Practice Nursing test with answers and rationale 1. When assessin assessing g a client client with with chest chest pain, the nurse obtains a thorough history. Which statement of the patient is most suggestive of anginal pectoris? a. The pain pain laste lasted d for for about about 45 minutes b. The pai pain n resolv resolved ed after after I ate sandwich c. The pain pain wors worsene ened d when when I took took a deep breath d. The pai pain n occur occurred red whi while le I was was mowing the loan 2. After After experi experienc encing ing a trans transien ientt ischaemic attack (TIA), a client is prescribed aspirin 80 mg p.o daily. The nurse should should teach the client client that this this medication has been prescribed to a. Contro Controll head headac ache he pain pain b. Enhanc Enhance e immun immune e respo response nse c. Preven Preventt intra intracr crani anial al bleed bleeding ing d. Decrea Decrease se platel platelet et coagul coagulati ation on 3. The physic physician ian pres prescrib cribes es severa severall drugs drugs for a client with hemorrhagic stroke . which drug order should the nurse question. a. Hepari Heparin n sodi sodiim im (hep (heploc lock) k) b. Dexam Dexameth ethas asone one ( decadr decadron) on) c. Methy Methyld ldop opa a (aldo (aldome met) t) d. Phento Phentoin in (dila (dilanti ntin) n) 4. A client client with peptic peptic ulcer ulcer is about about to begin a therapeutic regimen that includes a bland diet,antacids and ranitindine hcl (zantac). Which instructions should the nurse provide before this client is discharged.
a. Eat a three three balan balanced ced meal meal everyday b. Stop Stop taking taking the the drug drug when when the symptoms subside c. Avoid Avoid aspir aspirin in and and produ products cts that that contain aspirin d. Increa Increase se the the intak intake e of fluid fluids s containing caffeine 5. The nurse nurse is asses assessing sing a client client with Cushing’s disease. Which observation should be reported to the physician immediately. a. Pit Pittin ting g edem edema a of of the the legs legs b. Irregu Irregular lar apica apicall puls pulse e c. Dry Dry muc mucou ous s mem membr bran ane e d. Freq Freque uent nt urin urinat atio ion n 6. A client client with myastheni myasthenia a gravis gravis is receiving continuous mechanical ventilation. When the high pressure alarm on the ventilator sounds, what should the nurse do? a. Check Check the the presen presence ce of the the apica apicall pulse b. Suction Suction the patient’s patient’s artifici artificial al airway c. Increa Increase se the the oxygen oxygen perc percent entage age d. Ventil Ventilate ate using using a manu manual al resuscitation resuscitation bag 7. Which Which of of the foll follow owing ing take takes s the highest priority for parkinson’s crisis? a. Altere Altered d nutrit nutrition ion:: less than than body body requirements b. Ineffe Ineffecti ctive ve airwa airway y clearan clearance ce c. Alt Altere ered d urina urinary ry elim elimina inatio tion n d. Risk Risk for for inj injur ury y
8. Which Which nursin nursing g diagno diagnosis sis is most most appropriate appropriate for a client with Addison’s disease?
a. Fluid Fluid intake intake of of less less than than 2500 2500 ml ml in 24 hours
a. Risk Risk for for inf infec ecti tion on
b. Urine Urine outpu outputt of more more than than 200 200 ml/hr
b. Flui Fluid d volu volume me exc exces ess s
c. Bloo Blood d p ress ressur ure e of 90/ 90/50 50
c. Urin Urinar ary y ret retre rent ntio ion n
d. Pul Pulse se rate rate of 126 126 beat beats/m s/min in
d. Hypo Hypoth ther ermi mia a 9. Which Which of these these signs signs suggest suggest that a client with Symptom if Inappropriate Inappropriate Antidiuretic Hormone(SIADH) has developed complications? complications? a. Titani Titanic c contra contracti ctions ons b. Neck Neck vein vein dis diste tent ntio ion n c. Weig Weigh ht loss oss d. Polyuria 10.Which of these findings best correlates with a diagnosis of osteoarthritis? a. Joint Joint stiffn stiffness ess that decreases decreases with activity b. Eythema Eythema and edema edema over over the the affec affected ted joints c. Anorex Anorexia ia and weigh weightt loss loss
13.Which action should the nurse include in the plan of care for a client with a fiberglass cast on the right hand? a. Keep Keep the the caste casted d arm with with a light light blanket b. Avoid Avoid handl handling ing the the cast cast for for 24 hrs hrs or until dry c. Asses Assess s pedal pedal and and tibia tibiall pulse pulses s every 24 hrs d. Assess Assess movement movement and sensatio sensation n in the fingers of the right hand. 14.A client is admitted with a serum glucose level of 618 mg/dl. The client is awake and oriented, with hot, dry skin, a temperature of 100.6 F(38.1 C)PR of 116 bpm, and BP of 108/70 mmhg. Based on these findings, which nursing diagnosis receive the highest priority?
d. Feve Feverr and and mala malais ise e
a. Fluid Fluid volume volume defici deficitt r/t r/t osmoti osmotic c diuresis
11.When communicating with a client with (sensory) receptive aphasia, the nurse should?
b. Decrea Decreased sed car cardia diac c output output r/t r/t increased HR
a. Allow time for the clien clientt to respond respond b. Speak loudly loudly and and articula articulate te clearl clearly y c. Give Give the the clien clientt a writi writing ng pad pad d. Use shor short, t, simp simple le sente sentence nces s 12.Which outcome indicates that treatment for diabetes insipidus is effective?
c. Altere Altered d nutrit nutrition ion : less less than than body body requirements r/t to insulin deficiency d. Ineffectiv Ineffective e thermoreg thermoregulat ulation ion r/t to dehydration. 15.Which nursing action should take the highest priority when caring for a client with hemiparesis caused by cerebrovascular cerebrovascular accident?
a. Perfor Perform m passiv passive e range range of motio motion n exercise
mEq/L. which disorder these ABG values suggests?
b. Place Place the the client client on on the affe affecte cted d side
a. Respir Respirato atory ry alkalo alkalosis sis
c. Use handroll handrolls s or or pillow pillows s to support support d. Apply Apply antiem antiembol bolic ic stock stocking ings s 16.Then nurse should include which instruction when teaching a client about insulin administration? a. Administ Administer er insul insulin in after after the first first meal of the day b. Administ Administer er insul insulin in at at a 45 degre degree e angle into the deltoid muscle c. Shake Shake the the vial vial of the ins insuli ulin n vigorously before withdrawing the medication d. Draw up clear clear ins insulin ulin when mixing mixing two types of insulin in one syringe. 17.The nurse should expect a client with hypothyroidism hypothyroidism to report which of these health concerns?
b. Respir Respirato atory ry acidos acidosis is c. Meta Metabo boli lic c alk alkal alos osis is d. Meta Metabo boli lic c acid acidos osis is 20.A client is admitted to the ER with suspected overdose of unknown drug. The client ABG values indicates respiratory acidosis, acidosis, what should the nurse do first? a. Prepare Prepare to assist assist with with ventilati ventilation on b. Monitor Monitor the client’s client’s heart heart rhythm rhythm c. Prepar Prepare e to begin begin gastri gastric c lavage lavage d. Obtain Obtain urine urine for drug screenin screening g 21.A client is being returned to the room after subtotal thyroidectomy. Which piece of equipment is important to the nurse to bring to the client’s bedside? a. Indwel Indwellin ling g folley folley cath cathere ererr kit
a. Increase Increased d appetit appetite e and and weight weight loss
b. Trac Trache heos osto tomy my set set
b. Puffin Puffiness ess of of the fac face e and hand hands s
c. Card Cardia iac c moni monito torr
c. Nervou Nervousn sness ess and tremor tremors s
d. Hum Humidif idifie ierr
d. Increa Increasin sing g exopht exophthal halmo mos s 18.A client with hypothyroidism is receiving levothyroxine sodium(synthroid), sodium(synthroid), 50 mcg. P.O daily. Which of these findings should the nurse recognize as an adverse effect? a. Dysuria b. Leg cramps amps c. Tac Tachyca hycarrdia dia d. Blur Blurre red d visi vision on 19.A client ABG values are pH=7.12, PaCO2= 40 mmHg, and HCO3= 15
22.Which of these findings is an early sign of bladder cancer? a. Pain Painle less ss hem hemat atur uria ia b. Occa Occasi sion onal al poly polyri ria a c. Nocturia d. Dysuria 23.Which statement from a client who takes Nitroglycerin ( Nitrostat) as needed for angina pain indicates that further teaching is necessary? a. I store store the tablet tablets s in in a dark dark bottl bottle e
b. I take the tablet tablet in a full full glass glass of water
which laboratory test when caring for this patient?
c. I check check for for my my tongu tongue e to ting tingle le when I take a tablet
a. RBC co count
d. I’ll go to the hospital hospital if 3 tablet tablets, s, 5 minutes apart don’t relieve the pain 24.The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? a. 15 mm indu indura rati tion on b. Redd Redden ened ed area area c. 10 mm br bruise ise d. Blister 25.A client must take streptomycin sulfate for TB. Before the therapy begins, the nurse should inform the client to inform the physician if which of the following symptoms occur? a. Decrea Decreased sed color color discrim discrimina inatio tion n
b. Seru Serum m uri uric c acid acid c. Seru Serum m pota potass ssiu ium m 28.A client has been diagnosed with type 1 insulin dependent DM. which client’s comment correlates best with this disorder? a. I was thirst thirsty y all the the time. time. I just just couldn’t get enough to drink b. It seem seemed ed like like I had had no appet appetite ite.. I had to get myself eat c. I had had cough cough and cold cold that that jjus jjustt didn’t seem to go away d. I notice noticed d a pain pain when when I went went to the the bathromm 29.A client is receing chemotherapy chemotherapy for breast cancer. Which assessment finding indicates chemotherapy induced fluid and electrolyte imbalance?
b. Increa Increased sed urina urinary ry frequ frequenc ency y
a. Urine Urine outp output ut of of 400 400 ml in 8 hrs
c. Decrea Decreased sed hearin hearing g acuity acuity
b. Serum Serum pota potass ssium ium leve levell of 3.6 3.6 mEq/L
d. Incr Increa ease sed d appe appeti tite te.. 26.During a late stage stage of AIDS, AIDS, a client demonstrates demonstrates signs of AIDS related dementia. The nurse should give highest nursing prioroity to which of the following nursing diagnosis? a. Bathing Bathing or hygie hygiene ne self self care care deficit deficit b. Impair Impaired ed cerebr cerebral al perfus perfusion ion c. Dysfun Dysfuncti ctiona onall griev grieving ing d. Risk Risk for for inj injur ury y 27.A client with gout is receiving Probenecid. The nurse should monitor
c. BP of 120/64 120/64 to 130/ 130/72 72 mmHg mmHg d. Dry oral oral mucous mucous memb membran rane e and cracked lips 30.After chemotherapy, a client develops N/V . for this client, the nurse should give the highest priority to which action in the plan of care? a. Serve Serve small small porti portions ons of of bland bland food food b. Encour Encourage age rhyth rhythmic mic breat breathin hing g exercise c. Admin Administ ister er metoc metoclop lopro romid mide e and dexamethasone dexamethasone as prescribed
d. Withould Withould fluid for the the first first 4-6 hrs 31.A client is receiving Zidovdine (Retrovir) to treat AIDS, for this client, the nurse should monitor the value of which laboratory test? a. RBC co count b. Fastin Fasting g bloo blood d gluc glucose ose c. Seru Serum m calc calciu ium m d. Plat Platel elet et cou count nt 32.A client seeks care for low back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral intervertebral disk? a. Pain that radiates radiates down the poste posterior rior thigh b. Back Back pain pain when when the the knees knees are are flexed flexed c. Atroph Atrophy y of of the the lower lower legs legs d. Positi Positive ve Homan’ Homan’s s sign sign 33.For a client with hepatitis b, the nurse should monitor closely for the onset development of which clinical manifestation?
c. Consum Consuming ing a high high prote protein in , high high fiber diet d. Taking Taking only enteric enteric medicati medications ons 35.To prevent esophageal reflux in a client with hiatus hernia, the nurse should provide which discharge instructions? a. Lie down down after after meal meals s to prom promote ote digestion b. Avoid Avoid coff coffee ee and and alco alcohol holic ic beverages c. Consum Consuming ing low low protei protein, n, high high fiber fiber diet d. Limit Limit flu fluids ids with with meal meals s 36.A client with increasing difficulty swallowing , weight loss and fatigue just received a diagnosis of esophageal cancer. Because this client has difficulty swallowing, the nurse should give the highest priority to which action. a. Helpin Helping g the clie client nt cope cope with with body body image disturbance b. Ensur Ensuring ing adequ adequate ate nutri nutritio tion n
a. Jaundice
c. Mainta Maintain ining ing a paten patentt airw airway ay
b. Arm Arm and and leg leg prur prurit itus us
d. Prev Preven enti ting ng inj injur ury y
c. Fatigu Fatigue e dur during ing ambul ambulati ation on d. Irrita Irritabil bility ity and and drows drowsine iness ss 34.A client is recovering from ileostomy that was performed to treat inflammatory inflammatory bowel disease. During the teaching discharge, the nurse should stress: a. Increasi Increasing ng fluid fluid intake intake to to preve prevent nt dehydration b. Wearing Wearing applianc appliance e pouch pouch only at bedtime
37.The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient Vit. K absorption caused by this liver disease? a. Dysp Dyspne nea a and and fati fatigu gue e b. As Ascit cites es and ortho orthopne pnea a c. Pu Purp rpur ura a nd pete petech chai aie e d. Gyneco Gynecosm smast astia ia and testi testicu cular lar hypertrophy 38.Two days ago, the client underwent an autograft for secof and third degree
burns on the arms. Now the nurse finds the client doing arm ecxercise. Te nurse knows that exercise should be avoided because it may. a. Dislod Dislodge ge the autogr autograft aft
a. Encourag Encourage e oral oral feedin feedings gs as soon soon as possible b. Develo Develop p an altern alternati ative ve communication method
b. Increa Increase se the the edema edema in in the arms arms
c. Keep Keep the the trache tracheos ostom tomy y cuff cuff fully fully inflated
c. Increa Increase se the the amoun amountt of scar scarrin ring g
d. Keep Keep the the clien clientt flat flat in in bed bed
d. Decrease Decrease circulati circulation on of of the the finger fingers s 39.A client with UTI receives a prescription prescription for cotrimoxazole (Septra) 2 tablets P.O daily for 10 days. Which Which observation best demonstrates that the client followed the prescribed regimen? a. Increa Increase se urin urine e output output to to 2L in 24 24 hrs b. Decrea Decreased sed flan flank k and abdom abdomina inall discomfort c. Absenc Absence e of bacter bacteria ia on on urine urine culture d. Norm Normal al RBC RBC cou count nt 40.A client has undergone laryngectomy laryngectomy and tracheostomy formation. Which instruction should should the nurse give to the client and family about the operation? a. The tra trache cheost ostomy omy tube tube shou should ld be cleaned with alcohol and water. b. Family Family member members s shoul should d conit conitinue inue to converse with the client
42.After a left pneumonectomy, pneumonectomy, a client has a chest tube for drainage. For this client, the nurse must a. Monito Monitorr fluctu fluctuati ations ons in in the water water seal chamber b. Clamp Clamp the the ches chestt tube tube once once every every shift c. Encour Encourage age coughi coughing ng and and deep deep breathing d. Milk Milk the ches chestt tube tube every every 2 hrs 43.A client reports sharp chest pain in the right side of the chest and difficulty of breathing and has respiratory rate of 40 bpm. Which goal should the nurse consider as the top priority? a. Mainta Maintaina inance nce of adequa adequate te circulatory circulatory volume b. Mainta Maintaina inance nce of effe effecti ctive ve respiration c. An Anxi xiet ety y redu reduct ctio ion n d. Pain Pain red reduc ucti tion on
c. Oral Oral intake intake sho should uld be be limite limited d to 1 week only
44.A client develops brigh red urine while receiveing heparin for pulmonary embolus. What should the nurse do first?
d. The amo amount unt of of protei protein n in the the diet diet should be limited
a. Decrease Decrease the heparin heparin infusion infusion rate
41.When caring for a client who has just had a total laryngectomy,the nurse should plan to
b. Prepare Prepare to administ administer er protamin protamine e sulfate c. Monitor Monitor the paritial paritial thrombop thromboplast lastin in time(PTT)
d. Stop the infus infusion ion for 2 hrs hrs and start start it at a lower dose as prescribed 45.In a client is chronic bronchitis, which sign should lead the nurse to suspect right heart failure (cor pulmonale) a. Circum Circumor oral al cyano cyanosis sis b. Bila Bilate tera rall crac crackel kels s c. Prod Produc ucti tive ve coug cough h d. Leg edema 46.When caring for a client with endotracheal tube, the nurse should consider which action to be the most important?
b. Notify Notify the physicia physician n immediat immediately ely c. Asses Assess s the irrig irrigati ation on cathe catheter ter for for patency and drainage d. Asminsi Asminsiter ter meperidin meperidine e 50 mg IM as prescribe 49.A client with arterial insuffieciency insuffieciency has just undergone below knee amputation of the right leg. leg. Which action should the nurse include in the post op[ care plan? a. Elevat Elevate e the stum stump p fot the the first first 24 24 hrs b. Mainta Maintain in the the client client on on comple complete te bed rest
a. Auscultat Auscultate e the the lungs lungs for bilatera bilaterall breath sounds
c. Appy Appy heat heat to the the stump stump as as the the client desires
b. Turning Turning the client client from side to side side every 2 hrs
d. Remove Remove the the press pressure ure dres dressin sing g after the first 8 hrs
c. Monito Monitorr serial serial bloo blood d gas ever every y 4 hrs
50.Which of these laboratory test is the most accurate indicator of renal function
d. Provid Provide e frequen frequentt oral oral hygiene hygiene 47.The nurse administer albuterol (Proventil) as prescribed to a client with emphysema. Which findings indicate that the drug is producing a therapeutic effect? a. RR of of 22 22 b bpm pm b. Dialte Dialted d and reacti reactive ve pupil pupils s c. Urine Urine output output of 40 ml/hr ml/hr d. PR of 100 100 bpm bpm 48.After transurethral resection of the prostate for benign prostatic hypertrophy, a client returns to the room with continous bladder irrigation. On the first day after surgery, the client reports bladder pain, what should the nurse do first? a. Increa Increase se the the IV IV flow flow rate rate
a. BUN b. Creati Creatini nine ne cleara clearance nce c. Seru Serum m crea creati tini nine ne d. Urin rinaly alysis 51.Which nursing intervention is the most important when caring for a client with acute pyelonphritis? pyelonphritis? a. Admin Administ ister er sitz sitz bath bath twice twice a day day b. Increa Increase se fluid fluid inta intake ke to 3 L a day c. Use Use an indwel indwellin ling g (folley (folley)) cathet catheter er to measure urine output accurately d. Encour Encourage age the the clien clientt to drink drink cranberry juice to acidify the urine
52.Which nursing intervention is the most important during the acute oliguric phase of acuter renal failure?
c. Mainta Maintain in bed bed rest rest for 72 72 hrs pos postop top d. Turn the patient patient from side to side side using the log rolling technique
a. Encour Encouragi aging ng cough coughin ing g and deep deep breathing exercise b. Promo Promotin ting g carbohy carbohydra drate te intake intake c. Limi Limiti ting ng flu fluid id int intak ake e d. Cont Contro roll llin ing g pai pain n 53.A client with renal failure is undergoing continous ambulatory peritoneal dialysis (CAPD). Which nursing diagnosis is most apporopriate for this client? a. Alt Altere ered d urinar urinary y elimina eliminatio tion n b. Toilet Toileting ing self self car care e defici deficitt c. Senso Sensory ry or percep perceptua tuall altera alteratio tions ns d. Dress Dressing ing or or groomi grooming ng self self care care deficit 54.A client is admitted with a cervical spine injury caused by a diving accident. When planning this client’s care,the nurse should give which nursing diagnosis the highest priority? a. Impair Impaired ed physi physical cal mob mobili ility ty b. Ineff Ineffect ective ive breath breathing ing patte pattern rn c. Senso Sensory ry or perc percept eptual ual alte altera ratio tion n d. Activi Activity ty intole intoleran rance ce 55.The nurse is developing a plan of care for a patient who has undergone a laminectomy laminectomy to repair a herniated intervertebral intervertebral disk. Which action should the nurse include? a. Keep Keep the pill pillow ow under under the the knees knees at at all time b. Place the clien clientt in a semi semi fowler fowler’s ’s position
56.The nurse must total parenteral nutrition(TPN) through a triple lumen catheter line. What can the nurse do to prevent complications? complications? a. Cover Cover the the cathet catheter er inser insertio tion n site site with an occlusive dressing b. Use Use clean clean techni technique que when when changing the dressing c. Insert Insert an ind indwel wellin ling g urina urinary ry catheter d. Keep Keep the the client client on compl complete ete bed bed rest. 57.The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding should the nurse report to the physician immediately? a. Serum Serum pota potass ssium ium of of 4.9 mEq/L mEq/L b. Serum Serum sodi sodium um of of 135 135 mEq/L mEq/L c. Temper Temperatu ature re of of 99.2 99.2 F (37.3 (37.3)) d. Urine Urine outpu outputt of 400 400 ml ml in 24 24 hrs hrs 58.A cient is admitted with a gunshot wound to the abdomen. After an exploratory laparatomy, laparatomy, the client , the client is transferred to the ICU. Which assessment finding suggests that the client now is developing acute renal failure? a. BUN BUN lev level el of 22 mg/d mg/dll b. Serum Serum creat creatinin inine e level level of 1.2 mg/dl mg/dl c. Temp Temper erat atur ure e of of 1.2 1.2 F d. Urine Urine outpu outputt of 400 400 ml ml in 24 24 hrs hrs
59.A client seeks care for severe pain in the right upper quadrant of the abdomen, which is accompanied by nausea and vomiting. The physician makes a diagnosis of acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis should receive the highest priority? a. Pain Pain r/t r/t bil biliar iary y spas spasm m b. Knowledg Knowledge e deficit deficit r/t preven prevention tion of recurrence c. Anxiet Anxiety y r/t r/t unkno unknown wn outc outcome ome of hospitalization d. Altered Altered nutrition nutrition:: less less than body requirements r/t to biliary inflammatioin 60.For a client with advanced liver cirrhosis, which assessment finding best indicates deterioration of liver function? a. Fatigu Fatigue e and muscke muscke weak weaknes ness s b. ‘diffi ‘difficul culty ty in arous arousal al c. Naus Nausea ea and and ano anore rexi xia a d. Weig Weigh ht gai gain n 61.A client is admitted with increased ascites associated with cirrhosis. Which nursing diagnosis should receive the highest priority? a. Fatigue b. Flui Fluid d volu volume me exc exces ess s c. Ineff Ineffect ective ive brea breathi thing ng patte pattern rn d. Altered Altered nutrition nutrition:: less less than body requirements 62.A client with advanced cirrhosis has a prothrombin time of 15 seconds compared to a control time of 11 sec. which drug should the nurse expect to administer?
a. Spiro Spironol nolact actone one (alsdac (alsdacton tone) e) b. Phyton Phytonad adion ione( e( meph mephyto yton) n) c. Furo Furosi simi mide de (Las (Lasix ix)) d. Warfar Warfarin in (Coum (Coumadi adin) n) 63.The physician prescribes spironolactone(Aldactone) spironolactone(Aldactone) 50 mg P.O four times daily for a client with fluid retention due to liver cirrhosis, which finding indicates that the drug is producing a therapeutic effect? a. Serum Serum K level level of 3.5 3.5 mEq/ mEq/L L b. Weight Weight loss loss of 2 lb in in 24 hrs hrs c. Serum Serum Na level level of 135 mEq/L mEq/L d. Bloo Blood d pH pH of of 7.2 7.25 5 64.While preparing a client with for cholecystectomy, cholecystectomy, the nurse explains that incentive spirometry will be used after surgery. The nurse also should tell the client the primary purplose of incentive spirometry is: a. Increases Increases respirat respiratory ory effectiven effectiveness ess b. Preclude Preclude the need for nasogas nasogastric tric intubation c. Impro Improve ve nutriti nutrition onal al status status durin during g the recovery period d. Decrease Decrease the amount amount of of respi respirato ratory ry anesthesia 65.A client is transferred to ICU after evacuation of a subdural hematoma. To reduce the risk of increasing intracranial pressure , the nurse should: a. Encour Encourage age oral oral flui fluid d intake intake b. Suctio Suction n the clien clientt once once per shift shift c. Elevat Elevate e the head head of of the the bed to to high high fowlers
d. Admini Administ ster er a stool stool soft softene enerr as prescribed
a. Remove Remove the the weig weight ht onc once e every every shift
66.Two days after repairing a client’s ruptured cerebral aneurysm, the physician orders mannitol (osmitro) 1.5 g/kg, to be infused over 60 minutes. If the client weighs 175 lbs, how many grams of mannitol should be administered? administered?
b. Mainta Maintain in the the bed in in knee knee gatch gatch position
a. 263 g b. 119 g c. 75g d. 60 g 67.A client is receiving a n I.V infusion of mannitol after undergoing intracranial pressure surgery for removal of a brain tumor. To determine if this drug is producing its therapeutic effect, the nurse should consider which as the most significant a. Decrease Decrease level of consciou consciousnes sness s b. Elev Elevat ated ed BP c. Incr Increa ease sed d urine urine outp output ut d. Decr Decrea ease sed d heart heart rate rate 68.A client is hospitalized for open reducrion of a fractured femur. During postoperative postoperative assessments, assessments, the nurse monitors for signs of fat embolism, which include: a. Pallor Pallor and and coolne coolness ss of the the affecte affected d leg b. Nausea Nausea and and vomit vomiting ing afte afterr eating eating c. Hypoth Hypotherm ermia ia and and bra bradyc dycar ardia dia d. Restle Restless ssnes ness s and pete petechi chiae ae 69.A client is in Buck’s skin traction for right hip fracture. The nurse should include which action in this client’s plan of care.
c. Keep Keep the the client client is a semi semi fowler fowler’s ’s position d. Maintain Maintain traction traction in correct correct body allignment 70.A client who has just received a diagnosis of early glaucoma is being prepared for discharge. Which information information should the nurse provide during this client’s discharge teaching session? a. Instru Instructi ctions ons for for eye eye patchi patching ng b. Discharg Discharge e asses assessmen smentt of of visua visuall acuity c. Demons Demonstra tratio tion n of of eye eye drop drop instillation d. Instruct Instructions ions on intraocu intraocular lar lens cleaning 71.A client was admitted to a coronary care unit with acute myocardial infarction (MI). Now the client report midsternal pain radiating down the left arm, appears restless and is slightly diaphoretic. The nurse obtains the following assessment assessment findings: T= 00. 6 F (37.5 C); PR = 102 bpm, regular;slightly regular;slightly labored respiration of 26 bpm, and BP of 150/90 mmHg. When planning the client’s care, the nurse should give the highest priority to which nursing diagnosis? a. Risk Risk for alter altered ed body body temper temperatu ature re b. Decrea Decreased sed cardi cardiac ac outp output ut c. Anxiety d. Pain
72.A client with cirrhosis of the liver is increaslingly increaslingly confused and combative. Which of the following diets would the nurse expect to be ordered for this client? a. Low Low fat fat,, low low sod sodiu ium m b. High High carboh carbohydr ydrate ate,, low protei protein n c. Low pota potass ssium ium ,low ,low phos phospho phoru rus s d. Gluten Gluten and wheat wheat free. free. 73.Which of the following should the nurse teach a client using recombinant epoetin alpha (Epogen) for chronic renal failure? a. This This drug drug will will help help with with the the bleeding problems associated with kidney damage b. Epoeti Epoetin n alpha alpha shoul should d reduce reduce fatigue and improve energy level c. Taking Taking this this medi medica catio tion n may redu reduce ce the need for dialysis d. Once Once a good good blood blood level level is is established, the injectable form will be changed to an oral form 74.An appropriate plan of care for a client admitted with renal colic would include which of the following? a. Inserting Inserting an indwelli indwelling ng urinary urinary catheter b. Stra Strain inin ing g all all urin urine e c. Mainta Maintaini ining ng T tube tube patenc patency y d. Limiti Limiting ng fluid fluid intake intake 75.Which statement would not be included in discharge teaching for a client with a history of rheumatoid arthritis who was treated with severe anemia secondary to GI hemorrhage? hemorrhage? a. Take Take your your iron iron supple supplemen mentt with with orange juice
b. Use Use aspiri aspirin n for joint joint pain pain c. Plan Plan to take take iron iron for 6 month months s d. Avoid Avoid takin taking g iron iron with with tea tea or calcium supplements 76.A client with exacerbation of COPD and pneumonia has the following ABG results: pH 7.30, PaC02 60 mmHg, PaO2 75 mmHg and HCO3 is 24 Meq/L. The nurse anticipates wich intervention? a. Increa Increase se oxyge oxygen n via face face mask mask b. Encour Encourage age coug coughin hing g and deep deep breathing c. Admis Admister ter sodi sodium um bica bicarbo rbonat nate e d. No inte interve rventi ntion on is is neede neede.. ABG ABG values are normal 77.A client with cerebrovascular accident has a nursing diagnosis of ineffective airway clearance. The goal for this client is to mobilize pulmonary secretions. Which action should the nurse plan to take to meet this goal? a. Reposi Repositio tion n the clie client nt every every 2 hrs hrs b. Restrict Restrict fluids fluids to to 1000 1000 ml ml in 24 hrs hrs c. Asmin Asminist ister er O2 by nasal nasal canula canula as ordered d. Keep Keep the the head head of of the the bed bed at a 30 degrees angle 78.A client is admitted to the hospital with a productive cough, night sweats and fever. Which of these actions is most important in the client’s initial plan of care? a. asses assess s the client client’s ’s temper temperatu ature re every 8 hrs b. place place the the client client in resp respira irator tory y isolation
c. monitor monitor the client’f client’f fluidint fluidintake ake and output d. wear wear gloves gloves duri during ng all all clien clientt contact 79.a client with heart failure has been receiving an IV infusion at 125 ml/hr. Now the client is short of breath and the nurse notes of bilateral crackles, neck vein distention and tachycardia. What should the nurse do first? a. Noti Notify fy the the phy physi sici cian an b. Discontin Discontinue ue the IV access access device device c. Administ Administer er the prescrib prescribed ed diuretic diuretic d. Slow Slow the inf infusi usion on and and notify notify the the physician 80.After bronchoscopy, the client must receive NPO until the gag reflex returns. What is the best way to assess the gag reflex? a. Instr Instruct uct the the clie client nt to to cough cough b. Ask the client client to to extend extend the tongue tongue c. Tickle Tickle the uvula uvula with with a tong tongue ue blade d. Observe Observe while while the client client swall swallows ows sips of water. 81.A client with shock due to hemorrhage has these V/S: T= 97.6 F(36.4C), PR= 140 bpm, BP of 60/30 mmHG. For this client, the nurse should question which physician’s order? a. Monito Monitorr urine urine outp output ut every every hr hr b. Infuse Infuse IV flui fluids ds at at 83 ml/h ml/hrr c. Admist Admister er oxyge oxygen n by nasa nasall canula canula at at 3 L/min d. Draw Draw specim specimens ens for for hemogl hemoglobi obin n and hematocrit every 6 hrs
82.A client with history of atrial fibrillation presents to the outpatient clinic with nausea, vomiting, HR of 55 bpm, and visual disturbances. The nurse would further assess the client for which of the following conditions? conditions? a. Digita Digitalis lis g glyc lycos oside ide toxic toxicity ity b. Angina c. Hear Heartt fail failur ure e d. Depre epres ssion 83.A client’s ABG values are pH of 7.29, PaO2 48 mmHg, PaCO2 76 mmHg, mmHg, HCO3 of 36 mEq/l. the plan of care for this client with these values would include close monitoring for which of the following s/sx? a. Cyanos Cyanosis is and and rest restles lessne sness ss b. Flush Flushed ed skin skin and lethar lethargy gy c. Weakne Weakness ss and irrita irritabi bilit lity y d. An Anxi xiet ety y and and feve feverr 84.During postural drainage, movement of secretions from the lower respiratory tract to the upper respiratory tract occurs due to: a. Frict Friction ion betwee between n the the cilia cilia b. Forc Force e of of grav gravit ity y c. Incr Increa ease sed d insu insuli lin n use use d. Increased Increased red blood blood cell cell produ productio ction n 85.Clients with COPD may be bedridden at home and get little exercise. Which of the following is a normal physiologic physiologic reaction to prolonged period of bed rest and inactivity? a. Increa Increased sed sodi sodium um rete retent ntion ion b. Increa Increased sed calc calcium ium excr excreti etion on c. Incr Increa ease sed d insu insuli lin n use use
d. Increase Increased d red blood blood cell cell produ productio ction n 86.For a client with COPD who has trouble raising respiratory secretions, which of the following nursing measures would help reduce the tenacity of secretions? a. Ensuring Ensuring that the clien client’s t’s diet diet is is low low in Na b. Ensuring Ensuring that the client’s client’s oxygen oxygen therapy is continous c. Helpin Helping g the clie client nt maint maintain ain a hig high h fluid intake d. Keepi Keeping ng the the client client in in sittin sitting g position as much as possible 87.The nurse teaches the client with COPD to assess for signs and symptoms of right sided heart failure which include: a. Club Clubbi bing ng of of nail nail bed beds s b. Hype Hypert rten ensi sion on c. An Ankl kle e edem edema a d. Incr Increa ease sed d appet appetit ite e 88.While caring for a client who has sustained an MI, the nurse notes eight premature ventricular contractions in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water and 2 L/minte of oxygen. The nurse’s first course of action would be to:
b. Elevated Elevated creatinin creatinine e phosp phosphokin hokinase ase (CPK) value c. Agrees Agrees to to partic participa ipatin ting g in cardi cardiac ac rehabilitation rehabilitation program d. Can perf perfor orm m perso personal nal self self care care activities without pain. 90.Which of the following is expected for a client on the day of hospitalization after an MI? the client: a. Has minim minimal al chest chest pain pain b. Can iden identif tify y risk risk factor factors s for MI MI c. Agrees Agrees to to partic participa ipatin ting g in cardi cardiac ac rehabilitation rehabilitation program d. Can perf perfor orm m perso personal nal self self care care activities without pain 91.Nursing measures for the client who has had an MI include helping the client to avoid activity that results in valsalva maneuver. Which of the following actions would help prevent valsalva maneuver? Have the client: a. Take Take fewe fewerr deep deep breat breaths hs b. Clench Clench teet teeth h while while movin moving g in bed bed c. Drinks Drinks fluids fluids throug through h a stra straw w d. Avoid Avoid holding holding breath breath during during activity activity 92.A basic principle of any rehabilitation program , including cardiac rehabilitation begins:
a. Increa Increase se the the IV infus infusion ion rate rate
a. On disc dischar harge ge from from hos hospit pital al
b. Notify Notify the the physici physician an prom promptl ptly y c. Increa Increase se the oxyge oxygen n concen concentra tratio tion n
b. On disc dischar harge ge from from cardia cardiac c care care unit
d. Administ Administer er a prescrib prescribed ed analgesic analgesic
c. On adm admiss ission ion to the the hos hospit pital al
89.Whichof the following findings is an indicative of MI? a. Elevated Elevated serum serum cholester cholesterol ol level level
d. Four Four weeks weeks afte afterr the the onset onset of of disease 93.The client has a history of heart failure and the nurse is preparing the client to
go home. The nurse should instruct the client to: a. Monito Monitorr urine urine outpu outputt daily daily b. Maintain Maintain bed rest for at least least one week c. Monito Monitorr daily daily potas potassi sium um intak intake e d. Weig Weigh h dai daily ly 94.Digoxin is administred IV to clients with CHF primarily because the drugs acts to : a. Dilate Dilate corona coronary ry artery artery b. Increase Increase myocardia myocardiall c contr ontractil actility ity c. Decrea Decrease se card cardiac iac dysr dysrhyt hytmi mias as d. Decrease Decrease electric electrical al condu conductivi ctivity ty in in the heart 95.The client ask the nurse about the reason for taking enalapril maleate. The nurse based her response on the fact that enalapril is prescribed for people with heart failure to: a. Lower Lower blood blood pressure pressure by incre increasin asing g peripheral resistance b. Lower Lower the the heart heart rate rate by slowing slowing the conduction sytem c. Block Block the the conver conversi sion on of angio angioten tensi sin n 1 to angiotesin 11 d. Increase Increase cardiac cardiac contrac contractilit tility y thereby improving cardiac output 96.Metoprolol tartrate a Beta Beta adrenergic adrenergic antagonsist antagonsist may be administered to a client with heart failure because it acts to: a. Reduce Reduce peri periphe phera rall vascul vascular ar resistance b. Increa Increase se periphe peripheral ral vasc vascula ularr reistance
c. Redu Reduce ce flui fluid d vol volum ume e d. Improve Improve myocardi myocardial al contract contractility ility 97.The most effective measure the nurse can use to prevent the wound infection when changing a client’s dressing after coronary artery bypass surgery is to: a. Observ Observe e carefu carefull handwa handwashi shing ng procedures b. Cleans Cleanse e the incis incision ional al area area with with antiseptic c. Use Use prepac prepacked ked ster sterile ile dres dressin sing g to cover the wound d. Place Place soil soiled ed dress dressing ings s in a waterproof bag before disposing them 98.Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be communicated to the health care provider immediately? a. The pt has has a loud loud diast diastolic olic murmur murmur all across the precordium b. The pt has has crackles crackles audible audible to the the lung apices 99.When caring for a pt with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the pt for: a. Flan lank pain pain b. Hem Hemipar ipares esis is c. Dyspnea d. sp sple leno nom megal egaly y 100. the nurse is taking a history from a 24 y/o pt with hypertrophic cardiomyopathy. cardiomyopathy. Which information information obtained by the nurse is the most important? a. the pt reports reports using using cocaine once at 16 y/o
b. the patient has a history of upper respiratory respiratory infection c. the pt’s 29 year old brother has had a sudden cardiac arrest d. the pt has a family history of CAD
Answers to part 1 1. D. preci precipita pitating ting factors factors of angin angina a include exertion during physical activities,colds, activities,colds, after heavy meals , emotional stress wherein there’s an increase oxygen demand but less supply d/t of obstruction of blood flow. It may also occur during rest as a result of coronary spasm. Pain usually last for 3-5 minutes or 15-20 min especially after a heavy meal or anger. 2. D. TIA TIA is caused caused by temp tempora orary ry decreased in blood flow , could be caused by atherosclerosis,emboli atherosclerosis,emboli or thrombi. Anticoagulants Anticoagulants such as aspirin is given to dissolve the clot or prevent platelet aggregation that could lead to emboli or thrombi. 3. A. hemor hemorrh rhagi agic c stroke stroke can can lead lead to seizures. Thus antiseizures such as phentoin is prescribed. One often cause is hypertension causing small vessels in the brain to rupture and bleed thus antihypertensive such as methyldopa is included. The bleeding also cause edema or inflammation to the surrounding tissues so antiinflammatory such as dexamethason is given to reduce the edema. Heparin is an anticoagulant that may cause further bleeding and should be questioned. 4. C. teaching teaching should should include include small small frequent feeding to avoid too much HCl acid secretion, secretion, completing the prescribed medications medications even the patient seems to feel better, avoiding gastric irritants such as caffeine,
highly flavored foods, aspirin may cause ulcer and bleeding and should be avoided. 5. C. cushin cushing’s g’s disease disease is is an excessive excessive production of mineralocorticoids( mineralocorticoids( aldosterone- for sodium and water reabsorption), reabsorption), glucocorticoids( glucocorticoids( cortisol- breakdown of fats and protein and gluconeogenesis) gluconeogenesis) and androgens (masculine hormone. Although a pitting edema is a characteristic symptom of cushing disease because of excessive water and sodium reabsorption, reabsorption, it is not an emergency condition. Irregular apical pulse is the primary concern and should be reported immediately. 6. B. the the ventilat ventilator or will will alarm alarm to let let the the caregiver know there is a problem. Some of the most common alarms are high pressure, low pressure and battery. If the high pressure alarm sounds, it means that air is having a hard time getting into the lungs, it usually means suctioning is needed to get extra secretions out of the airway. Low pressure means that there might be an airleak or a disconnected tube. 7. B. Parkins Parkinson’s on’s crisi crisis s is also referred referred as as acute akinesia present in advanced state of the disease. The rigidity of the intercoastal muscle makes the patient unable to cough out accumulated sputum/secretions sputum/secretions .thus, patients with parkinson’s disease are prone to repiratory infections. 8. A. Addiso Addison’s n’s disease disease is is also also known known as Adrenal insufficiency. There’s insufficient adrenocorticotropic hormone (ACTH) production which includes epinephrine and norepinephrine norepinephrine that are helpful in the flight and fight response. If the body is unable to fight off stressors, this will lead to body exhaustion and increase susceptibility susceptibility to illnesses and
infections. Another adrenal hormone is aldosterone which is responsible for water and sodium reabsorption. Insufficient amount amount of this leads to increased loss of sodium and water, not urine retention and fluid excess. Excessive loss of sodium and water can lead to dehydration and increase temperature.
13.D. It is unnecessary to keep the cast warm, it should be exposed to cool air. Fiberglass is dried up within 10-15 minutes, there’s no need to assess the pedal and tibial pulses since it’s not the one casted. The casted part is the right arm so it is important to check distal circulation and sensation. sensation. Assess brachial and ulnar pulse.
9. B. antidiu antidiuretic retic hormone(A hormone(ADH) DH) preve prevents nts diuresis or urination. Excessive ADH leads to excess Na and H2O retention thereby gaining weight. Increased amount of fluid in the blood vessels causes increased venous return and fluid overload. Chronic condition may lead to congestive heart failure in which distended neck vein is one of the sign
14.A. hyperglycemia could lead to osmotic dieresis leading to fluid volume deficit as manifested by dry skin. Decreased cardiac output can’t be related to increasese HR, it is d/t dehydration and increased heart rate is a compensatory compensatory mechanism . there’s no data for insulin deficiency , there might be enough insulin but the cells are resistant to use it.
10.A. osteoarthritis is not an inflammatory inflammatory disease thereby doesn’t produce inflammatory and systemic sign and symptoms. It ‘s a wear and tear degenerative disease. Pain can occur after repetitive use of the joint . pain and stiffness can also occur after a long period of inactivity such as when you go to bed at night and suffer a pain and stiffness when you wake up in the morning.
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11.Receptive aphasia is characterized by fluent but meaningless speech with severe impairment of the ability understanding understanding spoken and written words. Short and simple sentences should be used. 12.A. DI is characterized by inadequate antidiuretic hormone leading to excessive loss of Na and H20 followed by hypotension and tachycardia. tachycardia. Tachycardia is a compensatory compensatory mechanism in an effort to pump more blood d/t the decreasing circulating circulating fluid. It is important to increase the fluid intake to prevent hypovolemic shock.
16.D. Insulin is usually administered before meal to anticipate the increase of blood sugar after eating. Never administer a subcutaneous insulin deltoid because you might give it IM. Deltoid is muscular so it is only used for IM insulin route. Don’t shake the bottle to mix, just roll gently between hands or by turning the bottle up and down slowly. 17.B. thyroid hormones are responsible for many metabolic processes. Options A,C,D are result of hyperthyroidism d/t increased metabolism and neuromuscular neuromuscular hyperactivity. One function of thyroid hormone is protein synthesis which maintain osmotic pressure in the blood vessels . if protein concentration concentration in the vessels is decreased,there’s decreased,there’s a fluid shift into the extracellular space leading to edema. 18.C. synthroid adverse effects typically resulted from overdose and include the signs and symptoms of
hyperthyroidism which includes tachycardia. 19.D. pH is below normal which suggest an acidosis. PaCO2 is for respiratory index while HCO3 is for metabolic. The pH follows HCO3, thereby it is metabolic acidosis 20.A. always follow the principle of ABC prioritization, prioritization, Airway, breathing, circulation. circulation. Respiratory Respiratory acidosis is typically the result of accumulation of CO2 in the body tissues due to hypoventilation. hypoventilation. First priority is to assist with the prescribed prescribed therapy which includes means to improve ventilation. 21.B. Bleeding / hematoma is a life threatening complication that obstructs airway postthyroidectomy. postthyroidectomy. Tracheostomy Tracheostomy set should be at the bedside to establish airway immediately if respiratory distress occurs. 22.A. In an early stage of cancer, it usually starts as a tumor , as tumor invades vascularized tumor, it may cause bleeding. 23.B. Nitroglycerin is an unstable substance and easily denatured when exposed to heat and light. The dark bottle protect the drug from the light. If the drug doesn’t tingle under the tongue, it could be that it’s not working anymore, it could be expired or denatured. You should not take more than 3 tablets , if the pain is not relieve in 15 minutes, you should consult the doctor because this is not an angina pain anymore, anymore, it could be a myocardial infarction. 24.A. mantoux test or tuberculin test is a screening test for pulmonary tuberculosis. tuberculosis. It is done by introducing a protein derivative of the causative bacteria in the dermis of the skin.
After 48-72 hours, an induration of 10 mm or more is a positive test and indicates that you might be positive for PTB, a further evaluation and testing is needed to confirm the presence of PTB. 25.C. Streptomycin is an antibiotic belonging to the aminoglycosides aminoglycosides family. Aminoglycosides work by inhibiting the bacterial protein synthesis. Streptomycin frequently affects the vestibular branch of the auditory nerve causing nausea, vomiting, vertigo. Symptoms Symptoms subside and recovery occur following discontinuation discontinuation of the drug. In long term therapy therapy however, however, ototoxic ototoxic effect causes hearing loss when extensive is usually permanent. 26.A. the main problem mention is dementia. People with dementia may not be able to think well enough to do normal activities of daily living such as getting dressed and eating. 27.A. Probenecid works by decreasing uric acid in the blood by promoting its kidney exctetion. In overdosage and intoxication, it causes various hematologic side effects. 28.A. DM type 1 is a decreased in insulin production leading to increasing amount of glucose in the blood. Hyperglycemia causes osmotic diuresis that leads to frequent urination and leads to dehydration. 29.D. A,B,C are normal findings. S/E iof chemotherapy includes nausea and vomiting, prolonged N/V caused dehydration. 30.C. it is more logical and appropriate to administer prescribed antiemtic first before feeding the patient. This is to avoid vomiting after a meal.
31.A. the most serious S/E of zidovudine is anemia, myopathy and neutripenia 32.A.The protruded or herniated disk irritates or compressed the surrounding surrounding nerve endings which causes severe back pain radiating to the thighs. 33.D. all options are clinical manifestation manifestation of hepatitis B. I think the most correct answer is D, because it needs closer monitoring and care. 34.A. ileostomy is bringing out the ileum which is the end of the small intestine into an opening on the abdomen. One important function of the colon is water absroption, since water is not anymore pass through the colon , most fluid is lost into the pouch rather than being absorb making the client more prone to dehydration. Pouch should be worn all the time. Low fiber diet should be advised postoperatively because surgery causes the bowel to swell making digestion of fiber difficult. Once the swelling has subsided(usually subsided(usually after 8 wks) the patient can resume a normal diet. 35.B. instruction to the patient should include avoiding acid stimulant such as coffee, alcohol, fatty foods,aspirin, foods,aspirin, tobacco, chocolate, peppermint,etc. peppermint,etc. you should also instruct patient to remain in upright position for atleat 30 min after eating and sleeping with the bed slightly elevated, small frequent feeding is better tolerated than 3 big meals. 36.B. Esophageal CA presents many signs and symptoms. However the question is asking specifically on the problem r/t to difficulty swallowing. You should look for a problem that is most related to difficulty swallowing, that is insufficient insufficient food intake and nutrition. The nurse should then ensure
adequate nutrition in relation to this problem. 37.C. Vit K is important in the clotting mechanism of the body. Lack of this can lead to bleeding. Purpura and petechiae are forms of bleeding 38.A. avoid exercise for 3-4 wks because this may stretch and injure the graft. 39.C. Antibacterial should work for what its designed for and that is to eliminate the causing bacteria of a disease. Even though the symptoms subside, still a number of the causative bacteria is present in the urinary tract, if the medication is stopped without completing the prescribed duration of antimicrobial antimicrobial therapy, they will again multiply and cause the exacerbation of the disease. Therefore, it is important to complete the whole duration of the drug therapy to ensure elimination of all the bacteria. 40.B. inner cannula is cleaned with Hydrogen Peroxide and rainsed with water. The stoma is also cleaned using a soapy wash cloth then rinsing it. Inner surrounding of the stoma with driep up sputum crust can be cleaned with a cotton tipped swab soaked in hydrogen peroxide. Alcohol promotes dryness. There’s no indication why you have to limit fluid intake. Protein intake should be increased to promote healing. Patient can still communicate communicate with proper speech therapy and learning other means of communication. 41.B. keep the bed elevated to promote ventilation of the lungs and reduces edema and swelling of the neck. The patient is on NGT feeding temporarily , no food is allowed by mouth until the pharyngeal suture line is healed. healed. The tracheostomy tracheostomy cuff
should not be fully inflated inflated to avoid pressure trauma to the windpipe. Usually 10 ml of air is used and the cuff should be deflated once in a while to relieve the pressure. In total laryngectomy, laryngectomy, speech rehabilitation training is necessary( esophageal voice, electrolarynx) electrolarynx) or using sign sign language. 42.A. clamp is only necessary when there is a leak along the tubing and is used used to locate the leak. Clamp should only be used in a limited time to prevent tension pneumothorax and mediastinal shift. Milking is only per MD order. To ensure that the drainage system is intact, the nurse should monitor for gently fluctuations in the water seal chamber with each inspiration inspiration and expirarion.This expirarion.This is called tidaling. Though coughing and deep breathing is also an important teaching, making sure the drainage system is intact is more important to serves its purpose. 43.B. Follow the ABC prioritization( prioritization( 1.Airway, 2.breathing, 3.circulation) 44.C. Assess first before you intervene. PTT is used to test how long it takes your blood to clot and check for bleeding problems especially when the patient is on blood thinning therapy such as heparin . 45.D. the question is asking specifically about sign of righ heart failure. Cor pulmonale is a right ventricular hypertrophy due to chronic lung disease. Right side heart failure is usually associated with signs of the venous system. Due to the hyperthropy of the right ventricle, there is insufficient filling, thus blood backs up up to the venous system causing peripheral edema.
46.A. the most priority is to ensure a patent airway, auscultating the presence of breathsound is an indication that the air way is patent. 47.A. albuterol is a bronchodilator bronchodilator that relaxes muscle of the airway and increases airflow into the lungs 48.C. always assess first before you intervene. Clots along the drainage can cause urine stasis and aggravate pain. 49.A. this is to prevent edema. 50.B. Creatinine clearance. Creatine is a byproduct of metabolism and excreted by the kidney. 51.B. increase fluid intake is very important to flushes out bacteria 52.C. in oliguric phase phase , it doesn’t mean mean that there is an insufficient insufficient fluid intake, it’s because there’s a decrease glomerular filtration leading to fluid accumulation accumulation in the body and fluid overload. Emphasize Na and fluid restriction at this point. 53.C. peritonitis is the most major risk in peritoneal dialysis d/t to introduction introduction of microorganism through the catheter. 54.B. airway and breathing is always the priority. 55.D. Pillows under knees can be used but should not be kept at all time to promote venous return and prevent blood clot formation. Ambulation is encouraged within hours after surgery to promote lung aeration. Pt can be positioned supine with a pillow under neck or at the sides. The patient should also change position at least every 2 hrs , when turning the body should be moved as a unit.
56.A. patients with central line catheter are ambulatory and urinary catheter is not needed unless there’s some kidney pathology that requires the use of it. Sterile technique is used when changing the dressing , occlusive dressing is used to prevent air from entering the line. 57.D. Normal serum potassium level is 3.5-5 mEq/L, normal serum sodium is 135-145 mEq/L. normal urine output is at least 30 ml/hr . 58.D. The first phase of acute renal failure is oliguric phase with urine output of 400ml or less in 24 hrs. Normal urine ourput in 24 hrs is 1500 ml. normal serum creatinine is .7-1.4 mg/dl. BUN is not significantly increased normal bun is 10-20 mg/dl. 59.A. one principle of prioritization is to look on the client’s needs on the clients perspective . pain is considered as the 5th vital sign. The pain is severe that needs to be addressed first among the other options. 60.B. All options except D are signs and symptoms of liver cirrhosis but option B poses the most serious complication. complication. Advanced liver cirrhosis can lead to hepatic encephalopathy which is the accumulation of toxins in thebrain leading to decreased mental function and coma. 61.C. airway and breathing is always the priority. The patient has difficulty of breathing because of the pressure exerted by the enlarged abdomen to the diaphragm. 62.B. The patient has prolonged clotting time which predisposes the patient to bleeding . Coaugulant such as phytonadion (Vit. K)should be given to counteract effect .warfarin is an ancticoagulant ancticoagulant which place the patient in increased risk of bleeding.
Furosemide and Spironolactone are diuretics. 63.B. Sprironolactone is a K sparing diuretic . It is used to excrete extra fluid from the body , therby, lose of body weight means tha most fluid are being excreted out. 64.A. incentive spirometry is a breathing device that promote maximal lung aeration and respiratory effectiveness 65.D. Elevate only to 15-30 degrees to promote venous return and reduce cerebral edema. Enforce any fluid restriction and monitor carefully input and output. Avoid activities that increase intrathoracic or intraabdominal pressure such as straining during bowel movement, this impedes blood flow from the cranium. Suctioning can stimulate the vagal reflex and further increase ICP, suctioning is only done if its extremely necessary. 66.1 kg= 2. 2 lbs 175 lb X 1 kg = 79.55 lbs 2.2 lbs 79.55 lbs X 1.5 g= 119 g
67.C. mannitol is a diuretic that excretes extra fluid out from the body. Increased UO is an indication that mannitol’s desired effect is achieved 68.A. bone marrow is also composed of fat globules that may escapes out during bone fracture and causes fat embolism. The fat globules can impede blood flow making the affected leg pale and cool. 69.D. traction should be continuous , the weight is never removed nor interrupted. The patient is in supine
with neck supported by a pillow. The leg with a traction should be held straight and never flexed. 70.C. Glaucoma occurs due to the pressure build up in the eye by increased amount of aqueous vitrous humor. Eye drops could either work by promoting the flow of the aqueous fluid or decrease the production of it. 71.D. One priority in acute MI is pain control drugs such as morphine to reduce catecholamine induced oxygen demand to injured injured heart heart muscle. muscle. 72.A. cirrhosis may lead to malnutrition. It is essential to maintain a healthy , nutritious diet such as increasing carbohydrate carbohydrate and protein intake. Low fat diet should be observed because bile is needed for digestion and bile is not sufficiently produced in cirrhotic liver. Salt and Na intake should also be minimal because patients with cirrhosis tends to retain extra fluid. When liver cirrhosis is complicated by hepatic encephalopathy, then this is the time that protein intake should be limited. 73.B. kidney produced erythropoietin erythropoietin necessary for blood cell formation, kidney damage leads to anemia. Signs and symptoms of anemia include easy fatigability and body weakness. Epogen is given SQ or IV to aids in erythropoeisis erythropoe isis and reduces symptoms of anemia 74.B. renal colic is a very excruciating pain caused by the passage of stone along the ureter. Indwelling catheter will not ease the pain. It may in fact add more to the pain experience. T tube is used to drain bile . Increased fluid intake should be encourage to help flush the stone. It is appropriate to collect all urine and strain for stone passage to assess assess effectiveness effectiveness of
therapy and or to study the stone composition. 75.B. Vit C such as orange juice enhances absorption, tea, coffee and calcium reduces iron absorption. Aspirin is avoided because it is a blood thinner and aggravates bleeding 76.B. Doctors always prescribed a low oxygen delivery to patients with COPD usually at 2 L/min because high concentration concentration of oygen can depress the respiratory drive. Besides high oxygen concentration is of no use if the airway is obstructed with secretions. It is very important to encourage the pt to cough out secretions to help clear the airway and encourage deep breathing. All ABG values are abnoramal. 77.A. Fluid may be increased to liquefy secretions. Oxygen administration and putting the pt in semi fowler’s do not help in mobilizing secretions. stroke patients who are on bed rest are prone to respiratory complications because of retention of secretions. Therefore assisted ambulation and frequent positioning may help to mobilize mobilize secretions . 78.B. the signs and symptoms presented are indications of PTB. It’s a safe precautionary precautionary practice to place the pt in respiratory isolation to prevent cross infection while further assessment assessment and evaluation is carried out. 79.B. the nurse should suspect a circulatory overload because of the assessment assessment findings. Initial action is to stop the IV to stop further introduction introduction of fluid. 80.C. contraction of the back of the throat when the uvula is tickled means that gag reflex has returned.
81.B. Iv rate should be a fast drip to immediately restore the fluid volume 82.A.Digitalis are given to patients with cardiac problems to strengthen heart contraction. Initial s/sx of Digitalis toxicity is GI manifestation such as N/V, loss of appetite, diarrhea. Other symptoms include visual changes, slow pulse , confusion etc. 83.B. With the ABG values presented, the pt is suffering from respiratory acidosis. 84.B. In postural drainage, the patient is placed on a trendelenberg trendelenberg position so gravity aids in the movement of mucus to the upper respiratory tract. 85.B. Immobilization Immobilization causes calcium lose from the bones into the bloodstream bloodstream and cause cause hypercalcemia. hypercalcemia. The kidney in response of hypercalcemia increases its excretion. 86.C. increased fluid intake loosen up secretions thus easy to expectorate 87.C. one classical sign of right side heart failure is edema due to decreased venous return. 88.B . Because PVC s may signal an impending life threatening rhythm , notify the physician if the pt has more than six PVCs per minute. minute. 89.B. creatine phospholinase is an enzyme normally found in muscle fibers. It is released in the bloodstream when there is muscle damage. MI is the interruption of blood supply causing heart muscle cells to die. 90.I’m not sure of the correct answer, answer, but I guess the best option is B. Pain in MI doesn’t last until the following day. Most patients after a heart attack are hesitant to resume activities, bed rest
is advised at least for the first couple of days at least 1-2 days. Patients are strongly advised to participate in cardiac rehabilitation program to help patients to recover quickly and improve their overall physical, mental and social functioning. functioning. 91.D. straining against a closed epiglottis which includes holding breath or forceful expiration stimulates valsalva maneuver. Pts should be advised to avoid holding breaths while moving . 92.C. rehabilitation begins upon admission 93.D. weight gain can be a sign that you the pt is retaining fluid and his heart condition is worsening. 94.B. Digitalis is given to increase cardiac contractility followed by decreased in HR 95.C. Enalapril is an ACE inhibitor (Angiotension (Angiotension Converting Enzyme inhibitor) that decreases BP. Angiotensin II is a potent vasoconstrictor. 96.A. beta adrenergic antagonist antagonizes the action of sympathetic response. It works by reducing the force of contraction of heart muscles thereby reducing peripheral resistance and blood pressure . 97.A. Proper handwashing has always been the single most effective measure to prevent cross contamination contamination and infection. 98.B. Mitral valve stenosis is the narrowing and stiffening of the mitral valve caused oftenly caused by rheumatic fever in adults. Due to the narrowed valve, blood is not efficiently pumped into the left ventricle, over time, pressure in the atrium increases and blood is backed up to the lungs
and cause pulmonary pulmonary hypertension and pulmonary edema which is manifested by presence presence of lung crackles. 99.C. Infective endocarditis is due to bacterial or fungal infection that affects the endocardium of the heart especially the heart valves. Over time, materials called vegetations developed along the valves. These contain bacteria, blood clots, debri from the infection. This vegetations prevent the valve from working properly and will lead to cardiac failure. 100. C. although th the sp specific causes of hypertrophic cardiomyopahty are not yet fully known. The primary cause seems to be genetic.
