client is ready for discharge to home if the client can: 1. Verbally describe the daily medications, doses, and times to be administered administered 2. Get the prescriptions filled 3. Be self-sufficient self-sufficient at home without any help 4. Independently dress and put on support hose Answer: 1 Rationale: Medication therapy is an essential essential part of the therapeutic regimen for treating heart failure. The client must have a clear understanding of which medications to take take and when to take them. Options 2 and 4 can be carried out with the assistance assistance of someone else. Option 3 may not be realistic realistic for this client. Test-Taking est-Taking Strategy: Use the process of elimination. Note the client’s client’s diagnosis and the issue of the question—that the client is ready for for discharge. Eliminate option 3 first because it is unrealistic. Next, eliminate options 2 and 4 because they can be accomplished by others or with the assistance of others. Remember, it is a priority priority that the client understands the medication regimen. regimen. Review home care instructions for for the client with heart failure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 321. 321 . 1993. A nurse notes that a client’s client’s urinalysis report contains a notation of positive red blood cells (RBCs). The nurse interprets that this finding is unrelated unrelated to which of the following items that is part pa rt of the client’s medical record? 1. Diabetes mellitus 2. Concurrent anticoagulant therapy 3. History of kidney stones 4. History of recent blow to the the right flank Answer: 1 Rationale: Hematuria can be caused by trauma to to the kidney, kidney, such as with blunt trauma trauma to the lower posterior trunk trunk or flank. Kidney stones can cause hematuria as they scrape the endothelial lining of the urinary system. Anticoagulant therapy can cause hematuria as a side effect. Diabetes mellitus does not cause hematuria, although it can lead lead to renal failure from prerenal causes. Test-Taking est-Taking Strategy: Use the process of elimination noting the key word unrelated . This word indicates a false response question and that you need to select the condition co ndition that is not a cause of hematuria. Begin to answer this question question by eliminating options 2 and 4, which are most likely to to cause RBCs in the urine. urine. From the remaining options, options, recalling


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that the scraping of the stones against mucosa could cause minor trauma and bleeding will direct you to option 1. Review the causes of RBCs in the urine if you you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 796. 1994. A client with acute glomerulonephritis had a urinalysis sent sent to the laboratory. laboratory. The report reveals that there is hematuria and proteinuria present in in the urine. The nurse interprets that these results are: 1. Consistent with glomerulonephritis 2. Inconsistent with glomerulonephritis 3. Unclear, and no conclusion can be drawn 4. Indicative of impending renal failure Answer: 1 Rationale: Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis. The urine may be small in volume, dark or smoky in color from the hematuria, and foamy from the proteinuria. Concurrent serum studies studies would reveal elevated blood urea nitrogen level, creatinine level, C-reactive protein level, and antistreptolysin O titer. Test-Taking est-Taking Strategy: Use the process of elimination. Noting the diagnosis of the client and recalling that the presence of hematuria and proteinuria in the urine is abnormal will direct you to option 1. Review the findings in glomerulonephritis glomerulonephritis if you had difficulty difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Renal Health/Renal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 438. 438 . Phipps, W., W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1210. 1995. A young young female client with acute pyelonephritis is scheduled for a voiding cystourethrogram. The nurse determines that this client would most likely benefit from increased support and teaching about the procedure because: 1. Radiopaque contrast is injected into the the bloodstream with a syringe syringe 2. Radioactive material is injected into the bladder with a syringe syringe 3. The client must lie on an x-ray table in a cold, barren room 4. The client must void while while the micturition process is filmed Answer: 4 Rationale: Having to void in the presence of others can be very embarrassing embarrassing for clients, and may actually interfere with the client’s client’s ability to void. The nurse teaches the client about the procedure to try to minimize stress from lack of preparation, and gives the


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client encouragement and emotional support. Screens may be used in the the radiology department to try to provide an element of privacy during this procedure. Test-Taking est-Taking Strategy: Begin to answer this question by eliminating options 1 and 2, since the contrast material is inserted into the bladder by means of a catheter. catheter. From the remaining options, note the key words young words young female client in client in the question and recall that the client has to void to allow filming of the movement of urine through the lower urinary tract. This will assist assist in directing you to the correct option. Review this diagnostic diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Renal Health/Renal Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 451. 1996. A nurse is caring caring for a client client with a suspected diagnosis of aplastic anemia. Which of the following tests would the nurse anticipate to be performed to confirm the diagnosis? 1. Bone marrow aspiration 2. Complete blood count 3. Sickle cell screen 4. Schilling test Answer: 1 Rationale: A bone marrow marrow aspiration will identify aplastic anemia and will identify pancytopenia, a deficiency in erythrocytes, leukocytes, and thrombocytes. A Schilling Schilling test is diagnostic for pernicious anemia. A sickle sickle cell screen is diagnostic for sickle cell anemia. A complete blood count will identify anemia but may not identify the specific type. confirm. Test-Taking est-Taking Strategy: Use the process of elimination and note the key word confirm. Recalling that anemias originate in the the bone marrow will direct you to option 1. Option 1 is the only option that mentions the bone marrow. marrow. Review the diagnostic tests for aplastic anemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Oncology Health/Oncology Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 261. 261 . 1997. During inspection of a client’s client’s skin, the nurse notes redness and an abrasion-type abrasion-type wound on the sacrum area. The nurse determines that this this finding is indicative indicative of a: 1. Stage 1 pressure ulcer 2. Stage 2 pressure ulcer 3. Stage 3 pressure ulcer 4. Stage 4 pressure ulcer Answer: 2


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Rationale: In a stage 1 pressure ulcer, the skin skin is intact, and the area is red and does not blanch with external pressure. In a stage 2 pressure pressure ulcer, the the skin is not intact, and the ulcer is superficial and may appear as an abrasion, blister, blister, or shallow crater. crater. In stage 3, skin loss is full-thickness, full-thickness, and there is a deep crater-like appearance. In stage 4, skin loss loss is full-thickness with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Test-Taking est-Taking Strategy: Use the process of elimination. Remembering that in stage 1 the skin is intact and that the skin disruption worsens as the stage number increases will assist in directing you to the correct option. If you had difficulty with with this question, review the characteristics of pressure ulcers. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Collection Content Area: Adult Health/Integumentary Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 273. 1998. A client who has undergone a cardiac catheterization catheterization using the right femoral femoral approach is returned to the nursing nursing unit. Thirty minutes later, later, the client complains of numbness and tingling of the right right foot. The pedal pulse is weak, and the foot foot is pale. The nurse notifies the registered nurse (RN) immediately because these symptoms are consistent with: 1. Femoral artery artery thrombus thrombus or hematoma 2. Local allergic reaction to the contrast dye 3. Right sciatic sciatic nerve damage 4. Early massive infection at the catheter insertion site site Answer: 1 Rationale: Adverse changes such as numbness and tingling, coolness, pallor, pallor, cyanosis, or sudden loss of peripheral pulses indicate serious circulatory impairment and are reported to the RN immediately, immediately, who will then contact the physician. Allergic reaction to the dye is a systemic problem, not a local one. The data in the question are not consistent with sciatic pain. Infection does not become apparent this quickly. quickly. Test-Taking est-Taking Strategy: Use the process of elimination and the ABCs—airway, ABCs—airway, breathing, and circulation—to answer the question. question. Noting that the signs and symptoms in the question indicate a circulatory problem will direct you you to option 1. Review the complications associated with a cardiac catheterization if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 564. 1999. A client client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse determines that which which of the following items would be of


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most help to the client? 1. Placing an oxygen cannula at the bedside for use if if needed 2. Performing continuous monitoring of oxygen saturation 3. Elevating the head of the bed to at least 45 degrees 4. Providing a walker to aid in ambulation Answer: 3 Rationale: The management of dyspnea is generally directed toward alleviating the cause. Symptom relief may be achieved or at least aided by placing the client at rest with the head of bed elevated. In severe cases, supplemental oxygen is used. Monitoring of oxygen saturation detects early complications complications but does not help the client. Likewise, placing an oxygen cannula at the bedside for use would not help the client. Test-Taking est-Taking Strategy: Use the process of elimination. The words “of most help to the client” direct you to look for the item that is going to have the best immediate effect from the client’s client’s perspective. Therefore eliminate options 1, 2, and 4 first. Review nursing measures for the client with dyspnea if you had difficulty with this question. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Ignatavicius, D., & Workman, M. (2002). Medical surgical nursing: Critical thinking for collaborative care (4th ed.). Philadelphia: W.B. Saunders, p. 688. 2000. The nurse prepares to administer administer erythromycin base (Ilotycin) (Ilotycin) ophthalmic ointment to a newborn infant immediately after delivery. delivery. The nurse understands that this ointment: 1. Is more irritating irritating to the newborn’s newborn’s eyes than silver nitrate drops 2. Must be administered at room room temperature to prevent side effects 3. Is staining to the infant’s infant’s skin and must be wiped wiped off immediately 4. Is effective effective in protecting the newborn from both Neisseria both Neisseria gonorrhoeae and chlamydia Answer: 4 Rationale: Erythromycin (Ilotycin) (Ilotycin) is effective effective in protecting the newborn from both Neisseria gonorrhoeae and chlamydia. It is less irritating irritating to the newborn’s newborn’s eyes than silver nitrate, does not stain, and may be administered at any safe temperature. Test-Taking est-Taking Strategy: Focus on the name of the medication. medication. Recalling that this medication is an antibiotic and that it is administered to the newborn in the immediate postdelivery period will direct direct you to option 4. Review the action of this medication if you had difficulty with this question. Level of Cognitive Cognitive Ability: Comprehension Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Murray, Murray, S., McKinney, McKinney, E., & Gorrie, T. T. (2002). Foundations (2002). Foundations of maternalnewborn nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 552, 972.

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