51. Stacy’s
mother states to the nurse that it is hard
to see
Stacy with no hair. The best response for
the nurse
is:
a. “Stacy
looks very nice wearing a hat”.
b. “You
should not worry about her hair,
just be
glad that she is alive”.
c. “Yes it
is upsetting. But try to cover up
your
feelings when you are with her or
else she
may be upset”.
d. “This is
only temporary; Stacy will regrow
new hair in
3-6 months, but may
be
different in texture”.
52. Stacy
has beginning stomatitis. To promote oral
hygiene and
comfort, the nurse in-charge
should:
a. Provide
frequent mouthwash with
normal
saline.
b. Apply
viscous Lidocaine to oral ulcers as
needed.
c. Use
lemon glycerine swabs every 2
hours.
d. Rinse
mouth with Hydrogen Peroxide.
53. During
the administration of chemotherapy
agents,
Nurse Oliver observed that the IV site is
red and
swollen, when the IV is touched Stacy
shouts in
pain. The first nursing action to take is:
a. Notify
the physician
b. Flush
the IV line with saline solution
c.
Immediately discontinue the infusion
d. Apply an
ice pack to the site, followed by
warm
compress.
54. The
term “blue bloater” refers to a male client
which of
the following conditions?
a. Adult
respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic
obstructive bronchitis
d.
Emphysema
55. The
term “pink puffer” refers to the female
client with
which of the following conditions?
a. Adult
respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic
obstructive bronchitis
d.
Emphysema
56. Jose is
in danger of respiratory arrest following
the
administration of a narcotic analgesic. An
arterial
blood gas value is obtained. Nurse Oliver
would
expect the paco2 to be which of the
following
values?
a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg
57. Timothy’s
arterial blood gas (ABG) results are as
follows; pH
7.16; Paco2 80 mm Hg; Pao2 46 mm
Hg; HCO3-
24mEq/L; Sao2 81%. This ABG result
represents
which of the following conditions?
a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
58. Norma
has started a new drug for hypertension.
Thirty
minutes after she takes the drug, she
develops
chest tightness and becomes short of
breath and
tachypneic. She has a decreased level
of
consciousness. These signs indicate which of
the following
conditions?
a. Asthma
attack
b.
Pulmonary embolism
c.
Respiratory failure
d.
Rheumatoid arthritis
Situation:
Mr. Gonzales was admitted to the hospital
with
ascites and jaundice. To rule out cirrhosis of the
liver:
59. Which
laboratory test indicates liver cirrhosis?
a.
Decreased red blood cell count
b.
Decreased serum acid phosphate level
c. Elevated
white blood cell count
d. Elevated
serum aminotransferase
60. 60.The
biopsy of Mr. Gonzales confirms the
diagnosis
of cirrhosis. Mr. Gonzales is at
increased
risk for excessive bleeding primarily
because of:
a. Impaired
clotting mechanism
b. Varix
formation
c.
Inadequate nutrition
d. Trauma
of invasive procedure
61. Mr.
Gonzales develops hepatic encephalopathy.
Which
clinical manifestation is most common
with this
condition?
a.
Increased urine output
b. Altered
level of consciousness
c.
Decreased tendon reflex
d.
Hypotension
62. When
Mr. Gonzales regained consciousness, the
physician
orders 50 ml of Lactose p.o. every 2
hours. Mr.
Gozales develops diarrhea. The nurse
best action
would be:
a. “I’ll
see if your physician is in the
hospital”.
b. “Maybe
you’re reacting to the drug; I
will
withhold the next dose”.
c. “I’ll
lower the dosage as ordered so the
drug causes
only 2 to 4 stools a day”.
d. “Frequently,
bowel movements are
needed to
reduce sodium level”.
63. Which
of the following groups of symptoms
indicates a
ruptured abdominal aortic
aneurysm?
a. Lower
back pain, increased blood
pressure,
decreased red blood cell (RBC)
count,
increased white blood (WBC)
count.
b. Severe
lower back pain, decreased blood
pressure,
decreased RBC count,
increased
WBC count.
c. Severe
lower back pain, decreased blood
pressure,
decreased RBC count,
decreased
RBC count, decreased WBC
count.
d.
Intermitted lower back pain, decreased
blood
pressure, decreased RBC count,
increased
WBC count.
64. After
undergoing a cardiac catheterization, Tracy
has a large
puddle of blood under his buttocks.
Which of
the following steps should the nurse
take first?
a. Call for
help.
b. Obtain
vital signs
c. Ask the
client to “lift up”
d. Apply
gloves and assess the groin site
65. Which
of the following treatment is a suitable
surgical
intervention for a client with unstable
angina?
a. Cardiac
catheterization
b.
Echocardiogram
c.
Nitroglycerin
d.
Percutaneous transluminal coronary
angioplasty
(PTCA)
66. The
nurse is aware that the following terms used
to describe
reduced cardiac output and
perfusion
impairment due to ineffective
pumping of
the heart is:
a.
Anaphylactic shock
b. Cardiogenic
shock
c.
Distributive shock
d.
Myocardial infarction (MI)
67. A
client with hypertension asks the nurse which
factors can
cause blood pressure to drop to
normal
levels?
a. Kidneys’
excretion to sodium only.
b. Kidneys’
retention of sodium and water
c. Kidneys’
excretion of sodium and water
d. Kidneys’
retention of sodium and
excretion
of water
68. Nurse
Rose is aware that the statement that
best
explains why furosemide (Lasix) is
administered
to treat hypertension is:
a. It
dilates peripheral blood vessels.
b. It
decreases sympathetic
cardioacceleration.
c. It
inhibits the angiotensin-coverting
enzymes
d. It
inhibits reabsorption of sodium and
water in
the loop of Henle.
69. Nurse
Nikki knows that laboratory results
supports
the diagnosis of systemic lupus
erythematosus
(SLE) is:
a. Elavated
serum complement level
b.
Thrombocytosis, elevated sedimentation
rate
c.
Pancytopenia, elevated antinuclear
antibody
(ANA) titer
d.
Leukocysis, elevated blood urea nitrogen
(BUN) and
creatinine levels
70. Arnold,
a 19-year-old client with a mild
concussion
is discharged from the emergency
department.
Before discharge, he complains of a
headache.
When offered acetaminophen, his
mother
tells the nurse the headache is severe
and she would
like her son to have something
stronger.
Which of the following responses by
the nurse
is appropriate?
a. “Your
son had a mild concussion,
acetaminophen
is strong enough.”
b. “Aspirin
is avoided because of the
danger of
Reye’s syndrome in children or
young
adults.”
c. “Narcotics
are avoided after a head
injury
because they may hide a
worsening
condition.”
d. Stronger
medications may lead to
vomiting,
which increases the
intracarnial
pressure (ICP).”
71. When
evaluating an arterial blood gas from a
male client
with a subdural hematoma, the
nurse notes
the Paco2 is 30 mm Hg. Which of
the
following responses best describes the
result?
a.
Appropriate; lowering carbon dioxide
(CO2)
reduces intracranial pressure (ICP)
b.
Emergent; the client is poorly
oxygenated
c. Normal
d.
Significant; the client has alveolar
hypoventilation
72. When
prioritizing care, which of the following
clients
should the nurse Olivia assess first?
a. A
17-year-old client’s 24-hours
postappendectomy
b. A
33-year-old client with a recent
diagnosis
of Guillain-Barre syndrome
c. A
50-year-old client 3 days
postmyocardial
infarction
d. A
50-year-old client with diverticulitis
73. JP has
been diagnosed with gout and wants to
know why
colchicine is used in the treatment of
gout. Which
of the following actions of
colchicines
explains why it’s effective for gout?
a. Replaces
estrogen
b.
Decreases infection
c.
Decreases inflammation
d.
Decreases bone demineralization
74. Norma
asks for information about osteoarthritis.
Which of
the following statements about
osteoarthritis
is correct?
a.
Osteoarthritis is rarely debilitating
b.
Osteoarthritis is a rare form of arthritis
c.
Osteoarthritis is the most common form
of
arthritis
d.
Osteoarthritis afflicts people over 60
75. Ruby is
receiving thyroid replacement therapy
develops
the flu and forgets to take her thyroid
replacement
medicine. The nurse understands
that
skipping this medication will put the client
at risk for
developing which of the following lifethreatening
complications?
a.
Exophthalmos
b. Thyroid
storm
c. Myxedema
coma
d. Tibial
myxedema
76. Nurse
Sugar is assessing a client with Cushing's
syndrome.
Which observation should the nurse
report to
the physician immediately?
a. Pitting
edema of the legs
b. An
irregular apical pulse
c. Dry
mucous membranes
d. Frequent
urination
77. Cyrill
with severe head trauma sustained in a car
accident is
admitted to the intensive care unit.
Thirty-six
hours later, the client's urine output
suddenly
rises above 200 ml/hour, leading the
nurse to
suspect diabetes insipidus. Which
laboratory
findings support the nurse's suspicion
of diabetes
insipidus?
a.
Above-normal urine and serum
osmolality
levels
b.
Below-normal urine and serum
osmolality
levels
c.
Above-normal urine osmolality level,
below-normal
serum osmolality level
d.
Below-normal urine osmolality level,
above-normal
serum osmolality level
78. Jomari
is diagnosed with hyperosmolar
hyperglycemic
nonketotic syndrome (HHNS) is
stabilized
and prepared for discharge. When
preparing
the client for discharge and home
management,
which of the following statements
indicates
that the client understands her
condition
and how to control it?
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."
b. "If
I experience trembling, weakness,
and
headache, I should drink a glass of
soda that
contains sugar."
c. "I
will have to monitor my blood glucose
level
closely and notify the physician if
it's constantly
elevated."
d. "If
I begin to feel especially hungry and
thirsty,
I'll eat a snack high in
carbohydrates."
79. A
66-year-old client has been complaining of
sleeping
more, increased urination, anorexia,
weakness,
irritability, depression, and bone pain
that
interferes with her going outdoors. Based
on these
assessment findings, the nurse would
suspect
which of the following disorders?
a. Diabetes
mellitus
b. Diabetes
insipidus
c.
Hypoparathyroidism
d.
Hyperparathyroidism
80. Nurse
Lourdes is teaching a client recovering
from
addisonian crisis about the need to take
fludrocortisone
acetate and hydrocortisone at
home. Which
statement by the client indicates
an
understanding of the instructions?
a.
"I'll take my hydrocortisone in the late
afternoon,
before dinner."
b.
"I'll take all of my hydrocortisone in the
morning,
right after I wake up."
c.
"I'll take two-thirds of the dose when I
wake up and
one-third in the late
afternoon."
d.
"I'll take the entire dose at bedtime."
81. Which
of the following laboratory test results
would
suggest to the nurse Len that a client has
a
corticotropin-secreting pituitary adenoma?
a. High
corticotropin and low cortisol levels
b. Low
corticotropin and high cortisol levels
c. High
corticotropin and high cortisol
levels
d. Low
corticotropin and low cortisol levels
82. A male
client is scheduled for a transsphenoidal
hypophysectomy
to remove a pituitary tumor.
Preoperatively,
the nurse should assess for
potential
complications by doing which of the
following?
a. Testing
for ketones in the urine
b. Testing
urine specific gravity
c. Checking
temperature every 4 hours
d.
Performing capillary glucose testing
every 4
hours
83.
Capillary glucose monitoring is being performed
every 4
hours for a client diagnosed with
diabetic
ketoacidosis. Insulin is administered
using a
scale of regular insulin according to
glucose
results. At 2 p.m., the client has a
capillary
glucose level of 250 mg/dl for which he
receives 8
U of regular insulin. Nurse Mariner
should
expect the dose's:
a. onset to
be at 2 p.m. and its peak to be
at 3 p.m.
b. onset to
be at 2:15 p.m. and its peak to
be at 3
p.m.
c. onset to
be at 2:30 p.m. and its peak to
be at 4
p.m.
d. onset to
be at 4 p.m. and its peak to be
at 6 p.m.
84. The physician
orders laboratory tests to confirm
hyperthyroidism
in a female client with classic
signs and
symptoms of this disorder. Which test
result
would confirm the diagnosis?
a. No
increase in the thyroid-stimulating
hormone
(TSH) level after 30 minutes
during the
TSH stimulation test
b. A
decreased TSH level
c. An
increase in the TSH level after 30
minutes
during the TSH stimulation test
d.
Below-normal levels of serum
triiodothyronine
(T3) and serum
thyroxine
(T4) as detected by
radioimmunoassay
85. Rico
with diabetes mellitus must learn how to
self-administer
insulin. The physician has
prescribed
10 U of U-100 regular insulin and 35
U of U-100
isophane insulin suspension (NPH) to
be taken
before breakfast. When teaching the
client how
to select and rotate insulin injection
sites, the
nurse should provide which
instruction?
a.
"Inject insulin into healthy tissue with
large blood
vessels and nerves."
b.
"Rotate injection sites within the same
anatomic
region, not among different
regions."
c.
"Administer insulin into areas of scar
tissue or
hypotrophy whenever
possible."
d.
"Administer insulin into sites above
muscles
that you plan to exercise heavily
later that
day."
86. Nurse
Sarah expects to note an elevated serum
glucose level
in a client with hyperosmolar
hyperglycemic
nonketotic syndrome (HHNS).
Which other
laboratory finding should the nurse
anticipate?
a. Elevated
serum acetone level
b. Serum
ketone bodies
c. Serum
alkalosis
d.
Below-normal serum potassium level
87. For a
client with Graves' disease, which nursing
intervention
promotes comfort?
a.
Restricting intake of oral fluids
b. Placing
extra blankets on the client's bed
c. Limiting
intake of high-carbohydrate
foods
d.
Maintaining room temperature in the
low-normal
range
88. Patrick
is treated in the emergency department
for a
Colles' fracture sustained during a fall.
What is a
Colles' fracture?
a. Fracture
of the distal radius
b. Fracture
of the olecranon
c. Fracture
of the humerus
d. Fracture
of the carpal scaphoid
89. Cleo is
diagnosed with osteoporosis. Which
electrolytes
are involved in the development of
this
disorder?
a. Calcium
and sodium
b. Calcium
and phosphorous
c.
Phosphorous and potassium
d.
Potassium and sodium
90. Johnny
a firefighter was involved in
extinguishing
a house fire and is being treated to
smoke
inhalation. He develops severe hypoxia
48 hours
after the incident, requiring intubation
and
mechanical ventilation. He most likely has
developed
which of the following conditions?
a. Adult respiratory
distress syndrome
(ARDS)
b.
Atelectasis
c.
Bronchitis
d.
Pneumonia
91. A
67-year-old client develops acute shortness of
breath and
progressive hypoxia requiring right
femur. The
hypoxia was probably caused by
which of
the following conditions?
a. Asthma
attack
b.
Atelectasis
c.
Bronchitis
d. Fat
embolism
92. A
client with shortness of breath has decreased
to absent
breath sounds on the right side, from
the apex to
the base. Which of the following
conditions
would best explain this?
a. Acute
asthma
b. Chronic
bronchitis
c.
Pneumonia
d.
Spontaneous pneumothorax
93. A
62-year-old male client was in a motor vehicle
accident as
an unrestrained driver. He’s now in
the
emergency department complaining of
difficulty
of breathing and chest pain. On
auscultation
of his lung field, no breath sounds
are present
in the upper lobe. This client may
have which
of the following conditions?
a.
Bronchitis
b.
Pneumonia
c.
Pneumothorax
d.
Tuberculosis (TB)
94. If a
client requires a pneumonectomy, what fills
the area of
the thoracic cavity?
a. The
space remains filled with air only
b. The
surgeon fills the space with a gel
c. Serous
fluids fills the space and
consolidates
the region
d. The
tissue from the other lung grows
over to the
other side
95.
Hemoptysis may be present in the client with a
pulmonary
embolism because of which of the
following
reasons?
a. Alveolar
damage in the infracted area
b.
Involvement of major blood vessels in
the
occluded area
c. Loss of
lung parenchyma
d. Loss of
lung tissue
96. Aldo
with a massive pulmonary embolism will
have an
arterial blood gas analysis performed to
determine
the extent of hypoxia. The acid-base
disorder
that may be present is?
a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
97. After a
motor vehicle accident, Armand an 22-
year-old
client is admitted with a pneumothorax.
The surgeon
inserts a chest tube and attaches it
to a chest
drainage system. Bubbling soon
appears in
the water seal chamber. Which of the
following
is the most likely cause of the
bubbling?
a. Air leak
b. Adequate
suction
c.
Inadequate suction
d. Kinked
chest tube
98. Nurse
Michelle calculates the IV flow rate for a
postoperative
client. The client receives 3,000 ml
of Ringer’s
lactate solution IV to run over 24
hours. The
IV infusion set has a drop factor of 10
drops per
milliliter. The nurse should regulate
the client’s
IV to deliver how many drops per
minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey,
a 6-year-old child with a congenital
heart disorder
is admitted with congestive heart
failure.
Digoxin (lanoxin) 0.12 mg is ordered for
the child.
The bottle of Lanoxin contains .05 mg
of Lanoxin
in 1 ml of solution. What amount
should the
nurse administer to the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
100. Nurse
Alexandra teaches a client about elastic
stockings.
Which of the following statements,
if made by
the client, indicates to the nurse
that the
teaching was successful?
a. “I will
wear the stockings until the
physician
tells me to remove them.”
b. “I
should wear the stockings even when I
am sleep.”
c. “Every
four hours I should remove the
stockings
for a half hour.”
d. “I
should put on the stockings before
getting out of bed in the morning.”
Posts
No comments :
Post a Comment