Kaplan - Question Trainer 2

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The nurse supervises care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?

1. An 18-month-old with respiratory syncytial virus.
2. A 4-year-old with Kawasaki disease.
3. A 10-year-old with Lyme disease.
4. A 16-year-old with infectious mononucleosis.

(1) correct—acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children

(2) acute systemic vasculitis in children under 5; standard precautions

(3) connective tissue disease; standard precautions

(4) standard precautions

The nurse assesses a client diagnosed with a spinal cord injury. Which of the following assessment findings by the nurse suggests the complication of autonomic dysreflexia? Select all that apply.

1. Urinary bladder spasm pain.
2. Severe pounding headache.
3. Profuse sweating.
4. Tachycardia.
5. Severe hypotension.
6. Nasal congestion.

(1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived

(2) correct—severe headache results from rapid onset of hypertension

(3) correct—especially of forehead

(4) pulse will slow

(5) BP will increase

(6) correct—also causes piloerection (goose flesh)

An adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which of the following?

1. Explain that the client will walk with a prosthesis soon after surgery.
2. Encourage the client to share feelings and fears about the surgery.
3. Take the informed consent form to the client and ask the client to sign it.
4. Evaluate how the client plans to complete schoolwork during hospitalization.

(1) fails to recognize his immediate concerns

(2) correct—discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning

(3) client is underage; parents will need to sign the permit

(4) is more appropriate for the postoperative period of time than for the preoperative period

A client at 16 weeks' gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by an amniocentesis?

1. Tetralogy of Fallot.
2. Talipes equinovarus.
3. Hemolytic disease of the newborn.
4. Cleft lip and palate.

(1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle

(2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot

(3) correct—maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis

(4) congenital deformity detected at birth, midline fissure or opening into lip or palate

The nurse evaluates the nutritional intake of an adolescent girl attending camp. The adolescent eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?

1. Her diet is low in calories and high in iron.
2. Her diet is low in calories and low in iron.
3. Her diet is high in calories and low in iron.
4. Her diet is high in calories and high in iron.

(1) only 1,200 to 1,500 kcal/day required, and 15 mg/day of iron

(2) only 1,200 to 1,500 kcal/day required

(3) correct-900 × 3 = 2,700 calories/day and women need 1,200 to 1,500 kcal/day (men need 1,500 to 1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required

(4) 18 mg/day of iron required

A client returns from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the client's chart should include which of the following?

1. Time and circumstances under which the rash was noted.
2. Explanation given to the client and family of the reason for the rash.
3. Notation on an allergy list and notification of the doctor.
4. The need for application of corticosteroid cream to decrease inflammation.

Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?

(1) would be noted, but is not as high a priority

(2) inappropriate

(3) correct—suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies

(4) inappropriate

A client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which of the following assessment findings?

1. Hypotension, backache, low back pain, fever.
2. Wet breath sounds, severe shortness of breath.
3. Chills and fever occurring about an hour after the infusion started.
4. Urticaria, itching, respiratory distress.

(1) correct—signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea

(2) describes symptoms of circulatory overload

(3) describes a febrile or pyrogenic reaction

(4) describes an allergic reaction

The nurse develops a comprehensive care plan for a young woman diagnosed with anorexia nervosa. The nurse refers the client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with which of the following?

1. Aggressive behaviors and angry feelings.
2. Self-identity and self-esteem.
3. Focusing on reality.
4. Family boundary intrusions.

(1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

(2) correct—clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do

(3) do not have problems with reality

(4) these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

Under the supervision of the registered nurse, a student nurse changes the dressing of a client with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, requires an intervention by the registered nurse?

1. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
2. The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
3. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
4. The student nurse securely tapes the edges of the sterile dressing with paper tape.

Strategy: "Requires an intervention" indicates incorrect behavior. All answers are implementations. Determine outcome of each answer. Is it desired?

(1) appropriate procedure

(2) appropriate procedure

(3) correct—should clean from insertion site outward toward outer abdomen

(4) appropriate procedure

The home care nurse performs an assessment of a client diagnosed with pneumonia secondary to chronic pulmonary disease. Which of the following nursing goals is MOST appropriate?

1. Maintain and improve the quality of oxygenation.
2. Improve the status of ventilation.
3. Increase oxygenation of peripheral circulation.
4. Correct the bicarbonate deficit.

Strategy: Determine the outcome of each answer.

(1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state

(2) correct—to improve the quality of ventilation refers to levels of carbon dioxide and oxygen

(3) not appropriate for the situation

(4) not appropriate for the situation

A client comes to the clinic for the results of a glycosylated hemoglobin (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of the procedure?

1. "This test is performed by sticking my finger and measuring the results."
2. "This test needs to be performed in the morning before I eat breakfast."
3. "This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks."
4. "I must follow my diet carefully for several days before the test."

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

(1) 3 to 5 ml of blood is needed

(2) timing of test is not important

(3) correct—when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6%

(4) current blood sugar doesn't affect test

The nurse recognizes which of these symptoms as characteristic of a panic attack?

1. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy.
2. Decreased blood pressure, chest pain, choking feeling.
3. Increased blood pressure, bradycardia, shortness of breath.
4. Increased respiratory rate, increased perceptual field, increased concentration ability.

(1) correct—panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of "losing it" or going crazy

(2) not accurate because typically the client has increased blood pressure related to stimulation of the sympathetic nervous system

(3) heart rate would be increased due to stimulation of the sympathetic nervous system

(4) client's perceptual field is decreased during a panic attack; client becomes less aware of his/her surroundings, and his/her performance is inhibited

The clinic physician diagnoses Graves' disease for a client. The nurse expects the client to exhibit which of the following symptoms?

1. Lethargy in the early morning.
2. Sensitivity to cold.
3. Weight loss of 10 lb in 3 weeks.
4. Reduced deep tendon reflexes.

(1) will be restless

(2) will have heat intolerance due to increased metabolic rate

(3) correct—increased metabolic rate causes weight loss even with increased appetite

(4) reflexes will be hyperactive

During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?

1. "Children develop trust from birth to 18 months of age."
2. "Children develop trust from 18 months to three years of age."
3. "Children develop trust from three to six years of age."
4. "Children develop trust from six to twelve years of age."

(1) correct—Erikson states that trust results from interaction with dependable, predictable primary caretaker

(2) toddler stage concerns autonomy verses shame and doubt

(3) preschool state concerns initiative versus guilt

(4) latency or school age stage concerns industry versus inferiority

The nurse recognizes which of the following nursing interventions is MOST important when caring for a client just placed in physical restraints?

1. Prepare PRN dose of psychotropic medication.
2. Check that the restraints have been applied correctly.
3. Review hospital policy regarding duration of restraints.
4. Monitor the client's needs for hydration and nutrition while restrained.

Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes.

(1) implementation; inappropriate for the client in restraints

(2) correct—assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained

(3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints

(4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained

The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which of the following as the primary goal of this type of group activity?

1. Provides psychosocial educational opportunities for stress and coping.
2. Provides an avenue for physical exercise.
3. Provides an environment for social interaction and companionship.
4. Reorients and provides a reality test for confused clients.

(1) is not primary goal of a reminiscing group

(2) is not primary goal of a reminiscing group

(3) correct—primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members

(4) groups that facilitate orientation to time, person, place, and current events are called reality orientation groups

The nurse is aware that which of the following assessments indicates hypocalcemia?

1. Constipation.
2. Depressed reflexes.
3. Decreased muscle strength.
4. Positive Trousseau's sign.

(1) symptom associated with hypercalcemia

(2) symptom associated with hypercalcemia

(3) symptom associated with hypercalcemia

(4) correct—positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia

When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse identifies which of the following instructions is BEST?

1. After pursed lip breathing, cough into a container.
2. Upon awakening, cough deeply and expectorate into a container.
3. Save all sputum for three days in a covered container.
4. After respiratory treatment, expectorate into a container.

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

(1) coughing into a container is indicated, but not pursed-lip breathing

(2) correct—specimens should be obtained in the early morning because secretions develop during the night

(3) appropriate for acid-fast stain for TB

(4) earliest specimen is most desirable

A patient has a Levin tube connected to intermittent low suction. At 7 A.M., the nurse charts that there is 235 ml of greenish drainage in the suction container. At 3 P.M., the nurse notes that there is 445 ml of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 ml of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?

1. 150 ml.
2. 210 ml.
3. 295 ml.
4. 385 ml.

(1) correct-445 − 235 = 210 − 60 = 150

(2) does not subtract 60 ml of fluid used to irrigate Levin tube

(3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate Levin tube

(4) does not subtract 235 ml that was in container from night shift

The nurse cares for a patient during a radium implant. During the removal of the implant, it is MOST important for the nurse to take which of the following actions?

1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps.
2. Handle the radium carefully using forceps and rubber latex gloves.
3. Chart the date and time of removal together with the total time of implant treatment.
4. Double-bag the radium implant before the person from radiology removes it from the room.

Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?

(1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

(2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

(3) correct—important that accurate documentation be maintained on the internal radium implant

(4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse should encourage the client to maintain an adequate intake of which of the following?

1. Sodium.
2. Protein.
3. Potassium.
4. Iron.

(1) correct—alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity

(2) doesn't interact with lithium

(3) doesn't interact with lithium

(4) doesn't interact with lithium

A college student comes to the college health services complaining of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumber puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis is made?

1. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm3.
2. CSF with RBCs present, Hgb 10 g/dL, HCT 37%, WBC 8,000/mm3.
3. CSF cloudy, Hgb 12 g/dL, HCT 37%, WBC 7,000/mm3.
4. CSF clear, Hgb 15 g/dL, HCT 40%, WBC 11,000/mm3.

(1) correct—CSF normally clear, colorless; normal WBC 5,000 to 10,000 per mm3, normal Hgb (male 13.5 to 17.5 g/dL, female 12 to 16 g/dL), normal HCT (male 41 to 53%, female 36 to 46%)

(2) indicates trauma or hemorrhage

(3) WBC too low, not typical of bacterial meningitis

(4) indicates viral meningitis

A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is because of which of the following?

1. Provides an avenue for nutrients to flow past an obstructed area.
2. Prevents fluid and gas accumulation in the stomach.
3. Administers drugs that can be absorbed directly from the intestinal mucosa.
4. Removes fluid and gas from the small intestine.

(1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction

(2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach

(3) tube provides for decompression instead of instillation of medications

(4) correct—Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus

The nurse prepares discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test?

1. The initial specimen should be collected as close to discharge as possible but not after 7 days.
2. The infant can have water but should not have formula for 6 hours before the test.
3. The test will need to be repeated at 6 weeks and at the 3-month check-up.
4. Blood will be drawn at three 1-hour intervals; there is no specific preparation.

(1) correct—if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age

(2) no restriction on formula intake

(3) test may be repeated within 2 weeks to ensure accuracy

(4) only one blood sample is needed

Promethazine hydrochloride (Phenergan) 25 mg IV push is ordered for a patient. Prior to administering this medication to the patient, the nurse should check which of the following?

1. The color of the medication solution.
2. The patient's pulse and temperature.
3. The time of the last analgesic dose the patient received.
4. The patency of the patient's vein.

(1) is true, but not as high a priority as answer choice (4)

(2) no relevance to the question asked

(3) Phenergan is used as an adjunct to analgesics but has no analgesic activity itself

(4) correct—is very important to determine absolute patency of the vein; extravasation will cause necrosis

The nurse reviews procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?

1. "It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart."
2. "It is my responsibility to witness the signature of the patient before surgery is performed."
3. "It is my responsibility to explain the surgery and ask the patient to sign the consent form."
4. "It is my responsibility to answer questions that the patient may have before surgery."

Strategy: "Nurse should intervene" indicates that you should look for an incorrect statement. Question is unstated. Read answer choices for clues.

(1) describes the nurse's responsibility in obtaining consent

(2) signature indicates that the nurse saw the patient sign the form

(3) correct—physician should provide explanation and obtain patient's signature

(4) the nurse should answer questions after the physician has obtained consent

A middle-aged woman is brought to the emergency department after being raped in her home. The client asks the nurse to call her husband to come to the emergency department. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?

1. Supportive and helpful to the victim.
2. Disconnected from and apathetic toward the victim.
3. Frustrated and feeling vulnerable, but denying need for help.
4. Emotionally distressed and needing assistance.

(1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so

(2) rarely feel disconnected

(3) usually family members will need and respond well to psychological intervention

(4) correct—sexual assault by rape is a crisis situation for victim and family members and friends

A clinic nurse obtains a health history from a client newly diagnosed with Buerger's disease. The nurse expects the client's complaints to include which of the following?

1. Heart palpitations.
2. Dizziness when walking.
3. Blurred vision.
4. Digital sensitivity to cold.

Strategy: Determine the cause of each sympton and how it relates to Buerger's disease.

(1) no cardiac involvement

(2) dizziness not seen; intermittent claudication (pain with exercise) seen

(3) optic nerve not affected

(4) correct—vasculitis of blood vessels in upper and lower extremities

Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?

1. Notes subjective data, such as "My breathing is much improved now."
2. Notes objective findings, such as decreased respiratory rate and pulse.
3. Consults with the respiratory therapist to determine effectiveness.
4. Auscultates the chest for change or clearing of adventitious breath sounds.

(1) subjective data and not as conclusive

(2) correct but not as effective

(3) not appropriate

(4) correct—to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?

1. Prevent iron deficiency anemia.
2. Decrease touch to prevent overstimulation.
3. Provide feedings via gavage to decrease energy expenditure.
4. Replace vitamins depleted as a result of poor maternal diet.

(1) not highest priority

(2) infant needs to be held and cuddled due to a poorly developed CNS

(3) usually unnecessary

(4) correct—frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

A client returns from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 ml/h into her left forearm. Several hours later, the IV infiltrates. The nurse supervises a student nurse preparing to insert a new peripheral intravenous catheter. The nurse should intervene in which of the following situations?

1. The student nurse selects a site where the veins are soft and elastic.
2. The student nurse selects a site on the distal portion of the left arm.
3. The student nurse selects a site close to the joint to provide for stability.
4. The student nurse holds the skin taut to stabilize the vein.

(1) acceptable site selection

(2) acceptable site selection

(3) correct inappropriate; movement in area could cause displacement

(4) acceptable procedure

A client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to observe which of the following?

1. Darker skin that is more pigmented.
2. Skin that is ruddy and oily.
3. Skin that is puffy and scaly.
4. Skin that is pale and dry.

(1) correct—increase in melanocyte-stimulating hormone results in "eternal tan"

(2) not seen with Addison's disease

(3) not seen with Addison's disease

(4) not seen with Addison's disease

Which of the following statements is both a correctly stated nursing diagnosis and a high priority for an older client immediately following a modified radical mastectomy and axillary dissection?

1. Anxiety related to the mastectomy.
2. Impaired skin integrity related to the mastectomy.
3. Pain related to surgical incision.
4. Self-care deficit related to dressing changes.

(1) is stated incorrectly with "related to the mastectomy"

(2) is stated incorrectly with "related to the mastectomy"

(3) correct—immediately after surgery the priority is optimizing the client's comfort

(4) is not an immediate priority

An older client with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?

1. Propranolol (Inderal), 80 mg PO QID.
2. Verapamil (Nifedipine), 40 mg PO TID.
3. Tetrahydrozoline (Visine), 2 gtt both eyes TID.
4. Timolol (Timoptic solution), 1 gtt both eyes daily

Strategy: "Medication should the nurse question" indicates a contraindication.

(1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma

(2) calcium channel blocker used as antianginal; not contraindicated

(3) correct—contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension

(4) reduces aqueous formation and increases outflow, used for glaucoma

The nurse cares for a client diagnosed with a recurrent urinary tract infection. The physician orders methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids?

1. Milk.
2. Cranberry juice.
3. Water.
4. Tea.

Strategy: Think about each answer.

(1) correct—should limit intake of alkaline foods and fluids

(2) should be increased to acidify urine

(3) does not need to be restricted

(4) does not need to be restricted

The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse identifies which of the following symptoms is a common initial side effect of this medication?

1. Nausea.
2. Visual disturbances.
3. Tinnitus.
4. Ataxia.

(1) correct—common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence

(2) seen with long-term use

(3) ringing in the ears is seen with long-term use

(4) unsteady gait rarely seen

The nurse assesses a client immediately after an exploratory laparotomy. Which of the following nursing observations indicates the complication of intestinal obstruction?

1. Protruding soft abdomen with frequent diarrhea.
2. Distended abdomen with ascites.
3. Minimal bowel sounds in all four quadrants.
4. Distended abdomen with complaints of pain.

(1) does not support intestinal obstruction

(2) does not support intestinal obstruction

(3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen

(4) correct—if an obstruction is present, the abdomen will become distended and painful

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?

1. 11 months of age.
2. 14 months of age.
3. 17 months of age.
4. 20 months of age.

(1) not able to physiologically control sphincters until 18 months of age

(2) not able to physiologically control sphincters until 18 months of age

(3) not able to physiologically control sphincters until 18 months of age

(4) correct—by 24 months may be able to achieve daytime bladder control

The nurse determines which of the following actions has HIGHEST priority when caring for the client diagnosed with hypoparathyroidism?

1. Develop a teaching plan.
2. Plan measures to deal with cardiac dysrhythmias.
3. Take measures to prevent a respiratory infection.
4. Assess laboratory results.

(1) not highest priority action related to the diagnosis

(2) correct—cardiac dysrhythmias related to low serum calcium would be the highest priority

(3) potential for respiratory infection is not a major threat

(4) not highest priority action related to the diagnosis

A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occurs with aging?

1. Decreased frequency.
2. Nocturia.
3. Incontinence.
4. Hematuria.

(1) frequency increases because bladder capacity decreases

(2) correct—decreased ability to concentrate urine increases urine formation and increased nocturnal urine production lead to need to awaken to void

(3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence

(4) blood in urine- sign of cancer, infection, or trauma of urinary tract, glomerular disease, renal calculi, bleeding disorders

The nurse cares for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why the client has the CBI. Which of the following responses by the nurse is BEST?

1. "The CBI prevents urinary stasis and infection."
2. "The CBI dilutes the urine to prevent infection."
3. "The CBI enables urine to keep flowing."
4. "The CBI delivers medication to the bladder."

(1) refers to a possible preoperative complication of infection due to the enlarged prostate

(2) not the reason for the CBI

(3) correct—continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client

(4) medication is not routinely administered via a CBI in a first-day postop TURP

A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which of the following times?

1. During the morning hours.
2. During the middle of the day.
3. During the afternoon hours.
4. During the evening hours.

(1) correct—client with reactive depression has the highest level of physical and psychic energy in the morning

(2) as the day progresses, energy level declines

(3) as the day progresses, energy level declines

(4) as the day progresses, energy level declines

The nurse identifies which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?

1. Identity versus identity diffusion.
2. Intimacy versus isolation.
3. Integrity versus despair and disgust.
4. Industry versus inferiority.

(1) appropriate for adolescents

(2) correct—is the stage for 19- to 35-year-olds

(3) for 65 years and older

(4) for 6 to 12 years of age

The nurse cares for a homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which of the following observations by the nurse confirms this suspicion?

1. The nurse notes that the bladder is distended.
2. The client complains of a constant urge to void.
3. The nurse notes that the urine is concentrated.
4. The client complains of a burning sensation.

(1) correct—bladder distention is one of the earliest signs of obstructed drainage tubing

(2) seen with a urinary tract infection

(3) seen with dehydration

(4) seen with a urinary tract infection

An older client receives total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse expects the patient to exhibit which of the following?

1. Tinnitus, vertigo, blurred vision.
2. Fever, malaise, anorexia.
3. Diaphoresis, confusion, tachycardia.
4. Hyperpnea, flushed face, diarrhea.

Strategy: Think about the cause of each symptom. Determine how it relates to TPN. Remember the "comma, comma, and" rule.

(1) not seen

(2) suggestive of infection

(3) correct—insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination

(4) not seen

The nurse anticipates a client diagnosed with a gastric ulcer to experience pain at which of the following times?

1. Two to three hours after a meal.
2. During the night.
3. Prior to the ingestion of food.
4. One-half to 1 hour after a meal.

(1) feature of a duodenal ulcer

(2) feature of a duodenal ulcer

(3) feature of a duodenal ulcer

(4) correct—pain related to a gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night; is not helped by ingestion of food

During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which of the following responses by the nurse is BEST?

1. "You are nauseated because of the fatigue you are feeling."
2. "The nausea is due to an increase in the basal metabolic rate."
3. "The nausea is caused by an elevation in the hormones."
4. "If you eat different kinds of foods, you won't be nauseated."

(1) describes an erroneous rationale for the nausea

(2) describes an erroneous rationale for the nausea

(3) correct—during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system

(4) describes an erroneous rationale for the nausea

A nursing assistant reports to the RN that a patient with anemia complains of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?

1. "Listen to the patient's breath sounds and report back to me."
2. "Set up the patient's lunch tray."
3. "Obtain a diet history from the patient."
4. "Instruct the patient to balance rest and activity."

(1) requires assessment; should be performed by the RN

(2) correct—standard, unchanging procedure; decreases cardiac workload

(3) involves assessment; should be performed by the RN

(4) assessment and teaching required; performed by the RN

A 4-year-old child is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse identifies which of the following symptoms as indicative of an increase in respiratory distress?

1. Bradycardia.
2. Tachypnea.
3. General pallor.
4. Irritability.

(1) tachycardia occurs early in hypoxia

(2) correct—increase in the respiratory rate is an early sign of hypoxia, also for tachycardia

(3) pallor is not specific for hypoxia

(4) client may be anxious and restless, but is generally not described as irritable

The nurse observes a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions?

1. Posterior and anterior base of right side.
2. Right anterior chest between the fourth and sixth intercostals.
3. Left of the sternum, midclavicular, at right fifth intercostal.
4. Posterior chest wall, midaxillary, right side.

(1) cannot auscultate the RML from the posterior

(2) correct—RML is found in the right anterior chest between the fourth and sixth intercostal spaces

(3) point of maximum impulse or apical pulse

(4) cannot auscultate the RML from the posterior

When caring for a client with myasthenia gravis, it is MOST important for the nurse to consider which of the following?

1. Prevent accidents from falls as a result of vertigo.
2. Maintain fluid and electrolyte balance.
3. Control situations that could increase intracranial pressure and cerebral edema.
4. Assess muscle groups toward the end of the day.

Strategy: Answers are a mix of assessment and implementation. Is there an appropriate assessment? Yes.

(1) does not experience vertigo

(2) fluid and electrolytes usually not a problem for this patient

(3) increased intracranial pressure is not associated with myasthenia gravis

(4) correct—client has increased muscle fatigue, needs more assistance toward end of day

The nurse cares for a client during an acute manic episode. The nurse identifies which client behavior is MOST characteristic of mania?

1. Agitation, grandiose delusions, euphoria, difficulty concentrating.
2. Difficulty in decision-making, preoccupation with self, distorted perceptions.
3. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
4. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.

Strategy: Remember the "comma, comma, and" rule. Each part of the answer must be correct.

(1) correct—characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior

(2) characteristic of depression

(3) indicative of schizophrenia

(4) consistent with personality disorders

A client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 mL/mm3, calcium 5 mEq/L. Based on the lab values, the nurse determines which of the following is the priority nursing diagnosis?

1. Risk for activity intolerance related to decrease in red cells.
2. Risk for infection related to low white cell count.
3. Risk for anxiety secondary to hypoparathyroid disease.
4. Risk for fluid volume deficit due to decreased fluid intake.

(1) not a priority

(2) correct—clients with a low WBC count are susceptible to infection

(3) not correctly stated as a nursing diagnosis and is not appropriate

(4) not a priority for this client

The nurse cares for a client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position?

1. This enables the client to read the nurse's lips.
2. The client does not have to turn her head to see the nurse.
3. The nurse will have the client's undivided attention.
4. There is a decrease in client's peripheral visual field.

(1) client is not hard of hearing

(2) correct—by decreasing movement of client's head, vertigo attacks may be decreased

(3) there is no problem with visual fields

(4) there is no problem with visual fields

A client receives morphine sulfate after admission to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication?

1. Increase in pulse pressure.
2. Decrease in anxiety.
3. Depression of the sympathetic nervous system.
4. Enhanced ventilation and decreased cyanosis.

1) is not affected by morphine sulfate

(2) correct—morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema

(3) is not the action of the medication

(4) medication does not improve ventilation

An adult client is admitted to the hospital unit diagnosed with hepatitis A. The nurse knows that the client's overall care during hospitalization should include which of the following?

1. Contact precautions.
2. Airborne precautions.
3. Standard precautions.
4. Droplet precautions.

(1) required with patient care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the patient's environment

(2) unnecessary; used with pathogens transmitted by airborne route

(3) correct—standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence

(4) unnecessary; used when pathogens transmitted by infectious droplets

The nurse identifies the MOST reliable client measure to evaluate the desired response of diuretic therapy includes which of the following?

1. Obtain daily weights.
2. Obtain urinalysis.
3. Monitor Na+ and K+ levels.
4. Measure intake.

(1) correct—effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights

(2) does not relate to the effects of diuretic therapy

(3) important to consider, but is not a priority

(4) important to consider, but is not a priority

The physician suggests play therapy for a 7-year-old child having some difficulty adjusting to the parents' impending divorce. The nurse identifies this type of therapy is effective for which of the following reasons?

1. Young children have difficulty verbalizing emotions.
2. Children hesitate to confide in anyone but their parents.
3. Play is an enjoyable form of therapy for children.
4. Play therapy is helpful in preventing regression.

(1) correct—children have difficulty putting feelings into words; play is how they express themselves

(2) somewhat true, but not best reason for play therapy

(3) not reason play therapy is used; is used because it is the best way for children to express themselves

(4) may encourage child to act out earlier developmental stage to reveal underlying conflicts

An older adult receives dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician?

1. PT 12 seconds and Hgb 15 g/dL.
2. BUN 18 mg/dL and creatinine 1.0 mg/dL.
3. K+ 3.4 mEq/L and Ca+ 5.5 mEq/L.
4. AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.

(1) normal PT 11 to 15 sec, normal Hgb male: 13.5 to 17.5 g/dL, female: 12.1 to 16.0 g/dL

(2) normal BUN 10 to 20 mg/dL, normal creatine 0.6 to 1.2 mg/dL

(3) correct—normal K+ 3.5 to 5.0 mEq/L, normal Ca+ 4.5 to 5.3 mEq/L, indicates hypokalemia and hypercalcemia

(4) normal AST (SGOT) 8 to 20 U/L, normal ALT (SGPT) 8 to 20 U/L

The nurse prepares a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching is successful?

1. "The dye used in the test will turn my urine green for about 24 hours."
2. "I will be put to sleep for this procedure. I will return to my room in two hours."
3. "This procedure will take about 90 minutes to complete. There will be no discomfort."
4. "The wires that will be attached to my head and chest will not cause me any pain."

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

(1) no dye is used for an MRI

(2) client is not anesthetized for this procedure

(3) correct—procedure takes approximately 90 minutes, not painful

(4) indicates misunderstanding of MRI because no wires are used

The nurse prepares the client for an IV pyelography (IVP) scheduled in 2 hours. The nurse should contact the physician if the client states which of the following?

1. "I take metformin (Glucophage) for type 2 diabetes."
2. "I completed the bowel prep last evening."
3. "I ate a light meal last evening."
4. "I had an IVP 3 years ago."

(1) correct—should discontinue 48 hours prior to procedure, contrast media can cause life-threatening lactic acidosis

(2) appropriate action; removes feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured

(3) appropriate action

(4) no reason to contact the physician

The nurse cares for a patient admitted 2 days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse will observe which of the following symptoms?

1. Decerebrate posturing, BP 160/100, pulse 56.
2. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
3. Glucosuria, osmotic diuresis, loss of water and electrolytes.
4. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.

(1) late signs of increased intracranial pressure or brain damage

(2) correct—signs of dehydration, increased output, low specific gravity, normal 1.010 to 1.030

(3) signs of hyperglycemia due to diabetes mellitus

(4) symptoms of SIADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus

The physician orders chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the physician based on which of the following rationales?

1. The nurse believes that the client's symptoms reflect alcohol withdrawal.
2. The nurse does not know if the client is allergic to this medication.
3. The nurse knows that the client is not psychotic.
4. The nurse routinely checks on the doctor's orders.

(1) correct—medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences

(2) not best rationale for checking with doctor about this order

(3) not best rationale for checking with doctor about this order

(4) not best rationale for checking with doctor about this order

The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?

1. A patient with a chest tube ambulating in the hall.
2. A patient with a colostomy requiring assistance with an irrigation.
3. A patient with a right-sided cerebral vascular accident (CVA) requiring assistance with bathing.
4. A patient refusing medication to treat cancer of the colon.

Strategy: Determine the skill level involved with each patient's care. The RN cares for patients who require assessment, teaching, and nursing judgment.

(1) stable patient with an expected outcome; assign to the LPN/LVN

(2) stable patient with an expected outcome; assign to the LPN/LVN

(3) standard, unchanging procedure; assign to the nursing assistant

(4) correct—requires assessment skills of the RN

During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?

1. An infant with septicemia.
2. A child with a tonsillectomy.
3. An infant with cleft lip repair.
4. A child with meningitis.

(1) not in need of restraints

(2) not in need of restraints

(3) correct—arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line

(4) not in need of restraints

A client develops a low intestinal obstruction. The nurse anticipates which of the following findings?

1. Nausea, vomiting, abdominal distention.
2. Explosive, irritating diarrhea.
3. Abdominal tenderness with rectal bleeding.
4. Midepigastric discomfort, tarry stool.

(1) correct—there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease

(2) would be no diarrhea

(3) would be no rectal bleeding, abdomen would be distended

(4) would be no GI bleeding

A client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses the client, the client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV is ordered stat. In planning care for this client, it is IMPORTANT for the nurse to consider which of the following?

1. The BP and respirations will need to increase before a second dose of Narcan can be given.
2. Narcan should not be given to the man because of his DNR status.
3. A dose of Narcan may need to be repeated in 2 to 3 minutes.
4. Narcan is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.

(1) will not change without Narcan, respirations increase within 2 min

(2) DNR indicates no resuscitation should be done if heart stops; does not preclude administration of drugs to correct iatrogenic problems

(3) correct—half-life of Narcan is short; may go back into respiratory depression; may need to be repeated

(4) used for respiratory depression of opiates, not used with barbiturates or sedatives

In planning discharge teaching for a client after a lumbar laminectomy, the nurse should instruct the client to exercise regularly to strengthen which muscles?

1. Anal sphincter.
2. Abdominal.
3. Trapezius.
4. Rectus femoris.

(1) does not contribute to support of the lumbar spine

(2) correct—strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine

(3) does not contribute to support of the lumbar spine

(4) does not contribute to support of the lumbar spine

The nurse plans care for a client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which of the following responses?

1. Cause the client to defend the idea.
2. Help the client clarify thoughts.
3. Facilitate better communication.
4. Lead to a breakdown of the defense.

(1) correct—contraindicated; encourages patient to engage in further distortion of reality

(2) needs reality testing from nurse, not questioning

(3) questioning is nontherapeutic; may cause patient to avoid nurse physically

(4) needs defense; questioning will further distort reality or elaborate on delusion

When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?

1. Short-term memory is more efficient than long-term memory.
2. The stress of an unfamiliar environment may cause confusion.
3. A decline in mental status is a normal part of aging.
4. Learning ability is reduced during hospitalization of the elderly client.

(1) just the opposite is true; long-term memory is more efficient than short-term memory

(2) correct—stress of an unfamiliar situation or environment may lead to confusion in elderly clients

(3) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

(4) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?

1. Low blood pressure and weight loss.
2. Thin extremities with easy bruising.
3. Decreased urinary output and decreased serum potassium.
4. Tachycardia with complaints of night sweats.

(1) BP increases and client gains weight

(2) correct—clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising

(3) no correlation with urinary output; potassium decreases

(4) no correlation with Cushing's syndrome

A patient with type 1 diabetes asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST?

1. "Human insulin is less likely to cause you to have a localized allergic reaction to the injection."
2. "Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia."
3. "Human insulin prevents the development of long-term damage to the eyes and kidneys."
4. "Human insulin does not cause the formation of antibodies because the protein structure is identical to your own."

(1) reactions caused by preservatives in insulin, which is same for all types of insulin

(2) no change in incidence of hypoglycemia or hyperglycemia

(3) complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used

(4) correct—protein molecules are identical to human insulin

A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?

1. Hyperactive deep tendon reflexes.
2. Peripheral neuropathy affecting the hands.
3. Disorientation to person, place, and time.
4. Impaired concentration and memory loss.

(1) not relevant to this condition

(2) not relevant to this condition

(3) correct—approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation

(4) is a sign of early-onset dementia

The nurse cares for a client receiving haloperidol (Haldol). The nurse should anticipate which of the following side effects?

1. Blood dyscrasia and extrapyramidal symptoms.
2. Hearing loss and unsteady gait.
3. Nystagmus and vertical gaze palsy.
4. Alteration in level of consciousness and increased confusion.

(1) correct—major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)

(2) not seen with haloperidol

(3) not seen with haloperidol

(4) not seen with haloperidol

The home care nurse plans activities for the day. Which of the following clients should the nurse see FIRST?

1. A new mother is breastfeeding her 2-day-old infant who was born 5 days early.
2. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
3. An elderly woman discharged from the hospital 3 days ago with pneumonia.
4. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.

(1) stable situation, not a priority

(2) assess for bleeding gums, hematuria, not the priority

(3) assess breath sounds, encourage fluids, cough and deep breathe

(4) correct—symptoms of pulmonary edema; requires immediate attention

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