1. Following a prostatectomy, the client has a three-way, indwelling catheter for continuous bladder irrigation. During evening shift, 2400 ml of irrigant was instilled. At the end of the shift, the drainage bag was drained of 2900 ml of fluid. The nurse calculates the urine output to be
A. 5300 ml.
B. 2900 ml.
C. 240 ml.
D. 500 ml.
Answer Rationale
A. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag.
B. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag.
C. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag.
D. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag (2900 ml drainage - 2400 ml irrigant = 500 ml urine).
2. An adult has just been brought in by ambulance after a motor vehicle accident and has moderate anxiety. When assessing the client, the nurse would expect which of the following from sympathetic nervous system stimulation?
A. A rapid pulse and increased respiratory rate.
B. Decreased physiologic functioning.
C. Rigid posture and altered perceptual focus.
D. Increased awareness and attending.
Answer Rationale
A. The sympathetic nervous system during moderate anxiety will increase the pulse and respirations.
B. If there is any decreased physiologic functioning, it is from the parasympathetic nervous system and not the sympathetic.
C. Both a rigid posture and either fixed or scattered perceptual focus indicate severe anxiety or panic, not moderate stress.
D. The increased awareness and attending as well as the ability to focus on most of what is really happening is a sign of mild anxiety. Learning can take place during mild anxiety.
3. An adult is on a clear liquid diet. The nurse can offer him
A. milk.
B. Jello.
C. freshly squeezed orange juice.
D. ice cream.
Answer Rationale
A. Milk is not permitted on a clear liquid diet, but is allowed on a full liquid diet.
B. Plain gelatins can be given on a clear liquid diet, as well as tea, coffee, ginger ale, or 7-Up.
C. The only fruit juices allowed on a clear liquid diet are those that are strained and clear (able to be seen through).
D. Ice cream is allowed with a full liquid diet, not a clear liquid diet.
4. An adult is being taught about a healthy diet. The nurse explains that the food pyramid can guide him
A. by indicating exactly how many servings of each group to eat.
B. on how many calories he should have.
C. in making daily food choices.
D. to divide food into four basic groups.
Answer Rationale
A. Each person differs in nutritional needs according to age, activity level, size, and other factors. Therefore the pyramid serves as a guide.
B. The food pyramid does not indicate caloric count. It can serve to guide eating patterns.
C. The pyramid helps to guide the client in choosing a variety of foods to obtain the nutrients he needs. It also aids in eating more of some groups (bread, cereal, rice, and pasta) and less of others (fats, oils, and sweets).
D. The pyramid replaces the old basic four, by dividing food into six groups: bread, cereal, rice, and pasta; fruit; vegetables; milk, yogurt, and cheese; meat, poultry, fish, dry beans, eggs, and nuts; and fats, oils, and sweets. It also indicates to eat more of some foods and less of others.
5. Before administering a tube feeding the nurse knows to perform which of the following assessments?
A. gastrointestinal (GI) tract, including bowel sounds, last BM, and distention.
B. The client's neurologic status, especially gag reflex.
C. The amount of air in the stomach.
D. That the formula is used directly from the refrigerator.
Answer Rationale
A. The GI tract should be assessed before each feeding to ensure functioning and minimal problems.
B. An altered neurologic status can be the reason for tube feedings, the gag reflex need not be present as the tube provides the conduit although it can be a significant risk factor for aspiration.
C. The gastric residue can be checked to evaluate gastric emptying. If there is more than 100 ml, then the feeding is often held and the physician contacted.
D. The formula is administered at room temperature to avoid cramping, which can occur if the formula is cold.
6. An adult is on long-term aspirin therapy and is experiencing tinnitus. The nurse best interprets this to mean:
A. the aspirin is working correctly.
B. the client ingested more medicine than was recommended.
C. client has an upper GI bleed.
D. he is experiencing a mild overdosage.
Answer Rationale
A. Tinnitus or ringing in the ears is a sign of an overdosage and the aspirin should be stopped to allow the tinnitus to clear.
B. Although the client has an overdosage, it does not mean that he took too much medicine. A build-up can occur, especially among those with limited liver or kidney function.
C. Although aspirin can cause GI irritation and bleeding, tinnitus or ringing in the ears is a sign of aspirin overdosage.
D. Tinnitus is a classic sign of aspirin overdosages, either from too much ingestion or limited excretion.
7. An adult is to receive an intramuscular (IM) injection of morphine for post-op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?
A. client's level of alertness and respiratory rate.
B. The last time the client ate or drank something.
C. The client's bowel habits and last bowel movement.
D. The client's history of addictions.
Answer Rationale
A. A decreasing level of alertness can signal early respiratory depression and a significant drop in the respiratory rate is a warning sign. Both should be taken prior to giving the medication for baseline purposes.
B. The last meal is important for surgery, but narcotic analgesics can be given after eating or drinking as long as care is given to avoid vomiting and aspiration.
C. Although constipation is a common side-effect of narcotics, it should not prohibit the administration of the drug.
D. A history of addictions does not preclude a client from receiving the analgesic.
8. An adult suffered second and third degree burns over 20% of his body two days ago. The nurse knows that the best way to assess fluid balance is to
A. maintain strict records of intake and output.
B. weigh the client daily.
C. monitor skin turgor.
D. check for edema.
Answer Rationale
A. Although inputs and outputs are important, they do not take into account other losses (especially through the wound) which can be significant.
B. This is the best way to assess fluid balance, especially acute changes in those with large losses or acutely ill.
C. Skin turgor can assist in assessing fluid balance, but daily weights can provide a better measure for the burn victim.
D. Edema informs the nurse about fluid in the interstitial spaces, but would not reflect the vascular component.
9. Ms. H. has gastroenteritis and is on digitalis. Her lab values are: K 3.2 mEq/L, Na 136 mEq/L, Ca 4.8 mEq/L, and Cl 98 mEq/L. The nurse puts which of the following on the client's plan of care?
A. Monitor for hyperkalemia.
B. Avoid foods rich in potassium.
C. Observe for digitalis toxicity.
D. Observe for Trousseau's and Chvostek's signs.
Answer Rationale
A. The client has hypokalemia, not hyperkalemia, and needs to be observed for problems related to too little potassium.
B. Ms. H.'s problem is hypokalemia, too little potassium. She needs to increase the amount in her diet, not limit it.
C. Hypokalemia enhances digitalis toxicity, and must be observed for carefully.
D. These signs indicate hypocalcemia or hypomagnesemia. This client has hypokalemia.
10. Mr. B. is anxious and hyperventilating. His blood gases are: pH 7.47, PaCO 2 33. What is the best initial action for the nurse to take?
A. Try to have the client breathe slower or into a paper bag.
B. Monitor the client's fluid balance.
C. Give O 2 via nasal cannula.
D. Administer sodium bicarbonate.
Answer Rationale
A. The client is in respiratory alkalosis, and needs to increase the carbon dioxide. The easiest way to do this is to try and calm the client and/or have him breathe in and out of a paper bag, thus inhaling the exhaled carbon dioxide.
B. Fluid loss, especially vomiting and diarrhea will often result in metabolic alkalosis. This client's problem is respiratory alkalosis and would not be corrected through fluid administration.
C. The problem is not too little oxygen as much as it is too much exhalation of carbon dioxide.
D. There is not too little bicarbonate (which occurs with metabolic acidosis), rather too little carbonic acid.
11. A nurse is teaching a class in a community center about lung cancer. Which statement best demonstrates the client's understanding of the risk factors for lung cancer?
A. "My husband smokes, but I don't! So, I really don't need to worry about getting lung cancer."
B. "I guess I will need to eat more green and yellow vegetables."
C. "Just because I have COPD doesn't mean that I have a higher risk."
D. "I've worked with asbestos all my life and have never had any problems."
Answer Rationale
A. Cigarette smoke may be inhaled actively by smoking or passively (second hand smoke). Both types of inhalation are positively correlated with development of lung cancer.
B. Research has shown that there may be a correlation between vitamin A deficiency in the diet and the development of lung cancer. Daily consumption of green and yellow vegetables is encouraged.
C. Clients with chronic respiratory diseases are at higher risk for development of lung cancer.
D. Lung cancer has a higher incidence in industrial areas. Coal tar, radioactive ore, asbestos, nickel, silver, arsenic and plastics have been found to be carcinogenic. Asbestos exposure is a definite risk factor for development of lung cancer.
12. A client presents with symptoms of increased intracranial pressure, papilledema, and headache. No history of trauma is found. Vital signs are: BP 110/60, HR 80, T 98.9 ° F, RR 24. Based on this assessment, the nurse suspects the client has a(n):
A. brain tumor.
B. meningitis.
C. skull fracture.
D. encephalitis.
Answer Rationale
A. These findings are consistent with a brain tumor.
B. Meningitis is accompanied by fever, headache, nuchal rigidity, and Kernig's and Brudzinski's signs.
C. There is no history of head trauma.
D. The symptoms of encephalitis include headache, fever, vomiting, and meningeal signs.
13. Mr. P., a 45-year-old, complains of excessive weight loss and anorexia. Laboratory studies show that Mr. P. is anemic. Hepatocellular carcinoma is suspected. A liver biopsy is performed at the bedside. The nurse can expect that after the procedure Mr. P. will be
A. encouraged to ambulate to prevent the formation of venous thrombosis.
B. 2. Incorrect asked to turn, cough, and deep breathe every two hours for the next eight hours.
C. placed in a high Fowler's position to maximize thoracic expansion.
D. positioned on his right side with a pillow under the costal margin, and immobile for several hours.
Answer Rationale
A. Clients are to remain immobile on bedrest for several hours post liver biopsy.
B. Turning the client side to side is contraindicated; bleeding from the puncture site is encouraged.
C. High Fowler's position does not provide pressure against the puncture site, which would discourage bleeding.
D. The client experiencing a liver biopsy is at risk for bleeding or hemorrhage related to penetration of the liver capsule. Positioning on the right side acts as a tamponade against the puncture site discouraging bleeding from the site.
14. A 36 - year - old female reports double vision, visual loss, weakness, numbness of the hands, fatigue, tremors, and incontinence. On assessment, the nurse notes nystagmus, scanning speech, ataxia, and muscular weakness. Based on these findings, the nurse suspects the client has
A. Parkinson's disease.
B. myasthenia gravis (MG).
C. amyotrophic lateral sclerosis (ALS).
D. multiple sclerosis (MS).
Answer Rationale
A. The symptoms of Parkinson's include masklike appearance to the face, drooling, slow speech, and shuffling gait.
B. The symptoms of MG include weakness, fatigue, drooling, and ptosis.
C. The symptoms of ALS include progressive muscle weakness, atrophy, fasciculations, dysphagia, and spasticity of the flexor muscles.
D. These are the symptoms of MS, which is more common in women ages 20 - 40.
15. A client is being assessed to rule out cardiovascular problems. The nurse understands that some of the common symptoms associated with cardiovascular disease are
A. shortness of breath, chest discomfort, palpitations.
B. dyspnea, chest discomfort, sputum production.
C. fatigue, weight changes, mood swings.
D. mood swings, headaches, fainting.
Answer Rationale
A. Some of the most common clinical manifestations of cardiovascular disease are shortness of breath, chest pain or discomfort, dyspnea, palpitations, fainting, and peripheral skin changes such as edema.
B. Some of the most common clinical manifestations of respiratory disease are cough, sputum production, dyspnea, hemopytosis, wheezing, and chest pain.
C. Some of the most common clinical manifestations of endocrine disorders are fatigue, depression, decreased energy, sleep pattern disorders, weight changes, altered mood, changes in the condition of the skin and hair, sexual dysfunction.
D. Some of the most common clinical manifestations of neurologic disorders are behavior changes, mood swings, loss of consciousness, seizures, memory deficits, motor and sensory function problems.
16. A 52 - year - old patient is admitted to the nursing unit from the recovery room following a left pneumonectomy. When planning his care, the nurse can expect this patient to:
A. have a chest tube to water seal.
B. have a chest tube to suction.
C. be monitored closely for respiratory and cardiac complications.
D. have his left arm maintained in a sling to prevent pain and discomfort.
Answer Rationale
A. In an pneumonectomy, the entire lung is removed and the pleural space is left empty. Closed chest drainage is generally not used because it is helpful for serous fluid to accumulate in the empty space to prevent an extensive mediastinal shift.
B. In an pneumonectomy, the entire lung is removed and the pleural space is left empty. Closed chest drainage is generally not used because it is helpful for serous fluid to accumulate in the empty space to prevent an extensive mediastinal shift.
C. Post-op respiratory insufficiency may result from an altered level of consciousness related to anesthesia, pain medications, decreased respiratory effort secondary to pain, or inadequate airway clearance. So, the client must be monitored very closely with frequent vital sign checks and respiratory assessments.
D. It is very important that the client move the arm on the affected side. Generally the pain is due to muscle dissection and restricted positioning while the patient is in the OR. Encouraging use of analgesics and arm exercises will help decrease discomfort.
17. To prevent possible complication, which of the following questions should a nurse ask a client prior to a cardiac catheterization?
A. "Have you ever had a cardiac catheterization before?"
B. "Can you eat shellfish?"
C. "Do you understand the procedure?"
D. "Have you ever had a heart attack?"
Answer Rationale
A. Client teaching can enforce new material but does not reduce complications.
B. Shellfish contains iodine, which is also in the contrast media used during a catheterization. It is imperative to obtain information regarding iodine allergies.
C. Anxiety can be reduced by client education, but this does not reduce complications.
D. Past history is important; however, this information will not prevent life-threatening complications.
18. The nurse caring for a patient who has had a removal of the larynx and a permanent opening made into the trachea will plan care for a patient who has undergone a
A. total laryngectomy.
B. tracheostomy.
C. radical neck dissection.
D. partial laryngectomy.
Answer Rationale
A. A total laryngectomy is the removal of the larynx and formation of the tracheostomy. The esophagus remains attached to the pharynx. No air will enter through the nose. The patient will breathe through the tracheostomy. The procedure is indicated for large glottic tumors with fixation of vocal cords.
B. A tracheostomy is a surgical opening made into the trachea for airway management with a creation of a stoma. This procedure can be indicated for (but not limited to) long-term airway management, upper airway obstruction, altered level of consciousness, sleep apnea, airway burns.
C. Radical neck dissection is the removal of the lymphatic drainage channels and nodes, sternicleodomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. This procedure is indicated when metastasis occurs to the cervical lymph nodes from tumors in the upper aerodigestive tract.
D. A partial laryngectomy is removal of half or more of the larynx. This procedure is performed for cancer of the vocal cords.
19. Mr. W., a 55-year-old, is scheduled for a resection of the lower thoracic esophagus to remove a malignant tumor. In planning for Mr. W.'s postoperative care, the nurse would expect to
A. keep Mr. W. in a supine position to encourage thoracic expansion.
B. carefully advance the nasogastric tube past the anastomosis site.
C. frequently assess Mr. W.'s breath sounds.
D. provide a regular diet high in protein.
Answer Rationale
A. Post-op clients experiencing esophageal resections are positioned in a semi-Fowler's position to help prevent reflux of gastric contents.
B. Nasogastric tubes of clients with an esophageal resection should not be manipulated.
C. Surgical resection of the esophagus has a relatively high mortality rate related to pulmonary complications.
D. Clients with an esophageal resection when beginning to take food orally would have a liquid or soft diet.
20. Mr. J., a 35 - year - old stockbroker, has recently been diagnosed with peptic ulcer disease. Diagnostic studies confirm the presence of the gram - negative bacteria Helicobacter pylori in his gastrointestinal tract. If Mr. J. has a duodenal ulceration, the nurse would expect Mr. J. to describe the "ulcer pain" as:
A. located in the upper right epigastric area radiating to his right shoulder or back.
B. relieved by vomiting.
C. occurring two to three hours after a meal, often awakening him between 1:00 and 2:00 a.m.
D. worsening with the ingestion of food.
Answer Rationale
A. This pain is typical of the pain associated with cholecystitis.
B. Vomiting is more frequently associated with a gastric ulcer.
C. Duodenal ulcer pain characteristically occurs two to three hours after a meal, often awakening the client in the very early morning hours.
D. Pain that worsens with the ingestion of food is more often associated with gastric ulcers.
