nursing nclex quiz question and rationale part 1

Topic includes are various questions about Medical-Surgical Nursing:
 Colostomy Care
 Diagnostic Tests
 Various Diseases

1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?
A. Sudden weight loss
B. Polyuria
C. Hypertension
D. Shock

2. The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:
A. Pain
B. Weight
C. Hematuria
D. Hypertension

3. Matilda, with hyperthyroidism, is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:
A. Decrease the total basal metabolic rate.
B. Maintain the function of the parathyroid glands.
C. Block the formation of thyroxine by the thyroid gland.
D. Decrease the size and vascularity of the thyroid gland.

4. Ricardo was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:
A. Liver disease
B. Hypertension
C. Type 2 diabetes
D. Hyperthyroidism

5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
A. Ascites
B. Nystagmus
C. Leukopenia
D. Polycythemia

6. Norma, with recent colostomy, expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:
A. Eliminate foods high in cellulose.
B. Decrease fluid intake at meal times.
C. Avoid foods that in the past caused flatus.
D. Adhere to a bland diet prior to social events.

7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
A. Lie on my left side while instilling the irrigating solution.”
B. Keep the irrigating container less than 18 inches above the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
D. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”

8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
A. Administer Kayexalate
B. Restrict foods high in protein
C. Increase oral intake of cheese and milk.
D. Administer large amounts of normal saline via I.V.

9. Mario has burn injury. After 48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. 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

10. Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns?
A. Face and neck
B. Right upper arm and penis
C. Right thigh and penis
D. Upper trunk

11. Herbert, a 45-year-old construction engineer 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

12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
A. Take the pulse rate once a day, in the morning upon awakening
B. May be allowed to use electrical appliances
C. Have regular follow up care
D. May engage in contact sports

13. The nurse is aware that the most relevant knowledge about oxygen administration to a male client with COPD is
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.

14. Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit, Tonny is placed in Fowler’s position on either his right side or on his back. The nurse is aware that this position:
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return

15. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.

16. Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.

17. Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
D. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

18. Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating her kidneys, the nurse should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to 1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic vertebrae.

19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test is consistent with CRF if the result is:
A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found.
D. Alteration in the size, shape, and organization of differentiated cells.

21. During a routine checkup, Nurse Marianne assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma

22. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias

23. A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.

24. Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor

25. A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.

26. Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
A. Applying knee splints
B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises

27. Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).

28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.

29. Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected area
C. In long, even, outward, and downward strokes in the direction of hair growth
D. In long, even, outward, and upward strokes in the direction opposite hair growth

30. Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates

31. A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular veindistention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position

32. The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents

33. A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories from fat
C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat

34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a change in the client’s condition
C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
D. At the client’s request, the CCU nurse updates the client’s wife on his condition

35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cordarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.

36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg

37. A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?
A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values
C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel
D. Electroencephalogram, alkaline phosphatase, and aspartate aminotransferase levels, basic serum metabolic panel

38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?
A. Pancytopenia
B. Idiopathic thrombocytopenic purpura (ITP)
C. Disseminated intravascular coagulation (DIC)
D. Heparin-associated thrombosis and thrombocytopenia (HATT)

39. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?
A. Acetylsalicylic acid (ASA)
B. Corticosteroids
C. Methotrexate
D. Vitamin K

40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?
A. Allogeneic
B. Autologous
C. Syngeneic
D. Xenogeneic

41. Marco falls off his bicycle and injures his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?
A. Release of Calcium
B. Release of tissue thromboplastin
C. Conversion of factors XII to factor XIIa
D. Conversion of factor VIII to factor VIIIa

42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?
A. Dressler’s syndrome
B. Polycythemia
C. Essential thrombocytopenia
D. Von Willebrand’s disease

43. The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin’s disease?
A. Pericarditis
B. Night sweat
C. Splenomegaly
D. Persistent hypothermia

44. Francis with leukemia has neutropenia. Which of the following functions must be frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds

45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?
A. Brain
B. Muscle spasm
C. Renal dysfunction
D. Myocardial irritability

46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?
A. Less than 5 years
B. 5 to 7 years
C. 10 years
D. More than 10 years

47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?
A. Low platelet count
B. Elevated fibrinogen levels
C. Low levels of fibrin degradation products
D. Reduced prothrombin time

48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?
A. Influenza
B. Sickle cell anemia
C. Leukemia
D. Hodgkin’s disease

49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?
A. AB Rh-positive
B. A Rh-positive
C. A Rh-negative
D. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.

50. Stacy is discharged from the hospital following her chemotherapytreatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?
A. “I should contact the physician if Stacy has difficulty in sleeping”.
B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
C. “My physician should be called if Stacy is irritable and unhappy”.
D. “Should Stacy have continued hair loss, I need to call the doctor”.

Answers and Rationale
.
1. Answer: C. Hypertension
 Option C: Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.

2. Answer: A. Pain
 Option A: Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by urethral distention and smooth muscle spasm; relief from pain is the priority.

3. Answer: D. Decrease the size and vascularity of the thyroid gland.
 Option D: Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.

4. Answer: A. Liver Disease
 Option A: The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.

5. Answer: C. Leukopenia
 Option C: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.

6. Answer: C. Avoid foods that in the past caused flatus.
 Option C: Foods that bothered a person preoperatively will continue to do so after a colostomy.

7. Answer: B. Keep the irrigating container less than 18 inches above the stoma.”
 Option B: This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.

8. Answer: A. Administer Kayexalate
 Option A: Kayexalate, a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.

9. Answer: B. 28 gtt/min
 Option B: 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)

10. Answer: D. Upper trunk
 Option D: The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.

11. Answer: C. Bleeding from ears
 Option C: 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.

12. Answer: D. may engage in contact sports
 Option D: The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

13. Answer: A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
 Option A: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.

14. Answer: B. Facilitate ventilation of the left lung.
 Option B: Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining left lung by positioning the client on the opposite unoperated side.

15. Answer: A. Food and fluids will be withheld for at least 2 hours.
 Option A: Prior to bronchoscopy, the doctors spray the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.

16. Answer: C. hyperkalemia.
 Option C: Hyperkalemia is a common complication of acute renal failure. It’s life-threatening if immediate action isn’t taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate, if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels.
 Options A, B, and D: Hypernatremia, hypokalemia, and hypercalcemia don’t usually occur with acute renal failure and aren’t treated with glucose, insulin, or sodium bicarbonate.

17. Answer: A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
o Option A: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure.
o Option C: Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners.
 Option D: HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

18. Answer: A. The left kidney usually is slightly higher than the right one.
 Option A: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney.
 Option C: The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼”) wide, and 2.5 cm (1″) thick.
 Option B: The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column.
 Option D: They lie between the 12th thoracic and 3rd lumbar vertebrae.

19. Answer: C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl.
 Option C: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated, reflecting CRF and the kidneys’ decreased ability to remove nonprotein nitrogen waste from the blood.
 Option A: CRF causes decreased pH and increased hydrogen ions — not vice versa.
 Option B: CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium.
 Option D: A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.

20. Answer: D. Alteration in the size, shape, and organization of differentiated cells
 Option D: Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells.
 Option A: The presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin is called anaplasia.
 Option B: An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia.
 Option C: Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found is called metaplasia.
21. Answer: D. Kaposi’s sarcoma
 Option D: Kaposi’s sarcoma is the most common cancer associated with AIDS.
 Options A, B, and C: Squamous cell carcinoma, multiple myeloma, and leukemiamay occur in anyone and aren’t associated specifically with AIDS.

22. Answer: C. To prevent cerebrospinal fluid (CSF) leakage
 Option C: The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution.
 Options A, B, and D: Proper positioning doesn’t help prevent confusion, seizures, or cardiac arrhythmias.

23. Answer: A. Auscultate bowel sounds.
 Option A: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician.
 Option B: Palpation should be avoided postoperatively with abdominal distention.
 Options C and D: If peristalsis is absent, changing positions and inserting a rectal tube won’t relieve the client’s discomfort.

24. Answer: B. Lying on the left side with knees bent
 Option B: For a colonoscopy, the nurse initially should position the client on the left side with knees bent.
 Option A, C, and D: Placing the client on the right side with legs straight, pronewith the torso elevated, or bent over with hands touching the floor wouldn’t allow proper visualization of the large intestine.

25. Answer: A. Blood supply to the stoma has been interrupted
 Option A: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma’s blood supply and may lead to tissue damage or necrosis.
 Option B: A dusky stoma isn’t a normal finding.
 Option C: Adjusting the ostomy bag wouldn’t affect stoma color, which depends on blood supply to the area.
 Option D: An intestinal obstruction also wouldn’t change stoma color.

26. Answer: A. Applying knee splints
 Option A: Applying knee splints prevents leg contractures by holding the joints in a position of function.
 Option B: Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function.
 Option C: Hyperextending a body part for an extended time is inappropriate because it can cause contractures.
 Option D: Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

27. Answer: B. Urine output of 20 ml/hour.
 Option B: A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit.
 Option A: This client’s PaO2 value falls within the normal range (80 to 100 mm Hg).
 Option C: White pulmonary secretions also are normal.
 Option D: The client’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.

28. Answer: A. Turn him frequently.
 Option A: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
 Option B: During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers.
 Option C: Adequate hydration is necessary to maintain healthy skin and ensure tissue repair.
 Option D: A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

29. Answer: C. In long, even, outward, and downward strokes in the direction of hair growth
 Option C: When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.

30. Answer: A. Beta-adrenergic blockers
 Option A: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand.
 Option B: Calcium channel blockers reduce the workload of the heart by decreasing the heart rate.
 Option C: Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety.
 Option D: Nitrates reduce myocardial oxygen consumption but decrease left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).

31. Answer: C. Raised 30 degrees
 Option C: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees.
 Options B and D: Increased pressure can’t be seen when the client is supineor when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible).
 Option A: In high Fowler’s position, the veins would be barely discernible above the clavicle.

32. Answer: D. Inotropic agents
 Option D: Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output.
 Options A and B: Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart.
 Option C: Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.

33. Answer: B. Less than 30% of calories from fat
 Option B: A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat.
 Options A, C, and D: The other modifications are appropriate for this client.

34. Answer: C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress
 Option C: The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality.

35. Answer: B. Check endotracheal tube placement.
 Option B: ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry.
 Option A: Next, the nurse should make sure L.V. access is established.
 Option D: If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg.
 Option C: Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter – not symptomatic bradycardia.

36. Answer: C. 95 mm Hg
 Option C: Use the following formula to calculate MAP
MAP = systolic + 2 (diastolic)
MAP = 126 mm Hg + 2 (80 mm Hg)
MAP = 286 mm Hg
MAP = 95 mm Hg

37. Answer: C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel.
 Option C: An electrocardiogram evaluates the complaints of chest pain, laboratory tests determine anemia, and the stool test for occult blood determines blood in the stool.
 Option A: Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function.
 Option B: Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias.
 Option D: An electroencephalogram evaluates brain electrical activity.

38. Answer: D. Heparin-associated thrombosis and thrombocytopenia (HATT)
 Option D: HATT may occur after CABG surgery due to heparin use during surgery.
 Options B and C: Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery.
 Option A: Pancytopenia is a reduction in all blood cells.

39. Answer: B. Corticosteroids
 Option B: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets.
 Option C: Methotrexate can cause thrombocytopenia.
 Options A and D: Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.

40. Answer: D. Xenogeneic
 Option D: A xenogeneic transplant is between is between human and another species.
 Options A, B, and C: A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual.

41. Answer: B. Release of tissue thromboplastin
 Option B: Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors.
 Option A: Calcium is released to assist the conversion of factors X to Xa.
 Options C and D: Conversion of factors XII to XIIa and VIII to VIII a are part of the intrinsic pathway.

42. Answer: C. Essential thrombocytopenia
 Option C: Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency virus.
 Option D: The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE.
 Option B: Moderate to severe anemia is associated with SLE, not polycythemia.
 Option A: Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.

43. Answer: B. Night sweat
 Option B: In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritus.
 Option C: Although splenomegaly may be present in some clients, night sweats are generally more prevalent.
 Option A: Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms.
 Option D: Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.

44. Answer: D. Breath sounds
 Option D: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required.
 Options A, B, and C: Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.

45. Answer: B. Muscle spasm
 Option B: Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia.
 Options A, C, and D: The other options, which reflect parts of the nervous system, aren’t usually affected by MM.

46. Answer: C. 10 years
 Option C: Epidemiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.
• Option A: In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degradation products increase as fibrinolysis takes places.

47. Answer: A. Low platelet count
48. Answer: D. Hodgkin’s disease
• Option D: Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph node enlargement.
• Option A: Influenza doesn’t last for months.
• Option B: Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement.
• Option C: Leukemia doesn’t cause lymph node enlargement.
49. Answer: C. A Rh-negative
• Option C: Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rh-negative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and subsequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.
50. Answer: B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
• Option B: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the healthcare provider.
• Options A, C, and D: The other manifestations are expected side effects of chemotherapy.

Leave a Reply

Your email address will not be published. Required fields are marked *