Practice Nursing test with answers and rationale

1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement of the patient is most suggestive of anginal pectoris?a. The pain lasted for about 45 minutesb. The pain resolved after I ate sandwichc. The pain worsened when I took a deep

breathd. The pain occurred while I was mowing the

loan2. After experiencing a transient ischaemic attack

(TIA), a client is prescribed aspirin 80 mg p.o daily. The nurse should teach the client that this medication has been prescribed toa. Control headache painb. Enhance immune responsec. Prevent intracranial bleedingd. Decrease platelet coagulation

3. The physician prescribes several drugs for a client with hemorrhagic stroke . which drug order should the nurse question.a. Heparin sodiim (heplock)b. Dexamethasone ( decadron)c. Methyldopa (aldomet)d. Phentoin (dilantin)

4. A client with peptic ulcer is about to begin a therapeutic regimen that includes a bland diet,antacids and ranitindine hcl (zantac). Which instructions should the nurse provide before this client is discharged.a. Eat a three balanced meal everydayb. Stop taking the drug when the symptoms

subsidec. Avoid aspirin and products that contain

aspirind. Increase the intake of fluids containing

caffeine5. The nurse is assessing a client with Cushing’s

disease. Which observation should be reported to the physician immediately.a. Pitting edema of the legsb. Irregular apical pulsec. Dry mucous membraned. Frequent urination

6. A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high pressure alarm on the ventilator sounds, what should the nurse do?a. Check the presence of the apical pulseb. Suction the patient’s artificial airwayc. Increase the oxygen percentaged. Ventilate using a manual resuscitation bag

7. Which of the following takes the highest priority for parkinson’s crisis?a. Altered nutrition: less than body

requirementsb. Ineffective airway clearancec. Altered urinary eliminationd. Risk for injury

8. Which nursing diagnosis is most appropriate for a client with Addison’s disease?a. Risk for infectionb. Fluid volume excessc. Urinary retrentiond. Hypothermia

9. Which of these signs suggest that a client with Symptom if Inappropriate Antidiuretic Hormone(SIADH) has developed complications?a. Titanic contractionsb. Neck vein distentionc. Weight loss d. Polyuria

10. Which of these findings best correlates with a diagnosis of osteoarthritis?

a. Joint stiffness that decreases with activityb. Eythema and edema over the affected jointsc. Anorexia and weight lossd. Fever and malaise11. When communicating with a client with

(sensory) receptive aphasia, the nurse should?a. Allow time for the client to respondb. Speak loudly and articulate clearlyc. Give the client a writing padd. Use short, simple sentences

12. Which outcome indicates that treatment for diabetes insipidus is effective?a. Fluid intake of less than 2500 ml in 24 hoursb. Urine output of more than 200 ml/hrc. Blood p ressure of 90/50d. Pulse rate of 126 beats/min

13. Which action should the nurse include in the plan of care for a client with a fiberglass cast on the right hand?a. Keep the casted arm with a light blanketb. Avoid handling the cast for 24 hrs or until

dryc. Assess pedal and tibial pulses every 24 hrsd. Assess movement and sensation in the

fingers of the right hand.14. A client is admitted with a serum glucose level

of 618 mg/dl. The client is awake and oriented, with hot, dry skin, a temperature of 100.6 F(38.1 C)PR of 116 bpm, and BP of 108/70 mmhg. Based on these findings, which nursing diagnosis receive the highest priority?a. Fluid volume deficit r/t osmotic diuresisb. Decreased cardiac output r/t increased HRc. Altered nutrition : less than body

requirements r/t to insulin deficiencyd. Ineffective thermoregulation r/t to

dehydration.15. Which nursing action should take the highest

priority when caring for a client with hemiparesis caused by cerebrovascular accident?a. Perform passive range of motion exerciseb. Place the client on the affected sidec. Use handrolls or pillows to supportd. Apply antiembolic stockings

16. Then nurse should include which instruction when teaching a client about insulin administration?a. Administer insulin after the first meal of the

dayb. Administer insulin at a 45 degree angle into

the deltoid musclec. Shake the vial of the insulin vigorously

before withdrawing the medicationd. Draw up clear insulin when mixing two

types of insulin in one syringe.17. The nurse should expect a client with

hypothyroidism to report which of these health concerns?a. Increased appetite and weight lossb. Puffiness of the face and handsc. Nervousness and tremors

d. Increasing exophthalmos18. A client with hypothyroidism is receiving

levothyroxine sodium(synthroid), 50 mcg. P.O daily. Which of these findings should the nurse recognize as an adverse effect?a. Dysuriab. Leg crampsc. Tachycardiad. Blurred vision

19. A client ABG values are pH=7.12, PaCO2= 40 mmHg, and HCO3= 15 mEq/L. which disorder these ABG values suggests?a. Respiratory alkalosisb. Respiratory acidosisc. Metabolic alkalosisd. Metabolic acidosis

20. A client is admitted to the ER with suspected overdose of unknown drug. The client ABG values indicates respiratory acidosis, what should the nurse do first?a. Prepare to assist with ventilationb. Monitor the client’s heart rhythmc. Prepare to begin gastric lavaged. Obtain urine for drug screening

21. A client is being returned to the room after subtotal thyroidectomy. Which piece of equipment is important to the nurse to bring to the client’s bedside?a. Indwelling folley catherer kitb. Tracheostomy setc. Cardiac monitord. Humidifier

22. Which of these findings is an early sign of bladder cancer?a. Painless hematuriab. Occasional polyriac. Nocturiad. Dysuria

23. Which statement from a client who takes Nitroglycerin ( Nitrostat) as needed for angina pain indicates that further teaching is necessary?a. I store the tablets in a dark bottleb. I take the tablet in a full glass of waterc. I check for my tongue to tingle when I take

a tablet

d. I’ll go to the hospital if 3 tablets, 5 minutes apart don’t relieve the pain

24. The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?a. 15 mm indurationb. Reddened areac. 10 mm bruised. Blister

25. A client must take streptomycin sulfate for TB. Before the therapy begins, the nurse should inform the client to inform the physician if which of the following symptoms occur?a. Decreased color discriminationb. Increased urinary frequencyc. Decreased hearing acuityd. Increased appetite.

26. During a late stage of AIDS, a client demonstrates signs of AIDS related dementia. The nurse should give highest nursing prioroity to which of the following nursing diagnosis?a. Bathing or hygiene self care deficitb. Impaired cerebral perfusionc. Dysfunctional grievingd. Risk for injury

27. A client with gout is receiving Probenecid. The nurse should monitor which laboratory test when caring for this patient?a. RBC countb. Serum uric acidc. Serum potassium

28. A client has been diagnosed with type 1 insulin dependent DM. which client’s comment correlates best with this disorder?a. I was thirsty all the time. I just couldn’t get

enough to drinkb. It seemed like I had no appetite. I had to

get myself eatc. I had cough and cold that jjust didn’t seem

to go awayd. I noticed a pain when I went to the

bathromm29. A client is receing chemotherapy for breast

cancer. Which assessment finding indicates

chemotherapy induced fluid and electrolyte imbalance?a. Urine output of 400 ml in 8 hrsb. Serum potassium level of 3.6 mEq/Lc. BP of 120/64 to 130/72 mmHgd. Dry oral mucous membrane and cracked

lips30. After chemotherapy, a client develops N/V . for

this client, the nurse should give the highest priority to which action in the plan of care?a. Serve small portions of bland foodb. Encourage rhythmic breathing exercisec. Administer metoclopromide and

dexamethasone as prescribedd. Withould fluid for the the first 4-6 hrs

31. A client is receiving Zidovdine (Retrovir) to treat AIDS, for this client, the nurse should monitor the value of which laboratory test?a. RBC countb. Fasting blood glucosec. Serum calciumd. Platelet count

32. A client seeks care for low back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk?

a. Pain that radiates down the posterior thighb. Back pain when the knees are flexedc. Atrophy of the lower legsd. Positive Homan’s sign33. For a client with hepatitis b, the nurse should

monitor closely for the onset development of which clinical manifestation?a. Jaundiceb. Arm and leg pruritusc. Fatigue during ambulationd. Irritability and drowsiness

34. A client is recovering from ileostomy that was performed to treat inflammatory bowel disease. During the teaching discharge, the nurse should stress:a. Increasing fluid intake to prevent

dehydrationb. Wearing appliance pouch only at bedtimec. Consuming a high protein , high fiber dietd. Taking only enteric medications

35. To prevent esophageal reflux in a client with hiatus hernia, the nurse should provide which discharge instructions?a. Lie down after meals to promote digestionb. Avoid coffee and alcoholic beveragesc. Consuming low protein, high fiber dietd. Limit fluids with meals

36. A client with increasing difficulty swallowing , weight loss and fatigue just received a diagnosis of esophageal cancer. Because this client has difficulty swallowing, the nurse should give the highest priority to which action. a. Helping the client cope with body image

disturbanceb. Ensuring adequate nutritionc. Maintaining a patent airwayd. Preventing injury

37. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient Vit. K absorption caused by this liver disease?a. Dyspnea and fatigueb. Ascites and orthopneac. Purpura nd petechaied. Gynecosmastia and testicular hypertrophy

38. Two days ago, the client underwent an autograft for secof and third degree burns on the arms. Now the nurse finds the client doing arm ecxercise. Te nurse knows that exercise should be avoided because it may.a. Dislodge the autograftb. Increase the edema in the armsc. Increase the amount of scarringd. Decrease circulation of the fingers

39. A client with UTI receives a prescription for cotrimoxazole (Septra) 2 tablets P.O daily for 10 days. Which observation best demonstrates that the client followed the prescribed regimen?a. Increase urine output to 2L in 24 hrsb. Decreased flank and abdominal discomfortc. Absence of bacteria on urine cultured. Normal RBC count

40. A client has undergone laryngectomy and tracheostomy formation. Which instruction should the nurse give to the client and family about the operation?

a. The tracheostomy tube should be cleaned with alcohol and water.

b. Family members should conitinue to converse with the client

c. Oral intake should be limited to 1 week onlyd. The amount of protein in the diet should be

limited41. When caring for a client who has just had a

total laryngectomy,the nurse should plan toa. Encourage oral feedings as soon as possibleb. Develop an alternative communication

methodc. Keep the tracheostomy cuff fully inflatedd. Keep the client flat in bed

42. After a left pneumonectomy, a client has a chest tube for drainage. For this client, the nurse musta. Monitor fluctuations in the water seal

chamberb. Clamp the chest tube once every shiftc. Encourage coughing and deep breathingd. Milk the chest tube every 2 hrs

43. A client reports sharp chest pain in the right side of the chest and difficulty of breathing and has respiratory rate of 40 bpm. Which goal should the nurse consider as the top priority?a. Maintainance of adequate circulatory

volumeb. Maintainance of effective respirationc. Anxiety reductiond. Pain reduction

44. A client develops brigh red urine while receiveing heparin for pulmonary embolus. What should the nurse do first?a. Decrease the heparin infusion rateb. Prepare to administer protamine sulfatec. Monitor the paritial thromboplastin

time(PTT)d. Stop the infusion for 2 hrs and start it at a

lower dose as prescribed45. In a client is chronic bronchitis, which sign

should lead the nurse to suspect right heart failure (cor pulmonale)a. Circumoral cyanosisb. Bilateral crackelsc. Productive cough

d. Leg edema46. When caring for a client with endotracheal

tube, the nurse should consider which action to be the most important?a. Auscultate the lungs for bilateral breath

soundsb. Turning the client from side to side every 2

hrsc. Monitor serial blood gas every 4 hrsd. Provide frequent oral hygiene

47. The nurse administer albuterol (Proventil) as prescribed to a client with emphysema. Which findings indicate that the drug is producing a therapeutic effect?a. RR of 22 bpmb. Dialted and reactive pupilsc. Urine output of 40 ml/hrd. PR of 100 bpm

48. After transurethral resection of the prostate for benign prostatic hypertrophy, a client returns to the room with continous bladder irrigation. On the first day after surgery, the client reports bladder pain, what should the nurse do first?a. Increase the IV flow rateb. Notify the physician immediatelyc. Assess the irrigation catheter for patency

and drainaged. Asminsiter meperidine 50 mg IM as

prescribe49. A client with arterial insuffieciency has just

undergone below knee amputation of the right leg. Which action should the nurse include in the post op[ care plan?a. Elevate the stump fot the first 24 hrsb. Maintain the client on complete bed restc. Appy heat to the stump as the client desiresd. Remove the pressure dressing after the first

8 hrs50. Which of these laboratory test is the most

accurate indicator of renal functiona. BUNb. Creatinine clearancec. Serum creatinined. Urinalysis

51. Which nursing intervention is the most important when caring for a client with acute pyelonphritis?a. Administer sitz bath twice a dayb. Increase fluid intake to 3 L a dayc. Use an indwelling (folley) catheter to

measure urine output accuratelyd. Encourage the client to drink cranberry

juice to acidify the urine52. Which nursing intervention is the most

important during the acute oliguric phase of acuter renal failure?a. Encouraging coughing and deep breathing

exerciseb. Promoting carbohydrate intakec. Limiting fluid intaked. Controlling pain

53. A client with renal failure is undergoing continous ambulatory peritoneal dialysis (CAPD). Which nursing diagnosis is most apporopriate for this client?a. Altered urinary eliminationb. Toileting self care deficitc. Sensory or perceptual alterationsd. Dressing or grooming self care deficit

54. A client is admitted with a cervical spine injury caused by a diving accident. When planning this client’s care,the nurse should give which nursing diagnosis the highest priority?a. Impaired physical mobilityb. Ineffective breathing patternc. Sensory or perceptual alterationd. Activity intolerance

55. The nurse is developing a plan of care for a patient who has undergone a laminectomy to repair a herniated intervertebral disk. Which action should the nurse include?a. Keep the pillow under the knees at all timeb. Place the client in a semi fowler’s positionc. Maintain bed rest for 72 hrs postopd. Turn the patient from side to side using the

log rolling technique

56. The nurse must total parenteral nutrition(TPN) through a triple lumen catheter line. What can the nurse do to prevent complications?

a. Cover the catheter insertion site with an occlusive dressing

b. Use clean technique when changing the dressing

c. Insert an indwelling urinary catheterd. Keep the client on complete bed rest.

57. The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding should the nurse report to the physician immediately?a. Serum potassium of 4.9 mEq/Lb. Serum sodium of 135 mEq/Lc. Temperature of 99.2 F (37.3)d. Urine output of 400 ml in 24 hrs

58. A cient is admitted with a gunshot wound to the abdomen. After an exploratory laparatomy, the client , the client is transferred to the ICU. Which assessment finding suggests that the client now is developing acute renal failure?a. BUN level of 22 mg/dlb. Serum creatinine level of 1.2 mg/dlc. Temperature of 1.2 Fd. Urine output of 400 ml in 24 hrs

59. A client seeks care for severe pain in the right upper quadrant of the abdomen, which is accompanied by nausea and vomiting. The physician makes a diagnosis of acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis should receive the highest priority?a. Pain r/t biliary spasmb. Knowledge deficit r/t prevention of

recurrencec. Anxiety r/t unknown outcome of

hospitalizationd. Altered nutrition: less than body

requirements r/t to biliary inflammatioin60. For a client with advanced liver cirrhosis, which

assessment finding best indicates deterioration of liver function?a. Fatigue and muscke weaknessb. ‘difficulty in arousalc. Nausea and anorexiad. Weight gain

61. A client is admitted with increased ascites associated with cirrhosis. Which nursing diagnosis should receive the highest priority?a. Fatigueb. Fluid volume excessc. Ineffective breathing patternd. Altered nutrition: less than body

requirements62. A client with advanced cirrhosis has a

prothrombin time of 15 seconds compared to a control time of 11 sec. which drug should the nurse expect to administer?a. Spironolactone (alsdactone)b. Phytonadione( mephyton)c. Furosimide (Lasix)d. Warfarin (Coumadin)

63. The physician prescribes spironolactone(Aldactone) 50 mg P.O four times daily for a client with fluid retention due to liver cirrhosis, which finding indicates that the drug is producing a therapeutic effect?a. Serum K level of 3.5 mEq/Lb. Weight loss of 2 lb in 24 hrsc. Serum Na level of 135 mEq/Ld. Blood pH of 7.25

64. While preparing a client with for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery. The nurse also should tell the client the primary purplose of incentive spirometry is:a. Increases respiratory effectivenessb. Preclude the need for nasogastric

intubationc. Improve nutritional status during the

recovery periodd. Decrease the amount of respiratory

anesthesia65. A client is transferred to ICU after evacuation of

a subdural hematoma. To reduce the risk of increasing intracranial pressure , the nurse should:a. Encourage oral fluid intakeb. Suction the client once per shiftc. Elevate the head of the bed to high fowlersd. Administer a stool softener as prescribed

66. Two days after repairing a client’s ruptured cerebral aneurysm, the physician orders mannitol (osmitro) 1.5 g/kg, to be infused over 60 minutes. If the client weighs 175 lbs, how many grams of mannitol should be administered?a. 263 gb. 119 gc. 75gd. 60 g

67. A client is receiving a n I.V infusion of mannitol after undergoing intracranial pressure surgery for removal of a brain tumor. To determine if this drug is producing its therapeutic effect, the nurse should consider which as the most significanta. Decrease level of consciousnessb. Elevated BPc. Increased urine outputd. Decreased heart rate

68. A client is hospitalized for open reducrion of a fractured femur. During postoperative assessments, the nurse monitors for signs of fat embolism, which include:a. Pallor and coolness of the affected legb. Nausea and vomiting after eatingc. Hypothermia and bradycardiad. Restlessness and petechiae

69. A client is in Buck’s skin traction for right hip fracture. The nurse should include which action in this client’s plan of care.a. Remove the weight once every shiftb. Maintain the bed in knee gatch positionc. Keep the client is a semi fowler’s positiond. Maintain traction in correct body allignment

70. A client who has just received a diagnosis of early glaucoma is being prepared for discharge. Which information should the nurse provide during this client’s discharge teaching session?a. Instructions for eye patchingb. Discharge assessment of visual acuity c. Demonstration of eye drop instillationd. Instructions on intraocular lens cleaning

71. A client was admitted to a coronary care unit with acute myocardial infarction (MI). Now the client report midsternal pain radiating down the

left arm, appears restless and is slightly diaphoretic. The nurse obtains the following assessment findings: T= 00. 6 F (37.5 C); PR = 102 bpm, regular;slightly labored respiration of 26 bpm, and BP of 150/90 mmHg. When planning the client’s care, the nurse should give the highest priority to which nursing diagnosis?a. Risk for altered body temperatureb. Decreased cardiac outputc. Anxietyd. Pain

72. A client with cirrhosis of the liver is increaslingly confused and combative. Which of the following diets would the nurse expect to be ordered for this client?a. Low fat, low sodiumb. High carbohydrate, low proteinc. Low potassium ,low phosphorusd. Gluten and wheat free.

73. Which of the following should the nurse teach a client using recombinant epoetin alpha (Epogen) for chronic renal failure?a. This drug will help with the bleeding

problems associated with kidney damageb. Epoetin alpha should reduce fatigue and

improve energy levelc. Taking this medication may reduce the need

for dialysisd. Once a good blood level is established, the

injectable form will be changed to an oral form

74. An appropriate plan of care for a client admitted with renal colic would include which of the following?a. Inserting an indwelling urinary catheter b. Straining all urinec. Maintaining T tube patencyd. Limiting fluid intake

75. Which statement would not be included in discharge teaching for a client with a history of rheumatoid arthritis who was treated with severe anemia secondary to GI hemorrhage?a. Take your iron supplement with orange

juiceb. Use aspirin for joint painc. Plan to take iron for 6 months

d. Avoid taking iron with tea or calcium supplements

76. A client with exacerbation of COPD and pneumonia has the following ABG results: pH 7.30, PaC02 60 mmHg, PaO2 75 mmHg and HCO3 is 24 Meq/L. The nurse anticipates wich intervention?a. Increase oxygen via face maskb. Encourage coughing and deep breathingc. Admister sodium bicarbonated. No intervention is neede. ABG values are

normal77. A client with cerebrovascular accident has a

nursing diagnosis of ineffective airway clearance. The goal for this client is to mobilize pulmonary secretions. Which action should the nurse plan to take to meet this goal?a. Reposition the client every 2 hrsb. Restrict fluids to 1000 ml in 24 hrsc. Asminister O2 by nasal canula as orderedd. Keep the head of the bed at a 30 degrees

angle78. A client is admitted to the hospital with a

productive cough, night sweats and fever. Which of these actions is most important in the client’s initial plan of care?a. assess the client’s temperature every 8 hrsb. place the client in respiratory isolationc. monitor the client’f fluidintake and outputd. wear gloves during all client contact

79. a client with heart failure has been receiving an IV infusion at 125 ml/hr. Now the client is short of breath and the nurse notes of bilateral crackles, neck vein distention and tachycardia. What should the nurse do first?a. Notify the physicianb. Discontinue the IV access devicec. Administer the prescribed diureticd. Slow the infusion and notify the physician

80. After bronchoscopy, the client must receive NPO until the gag reflex returns. What is the best way to assess the gag reflex?a. Instruct the client to coughb. Ask the client to extend the tonguec. Tickle the uvula with a tongue blade

d. Observe while the client swallows sips of water.

81. A client with shock due to hemorrhage has these V/S: T= 97.6 F(36.4C), PR= 140 bpm, BP of 60/30 mmHG. For this client, the nurse should question which physician’s order?a. Monitor urine output every hrb. Infuse IV fluids at 83 ml/hrc. Admister oxygen by nasal canula at 3 L/mind. Draw specimens for hemoglobin and

hematocrit every 6 hrs82. A client with history of atrial fibrillation

presents to the outpatient clinic with nausea, vomiting, HR of 55 bpm, and visual disturbances. The nurse would further assess the client for which of the following conditions?a. Digitalis glycoside toxicityb. Anginac. Heart failured. Depression

83. A client’s ABG values are pH of 7.29, PaO2 48 mmHg, PaCO2 76 mmHg, HCO3 of 36 mEq/l. the plan of care for this client with these values would include close monitoring for which of the following s/sx?a. Cyanosis and restlessnessb. Flushed skin and lethargyc. Weakness and irritabilityd. Anxiety and fever

84. During postural drainage, movement of secretions from the lower respiratory tract to the upper respiratory tract occurs due to:a. Friction between the ciliab. Force of gravityc. Increased insulin used. Increased red blood cell production

85. Clients with COPD may be bedridden at home and get little exercise. Which of the following is a normal physiologic reaction to prolonged period of bed rest and inactivity?a. Increased sodium retentionb. Increased calcium excretionc. Increased insulin used. Increased red blood cell production

86. For a client with COPD who has trouble raising respiratory secretions, which of the following

nursing measures would help reduce the tenacity of secretions?a. Ensuring that the client’s diet is low in Nab. Ensuring that the client’s oxygen therapy is

continousc. Helping the client maintain a high fluid

intaked. Keeping the client in sitting position as

much as possible87. The nurse teaches the client with COPD to

assess for signs and symptoms of right sided heart failure which include:a. Clubbing of nail bedsb. Hypertensionc. Ankle edemad. Increased appetite

88. While caring for a client who has sustained an MI, the nurse notes eight premature ventricular contractions in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water and 2 L/minte of oxygen. The nurse’s first course of action would be to:a. Increase the IV infusion rateb. Notify the physician promptlyc. Increase the oxygen concentrationd. Administer a prescribed analgesic

89. Whichof the following findings is an indicative of MI?a. Elevated serum cholesterol levelb. Elevated creatinine phosphokinase (CPK)

valuec. Agrees to participating in cardiac

rehabilitation programd. Can perform personal self care activities

without pain.90. Which of the following is expected for a client

on the day of hospitalization after an MI? the client:a. Has minimal chest painb. Can identify risk factors for MIc. Agrees to participating in cardiac

rehabilitation programd. Can perform personal self care activities

without pain91. Nursing measures for the client who has had an

MI include helping the client to avoid activity

that results in valsalva maneuver. Which of the following actions would help prevent valsalva maneuver? Have the client:a. Take fewer deep breathsb. Clench teeth while moving in bedc. Drinks fluids through a strawd. Avoid holding breath during activity

92. A basic principle of any rehabilitation program , including cardiac rehabilitation begins:a. On discharge from hospitalb. On discharge from cardiac care unitc. On admission to the hospitald. Four weeks after the onset of disease

93. The client has a history of heart failure and the nurse is preparing the client to go home. The nurse should instruct the client to:a. Monitor urine output dailyb. Maintain bed rest for at least one weekc. Monitor daily potassium intaked. Weigh daily

94. Digoxin is administred IV to clients with CHF primarily because the drugs acts to :a. Dilate coronary arteryb. Increase myocardial contractilityc. Decrease cardiac dysrhytmiasd. Decrease electrical conductivity in the heart

95. The client ask the nurse about the reason for taking enalapril maleate. The nurse based her response on the fact that enalapril is prescribed for people with heart failure to:a. Lower blood pressure by increasing

peripheral resistanceb. Lower the heart rate by slowing the

conduction sytemc. Block the conversion of angiotensin 1 to

angiotesin 11d. Increase cardiac contractility thereby

improving cardiac output96. Metoprolol tartrate a Beta adrenergic

antagonsist may be administered to a client with heart failure because it acts to:a. Reduce peripheral vascular resistanceb. Increase peripheral vascular reistancec. Reduce fluid volumed. Improve myocardial contractility

97. The most effective measure the nurse can use to prevent the wound infection when changing a client’s dressing after coronary artery bypass surgery is to:a. Observe careful handwashing proceduresb. Cleanse the incisional area with antisepticc. Use prepacked sterile dressing to cover the

woundd. Place soiled dressings in a waterproof bag

before disposing them98. Which information obtained by the nurse when

assessing a patient admitted with mitral valve stenosis should be communicated to the health care provider immediately?a. The pt has a loud diastolic murmur all

across the precordiumb. The pt has crackles audible to the lung

apices99. When caring for a pt with infective endocarditis

of the tricuspid valve, the nurse will plan to monitor the pt for:a. Flank painb. Hemiparesisc. Dyspnead. splenomegaly

100. the nurse is taking a history from a 24 y/o pt with hypertrophic cardiomyopathy. Which information obtained by the nurse is the most important?

a. the pt reports using cocaine once at 16 y/ob. the patient has a history of upper respiratory infectionc. the pt’s 29 year old brother has had a sudden cardiac arrestd. the pt has a family history of CAD

Answers to part 1

1. D. precipitating factors of angina include exertion during physical activities,colds, after heavy meals , emotional stress wherein there’s an increase oxygen demand but less supply d/t of obstruction of blood flow. It may also occur during rest as a result of coronary spasm. Pain usually last for 3-5 minutes or 15-20 min especially after a heavy meal or anger.

2. D. TIA is caused by temporary decreased in blood flow , could be caused by

atherosclerosis,emboli or thrombi. Anticoagulants such as aspirin is given to dissolve the clot or prevent platelet aggregation that could lead to emboli or thrombi.

3. A. hemorrhagic stroke can lead to seizures. Thus antiseizures such as phentoin is prescribed. One often cause is hypertension causing small vessels in the brain to rupture and bleed thus antihypertensive such as methyldopa is included. The bleeding also cause edema or inflammation to the surrounding tissues so anti-inflammatory such as dexamethason is given to reduce the edema. Heparin is an anticoagulant that may cause further bleeding and should be questioned.

4. C. teaching should include small frequent feeding to avoid too much HCl acid secretion, completing the prescribed medications even the patient seems to feel better, avoiding gastric irritants such as caffeine, highly flavored foods, aspirin may cause ulcer and bleeding and should be avoided.

5. C. cushing’s disease is an excessive production of mineralocorticoids( aldosterone- for sodium and water reabsorption), glucocorticoids( cortisol- breakdown of fats and protein and gluconeogenesis) and androgens (masculine hormone. Although a pitting edema is a characteristic symptom of cushing disease because of excessive water and sodium reabsorption, it is not an emergency condition. Irregular apical pulse is the primary concern and should be reported immediately.

6. B. the ventilator will alarm to let the caregiver know there is a problem. Some of the most common alarms are high pressure, low pressure and battery. If the high pressure alarm sounds, it means that air is having a hard time getting into the lungs, it usually means suctioning is needed to get extra secretions out of the airway. Low pressure means that there might be an airleak or a disconnected tube.

7. B. Parkinson’s crisis is also referred as acute akinesia present in advanced state of the disease. The rigidity of the intercoastal muscle makes the patient unable to cough out

accumulated sputum/secretions .thus, patients with parkinson’s disease are prone to repiratory infections.

8. A. Addison’s disease is also known as Adrenal insufficiency. There’s insufficient adrenocorticotropic hormone (ACTH) production which includes epinephrine and norepinephrine that are helpful in the flight and fight response. If the body is unable to fight off stressors, this will lead to body exhaustion and increase susceptibility to illnesses and infections. Another adrenal hormone is aldosterone which is responsible for water and sodium reabsorption. Insufficient amount of this leads to increased loss of sodium and water, not urine retention and fluid excess. Excessive loss of sodium and water can lead to dehydration and increase temperature.

9. B. antidiuretic hormone(ADH) prevents diuresis or urination. Excessive ADH leads to excess Na and H2O retention thereby gaining weight. Increased amount of fluid in the blood vessels causes increased venous return and fluid overload. Chronic condition may lead to congestive heart failure in which distended neck vein is one of the sign

10. A. osteoarthritis is not an inflammatory disease thereby doesn’t produce inflammatory and systemic sign and symptoms. It ‘s a wear and tear degenerative disease. Pain can occur after repetitive use of the joint . pain and stiffness can also occur after a long period of inactivity such as when you go to bed at night and suffer a pain and stiffness when you wake up in the morning.

11. Receptive aphasia is characterized by fluent but meaningless speech with severe impairment of the ability understanding spoken and written words. Short and simple sentences should be used.

12. A. DI is characterized by inadequate antidiuretic hormone leading to excessive loss of Na and H20 followed by hypotension and tachycardia. Tachycardia is a compensatory mechanism in an effort to pump more blood d/t the decreasing

circulating fluid. It is important to increase the fluid intake to prevent hypovolemic shock.

13. D. It is unnecessary to keep the cast warm, it should be exposed to cool air. Fiberglass is dried up within 10-15 minutes, there’s no need to assess the pedal and tibial pulses since it’s not the one casted. The casted part is the right arm so it is important to check distal circulation and sensation. Assess brachial and ulnar pulse.

14. A. hyperglycemia could lead to osmotic dieresis leading to fluid volume deficit as manifested by dry skin. Decreased cardiac output can’t be related to increasese HR, it is d/t dehydration and increased heart rate is a compensatory mechanism . there’s no data for insulin deficiency , there might be enough insulin but the cells are resistant to use it.

15. Ewan ko pa16. D. Insulin is usually administered before meal to

anticipate the increase of blood sugar after eating. Never administer a subcutaneous insulin deltoid because you might give it IM. Deltoid is muscular so it is only used for IM insulin route. Don’t shake the bottle to mix, just roll gently between hands or by turning the bottle up and down slowly.

17. B. thyroid hormones are responsible for many metabolic processes. Options A,C,D are result of hyperthyroidism d/t increased metabolism and neuromuscular hyperactivity. One function of thyroid hormone is protein synthesis which maintain osmotic pressure in the blood vessels . if protein concentration in the vessels is decreased,there’s a fluid shift into the extracellular space leading to edema.

18. C. synthroid adverse effects typically resulted from overdose and include the signs and symptoms of hyperthyroidism which includes tachycardia.

19. D. pH is below normal which suggest an acidosis. PaCO2 is for respiratory index while HCO3 is for metabolic. The pH follows HCO3, thereby it is metabolic acidosis

20. A. always follow the principle of ABC prioritization, Airway, breathing, circulation. Respiratory acidosis is typically the result of

accumulation of CO2 in the body tissues due to hypoventilation. First priority is to assist with the prescribed therapy which includes means to improve ventilation.

21. B. Bleeding / hematoma is a life threatening complication that obstructs airway postthyroidectomy. Tracheostomy set should be at the bedside to establish airway immediately if respiratory distress occurs.

22. A. In an early stage of cancer, it usually starts as a tumor , as tumor invades vascularized tumor, it may cause bleeding.

23. B. Nitroglycerin is an unstable substance and easily denatured when exposed to heat and light. The dark bottle protect the drug from the light. If the drug doesn’t tingle under the tongue, it could be that it’s not working anymore, it could be expired or denatured. You should not take more than 3 tablets , if the pain is not relieve in 15 minutes, you should consult the doctor because this is not an angina pain anymore, it could be a myocardial infarction.

24. A. mantoux test or tuberculin test is a screening test for pulmonary tuberculosis. It is done by introducing a protein derivative of the causative bacteria in the dermis of the skin. After 48-72 hours, an induration of 10 mm or more is a positive test and indicates that you might be positive for PTB, a further evaluation and testing is needed to confirm the presence of PTB.

25. C. Streptomycin is an antibiotic belonging to the aminoglycosides family. Aminoglycosides work by inhibiting the bacterial protein synthesis. Streptomycin frequently affects the vestibular branch of the auditory nerve causing nausea, vomiting, vertigo. Symptoms subside and recovery occur following discontinuation of the drug. In long term therapy however, ototoxic effect causes hearing loss when extensive is usually permanent.

26. A. the main problem mention is dementia. People with dementia may not be able to think well enough to do normal activities of daily living such as getting dressed and eating.

27. A. Probenecid works by decreasing uric acid in the blood by promoting its kidney exctetion. In overdosage and intoxication, it causes various hematologic side effects.

28. A. DM type 1 is a decreased in insulin production leading to increasing amount of glucose in the blood. Hyperglycemia causes osmotic diuresis that leads to frequent urination and leads to dehydration.

29. D. A,B,C are normal findings. S/E iof chemotherapy includes nausea and vomiting, prolonged N/V caused dehydration.

30. C. it is more logical and appropriate to administer prescribed antiemtic first before feeding the patient. This is to avoid vomiting after a meal.

31. A. the most serious S/E of zidovudine is anemia, myopathy and neutripenia

32. A.The protruded or herniated disk irritates or compressed the surrounding nerve endings which causes severe back pain radiating to the thighs.

33. D. all options are clinical manifestation of hepatitis B. I think the most correct answer is D, because it needs closer monitoring and care.

34. A. ileostomy is bringing out the ileum which is the end of the small intestine into an opening on the abdomen. One important function of the colon is water absroption, since water is not anymore pass through the colon , most fluid is lost into the pouch rather than being absorb making the client more prone to dehydration. Pouch should be worn all the time. Low fiber diet should be advised postoperatively because surgery causes the bowel to swell making digestion of fiber difficult. Once the swelling has subsided(usually after 8 wks) the patient can resume a normal diet.

35. B. instruction to the patient should include avoiding acid stimulant such as coffee, alcohol, fatty foods,aspirin, tobacco, chocolate, peppermint,etc. you should also instruct patient to remain in upright position for atleat 30 min after eating and sleeping with the bed slightly elevated, small frequent feeding is better tolerated than 3 big meals.

36. B. Esophageal CA presents many signs and symptoms. However the question is asking specifically on the problem r/t to difficulty swallowing. You should look for a problem that is most related to difficulty swallowing, that is insufficient food intake and nutrition. The nurse should then ensure adequate nutrition in relation to this problem.

37. C. Vit K is important in the clotting mechanism of the body. Lack of this can lead to bleeding. Purpura and petechiae are forms of bleeding

38. A. avoid exercise for 3-4 wks because this may stretch and injure the graft.

39. C. Antibacterial should work for what its designed for and that is to eliminate the causing bacteria of a disease. Even though the symptoms subside, still a number of the causative bacteria is present in the urinary tract, if the medication is stopped without completing the prescribed duration of antimicrobial therapy, they will again multiply and cause the exacerbation of the disease. Therefore, it is important to complete the whole duration of the drug therapy to ensure elimination of all the bacteria.

40. B. inner cannula is cleaned with Hydrogen Peroxide and rainsed with water. The stoma is also cleaned using a soapy wash cloth then rinsing it. Inner surrounding of the stoma with driep up sputum crust can be cleaned with a cotton tipped swab soaked in hydrogen peroxide. Alcohol promotes dryness. There’s no indication why you have to limit fluid intake. Protein intake should be increased to promote healing. Patient can still communicate with proper speech therapy and learning other means of communication.

41. B. keep the bed elevated to promote ventilation of the lungs and reduces edema and swelling of the neck. The patient is on NGT feeding temporarily , no food is allowed by mouth until the pharyngeal suture line is healed. The tracheostomy cuff should not be fully inflated to avoid pressure trauma to the windpipe. Usually 10 ml of air is used and the cuff should be deflated once in a while to

relieve the pressure. In total laryngectomy, speech rehabilitation training is necessary( esophageal voice, electrolarynx) or using sign language.

42. A. clamp is only necessary when there is a leak along the tubing and is used to locate the leak. Clamp should only be used in a limited time to prevent tension pneumothorax and mediastinal shift. Milking is only per MD order. To ensure that the drainage system is intact, the nurse should monitor for gently fluctuations in the water seal chamber with each inspiration and expirarion.This is called tidaling. Though coughing and deep breathing is also an important teaching, making sure the drainage system is intact is more important to serves its purpose.

43. B. Follow the ABC prioritization( 1.Airway, 2.breathing, 3.circulation)

44. C. Assess first before you intervene. PTT is used to test how long it takes your blood to clot and check for bleeding problems especially when the patient is on blood thinning therapy such as heparin .

45. D. the question is asking specifically about sign of righ heart failure. Cor pulmonale is a right ventricular hypertrophy due to chronic lung disease. Right side heart failure is usually associated with signs of the venous system. Due to the hyperthropy of the right ventricle, there is insufficient filling, thus blood backs up to the venous system causing peripheral edema.

46. A. the most priority is to ensure a patent airway, auscultating the presence of breathsound is an indication that the air way is patent.

47. A. albuterol is a bronchodilator that relaxes muscle of the airway and increases airflow into the lungs

48. C. always assess first before you intervene. Clots along the drainage can cause urine stasis and aggravate pain.

49. A. this is to prevent edema.50. B. Creatinine clearance. Creatine is a byproduct

of metabolism and excreted by the kidney.

51. B. increase fluid intake is very important to flushes out bacteria

52. C. in oliguric phase , it doesn’t mean that there is an insufficient fluid intake, it’s because there’s a decrease glomerular filtration leading to fluid accumulation in the body and fluid overload. Emphasize Na and fluid restriction at this point.

53. C. peritonitis is the most major risk in peritoneal dialysis d/t to introduction of microorganism through the catheter.

54. B. airway and breathing is always the priority. 55. D. Pillows under knees can be used but should

not be kept at all time to promote venous return and prevent blood clot formation. Ambulation is encouraged within hours after surgery to promote lung aeration. Pt can be positioned supine with a pillow under neck or at the sides. The patient should also change position at least every 2 hrs , when turning the body should be moved as a unit.

56. A. patients with central line catheter are ambulatory and urinary catheter is not needed unless there’s some kidney pathology that requires the use of it. Sterile technique is used when changing the dressing , occlusive dressing is used to prevent air from entering the line.

57. D. Normal serum potassium level is 3.5-5 mEq/L, normal serum sodium is 135-145 mEq/L. normal urine output is at least 30 ml/hr .

58. D. The first phase of acute renal failure is oliguric phase with urine output of 400ml or less in 24 hrs. Normal urine ourput in 24 hrs is 1500 ml. normal serum creatinine is .7-1.4 mg/dl. BUN is not significantly increased normal bun is 10-20 mg/dl.

59. A. one principle of prioritization is to look on the client’s needs on the clients perspective . pain is considered as the 5th vital sign. The pain is severe that needs to be addressed first among the other options.

60. B. All options except D are signs and symptoms of liver cirrhosis but option B poses the most serious complication. Advanced liver cirrhosis can lead to hepatic encephalopathy which is

the accumulation of toxins in thebrain leading to decreased mental function and coma.

61. C. airway and breathing is always the priority. The patient has difficulty of breathing because of the pressure exerted by the enlarged abdomen to the diaphragm.

62. B. The patient has prolonged clotting time which predisposes the patient to bleeding . Coaugulant such as phytonadion (Vit. K)should be given to counteract effect .warfarin is an ancticoagulant which place the patient in increased risk of bleeding. Furosemide and Spironolactone are diuretics.

63. B. Sprironolactone is a K sparing diuretic . It is used to excrete extra fluid from the body , therby, lose of body weight means tha most fluid are being excreted out.

64. A. incentive spirometry is a breathing device that promote maximal lung aeration and respiratory effectiveness

65. D. Elevate only to 15-30 degrees to promote venous return and reduce cerebral edema. Enforce any fluid restriction and monitor carefully input and output. Avoid activities that increase intrathoracic or intraabdominal pressure such as straining during bowel movement, this impedes blood flow from the cranium. Suctioning can stimulate the vagal reflex and further increase ICP, suctioning is only done if its extremely necessary.

66. 1 kg= 2. 2 lbs175 lb X 1 kg = 79.55 lbs 2.2 lbs79.55 lbs X 1.5 g= 119 g

67. C. mannitol is a diuretic that excretes extra fluid out from the body. Increased UO is an indication that mannitol’s desired effect is achieved

68. A. bone marrow is also composed of fat globules that may escapes out during bone fracture and causes fat embolism. The fat globules can impede blood flow making the affected leg pale and cool.

69. D. traction should be continuous , the weight is never removed nor interrupted. The patient is

in supine with neck supported by a pillow. The leg with a traction should be held straight and never flexed.

70. C. Glaucoma occurs due to the pressure build up in the eye by increased amount of aqueous vitrous humor. Eye drops could either work by promoting the flow of the aqueous fluid or decrease the production of it.

71. D. One priority in acute MI is pain control drugs such as morphine to reduce catecholamine induced oxygen demand to injured heart muscle.

72. A. cirrhosis may lead to malnutrition. It is essential to maintain a healthy , nutritious diet such as increasing carbohydrate and protein intake. Low fat diet should be observed because bile is needed for digestion and bile is not sufficiently produced in cirrhotic liver. Salt and Na intake should also be minimal because patients with cirrhosis tends to retain extra fluid. When liver cirrhosis is complicated by hepatic encephalopathy, then this is the time that protein intake should be limited.

73. B. kidney produced erythropoietin necessary for blood cell formation, kidney damage leads to anemia. Signs and symptoms of anemia include easy fatigability and body weakness. Epogen is given SQ or IV to aids in erythropoeisis and reduces symptoms of anemia

74. B. renal colic is a very excruciating pain caused by the passage of stone along the ureter. Indwelling catheter will not ease the pain. It may in fact add more to the pain experience. T tube is used to drain bile . Increased fluid intake should be encourage to help flush the stone. It is appropriate to collect all urine and strain for stone passage to assess effectiveness of therapy and or to study the stone composition.

75. B. Vit C such as orange juice enhances absorption, tea, coffee and calcium reduces iron absorption. Aspirin is avoided because it is a blood thinner and aggravates bleeding

76. B. Doctors always prescribed a low oxygen delivery to patients with COPD usually at 2 L/min because high concentration of oygen can depress the respiratory drive. Besides high

oxygen concentration is of no use if the airway is obstructed with secretions. It is very important to encourage the pt to cough out secretions to help clear the airway and encourage deep breathing. All ABG values are abnoramal.

77. A. Fluid may be increased to liquefy secretions. Oxygen administration and putting the pt in semi fowler’s do not help in mobilizing secretions. stroke patients who are on bed rest are prone to respiratory complications because of retention of secretions. Therefore assisted ambulation and frequent positioning may help to mobilize secretions .

78. B. the signs and symptoms presented are indications of PTB. It’s a safe precautionary practice to place the pt in respiratory isolation to prevent cross infection while further assessment and evaluation is carried out.

79. B. the nurse should suspect a circulatory overload because of the assessment findings. Initial action is to stop the IV to stop further introduction of fluid.

80. C. contraction of the back of the throat when the uvula is tickled means that gag reflex has returned.

81. B. Iv rate should be a fast drip to immediately restore the fluid volume

82. A.Digitalis are given to patients with cardiac problems to strengthen heart contraction. Initial s/sx of Digitalis toxicity is GI manifestation such as N/V, loss of appetite, diarrhea. Other symptoms include visual changes, slow pulse , confusion etc.

83. B. With the ABG values presented, the pt is suffering from respiratory acidosis.

84. B. In postural drainage, the patient is placed on a trendelenberg position so gravity aids in the movement of mucus to the upper respiratory tract.

85. B. Immobilization causes calcium lose from the bones into the bloodstream and cause hypercalcemia. The kidney in response of hypercalcemia increases its excretion.

86. C. increased fluid intake loosen up secretions thus easy to expectorate

87. C. one classical sign of right side heart failure is edema due to decreased venous return.

88. B . Because PVC s may signal an impending life threatening rhythm , notify the physician if the pt has more than six PVCs per minute.

89. B. creatine phospholinase is an enzyme normally found in muscle fibers. It is released in the bloodstream when there is muscle damage. MI is the interruption of blood supply causing heart muscle cells to die.

90. I’m not sure of the correct answer, but I guess the best option is B. Pain in MI doesn’t last until the following day. Most patients after a heart attack are hesitant to resume activities, bed rest is advised at least for the first couple of days at least 1-2 days. Patients are strongly advised to participate in cardiac rehabilitation program to help patients to recover quickly and improve their overall physical, mental and social functioning.

91. D. straining against a closed epiglottis which includes holding breath or forceful expiration stimulates valsalva maneuver. Pts should be advised to avoid holding breaths while moving .

92. C. rehabilitation begins upon admission93. D. weight gain can be a sign that you the pt is

retaining fluid and his heart condition is worsening.

94. B. Digitalis is given to increase cardiac contractility followed by decreased in HR

95. C. Enalapril is an ACE inhibitor (Angiotension Converting Enzyme inhibitor) that decreases BP. Angiotensin II is a potent vasoconstrictor.

96. A. beta adrenergic antagonist antagonizes the action of sympathetic response. It works by reducing the force of contraction of heart muscles thereby reducing peripheral resistance and blood pressure .

97. A. Proper handwashing has always been the single most effective measure to prevent cross contamination and infection.

98. B. Mitral valve stenosis is the narrowing and stiffening of the mitral valve caused oftenly caused by rheumatic fever in adults. Due to the narrowed valve, blood is not efficiently pumped into the left ventricle, over time, pressure in the

atrium increases and blood is backed up to the lungs and cause pulmonary hypertension and pulmonary edema which is manifested by presence of lung crackles.

99. C. Infective endocarditis is due to bacterial or fungal infection that affects the endocardium of the heart especially the heart valves. Over time, materials called vegetations developed along the valves. These contain bacteria, blood clots, debri from the infection. This vegetations prevent the valve from working properly and will lead to cardiac failure.

100. C. although the specific causes of hypertrophic cardiomyopahty are not yet fully known. The primary cause seems to be genetic.