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Sunday, April 13, 2014

Answers and Rationale – TEST IV Care of Clients with Physiologic and Psychosocial Alterations part 2

Answers and Rationale – TEST IV Care of Clients with Physiologic and Psychosocial Alterations part 2

51. Answer: (D) “This is only temporary; Stacy
will re-grow new hair in 3-6 months, but
may be different in texture”.
Rationale: This is the appropriate
response. The nurse should help the
mother how to cope with her own feelings
regarding the child’s disease so as not to
affect the child negatively. When the hair
grows back, it is still of the same color and
texture.

52. Answer: (B) Apply viscous Lidocaine to
oral ulcers as needed.
Rationale: Stomatitis can cause pain and
this can be relieved by applying topical
anesthetics such as lidocaine before
mouth care. When the patient is already
comfortable, the nurse can proceed with
providing the patient with oral rinses of
saline solution mixed with equal part of
water or hydrogen peroxide mixed water
in 1:3 concentrations to promote oral
hygiene. Every 2-4 hours.

53. Answer: (C) Immediately discontinue the
infusion
Rationale: Edema or swelling at the IV site
is a sign that the needle has been
dislodged and the IV solution is leaking
into the tissues causing the edema. The
patient feels pain as the nerves are
irritated by pressure and the IV solution.
The first action of the nurse would be to
discontinue the infusion right away to
prevent further edema and other
complication.

54. Answer: (C) Chronic obstructive bronchitis
Rationale: Clients with chronic obstructive
bronchitis appear bloated; they have large
barrel chest and peripheral edema,
cyanotic nail beds, and at times,
circumoral cyanosis. Clients with ARDS are
acutely short of breath and frequently
need intubation for mechanical ventilation
and large amount of oxygen. Clients with
asthma don’t exhibit characteristics of
chronic disease, and clients with
emphysema appear pink and cachectic.

55. Answer: (D) Emphysema
Rationale: Because of the large amount of
energy it takes to breathe, clients with
emphysema are usually cachectic. They’re
pink and usually breathe through pursed
lips, hence the term “puffer.” Clients with
ARDS are usually acutely short of breath.
Clients with asthma don’t have any
particular characteristics, and clients with
chronic obstructive bronchitis are bloated
and cyanotic in appearance.

56. Answer: D 80 mm Hg
Rationale: A client about to go into
respiratory arrest will have inefficient
ventilation and will be retaining carbon
dioxide. The value expected would be
around 80 mm Hg. All other values are
lower than expected.

57. Answer: (C) Respiratory acidosis
Rationale: Because Paco2 is high at 80 mm
Hg and the metabolic measure, HCO3- is
normal, the client has respiratory acidosis.
The pH is less than 7.35, academic, which
eliminates metabolic and respiratory
alkalosis as possibilities. If the HCO3- was
below 22 mEq/L the client would have
metabolic acidosis.

58. Answer: (C) Respiratory failure
Rationale: The client was reacting to the
drug with respiratory signs of impending
anaphylaxis, which could lead to
eventually respiratory failure. Although
the signs are also related to an asthma
attack or a pulmonary embolism, consider
the new drug first. Rheumatoid arthritis
doesn’t manifest these signs.

59. Answer: (D) Elevated serum
aminotransferase
Rationale: Hepatic cell death causes
release of liver enzymes alanine
aminotransferase (ALT), aspartate
aminotransferase (AST) and lactate
dehydrogenase (LDH) into the circulation.
Liver cirrhosis is a chronic and irreversible
disease of the liver characterized by
generalized inflammation and fibrosis of
the liver tissues.

60. Answer: (A) Impaired clotting mechanism
Rationale: Cirrhosis of the liver results in
decreased Vitamin K absorption and
formation of clotting factors resulting in
impaired clotting mechanism.

61. Answer: (B) Altered level of consciousness
Rationale: Changes in behavior and level
of consciousness are the first sins of
hepatic encephalopathy. Hepatic
encephalopathy is caused by liver failure
and develops when the liver is unable to
convert protein metabolic product
ammonia to urea. This results in
accumulation of ammonia and other toxic
in the blood that damages the cells.

62. Answer: (C) “I’ll lower the dosage as
ordered so the drug causes only 2 to 4
stools a day”.
Rationale: Lactulose is given to a patients
with hepatic encephalopathy to reduce
absorption of ammonia in the intestines
by binding with ammonia and promoting
more frequent bowel movements. If the
patient experience diarrhea, it indicates
over dosage and the nurse must reduce
the amount of medication given to the
patient. The stool will be mashy or soft.
Lactulose is also very sweet and may
cause cramping and bloating.

63. Answer: (B) Severe lower back pain,
decreased blood pressure, decreased RBC
count, increased WBC count.
Rationale: Severe lower back pain
indicates an aneurysm rupture, secondary
to pressure being applied within the
abdominal cavity. When ruptured occurs,
the pain is constant because it can’t be
alleviated until the aneurysm is repaired.
Blood pressure decreases due to the loss
of blood. After the aneurysm ruptures, the
vasculature is interrupted and blood
volume is lost, so blood pressure wouldn’t
increase. For the same reason, the RBC
count is decreased – not increased. The
WBC count increases as cell migrate to the
site of injury.

64. Answer: (D) Apply gloves and assess the
groin site
Rationale: Observing standard precautions
is the first priority when dealing with any
blood fluid. Assessment of the groin site is
the second priority. This establishes where
the blood is coming from and determines
how much blood has been lost. The goal in
this situation is to stop the bleeding. The
nurse would call for help if it were
warranted after the assessment of the
situation. After determining the extent of
the bleeding, vital signs assessment is
important. The nurse should never move
the client, in case a clot has formed.
Moving can disturb the clot and cause
rebleeding.

65. Answer: (D) Percutaneous transluminal
coronary angioplasty (PTCA)
Rationale: PTCA can alleviate the blockage
and restore blood flow and oxygenation.
An echocardiogram is a noninvasive
diagnosis test. Nitroglycerin is an oral
sublingual medication. Cardiac
catheterization is a diagnostic tool – not a
treatment.

66. Answer: (B) Cardiogenic shock
Rationale: Cardiogenic shock is shock
related to ineffective pumping of the
heart. Anaphylactic shock results from an
allergic reaction. Distributive shock results
from changes in the intravascular volume
distribution and is usually associated with
increased cardiac output. MI isn’t a shock
state, though a severe MI can lead to
shock.

67. Answer: (C) Kidneys’ excretion of sodium
and water
Rationale: The kidneys respond to rise in
blood pressure by excreting sodium and
excess water. This response ultimately
affects sysmolic blood pressure by
regulating blood volume. Sodium or water
retention would only further increase
blood pressure. Sodium and water travel
together across the membrane in the
kidneys; one can’t travel without the
other.

68. Answer: (D) It inhibits reabsorption of
sodium and water in the loop of Henle.
Rationale: Furosemide is a loop diuretic
that inhibits sodium and water
reabsorption in the loop Henle, thereby
causing a decrease in blood pressure.
Vasodilators cause dilation of peripheral
blood vessels, directly relaxing vascular
smooth muscle and decreasing blood
pressure. Adrenergic blockers decrease
sympathetic cardioacceleration and
decrease blood pressure. Angiotensinconverting
enzyme inhibitors decrease
blood pressure due to their action on
angiotensin.

69. Answer: (C) Pancytopenia, elevated
antinuclear antibody (ANA) titer
Rationale: Laboratory findings for clients
with SLE usually show pancytopenia,
elevated ANA titer, and decreased serum
complement levels. Clients may have
elevated BUN and creatinine levels from
nephritis, but the increase does not
indicate SLE.

70. Answer: (C) Narcotics are avoided after a
head injury because they may hide a
worsening condition.
Rationale: Narcotics may mask changes in
the level of consciousness that indicate
increased ICP and shouldn’t
acetaminophen is strong enough ignores
the mother’s question and therefore isn’t
appropriate. Aspirin is contraindicated in
conditions that may have bleeding, such
as trauma, and for children or young
adults with viral illnesses due to the
danger of Reye’s syndrome. Stronger
medications may not necessarily lead to
vomiting but will sedate the client,
thereby masking changes in his level of
consciousness.

71. Answer: (A) Appropriate; lowering carbon
dioxide (CO2) reduces intracranial
pressure (ICP)
Rationale: A normal Paco2 value is 35 to
45 mm Hg CO2 has vasodilating
properties; therefore, lowering Paco2
through hyperventilation will lower ICP
caused by dilated cerebral vessels.
Oxygenation is evaluated through Pao2
and oxygen saturation. Alveolar
hypoventilation would be reflected in an
increased Paco2.

72. Answer: (B) A 33-year-old client with a
recent diagnosis of Guillain-Barre
syndrome
Rationale: Guillain-Barre syndrome is
characterized by ascending paralysis and
potential respiratory failure. The order of
client assessment should follow client
priorities, with disorder of airways,
breathing, and then circulation. There’s no
information to suggest the postmyocardial
infarction client has an arrhythmia or
other complication. There’s no evidence
to suggest hemorrhage or perforation for
the remaining clients as a priority of care.

73. Answer: (C) Decreases inflammation
Rationale: Then action of colchicines is to
decrease inflammation by reducing the
migration of leukocytes to synovial fluid.
Colchicine doesn’t replace estrogen,
decrease infection, or decrease bone
demineralization.

74. Answer: (C) Osteoarthritis is the most
common form of arthritis
Rationale: Osteoarthritis is the most
common form of arthritis and can be
extremely debilitating. It can afflict people
of any age, although most are elderly.

75. Answer: (C) Myxedema coma
Rationale: Myxedema coma, severe
hypothyroidism, is a life-threatening
condition that may develop if thyroid
replacement medication isn't taken.
Exophthalmos, protrusion of the eyeballs,
is seen with hyperthyroidism. Thyroid
storm is life-threatening but is caused by
severe hyperthyroidism. Tibial myxedema,
peripheral mucinous edema involving the
lower leg, is associated with
hypothyroidism but isn't life-threatening.

76. Answer: (B) An irregular apical pulse
Rationale: Because Cushing's syndrome
causes aldosterone overproduction, which
increases urinary potassium loss, the
disorder may lead to hypokalemia.
Therefore, the nurse should immediately
report signs and symptoms of
hypokalemia, such as an irregular apical
pulse, to the physician. Edema is an
expected finding because aldosterone
overproduction causes sodium and fluid
retention. Dry mucous membranes and
frequent urination signal dehydration,
which isn't associated with Cushing's
syndrome.

77. Answer: (D) Below-normal urine
osmolality level, above-normal serum
osmolality level
Rationale: In diabetes insipidus, excessive
polyuria causes dilute urine, resulting in a
below-normal urine osmolality level. At
the same time, polyuria depletes the body
of water, causing dehydration that leads
to an above-normal serum osmolality
level. For the same reasons, diabetes
insipidus doesn't cause above-normal
urine osmolality or below-normal serum
osmolality levels.

78. Answer: (A) "I can avoid getting sick by not
becoming dehydrated and by paying
attention to my need to urinate, drink, or
eat more than usual."
Rationale: Inadequate fluid intake during
hyperglycemic episodes often leads to
HHNS. By recognizing the signs of
hyperglycemia (polyuria, polydipsia, and
polyphagia) and increasing fluid intake,
the client may prevent HHNS. Drinking a
glass of nondiet soda would be
appropriate for hypoglycemia. A client
whose diabetes is controlled with oral
antidiabetic agents usually doesn't need
to monitor blood glucose levels. A highcarbohydrate
diet would exacerbate the
client's condition, particularly if fluid
intake is low.

79. Answer: (D) Hyperparathyroidism
Rationale: Hyperparathyroidism is most
common in older women and is
characterized by bone pain and weakness
from excess parathyroid hormone (PTH).
Clients also exhibit hypercaliuria-causing
polyuria. While clients with diabetes
mellitus and diabetes insipidus also have
polyuria, they don't have bone pain and
increased sleeping. Hypoparathyroidism is
characterized by urinary frequency rather
than polyuria.

80. Answer: (C) "I'll take two-thirds of the
dose when I wake up and one-third in the
late afternoon."
Rationale: Hydrocortisone, a
glucocorticoid, should be administered
according to a schedule that closely
reflects the bodies own secretion of this
hormone; therefore, two-thirds of the
dose of hydrocortisone should be taken in
the morning and one-third in the late
afternoon. This dosage schedule reduces
adverse effects.

81. Answer: (C) High corticotropin and high
cortisol levels
Rationale: A corticotropin-secreting
pituitary tumor would cause high
corticotropin and high cortisol levels. A
high corticotropin level with a low cortisol
level and a low corticotropin level with a
low cortisol level would be associated
with hypocortisolism. Low corticotropin
and high cortisol levels would be seen if
there was a primary defect in the adrenal
glands.

82. Answer: (D) Performing capillary glucose
testing every 4 hours
Rationale: The nurse should perform
capillary glucose testing every 4 hours
because excess cortisol may cause insulin
resistance, placing the client at risk for
hyperglycemia. Urine ketone testing isn't
indicated because the client does secrete
insulin and, therefore, isn't at risk for
ketosis. Urine specific gravity isn't
indicated because although fluid balance
can be compromised, it usually isn't
dangerously imbalanced. Temperature
regulation may be affected by excess
cortisol and isn't an accurate indicator of
infection.

83. Answer: (C) onset to be at 2:30 p.m. and
its peak to be at 4 p.m.
Rationale: Regular insulin, which is a
short-acting insulin, has an onset of 15 to
30 minutes and a peak of 2 to 4 hours.
Because the nurse gave the insulin at 2
p.m., the expected onset would be from
2:15 p.m. to 2:30 p.m. and the peak from
4 p.m. to 6 p.m.

84. Answer: (A) No increase in the thyroidstimulating
hormone (TSH) level after 30
minutes during the TSH stimulation test
Rationale: In the TSH test, failure of the
TSH level to rise after 30 minutes confirms
hyperthyroidism. A decreased TSH level
indicates a pituitary deficiency of this
hormone. Below-normal levels of T3 and
T4, as detected by radioimmunoassay,
signal hypothyroidism. A below-normal T4
level also occurs in malnutrition and liver
disease and may result from
administration of phenytoin and certain
other drugs.

85. Answer: (B) "Rotate injection sites within
the same anatomic region, not among
different regions."
Rationale: The nurse should instruct the
client to rotate injection sites within the
same anatomic region. Rotating sites
among different regions may cause
excessive day-to-day variations in the
blood glucose level; also, insulin
absorption differs from one region to the
next. Insulin should be injected only into
healthy tissue lacking large blood vessels,
nerves, or scar tissue or other deviations.
Injecting insulin into areas of hypertrophy
may delay absorption. The client shouldn't
inject insulin into areas of lipodystrophy
(such as hypertrophy or atrophy); to
prevent lipodystrophy, the client should
rotate injection sites systematically.
Exercise speeds drug absorption, so the
client shouldn't inject insulin into sites
above muscles that will be exercised
heavily.

86. Answer: (D) Below-normal serum
potassium level
Rationale: A client with HHNS has an
overall body deficit of potassium resulting
from diuresis, which occurs secondary to
the hyperosmolar, hyperglycemic state
caused by the relative insulin deficiency.
An elevated serum acetone level and
serum ketone bodies are characteristic of
diabetic ketoacidosis. Metabolic acidosis,
not serum alkalosis, may occur in HHNS.

87. Answer: (D) Maintaining room
temperature in the low-normal range
Rationale: Graves' disease causes signs
and symptoms of hypermetabolism, such
as heat intolerance, diaphoresis, excessive
thirst and appetite, and weight loss. To
reduce heat intolerance and diaphoresis,
the nurse should keep the client's room
temperature in the low-normal range. To
replace fluids lost via diaphoresis, the
nurse should encourage, not restrict,
intake of oral fluids. Placing extra blankets
on the bed of a client with heat
intolerance would cause discomfort. To
provide needed energy and calories, the
nurse should encourage the client to eat
high-carbohydrate foods.

88. Answer: (A) Fracture of the distal radius
Rationale: Colles' fracture is a fracture of
the distal radius, such as from a fall on an
outstretched hand. It's most common in
women. Colles' fracture doesn't refer to a
fracture of the olecranon, humerus, or
carpal scaphoid.

89. Answer: (B) Calcium and phosphorous
Rationale: In osteoporosis, bones lose
calcium and phosphate salts, becoming
porous, brittle, and abnormally vulnerable
to fracture. Sodium and potassium aren't
involved in the development of
steoporosis.         

90. Answer: (A) Adult respiratory distress
syndrome (ARDS)
Rationale: Severe hypoxia after smoke
inhalation is typically related to ARDS. The
other conditions listed aren’t typically
associated with smoke inhalation and
severe hypoxia.

91. Answer: (D) Fat embolism
Rationale: Long bone fractures are
correlated with fat emboli, which cause
shortness of breath and hypoxia. It’s
unlikely the client has developed asthma
or bronchitis without a previous history.
He could develop atelectasis but it
typically doesn’t produce progressive
hypoxia.

92. Answer: (D) Spontaneous pneumothorax
Rationale: A spontaneous pneumothorax
occurs when the client’s lung collapses,
causing an acute decreased in the amount
of functional lung used in oxygenation.
The sudden collapse was the cause of his
chest pain and shortness of breath. An
asthma attack would show wheezing
breath sounds, and bronchitis would have
rhonchi. Pneumonia would have bronchial
breath sounds over the area of
consolidation.

93. Answer: (C) Pneumothorax
Rationale: From the trauma the client
experienced, it’s unlikely he has
bronchitis, pneumonia, or TB; rhonchi
with bronchitis, bronchial breath sounds
with TB would be heard.

94. Answer: (C) Serous fluids fills the space
and consolidates the region
Rationale: Serous fluid fills the space and
eventually consolidates, preventing
extensive mediastinal shift of the heart
and remaining lung. Air can’t be left in the
space. There’s no gel that can be placed in
the pleural space. The tissue from the
other lung can’t cross the mediastinum,
although a temporary mediastinal shift
exits until the space is filled.        

95. Answer: (A) Alveolar damage in the
infracted area
Rationale: The infracted area produces
alveolar damage that can lead to the
production of bloody sputum, sometimes
in massive amounts. Clot formation
usually occurs in the legs. There’s a loss of
lung parenchyma and subsequent scar
tissue formation.

96. Answer: (D) Respiratory alkalosis
Rationale: A client with massive
pulmonary embolism will have a large
region and blow off large amount of
carbon dioxide, which crosses the
unaffected alveolar-capillary membrane
more readily than does oxygen and results
in respiratory alkalosis.

97. Answer: (A) Air leak
Rationale: Bubbling in the water seal
chamber of a chest drainage system stems
from an air leak. In pneumothorax an air
leak can occur as air is pulled from the
pleural space. Bubbling doesn’t normally
occur with either adequate or inadequate
suction or any preexisting bubbling in the
water seal chamber.

98. Answer: (B) 21
Rationale: 3000 x 10 divided by 24 x 60.

99. Answer: (B) 2.4 ml
Rationale: .05 mg/ 1 ml = .12mg/ x ml,
.05x = .12, x = 2.4 ml.

100. Answer: (D) “I should put on the stockings
before getting out of bed in the morning.
Rationale: Promote venous return by

applying external pressure on veins.

Answers and Rationale – TEST IV Care of Clients with Physiologic and Psychosocial Alterations part 1

Answers and Rationale – TEST IV Care of Clients with Physiologic and Psychosocial Alterations part 1   

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

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

3. Answer: (D) Decrease the size and
vascularity of the thyroid gland.
Rationale: 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
Rationale: 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
Rationale: 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.
Rationale: 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.”
Rationale: This height permits the solution
to flow slowly with little force so that
excessive peristalsis is not immediately
precipitated.             

8. Answer: (A) Administer Kayexalate
Rationale: 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
Rationale: This is the correct flow rate;
multiply the amount to be infused (2000
ml) by the drop factor (10) and divide the
result by the amount of time in minutes
(12 hours x 60 minutes)

10. Answer: (D) Upper trunk
Rationale: 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
Rationale: The nurse needs to perform a
thorough assessment that could indicate
alterations in cerebral function, increased
intracranial pressures, fractures and
bleeding. Bleeding from the ears occurs
only with basal skull fractures that can
easily contribute to increased intracranial
pressure and brain herniation.

12. Answer: (D) may engage in contact sports
Rationale: 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.
Rationale: 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.
Rationale: 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.
Rationale: Prior to bronchoscopy, the
doctors sprays 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.
Rationale: 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.
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.
Rationale: 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.
Because condylomata acuminata can
occur on the vulva, a condom won't
protect sexual partners. 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.
Rationale: The left kidney usually is
slightly higher than the right one. An
adrenal gland lies atop each kidney. 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. The
kidneys are located retroperitoneally, in
the posterior aspect of the abdomen, on
either side of the vertebral column. They
lie between the 12th thoracic and 3rd
lumbar vertebrae.

19. Answer: (C) Blood urea nitrogen (BUN)
100 mg/dl and serum creatinine 6.5mg/dl.
Rationale: 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. CRF
causes decreased pH and increased
hydrogen ions — not vice versa. CRF also
increases serum levels of potassium,
magnesium, and phosphorous, and
decreases serum levels of calcium. 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
Rationale: Dysplasia refers to an alteration
in the size, shape, and organization of
differentiated cells. The presence of
completely undifferentiated tumor cells
that don't resemble cells of the tissues of
their origin is called anaplasia. An increase
in the number of normal cells in a normal
arrangement in a tissue or an organ is
called hyperplasia. 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
Rationale: Kaposi's sarcoma is the most
common cancer associated with AIDS.
Squamous cell carcinoma, multiple
myeloma, and leukemia may occur in
anyone and aren't associated specifically
with AIDS.

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

23. Answer: (A) Auscultate bowel sounds.
Rationale: 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. Palpation should be
avoided postoperatively with abdominal
distention. 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
Rationale: For a colonoscopy, the nurse
initially should position the client on the
left side with knees bent. Placing the
client on the right side with legs straight,
prone with 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
Rationale: 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. A dusky stoma isn't a normal
finding. Adjusting the ostomy bag
wouldn't affect stoma color, which
depends on blood supply to the area. An
intestinal obstruction also wouldn't
change stoma color.                        

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

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

28. Answer: (A) Turn him frequently.
Rationale: 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. 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.
Adequate hydration is necessary to
maintain healthy skin and ensure tissue
repair. 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
Rationale: 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
Rationale: 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. Calcium
channel blockers reduce the workload of
the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen
demand, promote vasodilation, and
decrease anxiety. Nitrates reduce
myocardial oxygen consumption bt
decreasing left ventricular end diastolic
pressure (preload) and systemic vascular
resistance (afterload).

31. Answer: (C) Raised 30 degrees
Rationale: 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.
Increased pressure can’t be seen when
the client is supine or 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). In
high Fowler’s position, the veins would be
barely discernible above the clavicle.

32. Answer: (D) Inotropic agents
Rationale: Inotropic agents are
administered to increase the force of the
heart’s contractions, thereby increasing
ventricular contractility and ultimately
increasing cardiac output. Beta-adrenergic
blockers and calcium channel blockers
decrease the heart rate and ultimately
decreased the workload of the heart.
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
Rationale: A client with low serum HDL
and high serum LDL levels should get less
than 30% of daily calories from fat. 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
Rationale: 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.
Rationale: 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. Next, the nurse should
make sure L.V. access is established. 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. 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
Rationale: Use the following formula to
calculate MAP
MAP = systolic + 2 (diastolic)
3
MAP=126 mm Hg + 2 (80 mm Hg)
3
MAP=286 mm HG
3
MAP=95 mm Hg

37. Answer: (C) Electrocardiogram, complete
blood count, testing for occult blood,
comprehensive serum metabolic panel.
Rationale: An electrocardiogram evaluates
the complaints of chest pain, laboratory
tests determines anemia, and the stool
test for occult blood determines blood in
the stool. 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. Prothrombin time,
partial thromboplastin time, fibrinogen
and fibrin split products are measured to
verify bleeding dyscrasias; an
electroencephalogram evaluates brain
electrical activity.

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

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

40. Answer: (D) Xenogeneic
Rationale: An xenogeneic transplant is
between is between human and another
species. 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)
Rationale: Tissue thromboplastin is
released when damaged tissue comes in
contact with clotting factors. Calcium is
released to assist the conversion of
factors X to Xa. Conversion of factors XII to
XIIa and VIII to IIIa are part of the intrinsic
pathway.

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

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

44. Answer: (D) Breath sounds
Rationale: 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. Although assessing
blood pressure, bowel sounds, and heart
sounds is important, it won’t help detect
pneumonia.

45. Answer: (B) Muscle spasm
Rationale: 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. The other
options, which reflect parts of the nervous
system, aren’t usually affected by MM.        

46. Answer: (C) 10 years
Rationale: Epidermiologic studies show
the average time from initial contact with
HIV to the development of AIDS is 10
years.

47. Answer: (A) Low platelet count
Rationale: 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
degeneration products increase as
fibrinolysis takes places.             

48. Answer: (D) Hodgkin’s disease
Rationale: Hodgkin’s disease typically
causes fever night sweats, weight loss,
and lymph mode enlargement. Influenza
doesn’t last for months. 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.
Leukemia doesn’t cause lymph node
enlargement.                     

49. Answer: (C) A Rh-negative
Rationale: Human blood can sometimes
contain an inherited D antigen. Persons
with the D antigen have Rh-positive blood
type; those lacking the antigen have Rhnegative
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 sub sequent transfusions with Rhpositive
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”.
Rationale: Persistent (more than 24 hours)
vomiting, anorexia, and diarrhea are signs
of toxicity and the patient should stop the
medication and notify the health care
provider. The other manifestations are

expected side effects of chemotherapy.
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