. .1.. . Gregorio, a 54 year old client diagnosed with benign prostatic hyperplasia isbeing scheduled for TURP at 7am the following day.The circulating nurse anticipates that in order to perform TURP Gregorio must beplaced in what position?/· . DorsaI Recumbent· · . Lithotomy/· :. Jack knife/ [. Trendelenburg

:::: . .E::T .. :, E .: B. Lithotomy

:. .TI: . LE: Transurethral resection of the prostate surgery or TURP is done inthe Iithotomy position in order for the surgeon to have an ease in the performance ofsurgery since a scope and a resectoscope is inserted into the clients urethra.

2. . TURP is a surgery that can- be performed in around 1-2 hours. The role of an

operating room nurse is to anticipate which possible method of anaesthesia will be

used by the anaesthesiologist. TURP can be performed using what method of

anesthesia?

/ú . Local lnfiltration

/ú . General lnhalation

ú ú :. Subarachnoid block

/ [. General lntravenous

:::: . .E::T ... :, .. E .: C. Subarachnoid block

:. .TI: . LE: Subarachnoid block , The area of surgery is in the pelvic area

hence subarachnoid block or spinal anesthesia can be utilized for procedures below

the thoracic nerve or at the Ievel of the diaphragm and will Iast for Iess than 3-4

hours.

*** Any other useful examples for our users? ***

3. The anesthesiologist of Gregorio incorporated epinephrine with the anesthetic agent. Epinephrine Hcl can be incorporated to bring about which of the following effects?

a. Increase the client’s heart rateb. Bring about bronchodilationc. Prolong the effect of the drugd. Promote vasodilation

Rationale: Epinephrine is an adrenergic agonist that can stimulate alpha receptors to bring about localized vasoconstriction in spinal anesthesia. Causing vasoconstriction can delay drug absorption thus can prolong the drug effect of the anesthetic agent and les amount if anesthesia will be used.

4. The nurse will anticipate which incision for TURP?

A. Supra pubic incision

B. Pfannensteil incision

C. Inguinal incision

D. no incision

CORRECT ANSWER: D. no incision

RATIONALE: TURP or transurethral resection of the prostate is a surgery that does not require a surgical incision since a scope and a resectoscope is inserted in the client's urethra only.

5. After the TURP , the Scrub Nurse anticipates that she needs to prepare which of the following supplies to help prevent bleeding in the post- op period and to allow the drainage of excess blood clots and retained prostatic fragments?

A. 3-way foley catheter

B. nelaton catheter and saline wash

C. heparinized syringe

D. Levine tube French 16

CORRECT ANSWER: A. 3-way foley catheter RATIONALE: The 3-way foley catheter will be used post op for cystoclysis (Continous bladder

irrigation) to prevent bleeding by increasing the flow of the fluid into the bladder and to flush blood clots and prostatic fragments from the operative site which can stimulate bladder spasm that leads to bleeding. Option B, nelaton catheter, is not used since this is only used as a single straight catheter to drain urine. If used frequently it can cause irritation and further increase the risk for bleeding. Option C heparin will further cause bleeding due to its anti-coagulant property. Option D. Levine tube is not related since this is

the tube used for gastric decompression.

6. Antonio, a 69 year old client was admitted with a chief complaint of gross hematuria and severe lumbar pain. He was diagnosed to have stones in the renal pelvis .

What do you call the surgical removal of stones in the renal pelvis using an open approach?

A. Cystolithotomy

B. Pyelolithotomy

C. Nephrectomy

D. Pelvic laparotomy

CORRECT ANSWER: B. Pyelolithotomy RATIONALE: Pyel- stands for the renal pelvis and lithotomy is the suffix used for the surgical removal

of a stone, Cysto stands for the urinary bladder and nephrectomy is for the removal of a kidney. Pelvic laparotomy is a surgery done to explore the pelvic organs such as the Uterus, ovaries and fallopian tubes

7. Another approach for removing stones is with the use of a non invasive procedure called ESWL, ESWL stands for?

A. Extra corporeal Shockwave lithotomy

B. Extra renal Sonicwave lithotripsy

C. Extracorporeal Shock wave lithotripsy

D. Extrarenal Sonic wave lithotomy

CORRECT ANSWER: C. Extracorporeal Shock wave lithotripsy RATIONALE: This surgery is a non invasive procedure which crushes stones with the use of shock

waves , and the stones, after being crushed, are then voided by the client. The client after the procedure is encourage to increase his fluid intake to flush out the stone sediments.

8. Antonio opted to have the open approached surgery for the removal of his kidney stones. In performing the open surgery, the client will be placed in a lumbotomy position. Which of the following positioning equipment is not needed in performing the procedure?

A. Axillary roll

B. shoulder roll

C. pillow rolls

D. "donut"

CORRECT ANSWER: B. shoulder roll RATIONALE: SHOULDER ROLL is not needed. This is usually used for neck surgeries to

hyperextend the neck part. In doing lumbotomy position the client will be placed on a side lying position therefore an axillary roll will be needed to prevent undue pressure on the dependent axilla, pillow rolls can be used in front and at the back to immobilize the patient and the donut will be placed on the clients head.

9. In performing the Open surgery for the removal of urinary stones , the surgeon may need a knife to cut through tubular structures such as the renal pelvis or ureters. Which of the following blades is the most appropriate to aid the surgeon in performing the said surgery?

A. Blade 10

B. Blade 11

C. Blade 12

D. Blade 15

CORRECT ANSWER: C. Blade 12 RATIONALE: Blade 12 is also called hooked knife and is usually used to cut through tubular

structures and for oropharyngeal surgeries. Blade 10 and 20 are the usual blades used to cut the skin; Blade 15 is the smallest belly and is used for making small and curvilinear incisions; Blade 11 is used for stabbing and puncturing tissues.

10. Antonio was placed on Epidural anesthesia and was given Morphine sulfate along with Sensorcaine (Marcaine) . The anaesthesiologist noted a marked decrease on the clients SaO2 and the RR was down to 8 breaths per minute. She is suspecting opioid toxicity. The circulating nurse anticipates that she needs to prepare an appropriate Antidote to counteract the effects of the morphine. Which of the following drugs should the circulating nurse prepare?

A. nalbuphine (nubain)

B. Naloxone (narcan)

C. Neostigmine (Prostigmine)

D. Vecuronium bromide (norcuron)

CORRECT ANSWER: B. Naloxone (narcan) RATIONALE: Naloxone (Narcan) is a narcotic antagonist which can help counter act the effects of an

opioid narcotic. A. Nalbuphine (nubain) is incorrect since it is a narcotic agonist-antagonist thus can further aggravate the toxicity, option C Neostigmine (prostigmine) is an Acetylcholinesterase inhibitor which can be used for excess muscle relaxation brought about by neuro muscualr junction blocking agents or myasthenia gravis and option D vecuronium bromide is an example of a neuro-muscular junction blocking agent used as an adjunct drug for general anesthesia.

11. Erlinda a 40 year old female client was admitted due to right upper quadrant pain accompanied by jaundice , She was diagnosed to have cholelithiasis .

Cholelithiasis can be managed using Open Cholecystectomy or Laparoscopic Cholecystectomy. This procedure involves the insufflation of a gas in the peritoneal cavity which utilizes __

A. Carbon Dioxide

B. Nitrous oxide

C. Oxygen

D. Helium

CORRECT ANSWER: A. Carbon Dioxide RATIONALE: Carbon dioxide is the common gas utilized to insufflate the peritoneal cavity since it can

be absorbed in the surrounding tissues and expelled through the respiratory tract. Oxygen is not used because it supports combustion and can cause burns or fire when cautery is used. Nitrous Oxide is usually used as an anesthetic agent. While helium is commonly used to inflate party balloons

12. Because of the need for insufflation, clients who will undergo laparoscopic cholecystectomy need to undergo the procedure under General Inhalation anesthesia. During the administration of anesthesia when stage II or stage of excitement is reached, the circulating nurse can note the following responses from the client:

A. may feel drowsy or dizzy but hearing seems to be exaggerated

B. loses consciousness but is still sensitive to external stimuli

C. pupils are smaller but the eyelid reflex along with other reflexes are lost

D. pupils are fixed and dilated and there is no respiration noted

CORRECT ANSWER: B. loses consciousness but is still sensitive to external stimuli

RATIONALE: Loses consciousness but is still sensitive to external stimuli, is a characteristic sign of the second stage of anaesthesia. Other signs may include irregular respiration but with increased muscle tone and involuntary responses. It is therefore very important that at this stage the OR suite must be quiet to prevent undue stimulation. Choice A speaks of stage I or induction , Choice C is noted in stage III which is the surgical anaesthesia and Choice D describes the danger stage or stage IV where medullary paralysis occurs.

13. A client is scheduled for an Open Cholecystectomy and the surgeon will utilize a Kocher incision. The circulating nurse therefore must do skin preparation. This will cover what skin areas?

A. From neck to symphisis pubis

B. From nipple line to anterior 1/3 of the thigh

C. From umbilicus to the whole thigh

D. From breast to umbilicus

CORRECT ANSWER: B. From nipple line to anterior 1/3 of the thigh RATIONALE: From nipple line to anterior 1/3 of the thigh. Kochers incision is also called Right

subcostal incision therefore this incision must be prepared covering the mentioned areas

14. After doing the initial incision, the surgeon cuts through the subcutaneous layers and asks for a retractor. Which of the following instruments should the scrub nurse hand to the surgeon?

A. Balfour

B. Senn retractor

C. Army-navy retractor

D. Gelpi retractor

CORRECT ANSWER: C. Army-navy retractor RATIONALE: The Army Navy retractor, also known as parabeau or skin retractor, is usually used to

retract the first two layers of the abdomen and other areas in surgery; a balfour is used as a self retaining retractor to retract the peritoneum; a senn retractor is used for retracting tissues in minor surgeries; and gelpi is a self retaining retractor used to retract superficial wounds especially in neuro surgeries.

15. Upon reaching the fascia the surgeon asked for a scissor to cut through this tough tissue layer. Which of the following cutting instruments is most appropriate to be handed over by the scrub nurse?

A. Iris scissor

B. mayo straight scissor

C. Potts scissor

D. mayo curve scissor

CORRECT ANSWER: D. mayo curve scissor RATIONALE: The Mayo curve scissor is used to cut through tough tissues such as skin, fascia and

muscles. Mayo straight scissors are used to cut sutures and supplies used in the surgery, Potts scissor is an angulated scissor used to cut delicate tissues and blood vessels and an iris scissor is used for plastic surgeries and cutting fine tissues.

16. In doing the open cholecystectomy, the surgeon reached the peritoneum and has located the gall bladder and its surrounding blood vessels. He clamps the cystic artery using 2 mixters, and then asks for a scissor. The scrub nurse should give the surgeon what instrument?

A. mayo straight scissor

B. mayo curve scissor

C. metzembum

D. bandage scissor

CORRECT ANSWER: C. metzembum RATIONALE: Metzembum is used to cut through delicate tissues such as blood vessels. , mayo

curve scissor is used to cut through tough tissues such as skin, fascia and muscles. Mayo straight scissors are used to cut sutures and supplies used in the surgery. Bandage scissor is used for general cutting of supplies, dressings and bandages.

17. Before closing the peritoneum the surgeon asked for a T-tube to allow the drainage of bile and allow the inflammation in the Common bile duct to subside. The surgeon then informs the scrub nurse to prepare a stay suture. Which of the following is the most appropriate to be used as the stay suture?

A. Silk 2-0 on a cutting needle

B. nylon 5-0 on a atraumatic needle

C. Chromic 3-0 on a round needle

D. Cotton 4-O free tie

CORRECT ANSWER: A. Silk 2-0 on a cutting needle RATIONALE: Silk 2-0 on a cutting needle. Cutting needles are used to suture through tough tissues

such as the skin. Silk is a non-absorbable suture which can be used for the said purpose.

18. Jenna, a 21 year old fashion model underwent excision of subcutaneous mass at her right cheek. She is very much anxious about how the surgical wound will look like after the surgery.

To minimize scarring, the scrub nurse knows that she must prepare a thin suture such as Nylon 5-0 loaded on which of the following needles?

A. Intestinal needle

B. dura needle

C. reverse cutting needle

D. atraumatic needle

CORRECT ANSWER: D. atraumatic needle RATIONALE: Atraumatic needles, also known as eyeless needles, leave less trauma to tissues thus

can minimize the potential of scarring and keloid formation.. Reverse cutting is a traumatic needle which can bring about more scars though it can also be used to suture the skin. Intestinal and dura needles are inappropriate to be used in the skin since they are thin and tapered.

19. During the skin closure, the surgeon asked for pick up forceps to grasp the skin . Which of the following is most appropriate to be given by the scrub nurse?

A. Thumb forceps

B. Debakey forceps

C. Adson forceps with teeth

D. Russian forceps

CORRECT ANSWER: C. Adson forceps with teeth RATIONALE: Adson forceps with teeth is used for grasping skin layers during closure. Debakey is

used to grasp delicate tissues such as blood vessels. Thumb forceps used to grasp delicate tissues. Russian forceps is used to grasp tough tissues in the peritoneal cavity.

20. Victoria a 70 year old diabetic client is experiencing Chronic Renal failure due to DM nephropathy and has an IJ catheter as port for her hemodialysis. She has a non healing wound at her left foot with signs of gangrene.

Victorina was scheduled for an AVF creation to create a more permanent access for her hemodialysis. AVF stands for ___

A. Atrio-ventricular fistula

B. Arterio-venous fistula

C. Atrio-venous fistula

D. Arterio-ventricular fistula

CORRECT ANSWER: B. Arterio-venous fistula RATIONALE: Arterio-venous fistula (AVF) is a surgical procedure where an abnormal connection will

be created between an artery and a vein and will be connected through surgical anastomosis.

21. After the incision on the clients forearm the doctor tried to locate for the suitable blood vessels to be anastomosed . The surgeon then asked for a pick up forceps. Which of the following is most suitable to be used to grasp the blood vessels?

A. adson forceps with out teeth

B. tissue forceps

C. debakey forceps

D. ureteral forceps

CORRECT ANSWER: C. debakey forceps RATIONALE: The Debakey forceps is used to grasp delicate tissues especially blood vessels. Adson

forceps are used grasping tissues during wound closure. Tissue forceps are used to grasp tough tissues and the Uretheral forceps are used to grasp the ureter.

22. After identifying the blood vessels, the surgeon is now ready to perform surgical anastomosis on the artery and vein. Which of the following sutures is most appropriate to be used as suture for the blood vessels?

A. Surgical gut (Chromic)

B. polypropelene (Prolene)

C. silk ( Mersilk)

D. Stainless steel ( Ethicon)

CORRECT ANSWER: B. polypropelene (Prolene) RATIONALE: Polypropelene (Prolene) is a non absorbable suture which is usually used for plastic

and cardiovascualr surgeries . Silk can be used to ligate blood vessels but is not appropriate to be used for anastomosis of blood vessels. Surgical gut can be used for general closure. Stainless steel can be used to close or connect bones and bony structures.

23. In doing the anastomosis of vessels the surgeon asked for a 6-0 suture which is just appropriate to the size of the blood vessels to be sutured. He then asked for a needle holder to hold the very small needle. Which of the following suturing instruments should the scrub nurse anticipate to give?

A. mayo hegar needle holder

B. Castroviejo

C. halsted clamp

D. thumb forceps

CORRECT ANSWER: B. Castroviejo RATIONALE: Needles should be handled with appropriate needle holders and a Castroviejo is a self

locking needle holder used for fine or very small needles. A mayo-hegar needle holder is the common needle holder in use for basic abdominal surgeries. A halsted clamp is a small clamp but should not be used to hold needles. The thumb forceps is not used to hold needles

24. During the Creation of the AVF , the surgeon also asked for heparin diluted with normal Saline solution to heparinize the blood vessels. Heparin can be used during cardiovascualr surgeries to__

A. prevent bleeding at the site

B. prevent blood clots at the anastomosis site

C. anesthetize the affected region

D. prevent infection at the surgical site

CORRECT ANSWER: B. prevent blood clots at the anastomosis site RATIONALE: Heparin is an anti coagulant which prevents blood clots. During anastomosis, the blood

supply at the sutured area is temporarily cut off thus increasing the risk of developing clots at the site. Having clots at the anastomosis site will defeat the purpose of the surgery.

25. After the AVF creation, the client also underwent wound debridement. The wound was a little deep

and was infected thus the surgeon opted to suture the site, though it is infected, to prevent the risk of bleeding at the site. Which of the following sutures is best suited to be used to close an infected surgical site?

A. synthetic monofilament sutures

B. silk

C. cotton

D. surgical guts

CORRECT ANSWER: A. synthetic monofilament sutures RATIONALE: Synthetic monofilament sutures, are the best choice to close these types of wound.

Because it causes less reaction than the other braided sutures . Surgical guts can be used to close infected wounds but it is more reactive thus might not be able to sustain the wound closure until it heals. Cotton and Silk sutures are more often associated with inflammation and irritation thus can cause delay in wound healing.

26. Carlos, a 21 year old registered nurse, has been recently assigned in the operating room for orientation and training for 1 month. He is very much excited and eager to learn a lot during this pre-employment phase.

On Carlos first day of exposure, he was tasked by the Nurse Supervisor to observe the different surgical procedures in the area . He entered an OR suite where Myrna, an 18 year old client, was being prepped for surgery. He was then asked by the circulating nurse about the purposes of doing the skin prep. All of the following are appropriate responses of Carlos except:

A. Skin prep is done to render the skin sterile prior to the procedure

B. Skin prep is done to reduce the resident and transient flora in the skin

C. Skin prep is done to minimize the risk for post operative wound infections

D. Skin prep is done to prepare the area of not just the preferred incision but also possible sites drain placements.

CORRECT ANSWER: A. Skin prep is done to render the skin sterile prior to the procedure RATIONALE: This is incorrect since the skin can not be sterilized no matter how it is prepped.

27. After the Skin Prep, the surgeon remembered and instructed the nurses to prepare a mono polar electrosurgical pencil so he can perform the surgery faster . The senior nurse asked a nurse-orientee to place the dispersive pad or return electrode on the client. Which of the following actions of the nurse-orientee is inappropriate whenever a dispersive pad is placed?

A. he applies the pad in complete contact to an area with good vascular and muscular tissues

B. he cuts the pad to adjust its size to fit appropriately to the patient

C. he avoids placing it on areas with scars or metal implants

D. he avoids placing the pad to an area where it can get wet

CORRECT ANSWER: B. he cuts the pad to adjust its size to fit appropriately to the patient RATIONALE: This is an inappropriate action. Cautery pads should not be cut to fit to the size of the

area where you intend to place it since cutting can alter the electrical connections and insulation of the pad.

28. During the surgery, a nurse-orientee was very excited and observant on the things that were happening during the surgery. He noted that after reaching the peritoneum, the Surgeon asked for a grasping instrument that he will use to locate and grasp the appendix. The nurse-orientee knows that this grasping instrument is__

A. Kocher

B. tissue forceps

C. Babcock

D. allis

CORRECT ANSWER: C. Babcock RATIONALE: Babcock is a non toothed grasping instrument which is used to hold delicate tissues

such as the fallopian tubes and portions of the intestine. All the other options are toothed instruments and are therefore not used to hold delicate tissues such as the intestines.

29. After removing the appendix the surgeon is already checking for any bleeders. The scrub nurse anticipates that the first counting during closure must be performed when:

A. the surgeon asks them to perform the count anytime

B. they are about to close the peritoneal cavity

C. the fascia will be sutured

D. the subcutaneous will be sutured

CORRECT ANSWER: B. they are about to close the peritoneal cavity RATIONALE: Initial counting must be performed during the closure of the first layer therefore in this

scenario the counting must be done before the closure of the peritoneum. Counting is a responsibility of OR nurses and is therefore should not be done based on the Surgeons instructions only.

30. After 2 weeks of orientation Carlos, the OR nurse-orientee was given the opportunity to do his first independent scrub to assist a caesarean section delivery. He is very much excited and nervous in doing his tasks. He reviews the basic principles of asepsis and knows a violation has occurred when:

A. He is in doubt regarding the sterility of an object thus render it unsterile

B. Gowns are considered sterile by members of the team in front up to the sleeves and axillary areas.

C. Considers the edges of sterile packages unsterile once opened

D. Considers that tables are sterile at table level only

CORRECT ANSWER: B. Gowns are considered sterile by members of the team in front up to the sleeves and axillary areas.

RATIONALE: This is a violation on asepsis. Remember gowns are sterile in the sleeves only. 2 inches above the elbows, the axillary region are considered unsterile since it can accumulate moisture which can contaminate sterile areas. All the other options upholds the principles of asepsis.

31. After the sterile draping, while the circulating nurse was moving the sterile back table, some sterile water from the basin filled with sterile water spilled on the sterile table. What will be the most appropriate action of Carlos in this scenario:

A. Ignores the incident since the water is sterile anyway

B. Renders the entire back table unsterile and asks for a new set of instruments and supplies

C. Asks for a spare towel and covers the wet area before proceeding with the surgery

D. Renders the part unsterile and avoids placing instruments and supplies only at that area.

CORRECT ANSWER: C. Asks for a spare towel and covers the wet area before proceeding with the surgery

RATIONALE: One basic principle on asepsis is doing remedy if contamination occurs. Option A is a clear violation since anything wet leaves room for contamination thus needing immediate action, Option B is incorrect since it is not cost effective and will put of a lot of hassle and will be a waste of time since the wet area is the only part that requires immediate remedy. Option D is incorrect though you will not place sterile instruments at that area, one important principle on asepsis is keeping only sterile objects to come in contact with sterile objects. It is therefore inappropriate to combine sterile and unsterile areas on one table.

32. Even though Carlos is just new in the practice of operating room nursing, being a registered nurse makes him responsible for his actions as a professional. Since Carlos assisted on a ceasarian section delivery, which of the following actions could exhibit a potential risk of negligence on the part of Carlos and his circulating nurse?

A. Does the initial count during the closure of the peritoneum

B. Informs the surgeon of a lacking sponge and insists on locating it first before closing the body cavity

C. Hands appropriate sutures to the surgeon during closing

D. Does the final count during the closing of the skin

CORRECT ANSWER: A. Does the initial count during the closure of the peritoneum RATIONALE: Counting during the closing of the peritoneum can put them at risk of doing a negligent

act. Remember that in caesarean section there is an open cavity within a cavity which is the uterus. It is important to note that an additional counting is needed to be performed whenever a surgery involves a cavity within a cavity. All the other options are appropriate actions and can ensure safe and competent practice in the Operating Room.

33. Jane, an obese 32 year old, is admitted to the hospital after a vehicular accident. She has multiple skin lacerations and a fractured hip. She is brought to the OR for surgery.

After surgery, Joy is to receive a piggy-back of Cefuroxime Sodium 500 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at:

A. 25 gtt/min

B. 30 gtt/min

C. 35 gtt/min

D. 45 gtt/min

CORRECT ANSWER: A. 25 gtt/min RATIONALE: To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor

(10) and divide the result by the amount of time in minutes (20

34. A 25 year old, female, obese client becomes concerned about her weight. She asks their office nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when:

A. Fats are controlled in the diet

B. Eating habits are altered

C. Sugar intake is regulated

D. Exercise is part of the program

CORRECT ANSWER: B. Eating habits are altered RATIONALE: For weight reduction to occur and be maintained, a new dietary program, with a

balance of foods from the basic four food groups, must be established and continued. This will require altering eating habits/behaviors.

35. The nurse teaches an obese, diabetic client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when the client says that exercise will:

A. Increase her lean body mass

B. Lower her metabolic rate

C. Decrease her appetite

D. Decrease her heart rate

CORRECT ANSWER: A. Increase her lean body mass RATIONALE: Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.

Exercise increases the metabolism of the body and thus increases the heart rate.

36. The physician orders non-weight bearing with crutches for a client, who had surgery for a fractured hip that was incurred during a football game. The most important activity to facilitate walking with crutches before ambulation is begun is:

A. Exercising the triceps, finger flexors, and elbow extensors

B. Sitting up at the edge of the bed to help strengthen back muscles

C. Doing isometric exercises on the unaffected leg

D. Using the trapeze frequently for pull-ups to strengthen the biceps muscles

CORRECT ANSWER: A. Exercising the triceps, finger flexors, and elbow extensors

RATIONALE: These sets of muscles, flexors and extensors, are used when walking with crutches and therefore need strengthening prior to ambulation. The weight of the body in crutch walking is supported by the arms and palms therefore the strength of the upper extremities must be assured. Doing pull-ups limits strengthening only for the biceps.

37. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on:

A. The palms and axillary regions

B. Both feet placed wide apart

C. The palms of her hands

D. Her axillary regions

CORRECT ANSWER: C. The palms of her hands RATIONALE: The palms and not the axilla should bear the clients weight to avoid damage to the

nerves in the axilla (brachial plexus). The crutch length should be measured to be two inches below the axilla to prevent this damage.

38. A 46 year-old radio commentator is admitted to the ER because of severe chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed.

The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer:

A. 8 minims

B. 10 minims

C. 12 minims

D. 15 minims

CORRECT ANSWER: C. 12 minims RATIONALE: 1 ml = 15 minims Desired is 8 mg; stock is 10 mg/ml Using ratio and proportion: 8

mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate

39. A client asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:

A. Will help prevent erratic heart beats

B. Relieves pain and decreases level of anxiety

C. Decreases anxiety

D. Dilates coronary blood vessels

CORRECT ANSWER: B. Relieves pain and decreases level of anxiety RATIONALE: Morphine is a specific central nervous system depressant used to relieve the pain

associated with myocardial infarction. It also decreases anxiety and apprehension that help decrease myocardial oxygen demand.

40. A client is admitted to the hospital because of a complaint of dyspnea and chest pain. Oxygen 3L/min by nasal cannula is prescribed. The nurse institutes safety precautions in the room because oxygen:

A. Converts to an alternate form of matter

B. Has unstable properties

C. Supports combustion

D. Is flammable

CORRECT ANSWER: C. Supports combustion RATIONALE: The nurse should know that Oxygen is necessary to produce fire, thus precautionary

measures are important regarding its use. It is not flammable.

41. A client is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is a reliable early indicator of a myocardial infarction is:

A. SGPT

B. LDH

C. CK-MB

D. Myoglobin

CORRECT ANSWER: C. CK-MB

RATIONALE: The cardiac marker, Creatinine phosphokinase (CK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begins to rise in 3-6 hours, peak in 12-18 hours and is elevated 48 hours after the occurrence of the infarct. Myoglobin begins to rise earlier in one hour but is not cardio-specific. The other markers mentioned rise later and are not cardio-specific as well. The CK-MB therefore is most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage. The nurse needs to note, during initial assessment, the time the pain started so the appropriate cardiac marker can be evaluated.

42. An early finding in the EKG of a client with an infarcted myocardium would be:

A. Disappearance of Q waves

B. Elevated ST segments

C. Absence of P wave

D. Flattened T waves

CORRECT ANSWER: B. Elevated ST segments RATIONALE: This is a typical early finding after a myocardial infarct because of the altered

contractility of the heart. The insufficient oxygen to the myocardium leads to anaerobic metabolism of the myocardial cells. Lactic acids are produce and deplete the ATP, which is the energy source of the cells. Without ATP, there is free movement of ions across the plasma membrane causing a change in membrane potential as sodium moves into the cell and potassium moves out. This inhibits conduction of electrical impulses that leads to decrease myocardial contractility. The ST segment can be elevated as much as 10 mm or more. The other EKG findings that may be associated with MI are a large Q wave and inversion of the T wave. The other options are not typical of MI.

43. A client, who had a myocardial infarction 3 days earlier, has been complaining to the nurse about a lot of issues related to his hospital stay. The best initial nursing response would be to:

A. Allow him to release his feelings and then leave him alone to allow him to regain his composure

B. Allow him to verbalize and then refocus the conversation on his fears, frustrations and anger about his condition

C. Explain how his being upset dangerously disturbs his need for rest

D. Attempt to explain the purpose of different hospital routines

CORRECT ANSWER: B. Allow him to verbalize and then refocus the conversation on his fears, frustrations and anger about his condition

RATIONALE: This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympatho-adrenal response causing the release of catecholamines that can increase cardiac contractility and workload. This can

further increase myocardial oxygen demand.

44. Twenty four hours after admission for an Acute MI, the clients temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the fever, including:

A. Shortness of breath

B. Chest pain

C. Elevated blood pressure

D. Increased pulse rate

CORRECT ANSWER: D. Increased pulse rate RATIONALE: Fever causes an increase in the bodys metabolism, which results in an increase in

oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.

45. A client who is admitted to the hospital for chest pain, asks the nurse, Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress? The most appropriate initial response would be for the nurse to:

A. Suggest he discuss his feelings of vulnerability with his physician.

B. Tell him that he certainly needs to be especially careful about his diet and lifestyle.

C. Avoid giving him direct information and help him explore his feelings

D. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.

CORRECT ANSWER: C. Avoid giving him direct information and help him explore his feelings RATIONALE: To help the patient verbalize and explore his feelings, the nurse must reflect and

analyze the feelings that are implied in the clients question. The focus should be on collecting data to minister to the clients psychosocial needs.

46. A 55 year- old, female, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered. The nurse recognizes that the primary purpose of the Schilling test is to determine the clients ability to:

A. Store vitamin B12

B. Digest vitamin B12

C. Absorb vitamin B12

D. Produce vitamin B12

CORRECT ANSWER: C. Absorb vitamin B12 RATIONALE: Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due

to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.

47. Ana, who underwent subtotal gastrectomy 6 months earlier, is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:

A. 0.5 ml

B. 1.0 ml

C. 1.5 ml

D. 2.0 ml

CORRECT ANSWER: D. 2.0 ml RATIONALE: The desired is 0.2 mg; the stock is 100mcg/1ml First convert milligrams to micrograms

and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : 1 ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.

48. Health teachings to be given to a client with Pernicious Anemia regarding his therapeutic regimen concerning Vit. B12 will include:

A. Oral tablets of Vitamin B12 will control his symptoms

B. IM injections are required for daily control

C. IM injections once a month will maintain control

D. Weekly Z-track injections provide needed control

CORRECT ANSWER: C. IM injections once a month will maintain control RATIONALE: Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic

factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow

49. The nurse knows that a client, who had total gastrectomy and with Pernicious Anemia, understands the teaching regarding the vitamin B12 injections when she states that she must take it:

A. When she feels easily fatigued

B. During exacerbations of weakness and dizziness

C. Until her symptoms subside

D. For the rest of her life

CORRECT ANSWER: D. For the rest of her life RATIONALE: With the absence of gastric secretions related to gastrectomy, the intrinsic factor does

not return even with therapy. B12 injections will be required for the remainder of the clients life. B12 injection is made available to the body without the need for the intrinsic factor from the gastric secretions.

50. A 45 year old artist diagnosed with colorectal Ca has recently had an abdomino-perineal resection and colostomy. He accuses the nurse of being uncomfortable during a dressing change, because his wound looks terrible. The nurse recognizes that the client is using the defense mechanism known as:

A. Reaction Formation

B. Sublimation

C. Intellectualization

D. Projection

CORRECT ANSWER: D. Projection RATIONALE: Projection is the attribution of unacceptable feelings and emotions to others which may

indicate the clients non-acceptance of his condition. This has to be explored further by the nurse to help the client cope with his condition.

51. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:

A. When the client would have normally had a bowel movement

B. After the client accepts he had a bowel movement

C. Before breakfast and morning care

D. At least 2 hours before visitors arrive

CORRECT ANSWER: A. When the client would have normally had a bowel movement RATIONALE: Irrigation should be performed at the time the client normally defecated before he had

the colostomy to maintain continuity in lifestyle and usual bowel function/habit. This is an aspect that needs to be considered in the rehabilitation of the client.

52. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:

A. Stops the flow of fluid when he feels uncomfortable

B. Lubricates the tip of the catheter before inserting it into the stoma

C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion

D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled. CORRECT ANSWER: C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion RATIONALE: The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes

hook is too high which can create increase pressure and sudden intestinal distention. This leads to abdominal cramping and discomfort to the client. The main purpose of the irrigation is for bowel training to stimulate peristalsis for the return of regular bowel activity and not to cleanse the bowels. This should be done at the same time each day. 1000 ml of solution is used for the purpose.

53. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :

A. Abdominal cramps during fluid inflow

B. Difficulty in inserting the irrigating tube

C. Passage of flatus during expulsion of feces

D. Inability to complete the procedure in half an hour.

CORRECT ANSWER: B. Difficulty in inserting the irrigating tube RATIONALE: Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be

reported to the physician. Forcing the tube in could lead to intestinal perforation. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The cramps could be due to high pressure, rapid flow of solution or the use of a cold solution. The procedure may take longer than half an hour.

54. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of

his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:

A. A reaction formation to his recent altered body image.

B. A difficult time accepting reality and is in a state of denial.

C. Impotency due to the surgery and needs sexual counseling

D. Suicide thoughts and should be seen by psychiatrist

CORRECT ANSWER: B. A difficult time accepting reality and is in a state of denial. RATIONALE: As long as no one else confirms the presence of the stoma and the client does not

need to adhere to a prescribed regimen, the clients denial is supported. Denial is the first stage anyone goes through in illness. The nurse and the clients significant others will have to help him through this.

55. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:

A. Food low in fiber so that there is less stool

B. Everything he ate before the operation but will avoid those foods that cause gas

C. Bland foods so that his intestines do not become irritated

D. Soft foods that are more easily digested and absorbed by the large intestines

CORRECT ANSWER: B. Everything he ate before the operation but will avoid those foods that cause gas

RATIONALE: There is no special diet for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods and foods that the client observes that cause distention and discomfort should be avoided.

56. A 40 year-old truck driver, is brought to the emergency room after a vehicular accident. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated.

When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:

A. Level of consciousness and pupil size

B. Abdominal contusions and other wounds

C. Pain, Respiratory rate and blood pressure

D. Quality of respirations and presence of pulses

CORRECT ANSWER: D. Quality of respirations and presence of pulses RATIONALE: Respiratory and cardiovascular functions are essential for oxygenation. These are top

priorities to trauma management. There is a need to maintain or reestablish basic life functions. In this type of case, we expect a lot of blood loss which can lead to decrease circulating volume or hypovolemia and the client can go into hypovolemic shock. Hypovolemia leads to decrease tissue perfusion which leads to tissue hypoxia organs of the body that can eventually lead to organ dysfunctions thus multi-organ failure. When we perform initial assessment, we always start with our ABC's - airway, breathing (note the quality of the breathing and its rate), and circulation (Check pulses! Not BP. The pulse is more important at this point to indicate circulation/perfusion.A BP is well appreciated only if there is a good pulse. Don't waste your time checking on the BP if the pulse is not there.). The ABCs are the primary physiologic /life functions and needs of the body as these are essential for oxygenation. Without Oxygen, a person dies. After assessing the ABC and we see that there is a problem in any of these areas , we immediately proceed to re-establish for the ABC. This is fundamental in nursing assessment and intervention. Checking out for pain and relieving pain comes later.

57. A client with acute airway obstruction undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:

A. Facilitate his verbal communication

B. Maintain sterility of the ventilation system

C. Assess his response to the intervention

D. Prepare him for an emergency tracheostomy

CORRECT ANSWER: C. Assess his response to the intervention RATIONALE: It is a primary nursing responsibility to evaluate effect of interventions done to the client

particularly if the airway is involved. Nothing is achieved if the equipment is working and the client is not responding.

58. A chest tube with water seal drainage is inserted to a client following a multiple chest injury causing a hemothorax on the L lung. A few hours later, the clients chest tube seems to be obstructed. The nurse observes the long tube in the water-sealed bottle is not fluctuating. The most appropriate nursing action would be to:

A. Prepare for chest tube removal

B. Assess the client's respiration and auscultate for breath sounds

C. Arrange for a stat Chest x-ray film.

D. Clamp the tube immediately

CORRECT ANSWER: B. Assess the client's respiration and auscultate for breath sounds RATIONALE: Prompt and accurate assessment will direct the nurse to the next most appropriate

action to take. Absence of fluctuation in the water seal bottle at this time indicates the presence of obstruction especially in the case of a hemothorax and because the tube has just been inserted only a few hours earlier. Blood clots can clog the tube and cause further lung collapse and respiratory distress. Absence or diminished breath sounds indicate lung collapse. In this event, the MD should be notified immediately. Clamping the tube is NOT done as this can further cause obstruction that can lead to further lung collapse and mediastinal shift.

59. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is:

A. Increased breath sounds

B. Constant bubbling in the drainage chamber

C. Crepitus detected on palpation of chest

D. Increased respiratory rate

CORRECT ANSWER: A. Increased breath sounds RATIONALE: The chest tube normalizes intrathoracic pressure and restores negative intra-pleural

pressure, drains fluid and air from the pleural space, and improves pulmonary function. Breath sounds indicate the free passage of air in the air passages. Increased breath sounds indicate better lung expansion. Constant bubbling indicates an air leak. Crepitus may indicate subcutaneous emphysema . An increased RR indicates respiratory distress & hypoxia.

60. In the evaluation of a clients response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:

A. Urinary output is 30 ml in an hour

B. Central venous pressure reading of 2 cm H2O

C. Pulse rates of 120 and 110 in a 15 minute period

D. Blood pressure readings of 50/30 and 70/40 within 30 minutes

CORRECT ANSWER: A. Urinary output is 30 ml in an hour

RATIONALE: A rate of at least 30 ml/hr is considered adequate that indicates good perfusion of kidney, heart and brain. A CVP 0f 2cm indicates decreased circulatory volume, and options C & D are indications of decreasing cardiac output and tissue perfusion that leads to hypoxia. Hypoxia is initially indicated by restlessness and tachycardia.

61. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:

A. Complete safety of the procedure

B. Expectation of postoperative bleeding

C. Risk of the procedure with his other injuries

D. Presence of abdominal drains for several days after surgery

CORRECT ANSWER: D. Presence of abdominal drains for several days after surgery RATIONALE: Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area

that could lead to abscess formation. The rest of the options are for the doctor to discuss with the client.

62. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:

A. Encourage bed rest with active and passive range of motion exercises

B. Encourage frequent coughing and deep breathing

C. Turn him from side to side at least every 2 hours

D. Continue observing for dyspnea and crepitus

CORRECT ANSWER: B. Encourage frequent coughing and deep breathing RATIONALE: This nursing action prevents collection of respiratory secretions that can lead to

atelectasis and respiratory infection. It also promotes adequate lung re-expansion and gas exchange.

63. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:

A. Give him explanations of why there is a need to quickly increase his activity

B. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle

C. Appear cheerful and non-critical regardless of his response to attempts at intervention

D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving

CORRECT ANSWER: D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving

RATIONALE: Grief is noted whenever a significant part of the body is severed. The manifestations presented by the client is noted in the stage of depression of grieving. This withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the clients behavior is an important factor in the nurses intervention.

64. A laboratory technician is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. He discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that he is using the defense mechanism known as:

A. Reaction formation

B. Sublimation

C. Intellectualization

D. Rationalization

CORRECT ANSWER: C. Intellectualization RATIONALE: People use defense mechanisms to cope with stressful events. Intellectualization is the

use of reasoning and thought processes to avoid the emotional upsets.

65. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:

A. Increase his activity level and ambulate frequently

B. Sleep with the head of his bed slightly elevated

C. Drink citrus juices frequently for nourishment

D. Use a soft toothbrush and electric razor

CORRECT ANSWER: D. Use a soft toothbrush and electric razor

RATIONALE: Suppression of red bone marrow activity increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. The use of soft toothbrush and electric razor decreases the potential for any injury that can lead to bleeding. Anemia and leukopenia are the two other problems noted with bone marrow depression.

66. While receiving blood transfusion, a client develops flank pain, chills, fever and hematuria. The nurse recognizes that the client is probably experiencing:

A. An anaphylactic transfusion reaction

B. An allergic transfusion reaction

C. A hemolytic transfusion reaction

D. A pyrogenic transfusion reaction

CORRECT ANSWER: C. A hemolytic transfusion reaction RATIONALE: A Hemolytic transfusion reaction results from a recipients antibodies that are

incompatible with transfused RBCs that leads to RBC hemolysis. This is also called Type II hypersensitivity. The manifestations result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations

67. A client cracks jokes about his leukemia even though he is becoming more ill and weaker. The nurses most therapeutic response would be:

A. Your laughter is a cover for your fear.

B. He who laughs on the outside, cries on the inside.

C. Why are you always laughing?

D. Does it help you to joke about your illness?

CORRECT ANSWER: D. Does it help you to joke about your illness? RATIONALE: This non-judgmentally, on the part of the nurse, points out the client's behavior.

69. During an 8 hour shift, the client drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:

A. +55 ml

B. +137 ml

C. +235 ml cccccccccccccchhhhhhhhhhhhhaaaaaaaaaannnnnnnnngggggggggeeeeeeee

D. +485 ml

CORRECT ANSWER: C. +235 ml RATIONALE: The clients intake was 180 ml (6oz x 30 ml) and loss thru the vomitus was 125 ml of

fluid; loss is subtracted from intake

70. A 65-year old male teacher is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:

A. Crushing chest pain

B. Dyspnea on exertion

C. Extensive peripheral edema

D. Jugular vein distention

CORRECT ANSWER: B. Dyspnea on exertion RATIONALE: Dyspnea upon exertion is a manifestation of pulmonary congestion and edema that

occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion. The other manifestations are typical of right-sided heart failure. Its symptoms reflect systemic venous congestion.

71. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:

A. Distal tubule

B. Collecting duct

C. Glomerulus of the nephron

D. Ascending limb of the loop of Henle

CORRECT ANSWER: D. Ascending limb of the loop of Henle RATIONALE: This is the site of action of Lasix being a potent loop diuretic. Lasix decreases the

preload or venous return thus decreasing the cardiac workload. Use of diuretics is one of the essential elements in the management of CHF

72. The client weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:

A. 0.5 L

B. 1.0 L

C. 2.0 L

D. 3.5 L

CORRECT ANSWER: C. 2.0 L RATIONALE: One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals

approximately 2 Liters.

73. A client has been receiving Digitalis, Lasix, and Isordil tablets for his CHF. He is on bedrest with bathroom privileges. His apical pulse rate is 44. The nurse concludes that his pulse rate is most likely the result of the:

A. Lasix

B. Isordil

C. Bed-rest regimen

D. Digitalis

CORRECT ANSWER: D. Digitalis RATIONALE: A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases

the conduction speed of impulses within the myocardium and slows the heart rate. These effects results in a more effective and increased the cardiac output that will greatly lessen the congestion of the heart. But a heart rate of less than 60/min can indicate toxicity from Digitalis and must be reported to the MD.

74. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately:

A. 2200 calories

B. 2000 calories

C. 2800 calories

D. 1600 calories

CORRECT ANSWER: B. 2000 calories RATIONALE: There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate

and protein. Fat: 90g X 9 = 810 Protein: 100g X 4= 400 CHO: 190 X 4= 760 TOTAL: 1970 calories

75. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:

A. Magnesium

B. Sodium

C. Potassium

D. Calcium

CORRECT ANSWER: B. Sodium RATIONALE: Restriction of sodium reduces the amount of water retention that reduces the cardiac

workload. Reducing the cardiac workload improves cardiac performance with the improvement in cardiac output. For severe restriction, the client is allowed 200-500mg/day.

76. A 40-year old male attendant diagnosed with a previous history of SLE develops GI bleeding while on duty and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:

A. The medications he has been taking

B. Any recent foreign travel

C. His usual dietary pattern

D. His working patterns

CORRECT ANSWER: A. The medications he has been taking RATIONALE: Some medications, such as aspirin and prednisone, irritate the stomach lining and may

cause gastric bleeding with prolonged use.

77. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:

A. Three large meals large enough to supply adequate energy.

B. Regular meals and snacks to limit gastric discomfort

C. Limited food and fluid intake when he has pain cccccchhhhhhhhhaaaaannnnnggggggggeeeeeeee

D. A flexible plan according to his appetiteCORRECT ANSWER: B. Regular meals and snacks to limit gastric discomfort RATIONALE: Presence of food in the stomach at regular intervals interacts with HCl limiting acid

mucosal irritation. Mucosal irritation can lead to bleeding.

78. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:

A. Increasing HCO3

B. Decreasing PCO2

C. Decreasing pH

D. Decreasing PO2

CORRECT ANSWER: B. Decreasing PCO2 RATIONALE: Hyperventilation results in the increased elimination of carbon dioxide from the blood

that can lead to respiratory Alkalosis seen in the ABG result as decreased pCO2, normal HCO3 and a ph >7.45.

79. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:

A. 400 Kilocalories

B. 600 Kilocalories

C. 800 Kilocalories

D. 1000 Kilocalories

CORRECT ANSWER: B. 600 Kilocalories RATIONALE: Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only

about a third of the basal energy need

80. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:

A. Encouraging adequate fluids

B. Elevating the legs on a pillow

C. Massaging gently the legs with lotion

D. Performing active-assistive leg exercises

CORRECT ANSWER: D. Performing active-assistive leg exercises RATIONALE: Inactivity causes venous stasis, hypercoagulability, and external pressure against the

veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon

81. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

A. Reactive pupils

B. A depressed fontanel

C. Bleeding from ears

D. An elevated temperature

CORRECT ANSWER: C. Bleeding from ears RATIONALE: The nurse needs to perform a thorough assessment that could indicate alterations in

cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.

82. An unconscious client is admitted to the ICU. IV fluids are started and an indwelling catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:

A. Emptying the drainage bag frequently

B. Collecting a weekly urine specimen

C. Maintaining the ordered fluid requirement/hydration

D. Assessing urine specific gravity

CORRECT ANSWER: C. Maintaining the ordered fluid requirement/hydration RATIONALE: Promoting hydration maintains urine production at a higher rate. The increase urine

volume flushes the bladder and prevents urinary stasis and possible infection.

83. The nurse performs full range of motion on a bedridden clients extremities. When putting his ankle through range of motion, the nurse must perform:

A. Flexion, extension and left and right rotation

B. Abduction, flexion, adduction and extension

C. Pronation, supination, rotation, and extension thhhhhhhhiniiikkkkkkkkkkk

D. Dorsiflexion, plantar flexion, eversion and inversion

CORRECT ANSWER: D. Dorsiflexion, plantar flexion, eversion and inversion RATIONALE: These movements include all possible range of motion for the ankle joint.

84. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:

A. 30 degrees

B. 45 degrees

C. 60 degrees

D. 90 degrees

CORRECT ANSWER: A. 30 degrees RATIONALE: Shearing force occurs when 2 surfaces move against each other. When the bed is at

an angle greater than 30 degrees, the torso/trunk tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores. Frequent change of position at least every two hours and special attention to pressure areas will further help prevent the problem.

85. Transurethral resection of the prostate (TURP) is performed on a client with BPH. Following the surgery, nursing care should include:

A. Changing the abdominal dressing

B. Maintaining patency of the cystotomy tube

C. Maintaining patency of a three-way Foley catheter for cystoclysis

D. Observing for hemorrhage and wound infection

CORRECT ANSWER: C. Maintaining patency of a three-way Foley catheter for cystoclysis RATIONALE: The primary nursing responsibility in a client with a cystoclysis following a TURP is to

maintain the patency of the 3-way catheter. This promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation; promotes hemostasis and also promotes drainage of retained prostatic fragments. The presence of blood clots and retained prostatic fragments in the bladder can induce bladder spasms that also can induce bleeding. There is no incision in TURP thus dressing and wound infection cannot be expected.

86. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:

A. Sepsis

B. Hemorrhage

C. Leakage around the catheter

D. Urinary retention with overflow

CORRECT ANSWER: B. Hemorrhage RATIONALE: After transurethral surgery, hemorrhage is common because of venous oozing and

bleeding from many small arteries in the prostatic bed. Also, retained prostatic tissue and blood clots can cause bladder spasms that can lead to bleeding.

87. Following prostate surgery, the doctor may order the retention catheter to be secured to the clients leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:

A. Limit discomfort

B. Provide hemostasis

C. Reduce bladder spasms

D. Promote urinary drainage

CORRECT ANSWER: B. Provide hemostasis RATIONALE: The pressure of the balloon against the small blood vessels of the prostate creates a

tampon-like effect that causes them to constrict thereby preventing bleeding.

88. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurses initial action should be to:

A. Irrigate the catheter with saline

B. Milk the catheter tubing

C. Remove the catheter

D. Notify the physician

CORRECT ANSWER: B. Milk the catheter tubing RATIONALE: To check for the patency of the catheter tubing, note for kinks or dependent loops or

that the client could be lying on the tube. Milking of the tube may be done to dislodge any obstruction and allow for drainage. A physicians order is not necessary for a nurse to check catheter patency. The irrigation and removal of the catheter, in this instance, is not done by the nurse but by the physician

89. The nurse would know that a post-TURP client understood his discharge teaching when he says I should:

A. Get out of bed into a chair for several hours daily

B. Call the physician if my urinary stream decreases

C. Attempt to void every 3 hours when I'm awake

D. Avoid vigorous exercise for 6 months after surgery

CORRECT ANSWER: B. Call the physician if my urinary stream decreases RATIONALE: Urethral mucosa in the prostatic area is damaged during surgery and strictures may

form with healing that causes partial or even complete urinary obstruction. Obstruction to the urinary flow is manifested by decrease in the urinary stream.

90. A 30 year old female teacher is admitted to the surgical unit for a subtotal thyroidectomy. She is

diagnosed with Graves Disease. When assessing the client, the nurse would expect to find:

A. Lethargy, weight gain, and forgetfulness

B. Weight loss, protruding eyeballs, and lethargy

C. Weight loss, exopthalmos and restlessness

D. Constipation, dry skin, and weight gain

CORRECT ANSWER: C. Weight loss, exopthalmos and restlessness RATIONALE: Classic signs associated with hyperthyroidism are weight loss and restlessness

because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

91. A client undergoes Subtotal Thyroidectomy for Graves Disease. In planning for the clients return from the OR, the nurse would consider that in a subtotal thyroidectomy:

A. The entire thyroid gland is removed

B. A small part of the gland is left intact

C. One parathyroid gland is also removed

D. A portion of the thyroid and four parathyroids are removed

CORRECT ANSWER: B. A small part of the gland is left intact RATIONALE: Subtotal thyroidectomy allows some thyroid tissue to remain. This may provide enough

hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

92. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:

A. A crash cart with bed board

B. A tracheostomy set and oxygen

C. An airway and rebreathing mask

D. Two ampules of sodium bicarbonate

CORRECT ANSWER: B. A tracheostomy set and oxygen RATIONALE: Acute respiratory obstruction in the post-operative period can result from edema,

subcutaneous bleeding that presses on the trachea causing an airway obstruction. Hypocalcemia and tetany, caused by accidental removal of the parathyroid gland, may also cause a laryngospasm which also contributes to airway obstruction

93. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:

A. Observing for signs of tetany

B. Checking her throat for swelling

C. Asking her to state her name out loud

D. Palpating the side of her neck for blood seepage

CORRECT ANSWER: C. Asking her to state her name out loud RATIONALE: If the recurrent laryngeal nerve is injured during surgery, the client will be hoarse and

have difficult speaking

94. On a post-thyroidectomy clients discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:

A. Intolerance to heat

B. Dry skin and fatigue

C. Progressive weight loss

D. Insomnia and excitability

CORRECT ANSWER: B. Dry skin and fatigue RATIONALE: Dry skin is most likely caused by decreased glandular function and fatigue caused by

decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism. The other options are classic of hyperthyroidism.

95. A clients exopthalmos continues inspite of thyroidectomy for Graves Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: I should:

A. Keep the lights on in my room at night

B. Avoid moving my extra-ocular muscles

C. Use artificial tears to prevent drying up of my cornea

D. Avoid excessive blinking

CORRECT ANSWER: C. Use artificial tears to prevent drying up of my cornea RATIONALE: The use of artificial tears will keep the cornea moist thus prevent corneal irritation and

ulceration.

96. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious.

Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Claras body surface that is burned is:

A. 4.5%

B. 9%

C. 18 %

D. 22.5%

CORRECT ANSWER: D. 22.5% RATIONALE: The entire right lower extremity is 18%, the anterior portion of the right upper extremity

is 4.5% giving a total of 22.5%

97. The nurse applies mafenide acetate (Sulfamylon cream) to a client who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:

A. Inhibit bacterial growth

B. Relieve pain from the burn

C. Prevent scar tissue formation

D. Provide chemical debridement

CORRECT ANSWER: A. Inhibit bacterial growth RATIONALE: Sulfamylon is effective against a wide variety of gram positive and gram negative

organisms including anaerobes.

98. Eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q 12h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

A. 18 gtt/min

B. 28 gtt/min

C. 32 gtt/min

D. 36 gtt/min

CORRECT ANSWER: B. 28 gtt/min RATIONALE: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop

factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

99. A burn client receives a temporary heterograft (pig skin) on some of his burns. These grafts will:

A. Debride necrotic epithelium

B. Be sutured in place for better adherence

C. Relieve pain and promote rapid epithelialization

D. Frequently be used concurrently with topical antimicrobials.

CORRECT ANSWER: C. Relieve pain and promote rapid epithelialization RATIONALE: The graft covers nerve endings, which reduces pain and provides a framework for

granulation that promotes effective healing. Covering the wounds will also prevent infection which is so common in burn clients. The other options are irrelevant

100. A client with burns on the chest has periodic episodes of dyspnea. The nurse knows that the position that would provide for the greatest respiratory capacity for the client would be the:

A. Semi-fowler's position

B. Sims' position

C. Orthopneic position

D. Supine position

CORRECT ANSWER: C. Orthopneic position RATIONALE: The orthopneic position lowers the diaphragm and provides for maximal thoracic

expansion. Close supervision of the client when deep breathing must be done to ensure effectiveness of his ventilatory effort.

101. A 20- year old college student is admitted to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

A. Brief exaggeration of symptoms

B. Prolonged symptomatic improvement

C. Rapid but brief symptomatic improvement

D. Symptomatic improvement of just the ptosis

CORRECT ANSWER: C. Rapid but brief symptomatic improvement RATIONALE: Tensilon acts systemically to increase muscle strength; with a peak effect in 30

seconds, It lasts several minutes. A positive Tensilon test indicates further assessment to confirm MG. A negative result demands further exploration as to the cause of the muscle weakness

102. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:

A. Develop a teaching plan

B. Facilitate psychologic adjustment

C. Maintain the present muscle strength

D. Prepare for the appearance of myasthenic crisis

CORRECT ANSWER: C. Maintain the present muscle strength RATIONALE: Until diagnosis is confirmed, primary goal should be to maintain adequate activity to

maintain muscle strength and prevent muscle atrophy. The nurse should note for any weakness of the thoracic muscles with can affect ventilation.

103. The most significant initial nursing observations that need to be made about a client with

myasthenia include:

A. Ability to chew and speak distinctly

B. Degree of anxiety about her diagnosis

C. Ability to smile an to close her eyelids

D. Respiratory exchange and ability to swallow

CORRECT ANSWER: D. Respiratory exchange and ability to swallow RATIONALE: Muscle weakness of the respiratory muscles can lead to respiratory failure that will

require emergency intervention and inability to swallow may lead to aspiration.

104. The newly admitted client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:

A. Change her diet order from soft foods to clear liquids

B. Place an emergency tracheostomy set in her room

C. Assess her respiratory status before and after meals

D. Coordinate her meal schedule with the peak effect of her medication, Mestinon

CORRECT ANSWER: D. Coordinate her meal schedule with the peak effect of her medication, Mestinon

RATIONALE: Dysphagia is minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow. The client can be scheduled her meals at this time.

105. A client with myasthenia gravis, is concerned about her fluctuating physical condition and generalized weakness. In planning for her care it would be most important to:

A. Have one of her family members stay with her

B. Space her activities and encourage bed rest

C. Restrict her activities and encourage bed rest

D. Teach her the limitations imposed by her disease

CORRECT ANSWER: B. Space her activities and encourage bed rest RATIONALE: Spacing activities will encourage maximal functioning within the limits of the clients

strength and fatigue. Preventing fatigue by allowing sufficient rest in between will greatly affect also the clients self-worth and ability for self care.

106. A 65 years old, female meat vendor has a history of hypertension for the past 10 years. She has mild dyspnea on exertion and pedal edema.

The nurse recognizes that the clients dyspnea on exertion is probably:

A. A result of left ventricular failure

B. Associated with wheezing and coughing

C. A sign of advanced congestive heart failure

D. Accompanied by a rise in central venous pressure

CORRECT ANSWER: A. A result of left ventricular failure RATIONALE: Hypertension causes the heart to compensate for increased peripheral vascular

resistance that increases cardiac workload by LV hypertrophy. This results in the failing left ventricles inability to pump blood effectively out of the heart and to accept blood returning from the lungs. This results in increased vascular pressure in the lungs or pulmonary congestion manifested by dyspnea upon exertion.

107. Hydrochlorothiazide (HydroDIURIL) 50 mg bid is ordered for a hypertensive client. The nurse would know that the client understands the side effects of HydroDIURIL when he says, I should call the physician if I develop:

A. Insomnia

B. A stuffy nose

C. Increased thirst

D. Generalized weakness

CORRECT ANSWER: D. Generalized weakness RATIONALE: Generalized weakness is a sign of significant hypokalemia, which may be a sequela to

diuretic therapy especially to Hydrochlorothiazide which is a sodium and potassium excreting diuretic. Should hypokalemia occur, the client may be ordered a potassium-sparing diuretic like Spironolactone and potassium supplements.

108. The physician orders potassium supplements to a client receiving diuretic. The nurse recognizes

that the client understands the teaching about potassium when she indicates that she should:

A. Take the drug with a minimal amount of water

B. Use salt substitutes with food

C. Report any sign of abdominal colic and diarrhea

D. Increase the dosage if she has muscle cramps

CORRECT ANSWER: D. Increase the dosage if she has muscle cramps RATIONALE: Hyperkalemia manifests itself with an increase in GI motility such as colic and explosive

diarrhea. K imbalances need to be closely monitored as they can lead to cardiac irregularities and arrest.

109. The dietary practice that will help a hypertensive client reduce his dietary intake of sodium is:

A. Using an artificial sweetener in her coffee

B. Using catsup for cooking and flavoring

C. Increasing her use of dairy products

D. Avoid the use of carbonated beverages

CORRECT ANSWER: D. Avoid the use of carbonated beverages RATIONALE: A lot of people prefer to drink carbonated beverages. Carbonated beverages are

generally high in sodium and should be avoided. Sauces and dairy products contain some amount of sodium but not as much as carbonated drinks.

110. A most beneficial teaching plan for a client with HPN should include having the client:

A. Sleep flat in bed

B. Have rest periods during the day

C. Follow a low-potassium diet

D. Take her pulse at least three times a day

CORRECT ANSWER: B. Have rest periods during the day RATIONALE: Rest decreases demand on the heart and will also prevent fatigue and physical stress

that helps maintain a normal blood pressure.

111. A hypertensive client arrives for another appointment and tells the nurse, My feet are killing me. These shoes got so tight. The nurses best initial action is to:

A. Listen to the client's breath sounds

B. Take the client's pulse rate

C. Notify the physician

D. Weigh the client

CORRECT ANSWER: D. Weigh the client RATIONALE: Shoes that become too tight may indicate pedal edema, which is a sign of fluid

retention. Weight gain is a good indicator of fluid retention which is common in clients with hypertension. 2.2 lbs weight gain is equal to one liter of fluid retained.

112. A 63-year old carpenter, is admitted to the hospital with upper right quadrant discomfort, jaundice, and a recent 25- pound weight loss. After a diagnostic workup, carcinoma of the pancreas is suspected and an exploratory laparotomy is scheduled.

Before surgery, meperidine (Demerol) is ordered for pain. Morphine sulfate is contraindicated for the client because it:

A. Causes respiratory excitement

B. Stimulates pancreatic duct secretion

C. Causes spasm of the pancreatic ducts

D. Stimulates the Sympathetic Nervous System

CORRECT ANSWER: C. Causes spasm of the pancreatic ducts RATIONALE: Morphine sulfate is spasmogenic and increases spasms of smooth muscle and is

contraindicated in all conditions in which there is obstruction of smooth muscle ducts. In its place, Meperidine is preferred.

113. The physician orders atropine sulfate preoperatively. After administering the atropine to the client, the nurse should be particularly observant for the occurrence of:

A. Polyuria

B. Diarrhea

C. Murmurs

D. Tachycardia

CORRECT ANSWER: D. Tachycardia RATIONALE: Vagal stimulation slows the heart. Atropine, a vagolytic drug blocks vagal innervation,

and thereby increased heart rate can occur. The nurse must check for the heart rate before giving the drug. The drug is withheld if the heart rate is more than 100/min.

114. A Whipple procedure is performed on the client with Pancreatic Ca. When the client returns from surgery, the nurse should expect him to have a:

A. Chest tube

B. Intestinal tube

C. Nasogastric tube

D. Gastrostomy tube

CORRECT ANSWER: C. Nasogastric tube RATIONALE: This surgery involves the stomach, duodenum, pancreas and common bile duct. A

nasogastric tube connected to suction or gravity drainage removes gastric secretions and prevents abdominal distention.

115. After surgery, a client should be encouraged to turn from side to side and to carry out deep breathing exercises. These activities are essential to prevent:

A. Metabolic Acidosis

B. Metabolic Alkalosis

C. Respiratory Acidosis

D. Respiratory Alkalosis

CORRECT ANSWER: C. Respiratory Acidosis RATIONALE: Shallow respirations, bronchial tree obstruction and atelectasis compromise ventilation

and eventually gas exchange in the lungs. This causes an elevated carbon dioxide level due to CO2 retention that leads to respiratory acidosis.

116. The spouse of a client, who underwent Whipples surgery, asks the nurse about preparing meals for her husband. The statement that the nurse should include in teaching about the diet would be:

A. Meals should be low fat because of interference with the fat digestion mechanism.

B. Meals should be restricted in calories and CHON because of compromised liver function.

C. The diet should be low in calories to prevent taxing the diseased pancreas.

D. There are no dietary restrictions; he may eat as desired.

CORRECT ANSWER: A. Meals should be low fat because of interference with the fat digestion mechanism.

RATIONALE: Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine. Fat metabolism is interfered with that causes dyspepsia.

117. A long term complication that a post pancreatectomy client must be made aware of is his hypoinsulinism. The nurse would know that the client understands the teaching about hypoinsulinism when he indicates that he should seek medical supervision if he has:

A. Oliguria

B. Anorexia

C. Weight gain

D. Increased thirst

CORRECT ANSWER: D. Increased thirst RATIONALE: Polydipsia is a characteristic of hypoinsulinism (diabetes mellitus) because of impaired

carbohydrate metabolism related to surgical removal of the pancreas. It causes other related symptoms such as polyphagia, polyuria and weight loss.

118. Situation: After a partial nephrectomy, the client returns to the Urology unit with a nephrostomy tube in place.

An acute life threatening complication that the nurse should assess the client for in the early post operative period is:

A. Sepsis

B. Renal failure

C. Hemorrhage

D. Paralytic ileus

CORRECT ANSWER: C. Hemorrhage RATIONALE: The kidney, an extremely vascular organ receives a large percentage of blood from the

aorta via the renal artery. Blood that goes to the kidneys is cleared of toxic wastes through glomerular filtration in the highly vascular glomerulus. Any injury to the kidney can lead to bleeding.

119. The nurses post operative plan of care for Gary after a partial nephrectomy includes:

A. Giving him a regular diet on the first post operative day

B. Leaving the original dressing in place for at least the first 48 hours

C. Clamping the nephrostomy tube when he is out of bed chaaaangggggggggggggeeeeeeee

D. Leaving the original dressing in place for at least the first 48 hours

CORRECT ANSWER: B. Leaving the original dressing in place for at least the first 48 hours RATIONALE: Turning facilitates drainage from the operative site and also promotes adequate lung

expansion and ventilation.

120. A post partial nephrectomy client still has residual obstruction to urine flow and is being discharged with the nephrostomy tube in place. The nurse should instruct him to:

A. Irrigate the nephrostomy tube

B. Change dressings frequently

C. Remain on bed rest at home

D. Limit his intake of fluids

CORRECT ANSWER: B. Change dressings frequently RATIONALE: The dressing will need to be changed at home because drainage can persist for several

weeks. Unchanged dressings can lead to infection. To prevent further infection and promote urinary flow, fluids are encouraged and the client needs to ambulate. The nephrostomy tube can only be irrigated by the doctor.

121. A client has been taught how to care for his nephrostomy tube and how to change his dressing. On the day of discharge he states, I hope I can handle all this at home. Its a lot to remember. The best response by the nurse would be:

A. Im sure you can do it!

B. Oh, your wife can do it for you.

C. You seem to be nervous about going home.

D. Perhaps you can stay in the hospital another day.

CORRECT ANSWER: C. You seem to be nervous about going home. RATIONALE: This response by the nurse encourages reflection by the client. This also conveys

acceptance and encourages further communication.

122. Natalia, 70 years old, comes to the community health center complaining of increased thirst and appetite and weight loss.

Diabetes mellitus is diagnosed, and the physician prescribes Glucophage. While taking this medication, Natalia should be taught to observe for:

A. Hypoglycemia

B. Diabetic coma

C. Weight loss

D. Ketonuria

CORRECT ANSWER: A. Hypoglycemia RATIONALE: Oral antihyperglycemic agents can decrease serum glucose levels. The other options

relate to increase in blood glucose level.

123. Preoperative teaching for a client who is to undergo cataract surgery should include the importance of :

A. Remaining in bed for 48 hours

B. Breathing and coughing deeply

C. Avoiding bending from the waist

D. Lying in the supine position for 12 hours

CORRECT ANSWER: C. Avoiding bending from the waist RATIONALE: It is important that increase in intraocular pressure be avoided after cataract surgery.

Bending activity increases intraocular pressure and must be avoided by the client.

124. Safety is a nursing concern for a client following a cataract surgery. The nurse can provide for this by:

A. Putting the side rails up while the client is in bed

B. Darkening the room by closing the window shades

C. Applying a vest restraint until the dressing is removed

D. Immobilizing the client's head by placing a sandbag on each side

CORRECT ANSWER: A. Putting the side rails up while the client is in bed RATIONALE: Safety is a nursing priority after cataract surgery. Putting up the side rails will keep the

client from falling out of bed and will provide a sense of security. The other options are irrelevant. Restraints are not used and not indicated.

125. The physician orders 30 U of insulin to be added to a diabetic clients IV infusion of glucose and water. The nurse understands that the only insulin that can be used is:

A. Lente insulin

B. NPH Insulin

C. Regular Insulin

D. Ultralente insulin

CORRECT ANSWER: C. Regular Insulin RATIONALE: Regular insulin is the only insulin that acts rapidly and is compatible with intravenous

solutions.

126. A client who had eye surgery complains of nausea after surgery. The nurse should:

A. Instruct her to deep breathe until the nausea subsides

B. Explain that this is expected following surgery

C. Administer the anti-emetic drug as ordered

D. Give her some dry crackers to eat

CORRECT ANSWER: C. Administer the anti-emetic drug as ordered RATIONALE: Nausea and vomiting is a discomfort following surgery related to the use of anesthesia.

They should be avoided as they can increase intraocular pressure. Administering the ordered antiemetic will prevent nausea and vomiting. Deep breathing will relax the client but cannot give the assurance of preventing vomiting in a client.

127. A client who had eye surgery is being taught how to administer his own eye drops before discharge. The nurse approves his technique when he :

A. Squeezes her eye shut after instilling the eye drops

B. Raises her eyelid with gentle traction

C. Administer the antiemetic drug as ordered

D. Holds the dropper tip above the eye towards the conjunctival sac.

CORRECT ANSWER: D. Holds the dropper tip above the eye towards the conjunctival sac. RATIONALE: To protect against physical injury and infection, the dropper tip should not touch the eye

and that the medicine is instilled at the conjunctival sac

128. A client with lymphocytic lymphoma develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. The nurse should explain that:

A. Dehydration caused by nausea, vomiting and diarrhea results in hemoconcentration

B. Steroid hormones have a depressant effect on the immune system

C. Lymph node activity is depressed by the radiation therapy and chemotherapy

D. Cancer cells are the primary target of the drugs but normal cells are also susceptible to the effects of chemotherapeutic drugs

CORRECT ANSWER: D. Cancer cells are the primary target of the drugs but normal cells are also susceptible to the effects of chemotherapeutic drugs

RATIONALE: Chemotherapy can destroy actively proliferating cells in the body. The bone marrow is an area of active cellular proliferation. This causes bone marrow depression and destroys indiscriminately normal erythrocytes, WBC, platelets along with the neoplastic cells.

129. A client who develops pancytopenia during the chemotherapy should be taught to:

A. Begin a program of aggressive strict mouth care

B. Avoid traumatic injuries and exposure to infection

C. Increase her oral fluid intake to a minimum of 1000 ml daily

D. Report any unusual muscle cramps or tingling sensations to the extremities.

CORRECT ANSWER: B. Avoid traumatic injuries and exposure to infection RATIONALE: Pancytopenia causes a decrease in blood cells. The reduced platelets increase the

likelihood of uncontrolled bleeding. The reduced lymphocytes increase susceptibility to infection. Aggressive mouth care implies using strong mouthwashes that can further irritate the oral mucous membranes. Fluid intake is encouraged as the clients uric acid level increases with chemotherapy.

130. A 30 year-old female social worker has had a variety of vague complaints for the past 6 months. The physician suspects multiple sclerosis and plans to complete neurologic assessment.

When testing the trigeminal nerve, the nurse should expect the physician to evaluate:

A. Ocular muscle movement

B. Shrugging of the shoulders

C. Smiling and frowning

D. Corneal sensation

CORRECT ANSWER: D. Corneal sensation RATIONALE: The afferent sensory branch of the trigeminal nerve innervates the cornea

131. The client is suspected of having multiple sclerosis. The nurse will expect her to complain about the most common initial symptom associated with multiple sclerosis, which is:

A. Diarrhea

B. Headaches

C. Skin infection

D. Visual disturbances

CORRECT ANSWER: D. Visual disturbances RATIONALE: Visual disturbances such as diplopia and blurred vision are common initial symptoms

from impaired CN dysfunction and conduction deficits to the optic nerve.

132. A client diagnosed of Multiple Sclerosis asks the nurse Will I experience pain? The nurses best response would be:

A. Tell me about your fears regarding pain

B. Analgesics will be ordered to control the pain.

C. Lets make a list of the things you need to ask your doctor

D. Pain is not a characteristic symptom of this disease process.

CORRECT ANSWER: D. Pain is not a characteristic symptom of this disease process. RATIONALE: This is a truthful answer that provides hope for the client. Pain is a common source of

fear among clients regardless of the diagnosis.

133. A client appears obviously upset with his diagnosis of Multiple sclerosis and asks, Am I going to die? The nurses best response would be:

A. Most individuals with your disease live a normal life span

B. Is your family here? I would like to explain your disease to all of you

C. The prognosis is variable, most individuals experience remissions and exacerbations

D. Why dont you speak with your doctor who can give you more details about your disease?

CORRECT ANSWER: C. The prognosis is variable, most individuals experience remissions and exacerbations

RATIONALE: This is a truthful answer that provides some realistic hope. With compliance to the medical regimen, the client can be on remission for a long time.

134. During an exacerbation of Multiple Sclerosis, the client complains of urinary urgency and frequency. The initial nursing action should be to:

A. Initiate a regimen to monitor urinary output

B. Develop a plan to ensure high fluid intake

C. Begin teaching self catheterization

D. Palpate the suprapubic area

CORRECT ANSWER: D. Palpate the suprapubic area RATIONALE: Assessment is the priority. The nurse should determine if the symptoms are caused by

a full bladder.

135. A client is given a diagnosis of cystitis. The nurse recognizes that Escherichia Coli is a common causative agent in cystitis. The reason for this is that it is:

A. A particularly virulent bacteria

B. Commonly found in the kidneys

C. Usually found in the intestinal tract

D. A competitor with Candida for host sites

CORRECT ANSWER: C. Usually found in the intestinal tract RATIONALE: It is a fact that E. coli is commonly found in the bowel and because of close anatomic

proximity and improper hygiene after bowel movements, the microorganism may spread to the nearby urethra and thus the bacteria gains its way into the urinary system. This infection can best be prevented by good and proper perineal hygiene

136. A 40 year old salesman, is admitted to the hospital with a tentative diagnosis of duodenal peptic ulcer.

When performing the initial history and physical assessment the nurse would expect him to describe the pain as:

A. Located in the right shoulder and preceded by nausea

B. Gnawing, dull, aching epigastric pain or boring pain in the back

C. Sudden sharp abdominal pain increasing in intensity

D. Heartburn and substernal discomfort when lying down

CORRECT ANSWER: B. Gnawing, dull, aching epigastric pain or boring pain in the back RATIONALE: Classic symptoms include gnawing, boring, or dull pain located in the mid epigastrium

or back. The pain is caused by irritation and erosion of the mucosal lining related to hypersecretion of HCl. Option A is caused by biliary colic. Option D is related to gastric reflux disorder.

137. A clients peptic ulcer is confirmed by a gastroscopy and upper GI series. The physician orders ranitidine (Zantac) 150 mg bid with meals. The nurse should check this order with the physician because:

A. This drug is usually given with meals

B. Zantac may be given by a variety of routes

C. Zantac is contraindicated for peptic ulcer

D. This is less than the recommended dose

CORRECT ANSWER: B. Zantac may be given by a variety of routes RATIONALE: It is necessary to clarify the route of administration because the medication can be

given po, IV or IM. The other options are irrelevant.

138. A client hospitalized for peptic ulcer vomits his undigested antacids and complains of severe epigastric pain. The nursing assessment reveals absence of bowel sounds, pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the physician, the nurse should:

A. Place the client in Trendelenburg position

B. Ask the client of he has had red or black stools

C. Start O2 per nasal cannula at 3 to 4 L per minute

D. Keep the client NPO in preparation for any possible surgery

CORRECT ANSWER: D. Keep the client NPO in preparation for any possible surgery RATIONALE: These are classic indicators of perforated peptic ulcer for which immediate surgery is

indicated. Assessing for possible complications should be part of the nursing assessment.

139. Subtotal gastrectomy (Billroth I) is performed on a client with peptic ulcer. The client recovers from surgery and begins to eat more food in varied forms. After meals he experiences a cramping discomfort and a rapid pulse with waves of weakness, which are frequently followed by nausea and vomiting. The nurse recognizes that this response is known as dumping syndrome and is caused by:

A. A slowed passage of food dumping into the small intestine

B. A rapid passage of dilute food mixture into the small intestine

C. Rapid passage of hyperosmolar food solution into the small intestine

D. Food that is less concentrated than surrounding extracellular fluid entering the small intestine.

CORRECT ANSWER: C. Rapid passage of hyperosmolar food solution into the small intestine RATIONALE: Without an adequate stomach reservoir, the hypertonic oncentrated food mass from the

stomach dumps into the small intestine, drawing fluid from surrounding blood and tissue and causing hypovolemia and typical shock symptoms. The initial manifestations of this complications are brought about by hypovolemia.

140. About 2 hours after the initial post-meal attack of the dumping syndrome, the client experiences a second period of discomfort, feeling somewhat shaky. This later follow-up effect, which is precipitated by the dumping syndrome, is caused by:

A. Mild hypoglycemia from an overproduction of insulin that occurs in response to the postprandial blood glucose rise

B. Hyperglycemia from a rapidly absorbed glucose load, which overwhelms the insulin-adjusting mechanism

C. The increased fat content and larger amount of seasoned food, creating digestive discomfort

D. The increased use of simple carbohydrates in meals, creating a more prolonged glucose rise

CORRECT ANSWER: A. Mild hypoglycemia from an overproduction of insulin that occurs in response to the postprandial blood glucose rise

RATIONALE: The rapid absorption of sugars from the food mass causes elevation of blood sugar, and the aggressive insulin response to bring the blood sugar to normal often causes transient hypoglycemic symptoms.

141. The nurse understands that when a diabetic client undergoes surgery, his Insulin requirements postoperatively will:

A. Decrease immediately

B. Fluctuate widely

C. Increase sharply

D. Remain elevated

CORRECT ANSWER: D. Remain elevated RATIONALE: Emotional and physical stress related to surgery leads to hyperglycemia and cause

insulin requirements to remain elevated in the postoperative period

142. The nurse understands that, for a client who undergoes pelvic surgery, his plan of care must include the prevention of postoperative deep vein thrombosis. This can be achieved by increasing the:

A. Coagulability of the blood

B. Velocity of the venous return

C. Effetiveness of internal respiration

D. Oxygen- carrying capacity of the blood

CORRECT ANSWER: B. Velocity of the venous return RATIONALE: Because venous stasis is the major predisposing factor of pulmonary emboli, venous

flow velocity should be increased like the application of anti-embolic stockings or elastic bandages to the lower extremities and encouraging early ambulation

143. To prevent bleeding after prostatectomy, the client should be instructed to avoid straining on defecation. The nurse knows that he understands the related teaching when he says he must increase his intake of:

A. Milk products

B. Ripe bananas

C. Creamed potatoes

D. Green Vegetables

CORRECT ANSWER: D. Green Vegetables RATIONALE: Green vegetables contain fiber, which promotes defecation.

144. The most observable change caused by osteoporosis will occur in:

A. Facial bones

B. The long bones

C. The vertebral column

D. Joints of the hands and feet

CORRECT ANSWER: C. The vertebral column RATIONALE: Compression fractures of the vertebrae are the most frequent fractures in clients with

osteoporosis; a gradual collapse of vertebrae may be asymptomatic and only observed as kyphosis.

145. The physician applies Bucks extension (traction) on a client who recently had a hip fracture until surgery can be performed to replace the head of the femur with a prosthesis. When checking the clients Bucks extension, the nurse should be aware that:

A. Tape must cover the malleoli to adequately secure the weights to the leg

B. The padding is placed on the anterior aspects of the leg

C. The foot of the bed is routinely elevated

D. The spreader bar should fit snugly around the foot

CORRECT ANSWER: C. The foot of the bed is routinely elevated RATIONALE: Elevating the foot of the bed will provide counter traction. This will also keep the client

from being pulled down to the foot of the bed by the traction weight.

146. The nurse would recognize that a post-operative client is using the spirometer correctly when he:

A. Inhaled deeply, sealed her lips around the mouthpiece and exhaled

B. Coughed twice before inhaling deeply through the mouthpiece

C. Inhaled deeply through the mouthpiece, relaxed for a few seconds and then exhaled

D. Used the incentive spirometer for 10 consecutive breaths per hour

CORRECT ANSWER: C. Inhaled deeply through the mouthpiece, relaxed for a few seconds and then exhaled

RATIONALE: These are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. The other options are irrelevant.

147. A nurse is taking care of a client, who has received doctors orders on her 10th post-operative day after left hip replacement surgery, to sit for short periods. When getting her out of bed the nurse should place her in a:

A. Soft armchair with her left leg straight out in front

B. Firm armchair with her left leg elevated on a stool

C. Firm chair with her left foot flat on the floor's surface

D. Soft chair with enough pillows to keep the hip at a right angle

CORRECT ANSWER: C. Firm chair with her left foot flat on the floor's surface RATIONALE: This action puts the least strain on the prosthesis, and the hip may be flexed to 90

degrees 10 days after surgery. No Hip flexion beyond 90 degrees is allowed as this might dislodge the prosthesis.

148. A menopausal client can best limit further progression of her osteoporosis by:

A. Increasing her consumption of milk and milk products

B. Increasing her consumption of eggs and cheese

C. Taking supplemental magnesium and vitamin E

D. Taking supplemental calcium and Vitamin D

CORRECT ANSWER: D. Taking supplemental calcium and Vitamin D RATIONALE: Research demonstrates that women past menopause need 1500 mg of Calcium a day

which is almost impossible to obtain through dietary sources because the average daily consumption of calcium is 300-500 mg. Thus the need for supplements. Vitamin D promotes the deposition of calcium into the bone

149. A client returns from the bronchoscopy procedure. The nurse should withhold food and fluid for several hours to prevent:

A. Abdominal distention

B. Aspiration of food

C. Dysphasia and dyspepsia

D. Projectile vomiting

CORRECT ANSWER: B. Aspiration of food RATIONALE: To allow for the insertion of the bronchoscope, throat muscles are anesthetized using

an anesthetic spray. This diminishes the protective gag reflex. The nurse therefore needs to keep the client on NPO until the gag reflex has returned.

150. Cancer of the lung is diagnosed in the client and a pneumonectomy is performed. When inspecting the clients dressing, the nurse observes some puffiness of the tissue around the area. When the area is palpated, the tissue feels spongy with crackles. In charting, the nurse should describe this observation as:

A. Chest distention

B. Crepitus

C. Pitting edema

D. Stridor

CORRECT ANSWER: B. Crepitus RATIONALE: There is air in the tissues and palpation results in a crackling sound referred to as

crepitus. This may indicate the presence of subcutaneous emphysema.

151. A client who underwent Right pneumonectomy is observed on the first post-operative day to have suddenly sat straight up in bed. His respirations are labored, and he is making a crowing sound. His skin is pale, cool and moist. Immediately the nurse should:

A. Notify the physician

B. Check the chest tube for patency

C. Auscultate the left lung

D. Inspect the incision for bleeding

CORRECT ANSWER: C. Auscultate the left lung RATIONALE: Assessment of the airway takes priority after chest surgery. Mediastinal shift with

airway obstruction may occur because pressure from retained secretions can build up on the operative side, causing the trachea to deviate toward the unoperative side. This can lead to airway obstruction. Auscultation of the unoperated side will help determine the presence of obstruction. Chest tubes are not usually noted following pneumonectomy since there is no more lung to re-expand

152. When turning a client who underwent left pneumonectomy, the nurse should plan the use of:

A. Supine position or left side lying position

B. Supine position until the chest tube is removed

C. Right side lying or left side lying position

D. High fowler's position or supine position

CORRECT ANSWER: A. Supine position or left side lying position RATIONALE: Lying on the operative side permits ventilation of the remaining lung and prevents fluid

from draining into the sutured bronchial stump and into the unaffected lung

153. After pneumonectomy, irradiation to the chest wall has been prescribed for the client with lung cancer on an outpatient basis. In teaching him about skin care, the nurse should emphasize:

A. Massaging 4 times a day to increase circulation

B. Frequent washing to remove desquamated cells

C. Keeping the skin dry and protected from abrasions

D. Using skin lotion twice daily to keep the skin supple

CORRECT ANSWER: C. Keeping the skin dry and protected from abrasions RATIONALE: The skin is the first line of defense and keeping it dry and safe from injury promotes

skin integrity. Skin applications and frequent washings are avoided.

154. The characteristics that would alert the nurse that a client is at increased risk of developing gallbladder disease would be:

A. Female, under the age of 40, family history of gallstones

B. Male over the age of 40, low serum cholesterol level

C. Male, under the age of 40 past history of hepatitis

D. Female, over the age of 40, obese

CORRECT ANSWER: D. Female, over the age of 40, obese RATIONALE: All these characteristics are well-established risk factors for gallbladder disease

(female, fat, forty and fertile

155. A client is to undergo an oral cholecystogram in the morning. As part of the preparation for this test, the nurse should tell her client:

A. The test will be administered on 2 successive day

B. The contrast medium in the pills may cause constipation

C. Any stones present will be readily visible on the x-ray film

D. A low-fat supper should be eaten the night before the test

CORRECT ANSWER: D. A low-fat supper should be eaten the night before the test RATIONALE: A low fat dinner is given so that large amounts of bile is stored in the gallbladder when

the test is done that can promote good radiographic visualization.

156. The presence of gallstones is confirmed and a client is given the diagnosis of Cholelithiasis. Cholecystectomy with common bile duct exploration is scheduled. In the immediate postoperative period, the nursing action that should assume the highest priority is:

A. Encourage her to take adequate fluids by mouth

B. Encourage her to cough and deep breathe

C. Change her dressings BID

D. Irrigating her T-tube frequently

CORRECT ANSWER: B. Encourage her to cough and deep breathe RATIONALE: Self splinting of the incision site that clients do to control the post-operative pain results

in shallow breathing which does not aerate the lungs adequately, particularly the lower right lobe. Clients need to be given pain relievers as ordered and encouraged deep breathing and coughing activities.

157. A hypertensive client is to be released from the hospital on regimen of Chlorothiazide and Aldomet. The nurse should instruct the client to:

A. Avoid eating fruits and vegetables because they limit the liver's effect on digestion

B. Take protein supplements to promote healing and speed her recovery

C. Modify her diet to compensate for the pharmacologic effects of her medication on electrolyte levels.

D. Return to her normal eating habits once she is home

CORRECT ANSWER: C. Modify her diet to compensate for the pharmacologic effects of her medication on electrolyte levels.

RATIONALE: Diuril is both a sodium & potassium excreting diuretic. The client must increase dietary intake of potassium because of potassium loss associated with Diuril

158. The physician orders TPN 1L q12 hours for 2 days to a client with Colitis. The primary nursing responsibility should be to monitor the clients

A. Electrolytes

B. Urinary output

C. Administration rate

D. Urine glucose levels

CORRECT ANSWER: C. Administration rate RATIONALE: The solution is hyperosmolar and a very concentrated source of glucose. Too rapid

infusion can cause hyperglycemia that can easily contribute to circulatory overload. An infusion pump should be used to ensure accurate infusion. At the same time, the clients blood glucose levels should be monitored.

159. The nurse should be aware that clients receiving only IV fluids lose weight because of:

A. Lack of bulk in the diet

B. Deficient carbohydrate intake

C. Insufficient intake of water-soluble vitamins

D. Increased concentrations of electrolytes in cells

CORRECT ANSWER: B. Deficient carbohydrate intake RATIONALE: IV fluids supply minimal calories not enough to meet daily nutritional requirements. A

client on only IV therapy will eventually lose weight and become malnourished.

160. A client develops an infection at the IV catheter insertion site. The nurse uses the term iatrogenic

when describing this infection because it resulted from:

A. The client's developmental level

B. Inadequate dietary pattern

C. A therapeutic procedure

D. Poor physical hygiene

CORRECT ANSWER: C. A therapeutic procedure RATIONALE: An iatrogenic infection is one that is caused by medical personnel, procedures or

environment of the health care Facility related to the treatment of a particular condition.

161. A client is admitted with severe left flank pain, nausea, and hematuria. The tentative diagnosis is a ureteral calculus. When he is first admitted, the initial nursing action is to:

A. Obtain a urine specimen for culture

B. Administer prescribed analgesics

C. Increase his fluid intake

D. Strain all urine output

CORRECT ANSWER: B. Administer prescribed analgesics RATIONALE: The pain of renal colic is excruciating and caused by spasms of the smooth muscles to

release the obstruction in the urinary tract. Unless relief is obtained the client will be unable to cooperate with other therapy.

162. When taking the admitting history of a client with possible Left ureteral calculus, the nurse would expect him to report:

A. Boring pain in the left flank

B. Pain that intensifies on urination

C. Pain that is dull and constant in the costovertebral angle

D. Spasmodic pain on the left side radiating to the suprapubis

CORRECT ANSWER: D. Spasmodic pain on the left side radiating to the suprapubis

RATIONALE: The pain with ureteral stones is caused by muscle spasm of the ureters in an attempt to dislodge the obstruction and is excruciating and intermittent that follows the path of the ureter to the bladder.

163. A 45 year-old jeepney driver is scheduled for an Intravenous Pyelogram (IVP). The nurse explains to him that on the day before the IVP he must:

A. Eat a fat-free dinner

B. Drink large amount of fluids

C. Omit dinner and limit beverages

D. Take a laxative before going to bed

CORRECT ANSWER: D. Take a laxative before going to bed RATIONALE: The urinary system is located retroperitoneally. Laxatives remove feces and flatus,

providing better visualization of the urinary system.

164. The clients serum Calcium is elevated and the Intravenous Pyelogram (IVP) confirms the presence of a ureteral calculus. If his blood tests indicated an elevated uric acid level instead of an elevated calcium level, the nurse would recognize that the doctor may consider the presence of:

A. BPH

B. Gout

C. Rheumatoid Arthritis

D. Tetany

CORRECT ANSWER: B. Gout RATIONALE: Elevated serum uric acid is noted in the assessment of clients with Gout. The

accumulation of uric acid can contribute to the occurrence of acid urinary calculi

165. A client is admitted to the hospital with a history of ureterolithiasis, lower third. His urinary output is noted to be much less than his intake. When it is noted that his bladder is not distended, the nurse should suspect the development of:

A. Shock

B. Hydroureter

C. Urinary retention

D. Pulmonary congestion

CORRECT ANSWER: B. Hydroureter RATIONALE: Calculi may obstruct the flow of urine to the bladder, allowing the urine to distend the

ureter causing hydroureter. Urinary retention presents itself with a distended bladder, even after voiding, with an increase in residual urine.

166. Before a client with a history of urinary calculi is discharged, the nurse needs to discuss the need to avoid UTI. The nurse knows that he understands signs of infection when he says he will report:

A. Pain radiating to the external genitalia

B. Urgency or frequency of urination

C. The inability to maintain an erection

D. An increase in alkalinity or acidity of urine

CORRECT ANSWER: B. Urgency or frequency of urination RATIONALE: These occur with a urinary tract infection because of bladder irritability. Burning on

urination and fever are additional signs of UTI

167. To facilitate micturation, a nurse should instruct a client with difficulty to voiding to:

A. Assume the normal position for voiding

B. Wash his hands after voiding

C. Drink cranberry juice daily

D. Use a urinal for voiding

CORRECT ANSWER: A. Assume the normal position for voiding RATIONALE: This uses gravity to allow urine to exert pressure on the area of the urinary trigone,

initiating relaxation of the urinary sphincter, and facilitating micturition.

168. A priority nursing action during the first 48 hours after admission of a client with jaundice and pedal edema, and a history of excessive alcohol intake for the last five years, will be to:

A. Monitor his vital signs

B. Increase his fluid intake

C. Improve his nutritional status

D. Identify his reasons for drinking

CORRECT ANSWER: A. Monitor his vital signs RATIONALE: A history of excessive alcohol intake for the last five years will surely manifest itself with

alcohol withdrawal. A clients vital signs, especially the pulse and temperature will rise before the client demonstrates any of the more severe symptoms of withdrawal from alcohol.

169. The nurse, aware of a clients history of excessive alcohol use, would expect his physical assessment to reveal a :

A. Type A Hepatitis

B. High blood ammonia

C. Small liver with a rough surface

D. High fever with a generalized rash

CORRECT ANSWER: C. Small liver with a rough surface RATIONALE: Scar tissue that forms as cirrhosis progresses, due to the hepatotoxic damage of

alcohol, causes the liver tissue to contract, making the liver small with a rough surface. Nodules are formed as scar tissue pulls the liver at certain points.

170. A client with a liver disorder reports that his gums bleed spontaneously. In addition, the nurse notes small hemorrhagic lesions on his face. The nurse recognizes that he needs additional:

A. Vitamin A

B. Bile salts

C. Vitamin K

D. Folic Acid

CORRECT ANSWER: C. Vitamin K

RATIONALE: Petechiae are evidences of capillary bleeding. The diseased liver is no longer able to metabolize vitamin K which is necessary in the formation of prothrombin.

171. When the physician schedules a paracentesis on a client, the nurse should:

A. Instruct him to empty his bladder

B. Encourage him to drink fluids

C. Shave and prep his abdomen

D. Medicate him for pain

CORRECT ANSWER: A. Instruct him to empty his bladder RATIONALE: The site of puncture for paracentesis is between the umbilicus and the symphysis

pubis. Instructing the client to void before paracentesis keeps the bladder in the pelvic area and prevents its accidental puncture when the abdominal cavity is entered.

172. Dexamethasone (Decadron) is ordered for the early management of a client with cerebral edema related to left intracerebral hemorrhage. This treatment is effective because it:

A. Acts as a hyperosmotic diuretic

B. Increases tissue resistance to infection

C. Reduces the inflammatory response of tissues

D. Decreases the formation of cerebral spinal fluid

CORRECT ANSWER: C. Reduces the inflammatory response of tissues RATIONALE: Corticosteroids act to decrease inflammation which decreases the cerebral edema.

This can decrease the increased intracranial pressure of the client

173. During the time that a client is receiving Dexamethasone, the nurse should observe for the development of negative side effect by:

A. Monitoring deep tendon reflexes

B. Measuring blood glucose levels

C. Culturing respiratory secretions

D. Auscultating for bowel sounds

CORRECT ANSWER: B. Measuring blood glucose levels RATIONALE: Conticosteroids such as Dexamethasone, have a hyperglycemic effect. The blood

sugar level therefore needs to be monitored regularly during the treatment

174. The neuromuscular status and decreased mobility of a client with Stroke must be assessed early. It is important for the nurse to consider any restrictions or abnormalities that are observed because:

A. Disuse hyperthrophy of the muscles will eventually result

B. Shortening and eventual atrophy of the muscles will occur

C. Rigid extension can occur, making therapy painful and difficult

D. Decreased movement on the affected side predisposes to infection

CORRECT ANSWER: B. Shortening and eventual atrophy of the muscles will occur RATIONALE: Shortening and eventual atrophy of muscles occurs due to lack of use, resulting in

contractures

175. A client is noted to manifest right hemianopsia as a result of his CVA. The nurse should:

A. Instruct the client to scan his surroundings

B. Corrects the client's misuse of equipment

C. Provide tactile stimulation to the client's affected extremities

D. Teach the client to look at the position of his right extremities

CORRECT ANSWER: A. Instruct the client to scan his surroundings RATIONALE: This client has lost vision from the right visual field. Scanning his environment

compensates for the loss allowing for better visualization.