1. Answer: C
Rationale: During suctioning, the nurse should monitor the client
closely for side effects including hypoxemia, cardiac irregularities resulting
from vagal stimulation, mucosal trauma, hypotension and paroxysmal coughing. If
side effects develop, especially cardiac irregularities, the procedure is
stopped and the client is oxygenated. Option D is incorrect because before you
notify the physician you must first perform your independent nursing
interventions.
2. Answer: C
Rationale:
The client should be hyperoxygenated
with 100% oxygen before suctioning and if tracheal secretions are thick and not
easily removed. A total of 3 to 5 ml of sterile normal saline may be instilled
into the trachea (per agency policy) to try to reduce the viscosity of the
secretions and stimulate coughing. Suction is not applied during insertion of
the catheter, however, intermittent suction and a twirling motion of the
catheter are used during withdrawal.
3.
Answer: B
Rationale: Hypoxemia can be caused by prolonged suctioning from
stimulation of the pacemaker cells within the heart. A vasovagal response may
occur causing bradycardia. The suctioning pass is limited to 15 seconds and the
clients is preoxygenated before suctioning
4. Answer: C
Rationale: The nurse monitors for the adverse effects of suctioning,
which include cyanosis, exessively rapid or slow heart rate, or the sudden
development of bloody secretions. If they occur, the nurse stops suctioning and
reports these signs to the physician immediately. Coughing is a normal response
to suctioning for the client with an intact cough reflex, and does not indicate
that the client is unable to tolerate the procedure.
5. Answer: B
Rationale: Suctioning also removes oxygen, which can cause cardiac
dysrhythmias; the nurse should try to prevent this by hyperoxygenating the
client before and after suctioning. Option A is incorrect because suction
should only be applied while removing the catheter in order to prevent trauma
to the trachea. Option C is incorrect because this kind of movement could cause
tracheal damage. Option D is incorrect because excessive suctioning irritates
the mucosa, which increases secretion production; suction only as needed.
6. Answer: A
Rationale: With normal breathing, the water level rises with
inspiration and falls with expiration. The opposite, falls with inspiration and
rises with expiration, occurs when the client is on positive pressure
mechanical ventilation. This is an expected normal occurrence in a chest tube
drainage system; therefore no action is necessary.
7. Answer: C
Rationale: Once the drainage tube is patent, the fluctuation in the
water column will resume; a lack of fluctuation because of lung reexpansion is
unlikely 36 hours after a traumatic open chest injury. Option A is unnecessary at this time; the
chest tube is occluded and nursing intervention should be attempted first. In
option B, checking of vital signs may be done eventually, but this is not the
priority at this time. Option d wo0uld compromise aeration of the unaffected
lung.
8. Answer: A Rationale: The
nurse ensures that all system connections are securely taped to prevent
accidental disconnection, and that an occlusive dressing is maintained at the
chest tube insertion site. Option B is incorrect because drainage is noted and
recorded every hour in the first 24 hours after insertion and every 8 hours
thereafter. In option C, it is correct to keep the system below the level of
the waist, however, sterile water is added to the suction control chamber only
as needed to replace evaporation losses. Option D is incorrect because
continuous bubbling in the water seal chamber indicates an air leak in the
system and requires immediate investigation and correction. In addition,
monitoring for crepitus is done once every 8 hours.
9.
Answer: C
Rationale: Covering the insertion site with petroleum gauze is a
priority nursing measure that prevents air from entering the chest cavity.
Notifying the physician in option A should be done after covering the insertion
site. Option B is incorrect because inserting a chest tube is not a nursing
action. Option D is incorrect because instructing the client to breathe deeply
will still cause the air to enter the chest cavity.
10. Answer: D Rationale:
Normal functioning of chest tubes is maintained and the drainage system is
transported below the level of the chest. Option A is incorrect because chest
tubes are not remove during transportation of the client; it can only be
removed after the physician is satisfied with the degree of reexpansion.
Removing the chest tube from the suction drainage system in option B is
incorrect because it will result in an equalization of intrapleural pressures
with atmospheric pressures, thus also increasing the risk of pneumothorax.
Option C is incorrect because current practice precludes the clamping of the
chest tube. It is believed that clamping increases the risk of a tension
pneumothorax because air may enter the intrapleural space during inspiration
but cannot escape during expiration.
11. Answer:
A Rationale: The
Venturi mask delivers the most accurate oxygen concentration. It is the best
oxygen delivery system for a client with emphysema, one of the chronic
obstructive pulmonary disease (COPD), because it delivers a precise oxygen
concentration. The aerosol mask (B), face tent (C) and tracheostomy collar (D)
are also high flow oxygen delivery systems but are most often used to
administer high humidity.
12. Answer: B Rationale: Oxygen is used
cautiously in a client with emphysema and should not exceed 3 liters per
minute. Because of the long-standing hypercapnia that occurs in this disorder,
the respiratory drive is triggered by low oxygen levels rather than increased
carbon dioxide levels, which is the case in a normal respiratory system. Option
A is incorrect because 1 liter per minute is too little to deliver enough
oxygen concentration. Options C and D are incorrect because they are to high,
which could prevent the respiratory drive of the client.
13. Answer: D Rationale: The stimulus to
breathe in a client with emphysema is low oxygen levels rather than rising CO2
levels. Frequent nursing observations are necessary to see how the client
handles low-flow oxygen administration. In option A, although humidification
will be necessary but this is not the most important nursing intervention. Option B is incorrect because low-flow oxygen
is appropriate and not contraindicated for a client with COPD. In option C,
High-Fowler's position may make it easier for the client to breathe, however,
the client will assume the position most helpful for him to breathe.
14. Answer: B
Rationale: Humidification of oxygen is extremely important in reducing
its drying effects on the mucous membranes of the bronchial tree.
Humidification of oxygen is generally provided by a water nebulizer. Options A,
C and D are incorrect because oxygen is not highly permeable in water; thus,
water tends to inhibit rather that facilitate oxygen diffusion across the
respiratory membrane. Humidification expands the volume of the inhaled gas, but
by doing so it decreases the partial pressure of the gas in the alveoli.
15.
Answer: B Rationale: To read blood gases, first note the pH.
In this case, pH is 7.38, which is within the normal range (7.35-7.45) but is
on the acidotic side. Next, look at the PCO2 and HCO3 to
see which one is causing the shift to acidosis. In this case the PCO2
is 55 (acidosis) and the HCO3 is 32 (alkalosis). Therefore, the
client has compensated respiratory acidosis because the kidneys have been able
to conserve enough bicarbonate to keep pH within normal range. In this case a
pH below 7.35 would indicate uncompensated respiratory acidosis, which is in
option A. If the client had uncompensated metabolic alkalosis in option C, pH
would be above 7.45. If the client had compensated metabolic alkalosis in
option D, pH would be between 7.41 and 7.45
16.
Answer: B
Rationale:
Neomycin sulfate is used preoperatively because it is poorly absorbed in the
intestinal tract and acts to decrease the bacteria count in the colon. As a
result of this action, postoperative infection is reduced (option A). Option C
and D are incorrect because neomycin does not reduce tumor size or directly
affects peristalsis.
17. Answer: B
Rationale:
The stoma will begin to secrete mucus
within 48 hours, and the proximal loop should begin to drain fecal material
within 72 hours. Option A is incorrect because ileostomies not colostomies begin
to drain immediately. Options C and D are incorrect because peristalsis
generally returns within 48-72 hours postoperatively.
18. Answer: C
Rationale: If cramping occurs during colostomy irrigation, the
irrigation flow is stopped temporarily and the client is allowed to rest.
Cramping may occur from infusion that is too rapid or is causing too much
pressure. Option A is incorrect because the physician does not need to be
notified immediately. Option B is incorrect because increasing the height of
the irrigation will cause further discomfort. In option D, medicating the
client for pain is not the most appropriate action.
19. Answer: D
Rationale: A prolapsed stoma is one in which bowel protrudes through
the stoma, with an elongated and swollen appearance. A stoma retraction is
characterized by sinking of the stoma (option A). Ischemia of the stoma would
be associated with dusky or bluish color (option B). A stoma with a narrowed
opening, either at the level of the skin or fascia, is said to be stenosed
20.Answer: A
Rationale: The client should be taught to include deodorizing foods in
the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also
reduces odor, but is a gas-forming food as well. Broccoli, cucumbers and eggs
are gas-forming foods.
21. Answer: C
Rationale: When gastrointestinal (GI) tubes are attached to suction,
it may be continuous or intermittent, with a pressure not exceeding 25 mm Hg.
The specific pressure and the intervals are prescribed by the physician.
Options A, B and D are incorrect
22. Answer: A Rationale: Patency of the tube
should be maintained to ensure continued suction. Use of normal saline prevents
fluid and electrolyte disturbances during irrigation. Option B is incorrect
because the stomach is not considered a sterile body cavity, so medical asepsis
is indicated. Option C is avoided because care must be take to avoid
traumatizing the mucosa. Option is incorrect because ice chips and water
represent fluid intake, which must be approved by the physician; being hypotonic in nature,
such intake may lower the serum electrolytes.
23. Answer: C Rationale: Looping the
nasogastric tube will prevent pressure on the nares that can cause pain and
eventual necrosis. Option A is incorrect because pinning the tube to the
client's gown would cause irritation to the nares each time the client moved
and might cause dislocation of the tube. In option B, prior to insertion of a
nasogastric tube, it is proper to lubricate the tip with viscous xylocaine, but
this is not applied to the nostril. In option D, a smaller tube might not be
large enough to drain the contents of the stomach and intestine, it might still
irritate the nose, and it may not be changed without a doctor's order.
24. Answer: B Rationale: After checking
residual feeding contents, the gastric contents are reinstilled into the
stomach by removing the syringe plunger and pouring the gastric contents via
the syringe into the nasogastric tube. Removal of the contents in option A
could disturb the client's electrolyte balance and the contents are not
discarded. Gastric contents are are not mixed with formula (option C) or
diluted with water (option D)
25. Answer: C Rationale: The presence of a
residual of 200 ml or more with a nasogastric tube feeding or 100 ml or more
with a gastrostomy tube feeding may indicate impaired absorption; the volume of
the next feeding may need to be reduced or the feeding postponed based on the
physician's order to reduce the risk for aspiration. Option A evaluates fluid
balance and is best performed over a 24-hour period. Option B is a method for
evaluating placement. In option D, although weighing the client regularly is
important in evaluating overall nutritional progress, it does not provide
information about absorption of a particular feeding.
26. Answer: A Rationale: The sigmoid and
descending colon is located on the left side. Therefore, the left lateral
position uses gravity to facilitate the flow of solution into the sigmoid and
descending colon. Acute flexion of the right leg allows for adequate exposure
of the anus. Options B, C and D are incorrect positions.
27.
Answer: B Rationale: For a high colonic
enema, the fluid must extend higher in the colon. If the height of the enema
fluid container above the anus is increased, the force and rate of flow also
increase. Option A would be too low for a high cleansing enema. Options C and D
would be too high and could cause mucosal injury.
28. Answer: B
Rationale: The rectal catheter should be inserted approximately 4
inches to pass the rectal sphincters. Option A is incorrect because a catheter
inserted just 2 inches will not be passed beyond the rectal sphincters. Options
C and D may damage the intestinal mucosa.
29. Answer: B
Rationale: Pain and cramping are usually due to intestinal spasm and
will subside when the enema is stopped briefly. If the client complains of
fullness or pain, the flow is stopped for 30 seconds and restarted at a slower
rate. The higher the solution container is held above the rectum, the faster
the flow and the greater the force in the rectum (option A). There is no need
to discontinue the enema and notify the physician at this time (option D).
30. Answer: C
Rationale: Prune juice and warm water can be administered
prophylactically by the nurse to promote defecation. Prune juice irritates the
bowel mucosa, stimulating peristalsis. Increased fiber in the diet may also
improve intestinal motility. Options A and D should be avoided because it can
promote dependency and can result in electrolyte imbalance. Option B is
incorrect because the routine use of laxatives promotes dependency.
31. Answer: D
Rationale: The nurse should know that deep partial-thickness
(second-degree) burns cause severe pain. The nurse should also know that during
the first 48 to 72 hours after a serious burn, there is a very poor peripheral
circulation due to hypovolemia; therefore, medications should be given via the
IV route. PO (option B) and IM (option C) medications are generally
contraindicated during this time. To do nothing (option A) would be
inappropriate, given the nature and extent of the injuries.
32. Answer: A
Rationale: To prevent contractures, the affected limb is kept straight
(knee extension) and slightly abducted (to prevent pressure in hip joint), and
the foot is supported (ankle flexion) to prevent footdrop. Options B, C and D
are incorrect because all or part of each response could produce a contracture.
33. Answer: A
Rationale: Hyponatremia, or decreased serum sodium, may develop in
clients with burns because sodium tends to move with water into edema fluids
and into denuded areas of the skin. Options B and D are incorrect because both
these mechanisms tend to increase sodium reabsorption by the kidney tubules. In
option C, inadequate fluid replacement would tend to mask hyponatremia because
of hemoconcentration.
34.
Answer: B Rationale: Age is important baseline information
because IV infusion rates to maintain appropriate quantity and specific gravity
of urinary output differ; for example, 10 to 20 ml/hr for infants versus 50 to
70 ml/hr for adults. Weight is significant if the Evans and Brooke formula is
used for fluid replacement therapy. Both of these formulas use both the size of
the burn and the weight of the client to calculate the amount of fluid to be
replaced. Vital signs and skin turgor are both important measure of the degree
or extent of hypovolemia. As dehydration develops, skin turgor becomes poor,
mucous membranes dry and the eyeballs feel soft. Likewise, the pulse may become
thready and the blood pressure may decrease. Size (weight), as discussed, not
sex would determine therapy (option A). Level of mentation in option C is less
helpful in this particular situation because of the fear, pain and acute
anxiety experienced by some clients. In option D, quantity and specific gravity
of urine output are important in assessing the adequacy of fluid replacement
rather than as part of the initial assessment
35. Answer: B Rationale: Desperation and panic
may strike while the injury is occurring but rarely occur during the recovery
period. During the acute stage of burn recovery, anxiety is common due
to the stress and pain of injury and dressing changes. Anxiety decreases the
individual's ability to perceive situations realistically, which may result in
an altered mental state (option A). During the intermediate phase of
burn recovery, clients may react to continued pain, changes in body image and
financial stress with various psychological responses, ranging from withdrawal
and depression (option C) to acting out anger by refusing to cooperate with the
medical regimen and by dependency (option D).
36. Answer: B Rationale: The anterior chest,
below the clavicle, is the preferred site for checking skin turgor in adults
because it is less subject to deterioration of connective tissue. Options A and
C are incorrect because the dorsal aspect of the forearm and the back of the
hand may both show signs of skin tenting simply as a result of aging. Option D
is incorrect because the abdomen is an appropriate place to check for skin
turgor in babies, not adults.
37. Answer: D Rationale: The closing of the
mitral and tricuspid valves, which constitute the S1 sound, is best
heard at the fifth intercostal space, left sternal border. Option A is
incorrect because normal heart sound, S1 and S2, are best
heard using the diaphragm of the stethoscope. The bell is used when
auscultating for extra heart sounds and murmurs. Option B is incorrect because
right side0lying is not an appropriate position for auscultating heart sounds.
Option C is incorrect because the second heart sound, S2, is best
heard at the second intercostal space, right sternal border.
38. Answer: B Rationale: Symptoms of
circulatory overload result from varying degrees of cardiac decompression, with
blood backing up into the pulmonary (moist crackles) and systemic circuits
(neck vein distention, dependent edema, periorbital edema and hepatomegaly).
Options A, C and D are incorrect because all or part are symptoms of
circulatory failure or hypovolemia. Such symptoms include apprehension, soft
eyeballs, flattened neck veins, shock, decreased pulse pressure and poor skin
turgor
39.
Answer: C Rationale: Dry skin is
primarily caused by sun exposure experienced during earlier years. Option A is
incorrect because age spots are normal skin changes and not a cause of dry
skin. In option B, although there are dietary effects on the skin health, this
is not the primary cause of dryness. In option D, although medications are
known to affect skin elasticity and sensitivity in older years, the effects of
medications taken in earlier years have not been verified.
40. Answer: B Rationale: As cerebral hypoxia
develops, the client becomes restless and drowsy well before any of the
characteristic signs and symptoms of increasing intracranial pressure are
present. Options A, C and D are all consistent with increasing intracranial
pressure but occur much later, after there has been significant cerebral
herniation and distortion of the brain.
41. Answer: B Rationale: The client is
scheduled for surgery; and because all of the other clients are stable,
completing preoperative orders for this client is the priority. Option A is
incorrect because the client is stable and the pain is not requiring immediate
attention. Option C is incorrect because the Hct, while slightly lower than
normal, has dropped significantly since the previous test. The level is not
life threatening. Option D is incorrect because the WBC level is not elevated
significantly to require immediate action by the nurse. It will require
monitoring.
42.
Answer: A Rationale: The onset of a
headache in a child with epilepsy could precipitate seizure or indicate a
closed head injury. The registered nurse will want to assess this child first.
Option B is incorrect because feeling scared and shaky is most probably a
reaction to the stress of the accident in a child with diabetes mellitus. It is
7:30 AM and this child would have tested the blood glucose level, taken the
prescribed amount of insulin and eaten breakfast at home prior to leaving for
school. The registered nurse will want to assess this child as priority number
2. Option C is incorrect because feeling stiff and sore in the morning is a
common complaint in a child with rheumatoid arthritis. However, this child
could have sustained a musculoskeletal injury and should be assessed as
priority number 4. Option D is incorrect because shoulder level pain is a
common compliant in a child with scoliosis. The Milwaukee brace is used almost
exclusively in a child with kyphosis so the registered nurse would expect the
pain to be centered in the neck and shoulders. However, this child could have
sustained a musculoskeletal injury despite the protection that the brace would
have offered and should be assessed as priority number 3.
43. Answer: C Rationale: The focus of care for
a child with sickle cell anemia is pain control. The registered nurse will want
to assess the child's pain status and reload the medication cassette as soon as
possible. This action will be the registered nurse's first priority. Option A
is incorrect because the registered nurse would expect that the dressing on a new
tracheostomy would require frequent changes. The registered nurse will want to
assess the tracheostomy and change the dressing as soon as possible, but this
is not the first priority. Option B is incorrect because the registered nurse
would expect that the urine produced by a child with acute glomerulonephritis
would be bloody (hematuria). The registered nurse will want to assess the urine
and compare it to other voided specimen, but this is not the first priority.
Option D is incorrect because the registered nurse would expect that vomiting
will occur in a child with pyloric stenosis. The registered nurse will want to
assess and record the amount of the emesis, but this is not the first priority.
44. Answer: A Rationale: maintaining the iv
site access is the priority. The new bag of solution would be started at a rate
that keeps the vein open while determining if the 1000 ml bag was ever hung or
had rapidly infused. Option B is incorrect because checking the records further
delays maintaining patency of the IV site. After the vein is kept open, then
the nurse can determine what has occurred. Option C is incorrect as there are
no observable signs of distress. A keep-open rate with a new bag of solution
will not put the client at risk if the 1000 ml had been infused too rapidly.
Option D is incorrect because it would not be the first priority. If the unit
was never hung, an incident report would not be completed.
45.Answer: A
Rationale: Airway or breathing problems should be treated first.
Option B, C and D are incorrect because these clients don't have any problem
with airway or breathing.
46. Answer: C Rationale: Louder breath sounds
on the right side of the chest indicate that the endotracheal tube may be
misplaced and is aerating only one lung. Option A is incorrect because dullness
to percussion is normal in the third to fifth intercostal spaces as the heart
is located there. Option B is incorrect because decreased paradoxical motion is
a desired effect when the client has a flail chest. Option D is incorrect
because pH of 7.36 is within normal limits.
47. Answer: D Rationale: When the
high-pressure alarm sounds on a mechanical ventilator, it is most likely due to
an obstruction. The obstruction can be caused by the client biting on the tube,
kinking of the tubing or mucus plugging requiring suctioning. It is also
important to check the tubing for the presence of any water and determine if
the client is out of rhythm with breathing with the ventilator. Options A and B
are incorrect because a disconnection or a cuff leak can cause sounding of the
low-pressure alarm. Option C is incorrect because the respiratory therapist
would be notified if the nurse could not determine the cause of the alarm.
48. Answer: B Rationale: Being able to hear
the client's voice indicates that the cuff on the tube is deflated, or he tube
is misplaced.. Option A is incorrect because the client should not be able to
audibly speak if the cuff on the endotracheal tube has adequately sealed the
trachea, and if the tube is correctly placed just above the carina. Option C is
incorrect because, in this case, the cuff pressure should be checked first, and
the position of the tube evaluated to determine the need for a new tube. Option
D is incorrect because the client would more likely not exhibit, or have
greatly diminished breath sounds on the left, if the tube had migrated to the
right side of the lung.
50. Answer: A Rationale: Once the client has
been weaned successfully and has achieved an acceptable level of consciousness
to sustain spontaneous respiration, an ET tube may be removed. The ET tube is
suctioned first and then the cuff is deflated (option B) and the tube is
removed. Option D is incorrect because there is no reason to have a code cart
placed at the bedside. This may cause alarm and concern in the client. Additionally,
the necessary resuscitative equipment should have already been at the client's
bedside.
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