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Tuesday, July 30, 2013

TEST III - Care of Clients with Physiologic and Psychosocial Alterations part 1

TEST III - Care of Clients with Physiologic and
Psychosocial Alterations part 1

1. Nurse Michelle should know that the drainage is
normal 4 days after a sigmoid colostomy when
the stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed

2. Where would nurse Kristine place the call light
for a male client with a right-sided brain attack
and left homonymous hemianopsia?
a. On the client’s right side
b. On the client’s left side
c. Directly in front of the client
d. Where the client like            

3. A male client is admitted to the emergency
department following an accident. What are the
first nursing actions of the nurse?
a. Check respiration, circulation,
neurological response.
b. Align the spine, check pupils, and check
for hemorrhage.
c. Check respirations, stabilize spine, and
check circulation.
d. Assess level of consciousness and
circulation.

4. In evaluating the effect of nitroglycerin, Nurse
Arthur should know that it reduces preload and
relieves angina by:
a. Increasing contractility and slowing
heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen
consumption.
d. Decreasing venous return through
vasodilation.

5. Nurse Patricia finds a female client who is postmyocardial
infarction (MI) slumped on the side
rails of the bed and unresponsive to shaking or
shouting. Which is the nurse next action?
a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the
precordium, and check the pulse.
d. Administer two quick blows.

6. Nurse Monett is caring for a client recovering
from gastro-intestinal bleeding. The nurse
should:
a. Plan care so the client can receive 8
hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and
medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.           

7. A male client was on warfarin (Coumadin) before
admission, and has been receiving heparin I.V.
for 2 days. The partial thromboplastin time (PTT)
is 68 seconds. What should Nurse Carla do?
a. Stop the I.V. infusion of heparin and
notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is
lower than normal.

8. A client undergone ileostomy, when should the
drainage appliance be applied to the stoma?
a. 24 hours later, when edema has
subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care
procedures.

9. A client undergone spinal anesthetic, it will be
important that the nurse immediately position
the client in:
a. On the side, to prevent obstruction of
airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15
degrees.
d. Flat on the stomach, with the head
turned to the side.

10. While monitoring a male client several hours
after a motor vehicle accident, which
assessment data suggest increasing intracranial
pressure?
a. Blood pressure is decreased from
160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an
occasional skipped beat.
c. The client is oriented when aroused
from sleep, and goes back to sleep
immediately.
d. The client refuses dinner because of
anorexia.

11. Mrs. Cruz, 80 years old is diagnosed with
pneumonia. Which of the following symptoms
may appear first?
a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough

12. A male client has active tuberculosis (TB). Which
of the following symptoms will be exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia

13. Mark, a 7-year-old client is brought to the
emergency department. He’s tachypneic and
afebrile and has a respiratory rate of 36
breaths/minute and has a nonproductive cough.
He recently had a cold. Form this history; the
client may have which of the following
conditions?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease
(COPD)
d. Emphysema

14. Marichu was given morphine sulfate for pain.
She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she
might have which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own

15. A 77-year-old male client is admitted for elective
knee surgery. Physical examination reveals
shallow respirations but no sign of respiratory
distress. Which of the following is a normal
physiologic change related to aging?
a. Increased elastic recoil of the lungs
b. Increased number of functional
capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity

16. Nurse John is caring for a male client receiving
lidocaine I.V. Which factor is the most relevant
to administration of this medication?
a. Decrease in arterial oxygen saturation
(SaO2) when measured with a pulse oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular
contractions (PVCs) on a cardiac monitor.
d. Increase in intracranial pressure (ICP).

17. Nurse Ron is caring for a male client taking an
anticoagulant. The nurse should teach the client
to:
a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.

18. Nurse Lhynnette is preparing a site for the
insertion of an I.V. catheter. The nurse should
treat excess hair at the site by:
a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.         

19. Nurse Michelle is caring for an elderly female
with osteoporosis. When teaching the client, the
nurse should include information about which
major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump

20. Nurse Len is teaching a group of women to
perform BSE. The nurse should explain that the
purpose of performing the examination is to
discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses

21. When caring for a female client who is being
treated for hyperthyroidism, it is important to:
a. Provide extra blankets and clothing to
keep the client warm.
b. Monitor the client for signs of
restlessness, sweating, and excessive
weight loss during thyroid replacement
therapy.
c. Balance the client’s periods of activity
and rest.
d. Encourage the client to be active to
prevent constipation.

22. Nurse Kris is teaching a client with history of
atherosclerosis. To decrease the risk of
atherosclerosis, the nurse should encourage the
client to:
a. Avoid focusing on his weight.
b. Increase his activity level.
c. Follow a regular diet.
d. Continue leading a high-stress lifestyle.

23. Nurse Greta is working on a surgical floor. Nurse
Greta must logroll a client following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.

24. A 55-year old client underwent cataract removal
with intraocular lens implant. Nurse Oliver is
giving the client discharge instructions. These
instructions should include which of the
following?
a. Avoid lifting objects weighing more than 5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel
movement or bending at the waist.

25. George should be taught about testicular
examinations during:
a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.

26. A male client undergone a colon resection. While
turning him, wound dehiscence with
evisceration occurs. Nurse Trish first response is
to:
a. Call the physician
b. Place a saline-soaked sterile dressing on
the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.

27. Nurse Audrey is caring for a client who has
suffered a severe cerebrovascular accident.
During routine assessment, the nurse notices
Cheyne- Strokes respirations. Cheyne-strokes
respirations are:
a. A progressively deeper breaths followed
by shallower breaths with apneic periods.
b. Rapid, deep breathing with abrupt
pauses between each breath.
c. Rapid, deep breathing and irregular
breathing without pauses.
d. Shallow breathing with an increased
respiratory rate.

28. Nurse Bea is assessing a male client with heart
failure. The breath sounds commonly
auscultated in clients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs

29. The nurse is caring for Kenneth experiencing an
acute asthma attack. The client stops wheezing
and breath sounds aren’t audible. The reason for
this change is that:
a. The attack is over.
b. The airways are so swollen that no air
cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.

30. Mike with epilepsy is having a seizure. During
the active seizure phase, the nurse should:
a. Place the client on his back remove
dangerous objects, and insert a bite block.
b. Place the client on his side, remove
dangerous objects, and insert a bite
block.
c. Place the client o his back, remove
dangerous objects, and hold down his arms.
d. Place the client on his side, remove
dangerous objects, and protect his head.

31. After insertion of a cheat tube for a
pneumothorax, a client becomes hypotensive
with neck vein distention, tracheal shift, absent
breath sounds, and diaphoresis. Nurse Amanda
suspects a tension pneumothorax has occurred.
What cause of tension pneumothorax should the
nurse check for?
a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal chamber
d. Excessive chest tube drainage

32. Nurse Maureen is talking to a male client; the
client begins choking on his lunch. He’s coughing
forcefully. The nurse should:
a. Stand him up and perform the
abdominal thrust maneuver from
behind.
b. Lay him down, straddle him, and
perform the abdominal thrust
maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this
time.

33. Nurse Ron is taking a health history of an 84 year
old client. Which information will be most useful
to the nurse for planning care?
a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status.

34. When performing oral care on a comatose client,
Nurse Krina should:
a. Apply lemon glycerin to the client’s lips
at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position,
with the head of the bed lowered.
d. Clean the client’s mouth with hydrogen
peroxide.

35. A 77-year-old male client is admitted with a
diagnosis of dehydration and change in mental
status. He’s being hydrated with L.V. fluids.
When the nurse takes his vital signs, she notes
he has a fever of 103°F (39.4°C) a cough
producing yellow sputum and pleuritic chest
pain. The nurse suspects this client may have
which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis

36. Nurse Oliver is working in an outpatient clinic.
He has been alerted that there is an outbreak of
tuberculosis (TB). Which of the following clients
entering the clinic today most likely to have TB?
a. A 16-year-old female high school
student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a
history of alcoholism
d. A 54-year-old businessman

37. Virgie with a positive Mantoux test result will be
sent for a chest X-ray. The nurse is aware that
which of the following reasons this is done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is
needed
c. To determine the extent of lesions
d. To determine if this is a primary or
secondary infection

38. Kennedy with acute asthma showing inspiratory
and expiratory wheezes and a decreased forced
expiratory volume should be treated with which
of the following classes of medication right
away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids

39. Mr. Vasquez 56-year-old client with a 40-year
history of smoking one to two packs of cigarettes
per day has a chronic cough producing thick
sputum, peripheral edema and cyanotic nail
beds. Based on this information, he most likely
has which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
Situation: Francis, age 46 is admitted to the hospital with
diagnosis of Chronic Lymphocytic Leukemia.

40. The treatment for patients with leukemia is bone
marrow transplantation. Which statement about
bone marrow transplantation is not correct?
a. The patient is under local anesthesia
during the procedure
b. The aspirated bone marrow is mixed
with heparin.
c. The aspiration site is the posterior or
anterior iliac crest.
d. The recipient receives
cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.

41. After several days of admission, Francis becomes
disoriented and complains of frequent
headaches. The nurse in-charge first action
would be:
a. Call the physician
b. Document the patient’s status in his
charts.
c. Prepare oxygen treatment
d. Raise the side rails

42. During routine care, Francis asks the nurse,
“How can I be anemic if this disease causes
increased my white blood cell production?” The
nurse in-charge best response would be that the
increased number of white blood cells (WBC) is:
a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of
cells.                          

43. Diagnostic assessment of Francis would probably
not reveal:
a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts

44. Robert, a 57-year-old client with acute arterial
occlusion of the left leg undergoes an
emergency embolectomy. Six hours later, the
nurse isn’t able to obtain pulses in his left foot
using Doppler ultrasound. The nurse
immediately notifies the physician, and asks her
to prepare the client for surgery. As the nurse
enters the client’s room to prepare him, he
states that he won’t have any more surgery.
Which of the following is the best initial
response by the nurse?
a. Explain the risks of not having the
surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the client’s refusal in the
nurses’ notes

45. During the endorsement, which of the following
clients should the on-duty nurse assess first?
a. The 58-year-old client who was admitted
2 days ago with heart failure, blood
pressure of 126/76 mm Hg, and a
respiratory rate of 22 breaths/ minute.
b. The 89-year-old client with end-stage
right-sided heart failure, blood pressure
of 78/50 mm Hg, and a “do not
resuscitate” order
c. The 62-year-old client who was admitted
1 day ago with thrombophlebitis and is
receiving L.V. heparin
d. The 75-year-old client who was admitted
1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem
(Cardizem)

46. Honey, a 23-year old client complains of
substernal chest pain and states that her heart
feels like “it’s racing out of the chest”. She
reports no history of cardiac disorders. The
nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and
the respiratory rate is 26 breaths/minutes.
Which of the following drugs should the nurse
question the client about using?
a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines

47. A 51-year-old female client tells the nurse incharge
that she has found a painless lump in her
right breast during her monthly selfexamination.
Which assessment finding would
strongly suggest that this client's lump is
cancerous?
a. Eversion of the right nipple and mobile
mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily
delineated
d. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the
nurse, "What is the usual treatment for this type
of cancer?" Which treatment should the nurse
name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy

49. Cristina undergoes a biopsy of a suspicious
lesion. The biopsy report classifies the lesion
according to the TNM staging system as follows:
TIS, N0, M0. What does this classification mean?
a. No evidence of primary tumor, no
abnormal regional lymph nodes, and no
evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant
metastasis
c. Can't assess tumor or regional lymph
nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable
metastasis of the regional lymph nodes,
and ascending degrees of distant
metastasis

50. Lydia undergoes a laryngectomy to treat
laryngeal cancer. When teaching the client how
to care for the neck stoma, the nurse should
include which instruction?
a. "Keep the stoma uncovered."
b. "Keep the stoma dry."
c. "Have a family member perform stoma
care initially until you get used to the
procedure."

d. "Keep the stoma moist."

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