NCLEX Physiological Adaptation Questions
Physiological Adaptation NCLEX Practice Questions
Question 1.
The nurse is preparing to extubate a client. Arrange in order of priority the actions that the nurse should take to perform this procedure.
(a) hyperoxygenate the client
(b) explain the procedure to the client
(c) immediately instruct the client to cough
(d) apply oxygen by nasal cannula or face mask
(e) thoroughly suction the ET tube and the oral cavity
(f) teach the client how to use an incentive spirometer every 2 hours
(g) rapidly deflate the ET tube cuff and remove tube at peak inspiration
(h) set up the prescribed oxygen delivery system and bring in equipment for emergency reintubation
Answer:
The correct order is:
(b) explain the procedure to the client
(h) set up the prescribed oxygen delivery system and bring in equipment for emergency reintubation 1. hyperoxygenate the client
(e) thoroughly suction the ET tube and the oral cavity
(g) rapidly deflate the ET tube cuff and remove tube at peak inspiration
(c) immediately instruct the client to cough
(d) apply oxygen by nasal cannula or face mask
(f) teach the client how to use an incentive spirometer every 2 hours
Rationale:
Explaining the procedure to the client first helps minimize fear. Equipment should be set up before performing the procedure. Hyperoxygenation should be performed before suctioning to avoid dropping the client's oxygen saturation levels. Deflating the tube cuff aids in removal and prevents injury to client. Coughing helps clear any remaining secretions. The nurse should apply oxygen to the client and ensure it is in place before teaching. The client should demonstrate use of incentive spirometer to verify proper technique and lower risk of respiratory complications.
Question2.
The nurse is reviewing labs on a client with second- and third-degree burns from a house fire. Which abnormal lab value would the nurse expect to find with this client?
(a) pH of 7.41
(b) albumin of 3.9 g/dL
(c) hemoglobin of 15 g/dL
(d) potassium of
(e) 9 mEq/L
Answer:
(d) potassium of
Rationale:
The normal pH in adults ranges from 7.35 to 7.45. Albumin values range from 3.5 to 5.0 g/dl. Normal hemoglobin ranges from 12 to 16 g/dL for women and 14 to 18 g/dL for men. Normal potassium levels are 3.5 - 5.0 mEq/L. Potassium levels become elevated in burns due to disruption of the sodium-potassium pump, red blood cell hemolysis, and tissue damage.
Question 3.
The nurse is teaching a newly diagnosed client about Guillain-Barre syndrome (GBS). What information would the nurse provide in her teaching? Select all that apply.
(a) GBS affects females more often than males.
(b) The acute period lasts several days to 2 weeks.
(c) GBS tends to be self-limiting with temporary paralysis.
(d) Common symptoms include muscle weakness and paralysis.
(e) Infections such as Epstein-Barr virus have been associated with GBS.
Answer:
(c) GBS tends to be self-limiting with temporary paralysis.
(d) Common symptoms include muscle weakness and paralysis.
(e) Infections such as Epstein-Barr virus have been associated with GBS.
Rationale:
Males develop GBS slightly more often than females. The acute or initial period lasts from 1 to 4 weeks, beginning with the onset of symptoms and ending when no further deterioration occurs. GBS tends to be self-limiting with muscle weakness and temporary paralysis. Infections are commonly associated with GBS, with Campylobacter jejuni one of the more common bacterial infections.
Question 4.
The nurse is caring for a client who just had a bone marrow biopsy. The nurse understands that which statement is the nursing priority for this client?
(a) keeping the client NPO for 2 hours
(b) avoiding contact sports for 24 hours
(c) monitoring the client for excessive bleeding
(d) applying alcohol to the site every 4 hours to prevent infection
Answer:
(c) monitoring the client for excessive bleeding
Rationale:
The priority after this procedure is monitoring the client for excessive bleeding. The nurse should observe the dressing for 24 hours for signs of bleeding or infection. It is not necessary to keep the client NPO after this procedure. Contact sports should be avoided for 48 hours. No further site care is required other than observing the dressing for 24 hours, unless signs of infection are noted.
Question 5.
A client newly diagnosed with gout asks the nurse about the condition. Which statement should the nurse include in teaching for this client?
(a) "Aspirin can be used for mild pain when you have a flare-up."
(b) "Avoid foods high in purines such as organ meats and shellfish."
(c) "Lasix can help keep your urine flushed out to lessen the chance of an attack."
(d) "A few glasses of wine every week will help you reduce stress, which can trigger an attack."
Answer:
(b) "Avoid foods high in purines such as organ meats and shellfish."
Rationale:
Foods high in purines should be avoided as they can trigger an exacerbation. All forms of aspirin and diuretics should be avoided. Excessive alcohol intake and fad "starvation" diets can trigger a flare-up.
Question 6.
The nurse is caring for a client with a diagnosis of upper Gl bleeding. Which findings on physical assessment are consistent with this diagnosis?
(a) increased heart rate
(b) decreased heart rate
(c) increased hemoglobin
(d) bounding peripheral pulses
Answer:
(a) increased heart rate
Rationale:
Upper Gl bleeding causes an increased heart rate, decreased hematocrit and hemoglobin, and weak peripheral pulses.
Question 7.
The nurse notes irritability, microcephaly, and short palpebral fissures in a newborn in the nursery. The nurse suspects which diagnosis for this
infant?
(a) syphilis
(b) TORCH syndrome
(c) brachial plexus injury
(d) fetal alcohol syndrome (FAS)
Answer:
(d) fetal alcohol syndrome (FAS)
Rationale:
FAS is characterized by microcephaly, small eyes or short palpebral fissures, thin upper lip, and flat midface. Syphilis presents with maculopapular dermal rash on palms and soles. TORCH syndrome is a group of infections that produce various congenital malformations. The acronym stands for toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex. Brachial plexus injury describes a type of paralysis associated with a difficult birth.
Question 8.
The nurse is providing dietary teaching to the parents of a 7-year-old child with celiac disease. Which statement by the parents indicate that dietary teaching was successful?
(a) "We will serve rice more often."
(b) "We will serve pretzels as a snack."
(c) "I will use rye bread for sandwiches."
(d) "We will start having steel-cut oatmeal for breakfast."
Answer:
(a) "We will serve rice more often."
Rationale:
Gluten avoidance is the key focus of managing celiac disease. Rice, millet, and corn are suitable dietary choices for this client. All rye, oats, wheat, and barley should be eliminated from the client's diet to avoid exacerbating the condition.
Question 9.
The nurse is caring for a client with a T-tube following a cholecystectomy. Which statement is correct regarding management of these tubes? Select all that apply.
(a) keep the drainage system at the level of the heart
(b) report foul order and purulent drainage to the health care provider
(c) remove the tube when drainage slows to less than 50 mL every 8 hours
(d) do not clamp or irrigate the T-tube without orders from the health care provider
(e) clamp the tube before meals and observe the client for abdominal distention or discomfort
Answer:
(b) report foul order and purulent drainage to the health care provider
(d) do not clamp or irrigate the T-tube without orders from the health care provider
(e) clamp the tube before meals and observe the client for abdominal distention or discomfort
Rationale:
Foul odor and purulent drainage should be reported, along with sudden increases in output. The T-tube should not be irrigated, clamped, or aspirated without an order. The tube should be clamped prior to meals. If nausea or vomiting occur, unclamp the tube. The drainage system should be kept below gallbladder level. The tube should not be removed without an order. The nurse should chart the amount, consistency, color, and odor of any drainage.
Question 10.
The nurse is precepting a student nurse on leukemia classifications. Which statement by the student nurse reflects an understanding of classifications of leukemia?
(a) "Acute lymphocytic leukemia has an average age of onset of 15 to 39 years."
(b) "Chronic myelogenous leukemia contains mostly granulocytes in the bone marrow."
(c) "Chronic myelogenous leukemia has mostly lymphocytes found in the bone marrow."
(d) "Acute myelogenous leukemia has primarily granulocytes present in the bone marrow."
Answer:
(b) "Chronic myelogenous leukemia contains mostly granulocytes in the bone marrow."
Rationale:
Chronic myelogenous leukemia contains mostly granulocytes, not lymphocytes, in the j bone marrow, with a typical age of onset in the 40s. Acute lymphocytic leukemia presents with mostly lymphoblasts in the bone marrow. It is the earliest-onset leukemia, appearing before age 15 years. Acute myelogenous leukemia appears after age 50 years, with mostly lymphocytes present in the bone marrow.
Question 11.
The nurse is caring for a client who is HIV positive and gave birth to a full-term infant.
The nurse is teaching the client about infections in HIV-positive infants. Which infection
does the nurse understand is the most common opportunistic infection in children and infants with HIV?
(a) hepatitis C
(b) strep throat
(c) cytomegalovirus infection
(d) Pneumocystis jiroveci pneumonia
Answer:
(d) Pneumocystis jiroveci pneumonia
Rationale:
Pneumocystis jiroveci pneumonia is the most common opportunistic infection in children with i HIV. Hepatitis C and strep throat are not commonly opportunistic infections limited to children with HIV. Although cytomegalovirus may be present in HIV, it is not the most common opportunistic infection.
Question 12.
The nurse is caring for a client who just returned from a right mastectomy. Which position does the nurse anticipate for the client?
(a) high Fowler's with the unaffected arm elevated on a pillow
(b) flat with the client positioned on the affected side or back
(c) semi-Fowler's with the affected arm supported on a pillow
(d) reverse Trendelenburg's with the arm on the affected side supported on a pillow
Answer:
(c) semi-Fowler's with the affected arm supported on a pillow
Rationale:
Following a mastectomy, the client should be positioned with the head of the bed at 30 degrees or more, with a pillow supporting the arm on the affected side to allow lymphatic fluid return. The other options describe either incorrect bed positioning or incorrect placement of the pillow.
Question 13.
The nurse is caring for a client in the ICU who has an arterial line for hemodynamic monitoring. Which action will the nurse take in caring for this client?
(a) position the client with the transducer at the level of the right atrium
(b) position the client with the transducer at the level of the left ventricle
(c) position the client with the transducer at the level of the right clavicle
(d) position the client with the transducer at the level of the right ventricle
Answer:
(a) position the client with the transducer at the level of the right atrium
Rationale:
The transducer must be at the level of the right atrium in order to accurately measure arterial blood pressure and other hemodynamic pressures. Options 2, 3, and 4 are incorrect positions for the transducer and will not give accurate results.
Question 14.
A 47-year-old client presents to the emergency department with severe hypotension, muscle weakness, fatigue, and vomiting. Labs reveal a potassium level of 6.1 mEq/L and a sodium level of 128 mEq/l. Which of the following should the nurse anticipate for this client?
(a) administration of IV spironolactone
(b) boluses of Lactated Ringer's to increase blood pressure
(c) administration of IV saline, dextrose, or hydrocortisone
(d) boluses of 0.45% normal saline with 40 mEq/L of potassium
Answer:
(c) administration of IV saline, dextrose, or hydrocortisone
Rationale:
This client is experiencing acute adrenal insufficiency, or Addisonian crisis. This is a life- threatening event if left untreated. Treatment consists of IV saline, dextrose, or hydrocortisone. IV spironolactone would not be given, since it is a potassium-sparing diuretic. Boluses of normal saline or dextrose 5% in normal saline are the fluids of choice to deliver medications and restore fluid balance. Since the client is hyperkalemic, fluids containing potassium would not be given. Also, potassium is never given as a bolus due to the risk of cardiac dysrhythmias.
Question 15.
The nurse is precepting a student nurse. The primary nurse asks the student nurse to figure the client's intake and output for the shift. Which statement by the student nurse indicates an understanding of this procedure?
(a) "Wound drainage is not included in output measurement."
(b) "I only need to count urinary output for my output total."
(c) "I don't need to count the client's emesis since it was a small amount."
(d) "I will include all IV fluids, liquids the client drank, IV flushes, and IV antibiotics in my intake total."
Answer:
(d) "I will include all IV fluids, liquids the client drank, IV flushes, and IV antibiotics in my intake total."
Rationale:
Intake includes everything the client took in liquid form, including IV fluids, flushes, and antibiotics; drinks; and soups. Output measurement includes wound drainage, diarrhea, urine, gastric suction, and emesis. All output, no matter how small or seemingly insignificant, is counted.
Question 16.
The nurse is caring for a client who is on 2 L/minute of oxygen via nasal cannula. The nurse understands that this flow rate corresponds to which FiO2?
(a) 24% FiO2
(b) 28% FiO2
(c) 32% FiO2
(d) 36% FiO2
Answer:
(b) 28% FiO2
Rationale:
Oxygen delivery at 2 L/minute via nasal cannula is equivalent to 28% FiO2. A flow rate of 1 L/minute is equal to 24% FiO2. A flow rate of 3 L/minute is equal to 32% FiO2. A flow rate of 4 L/minute is equivalent to 36% FiO2.
Question 17.
The nurse is discussing various oxygen delivery systems with a newly graduated nurse who has just begun working on the medical floor. Which statement by the student nurse indicates an understanding of the different oxygen delivery systems?
(a) "A tracheostomy collar requires a flow rate of at least 6 L/minute to be effective."
(b) "High-flow oxygen delivery systems include the venturi mask, face tent, and non-rebreather masks."
(c) "The non-rebreather mask should receive a high enough flow rate to keep the reservoir bag completely full."
(d) "Nasal cannulas, non-rebreather masks, simple face masks, and partial rebreather masks are examples of low-flow oxygen delivery systems."
Answer:
(d) "Nasal cannulas, non-rebreather masks, simple face masks, and partial rebreather masks are examples of low-flow oxygen delivery systems."
Rationale:
Nasal cannulas, non-rebreather masks, simple face masks, and partial rebreather masks are examples of low-flow oxygen delivery systems. A tracheostomy collar requires a flow rate of at least 10 L/minute to maintain the proper Fi02. High-flow oxygen delivery systems include the venturi mask, face tent, T-piece, tracheostomy collar, and aerosol mask. Non-rebreather masks should have a flow rate sufficient to keep the reservoir bag two-thirds full.
Question 18.
A nurse is providing pre-op teaching to a client who will be undergoing a coronary artery bypass graft. Which of the following should the nurse include in the teaching? Select all that apply.
(a) "Your medications will be changed after surgery."
(b) "You will be on strict bed rest for the first 48 hours."
(c) "You will be using a bedpan after surgery to urinate."
(d) "You will need to splint the chest incision when you cough or breathe deeply."
(e) "You will be on the ventilator after surgery and have one or more chest tubes."
Answer:
(a) "Your medications will be changed after surgery."
Rationale:
The client will be on different medications following surgery. The nurse should demonstrate to the client how to splint the incision when coughing or breathing deeply to minimize pain and lessen pressure on the incision site. After surgery, the client will be on the ventilator and have one or more chest tubes. The client will be encouraged to ambulate as early as possible to prevent complications from pneumonia. The client will have a urinary catheter following surgery and will not need to void in a bedpan.
Question 19.
The nurse is caring for a client with vitamin B12 deficiency anemia. Which physical assessment finding would the nurse expect to note in this client?
(a) glossitis
(b) paresthesias
(c) weakness and pallor
(d) dark purple or cyanotic skin on the face and mucous membranes
Answer:
(a) glossitis
Rationale:
Glossitis, or a smooth tongue, is a sign of vitamin B12 deficiency anemia. Inflammation causes the tongue to appear smooth. Paresthesias are found in pernicious anemia. Weakness and pallor are found in iron deficiency anemia. Dark purple or cyanotic skin on the face and mucous membranes are signs of polycythemia vera.
Question 20.
The nurse is caring for a client in the cardiac unit who has a systolic murmur. Which assessment finding would the nurse expect when auscultating this client's heart sounds?
(a) The murmur can be heard between S3 and S4.
(b) The murmur can be heard between S4 and S1.
(c) The murmur can be heard between S2 and S1.
(d) The murmur can be heard between SI and S2.
Answer:
(d) The murmur can be heard between SI and S2.
Rationale:
A systolic murmur occurs between the SI and S2 heart sounds. A diastolic murmur will be heard between S2 and SI. Options 1 and 2 are incorrect for hearing a systolic murmur. A murmur can occur during any phase of the cardiac cycle.
Question 21.
A student nurse is precepting on the cardiac unit with the charge nurse. The charge nurse is educating the student about heart sounds and asks the student nurse to describe what causes the SI sound. Which response by the student nurse reflects an understanding of cardiac sounds?
(a) "It is caused by the mitral and tricuspid valves closing."
(b) "It is caused by the mitral and pulmonic valves closing."
(c) "It is caused by the pulmonic and aortic valves closing."
(d) "It is caused by the aortic and tricuspid valves closing."
Answer:
(a) "It is caused by the mitral and tricuspid valves closing."
Rationale:
The mitral and tricuspid valves produce the SI sound when they close. Option 3 describes the action that produces the S2 sound. Options 2 and 4 do not describe the mechanism of the SI heart sound.
Question 22.
The nurse is seeing a client in the clinic who complains of a sore throat. The client asks for an antibiotic. How should the nurse respond? Select all that apply.
(a) "You can try gargling with warm saline to relieve the discomfort."
(b) "You should use a dehumidifier to dry out the air, which will soothe the throat."
(c) "Most sore throats are caused by viruses, which cannot be treated with antibiotics."
(d) "There are three or four antibiotics that we prescribe for a sore throat, so the doctor will decide which one you need."
(e) "You should increase your fluid intake. Drink lots of water and try warm soup to help with the discomfort."
Answer:
(c) "Most sore throats are caused by viruses, which cannot be treated with antibiotics."
(e) "You should increase your fluid intake. Drink lots of water and try warm soup to help with the discomfort."
Rationale:
Gargling with warm saline can decrease discomfort caused by a sore throat. Many people think that an antibiotic is what they need for a sore throat, when most sore throats are actually caused by a virus. Antibiotics are ineffective on viruses. Overuse of antibiotics for sore throats can lead to antibiotic resistance. Increased fluid intake with water and warm beverages or soups can help with the pain. A humidifier should be used to add moisture to the air. The doctor will not prescribe an antibiotic if it is determined that the client's sore throat is caused by a virus.
Question 23.
A client with third- and fourth-degree burns is in the burn unit. The nurse understands that which of the following is true regarding fluid shift in burn clients?
(a) The fluid shift can cause hypokalemia and hypovolemia.
(b) Hemoconcentration increases blood flow and reduces blood viscosity.
(c) Excessive weight loss can occur during the first 12 hours post burn due to the fluid shift.
(d) Severe edema can occur in areas that were not burned, due to the leakage of electrolytes and fluids from the vascular space.
Answer:
(d) Severe edema can occur in areas that were not burned, due to the leakage of electrolytes and fluids from the vascular space.
Rationale:
Severe edema can occur in areas that were not burned, due to the leakage of electrolytes and fluids from the vascular space. The fluid shift causes hyperkalemia and hypovolemia. Hemoconcentration is caused by vascular dehydration, which increases blood viscosity. Excessive weight gain can occur during the first 12 hours following the burn and may continue for 24 - 36 hours due to the fluid shift.
Question 24.
A cl ient is 2 hours post-op for a right total knee replacement. Upon assessment by the nurse, which information requires notification of the doctor?
(a) hemoglobin is 10.2 grams per liter
(b) bleeding on the dressing of 2 cm
(c) oral temperature of 100.4°F
(d) complaint of pain at incision site
Answer:
(a) hemoglobin is 10.2 grams per liter
Rationale:
Anemia is a prime concern after a total knee replacement. A hemoglobin level of 10.2 g/L is low (normal is 13.5 - 17.5 for men, 12.0- 15.5 for women) and might require a blood transfusion. Bleeding on the dressing of 2 cm is not of concern. Circle, date, and time the bleeding initially and monitor closely for changes. Recheck the temperature in 30 minutes; if above 100.6, report finding to the doctor. Complaint of pain at the incision site is routine, and pain medication should be administered as prescribed.
Question 25.
A client is brought to the ED following a drowning event. The nurse assigned to the client understands that which is true regarding drowning?
(a) Drowning in very cold water causes a worse outcome for the client than drowning in warmer water.
(b) Aspiration of both salt and fresh water increases surfactant in the lungs and leads to increased lung compliance.
(c) If possible, the cause of drowning should be determined in order to know if the client suffered a medical condition such as a seizure that requires follow-up treatment.
(d) Contaminants in the water such as microbes, mud, chemicals, and algae do not affect the degree of injury to the lungs.
Answer:
(c) If possible, the cause of drowning should be determined in order to know if the client suffered a medical condition such as a seizure that requires follow-up treatment.
Rationale:
A medical condition such as a seizure or stroke may have been the underlying cause of the drowning event and would require further treatment once the client's respiratory status is stabilized. Drowning in very cold water appears to have a protective effect by causing a reduction in cardiac output and reducing the cerebral metabolic rate, even with prolonged arrest. Aspiration of both salt and fresh water decreases surfactant to the lungs and leads to decreased lung compliance. Contaminants in the water such as microbes, mud, chemicals, and algae may play a significant role in how much damage to the lungs is sustained.
Question 26.
The nurse is caring for a client in ICU diagnosed with rabies following a bite from an infected raccoon. The nurse understands which to be true regarding rabies? Select all that apply.
(a) The client should not be bathed, and no running water should be present within hearing of the client.
(b) Current treatment includes two doses of immunoglobulin and six doses of rabies vaccine over a period of 21 days.
(c) Nuchal rigidity, convulsions, and tonic or clonic muscle contractions can occur during the neurological phase.
(d) In the prodromal phase, the client can have irritability, extreme salivation, sore throat, fever, and hyperexcitability.
(e) During the neurological phase, the client may have aches and pains in different parts of the body, along with sensitivity to light.
(f) During the paralytic phase, the client becomes unconscious, has loss of bowel and urinary control, and has irregular or labored breathing.
Answer:
(a) The client should not be bathed, and no running water should be present within hearing of the client.
(c) Nuchal rigidity, convulsions, and tonic or clonic muscle contractions can occur during the neurological phase.
(d) In the prodromal phase, the client can have irritability, extreme salivation, sore throat, fever, and hyperexcitability.
(f) During the paralytic phase, the client becomes unconscious, has loss of bowel and urinary control, and has irregular or labored breathing.
Rationale:
Rabies causes encephalitis, which causes paralysis and difficulty swallowing water. This manifests as an apparent fear of water, which can cause the client to become adversely irritated when he or she sees water or hears running water. Nuchal rigidity, convulsions, and tonic or clonic muscle contractions can occur during the neurological phase. In the prodromal phase, the client can have irritability, extreme salivation, sore throat, fever, and hyperexcitability.
During the paralytic phase, the client becomes unconscious, has loss of bowel and urinary control, and has irregular or labored breathing. Current treatment includes one dose of immunoglobulin and five doses of rabies vaccine over a period of 28 days. Aches and pains in different parts of the body and light sensitivity occur during the prodromal phase.
Question 27.
The nurse is caring for a client who had a basilar artery stroke. The nurse would expect which signs and symptoms in this client?
(a) memory problems, visual hallucinations, visual deficits, hemisensory disturbances
(b) weakness in the foot and leg, sensory loss in the foot and leg, incontinence, ataxia, lack of spontaneity
(c) impaired consciousness, visual loss, bilateral sensory and motor dysfunction, and pupil abnormalities
(d) ataxia, contralateral facial weakness, contralateral hemiplegia, visual deficits, speech impairments, perceptual impairments
Answer:
(c) impaired consciousness, visual loss, bilateral sensory and motor dysfunction, and pupil abnormalities
Rationale:
Impaired consciousness, visual loss, bilateral sensory and motor dysfunction, and pupil abnormalities are seen with basilar artery strokes. Memory problems, visual hallucinations, visual deficits, and hemisensory disturbances occur with posterior cerebral artery strokes. Weakness in the foot and leg, sensory loss in the foot and leg, incontinence, ataxia, and lack of spontaneity occurs with anterior cerebral artery strokes. Ataxia, contralateral facial weakness, contralateral hemiplegia, visual deficits, speech impairments, and perceptual impairments occur with middle cerebral artery strokes.
Question 28.
A client presents to the ED with complaints of sweating, heart palpitations, vertigo, and the urge to lay down shortly after eating. The nurse anticipates which diagnosis for this client?
(a) appendicitis
(b) cholecystitis
(c) ulcerative colitis
(d) dumping syndrome
Answer:
(d) dumping syndrome
Rationale:
Dumping syndrome signs and symptoms include sweating, heart palpitations, vertigo, and the urge to lay down shortly after eating. Onset of symptoms occurs within 5 to 30 minutes after eating. Signs and symptoms of appendicitis include rebound tenderness and abdominal rigidity, pain in the lower right quadrant, nausea and vomiting, and low-grade fever. Cholecystitis manifests with pain to the right upper quadrant that radiates to the right scapula, Murphy's sign, belching, indigestion, and nausea and vomiting. Signs and symptoms of ulcerative colitis include abdominal cramping and tenderness, severe diarrhea that may present with mucus and blood, weight loss, anorexia, and malaise.
Question 29.
The oncology nurse is assessing a client diagnosed with cancer of the tongue. Upon examination, which signs and symptoms would the nurse expect to find? Select1 all that apply.
(a) weight gain
(b) well-fitting dentures
(c) a black, hairy tongue
(d) difficulty swallowing
(e) a sore that bleeds or does not heal
(f) difficulty chewing or pain with chewing
Answer:
(d) difficulty swallowing
(e) a sore that bleeds or does not heal
(f) difficulty chewing or pain with chewing
Rationale:
Cancer of the tongue causes difficulty swallowing due to enlarged lymph nodes in the neck. Sores that bleed or do not heal over time are another sign of tongue cancer. Chewing may be difficult or painful for clients with cancer of the tongue. Weight loss, not weight gain, can occur due to difficulty chewing and swallowing. Poor-fitting dentures or loose teeth are another sign. A black, hairy tongue is caused by overgrowth of yeast and bacteria and is a benign condition unrelated to cancer of the tongue.
Question 30.
The nurse is caring for a 52-year-old African American male newly diagnosed with hypertension. He has a history of chronic kidney disease and diabetes. The nurse would expect to see which medication order for this client?
(a) enalapril 5 mg PO QD
(b) enalapril 5 mg PO QD and amiloride 5 mg PO QD
(c) enalapril 5 mg PO QD and atenolol 50 mg PO QD
(d) enalapril 5 mg PO QD and amlodipine 2.5 mg PO QD
Answer:
(d) enalapril 5 mg PO QD and amlodipine 2.5 mg PO QD
Rationale:
ACE inhibitors alone are less effective in African American clients unless they are combined with a calcium channel blocker or a thiazide diuretic. Therefore, the client would not be given an ACE inhibitor by itself. Amiloride can cause hyperkalemia in clients with impaired renal function, especially if given in conjunction with ACE inhibitors. Atenolol can increase the incidence of diabetes and mask symptoms of hypoglycemia, as well as delay recovery from hypoglycemic episodes.
Question 31.
The nurse is performing discharge teaching to a client diagnosed with chronic pancreatitis. Which statement by the client indicates an understanding of home management of the condition? Select all that apply.
(a) "I should avoid large, heavy meals."
(b) "I can have an occasional glass of red wine."
(c) "I can resume my daily jogging once I get home."
(d) "I should avoid smoking and caffeinated beverages."
(e) "I should add extra spices to my food to make it taste better."
Answer:
(a) "I should avoid large, heavy meals."
(d) "I should avoid smoking and caffeinated beverages."
Rationale:
Home management of chronic pancreatitis includes eating small meals throughout the day and avoiding heavy meals. Nicotine and caffeine can worsen symptoms. Alcohol contributes to flare-ups and should be avoided. The client should rest frequently until full strength has returned and the health care provider has approved of vigorous activity. Spicy foods stimulate the Gl tract and should be avoided. Bland, high-protein, low-fat, and moderate-carbohydrate meals and snacks are the best for the client.
Question 32.
The nurse is caring for a client with suspected connective tissue disease. Assessment findings include chronic back pain, weight loss, joint pain and itching, and visual disturbances. The nurse anticipates a diagnosis of which disorder for this client?
(a) Reiter syndrome
(b) Marfan syndrome
(c) ankylosing spondylitis
(d) systemic necrotizing vasculitis
Answer:
(c) ankylosing spondylitis
Rationale:
Chronic back pain, weight loss, joint pain and itching, and visual disturbances describe signs and symptoms of ankylosing spondylitis. Reiter syndrome is characterized by burning upon urination, joint pain, and eye infection with pain, redness, and drainage. Marfan syndrome presents with excessive height, elongated hands and feet, scoliosis, and cardiovascular problems. Signs and symptoms of systemic necrotizing vasculitis include peripheral arterial disease with severe pain and necrosis of fingers or toes, kidney or heart failure, and stroke-like symptoms.
Question 33.
Which assessment finding in a client with chronic kidney disease indicates late-stage symptoms?
(a) shortness of breath
(b) oliguria
(c) tea-colored urine
(d) edema in lower extremities
Answer:
(b) oliguria
Rationale:
Oliguria, the production of an abnormally small amount of urine, is indicative of stage 5 chronic kidney disease. Symptoms of stage 3 chronic kidney disease include shortness of breath, tea- colored urine, and edema in the lower extremities.
Question 34.
The ED nurse has admitted a client who is homeless and was found unresponsive in the street during below freezing temperatures. The client is diagnosed with severe hypothermia. The nurse should implement which measures for this client? Select all that apply.
(a) apply a heating blanket
(b) obtain an oral temperature
(c) assess level of consciousness
(d) position in the supine position
(e) massage the extremities vigorously
(f) prepare to administer CPR if indicated
Answer:
(c) assess level of consciousness
(d) position in the supine position
(f) prepare to administer CPR if indicated
Rationale:
The client's level of consciousness must be assessed as part of a standard admission assessment, as it will determine treatments needed. The client is placed supine to avoid orthostatic alterations in blood pressure due to cardiac instability. The client should be handled gently to prevent ventricular fibrillation. The nurse should administer CPR if the client does not have spontaneous circulation.
Heating blankets are contraindicated in severe hypothermia; the treatment of choice is extracorporeal rewarming via cardiopulmonary bypass or hemodialysis. A rectal temperature is the most accurate in the hypothermic client. Massaging the extremities may injure frostbitten extremities and should not be performed.
Question 35.
Which of the following is not a recommended preparation for electroconvulsive therapy (ECT)?
(a) premedication with an anticholinergic agent
(b) morning bath, NPO after midnight
(c) informed consent in writing
(d) administration of an anticonvulsant 30 minutes before ECT
Answer:
(d) administration of an anticonvulsant 30 minutes before ECT
Rationale:
The purpose of ECT is to trigger a short-term seizure of 30 - 90 seconds. As such, administration of an anticonvulsant prior to the procedure is contraindicated. An anticholinergic agent is administered prior to ECT to lessen secretions that could be aspirated. Cleansing the body prior to an ECT promotes effective transmission of the electrical current. Fasting after midnight prevents aspiration of stomach contents during the procedure. As an intrusive medical procedure, an informed consent in writing is required.
Question 36.
While in a restaurant the nurse notices a woman clutching her throat. The woman is unable to speak. The nurse asks the woman if she's choking, and she indicates yes. Which response by the nurse should be done first?
(a) establish an airway by tilting the chin back
(b) administer five quick chest compressions
(c) administer two rescue breaths
(d) perform the Heimlich maneuver
Answer:
(d) perform the Heimlich maneuver
Rationale:
The American Red Cross advises to complete the following if you encounter a conscious, choking person who is unable to cough, speak, or breathe: send someone to call 9-1 -1, lean the person forward, and give five back blows with the heel of your hand. If ineffective, perform the Heimlich maneuver to remove the obstruction. The other stated actions are performed on unconscious persons.
Question 37.
Which nursing action is most appropriate to initially relieve pain related to a recent soft tissue injury?
(a) administer an over-the-counter (OTC) medication for pain
(b) apply heat
(c) massage the area
(d) apply ice pack
Answer:
(d) apply ice pack
Rationale:
Applying ice to a recent soft tissue injury will decrease blood flow and decrease swelling; it should be done first. Administration of an OTC medication is effective, yet it is not the most appropriate nursing action to be done initially. Heat will increase blood flow and swelling. Massage promotes blood flow and can increase swelling, causing further damage.
Question 38.
What physical activity is recommended for a school-age child with asthma?
(a) distance running
(b) indoor swimming
(c) soccer
(d) basketball
Answer:
(b) indoor swimming
Rationale:
Indoor swimming is recommended as an exercise as it takes place in a warm, moist environment. Bronchoconstriction associated with asthma may occur with exercises that require prolonged rapid breathing, including distance running, soccer, and basketball.
Question 39.
A client has arterial blood gases drawn. The results are as follows: pH, 7.58; PQCO2, 48 mm Hg; HCO3, 44 mEq/L, Base Excess, +13 mEq/L. Which condition is indicated?
(a) respiratory alkalosis
(b) respiratory acidosis
(c) metabolic alkalosis
(d) metabolic acidosis
Answer:
(c) metabolic alkalosis
Rationale:
Metabolic (nonrespiratory) alkalosis is consistent with the stated values. The stated pH of 7.58 is alkalotic. The value of PaCO2, 48 mm Hg is within normal range indicating a nonrespiratory (metabolic) origin. The value of HC03 of 44 mEq/L is indicative of metabolic alkalosis. A Base Excess of +13 mEq/L is consistent with severe metabolic alkalosis.
Question 40.
The nurse is assessing a client with Parkinson's disease. Which sign of primary motor symptom involvement would the nurse expect to observe?
(a) resting tremor
(b) sleep disturbance
(c) constipation
(d) fatigue
Answer:
(a) resting tremor
Rationale:
A resting tremor is a primary motor symptom of Parkinson's disease seen in either the hand or the foot on one side of the body. Sleep disturbance, constipation, and fatigue are nonmotor symptoms of Parkinson's disease.
Question 41.
A nurse is reviewing the laboratory reports prior to physician rounds. The serum calcium level of a client with hyperparathyroidism is 14.6 mg/dl. Which treatment should the nurse anticipate?
(a) corticosteroids
(b) renal dialysis
(c) calcitonin
(d) intravenous bisphosphonates
Answer:
(d) intravenous bisphosphonates
Rationale:
The normal serum calcium level is 8.5 - 10.2 mg/dL, making the client's results extremely high (hypercalcemia). The condition typically results from hyperparathyroidism. The priority treatment of choice is intravenous bisphosphonates. Calcitonin is the secondary medical treatment of choice followed by corticosteroids. Renal dialysis is not considered an acceptable treatment.
Question 42.
A nurse is employed on an oncology unit. A 62-year-old client is admitted for surgical treatment of a meningioma. The nurse would anticipate modifying the environment for which symptom?
(a) difficulty swallowing
(b) seizures
(c) poor concentration
(d) impaired mobility
Answer:
(b) seizures
Rationale:
Seizures are associated with meningiomas along with headache, weakness in an arm or leg, and personality changes. Other stated symptoms are not seen with this type of cancer.
Question 43.
A client presents to the emergency room with severe pain in the upper right abdomen. The client is nauseated and has a temperature of 102.2°F. Which nursing action would be a priority at this time?
(a) relieve pain
(b) obtain vital signs
(c) administer IV fluids
(d) prepare for surgery
Answer:
(b) obtain vital signs
Rationale:
Assessment of the client is a priority in the nursing process; therefore, obtaining vital signs would be a priority. The nurse must assess before performing interventions such as relief of pain, administration of IV fluids, and preparation for surgery.
Question 44.
The nurse is preparing to administer cefazolin to a client who is allergic to penicillin. The client states that penicillin causes him to itch and be slightly short of breath. Which response by the nurse is correct?
(a) administer the cefazolin as ordered
(b) call the pharmacy to substitute another medication
(c) hold the medication and notify the health care provider
(d) give the client diphenhydramine and then administer the cefazolin
Answer:
(c) hold the medication and notify the health care provider
Rationale:
Cefazolin can cause a reaction in clients allergic to penicillin. The nurse should hold the medication and notify the health care provider. Administering the cefazolin is likely to trigger another allergic reaction, which potentially may worsen. The pharmacy cannot change health care provider orders. The nurse should consult the health care provider before giving diphenhydramine in order to give the cefazolin, as the provider will more than likely order another medication from a different drug family.
Question 45.
The nurse is caring for a client who has shortness of breath, +2 pitting edema bilaterally of the lower extremities, crackles in the bases of the lungs, and a weight gain of 7 pounds in 1 week. The nurse administers furosemide 40 mg IV as ordered. Which would the nurse anticipate to indicate that the furosemide was effective? Select all that apply.
(a) pitting edema of + 3
(b) pitting edema of + 1
(c) less shortness of breath
(d) an increase in urine output of 250 mL/hr
(e) a decrease or absence of crackles in the lungs
Answer:
(b) pitting edema of + 1
(d) an increase in urine output of 250 mL/hr
(e) a decrease or absence of crackles in the lungs
Rationale:
Furosemide increases urine output, which removes excess fluid from the body. Pitting edema of +1 indicates an improvement due to the fluid loss. Urine output of 250 mL/hr is an expected finding in this client. Crackles in the lungs should be decreased or absent. Pitting edema of +3 indicates an increase in edema. Shortness of breath should be resolved, not merely decreased.
Question 46.
The nurse is caring for a client with left-sided heart failure. Which assessment findings does the nurse anticipate for this client? Select all that apply.
(a) dyspnea
(b) engorged spleen
(c) dependent edema
(d) jugular vein distention
(e) weak peripheral pulses
(f) crackles or wheezes in the lungs
Answer:
(a) dyspnea
(e) weak peripheral pulses
(f) crackles or wheezes in the lungs
Rationale:
Left-side heart failure manifestations include dyspnea, weak peripheral pulses, and crackles or wheezes in the lungs. Left-sided heart failure causes pulmonary congestion and decreased cardiac output. Right-sided heart failure causes systemic congestion, leading to an engorged spleen, dependent edema, and jugular vein distention.
Question 47.
The nurse is providing teaching to a client newly diagnosed with type 2 diabetes. Which should the nurse include in her teaching?
(a) check the feet daily
(b) have eye examinations every 2 years
(c) use a heating pad to keep the feet warm
(d) take extra insulin before consuming sweets
Answer:
(a) check the feet daily
Rationale:
Diabetics should check the feet daily for injury since diabetes causes a loss of sensation in the feet over time. A cut that goes unnoticed may become infected and progress to amputation. Eye examinations should be done on a yearly basis. Heating pads should be avoided on the feet due to the risk of injury caused by loss of sensation. The client should be encouraged to adhere to a diabetic diet and not to take extra insulin just to be able to eat off-limits food.
Question 48.
The nurse is caring for a client who had an inguinal hernia repair. Which interventions by the nurse are appropriate for this client? Select all that apply.
(a) encouraging fluid intake
(b) relieving urinary retention
(c) applying heat to the scrotum
(d) teaching turning, coughing, and deep breathing
(e) keeping the client on bed rest for the first 12 hours after surgery
(f) teaching the client to avoid lifting more than 20 pounds until approved by the health care provider
Answer:
(a) encouraging fluid intake
(b) relieving urinary retention
Rationale:
Following an inguinal hernia repair, the nurse should encourage fluid intake to prevent constipation and straining during bowel movements. If the client cannot void, intermittent catheterization should be performed. Ice, not heat, should be applied to the scrotum to minimize swelling. The client should turn and deep breathe, but avoid coughing. The client should be encouraged to ambulate as soon as possible after surgery. Lifting more than 10 pounds should be avoided until approved by the health care provider.
Question 49.
The nurse is caring for a client experiencing an acute flare-up of diverticular disease. Which interventions by the nurse are appropriate for this client? Select all that apply.
(a) encourage a diet high in fiber
(b) insert a nasogastric (NG) tube
(c) administer enemas as ordered
(d) administer IV fluids as ordered
(e) encourage coughing and deep breathing
(f) check stools for frank or occult bleeding
Answer:
(b) insert a nasogastric (NG) tube
(d) administer IV fluids as ordered
(f) check stools for frank or occult bleeding
Rationale:
An NG tube is placed to avoid complications from nausea, vomiting, and abdominal distention. IV fluids correct dehydration. Monitoring stools for bleeding is important because blood loss may lead to a drop in blood pressure or, in severe cases, progress to hypovolemic shock. A client in the acute phase of diverticular disease should have a low-fiber diet if she is able to eat. A high-fiber diet should be introduced gradually once the acute phase has resolved. Enemas are contraindicated because they cause an increase in intestinal motility. Coughing should be avoided because it increases intraabdominal pressure.
Question 50.
The nurse is caring for a two-year-old client who presented to the ER with vomiting, currant jelly-like stools, and abdominal pain that causes the child to draw the knees up to the abdomen in a fetal position. Which interventions does the nurse anticipate for this client?
(a) assessing for respiratory distress
(b) orders for a soft diet as tolerated
(c) monitoring for a normal, brown stool
(d) preparing the client for a barium enema
(e) placement of a nasogastric (NG) tube
(f) monitoring for fever and changes in blood pressure
Answer:
(a) assessing for respiratory distress
(c) monitoring for a normal, brown stool
(e) placement of a nasogastric (NG) tube
(f) monitoring for fever and changes in blood pressure
Rationale:
This client is exhibiting signs of intussusception. The nurse should monitor for and report respiratory distress immediately. Respiratory distress can be caused by pressing the knees up to the abdomen. Passage of a normal, brown stool indicates reduction of the intussusception. An NG tube is placed to decompress the stomach. Fever and changes in blood pressure can indicate perforation and shock. The client should be kept NPO until the intussusception is resolved. A barium enema is contraindicated for any client at risk of bowel perforation.
Question 51.
The nurse comes upon a client in the clinic who appears to have experienced a sudden cardiac arrest. After retrieving the automated external defibrillator (AED), the nurse knows to use the equipment in the following manner, as per the American Red Cross. List the steps in order. Use all the steps.
(a) Make sure no one is touching the client. Tell everyone to "stand clear."
(b) Open the person's shirt and wipe the chest dry. Remove any visible patches.
(c) Attach the AED pads and plug in the connector.
(d) Push the "analyze" button to analyze the client's heart rhythm.
(e) Turn on AED. Follow visual and/or audio prompts.
(f) Begin CPR.
(g) As prompted, press the "shock" button after clearing the client.
Answer:
The correct order follows:
(e) Turn on AED. Follow visual and/or audio prompts.
(b) Open the person's shirt and wipe the chest dry. Remove any visible patches.
(c) Attach the AED pads and plug in the connector.
(a) Make sure no one is touching the client. Tell everyone to "stand clear."
(d) Push the "analyze" button to analyze the client's heart rhythm.
(g) As prompted, press the "shock" button after clearing the client.
(f) Begin CPR.
Question 52.
The nurse is caring for a client with a gastric ulcer. Which menu choice by the client indicates an understanding of the nurse's dietary teaching?
(a) yogurt with fresh berries
(b) dry wheat toast with water
(c) coffee with cream and a bagel
(d) a grilled cheese sandwich with milk
Answer:
(b) dry wheat toast with water
Rationale:
Dry wheat toast with water is the best menu option for this client. Clients with gastric ulcers should avoid foods that contain caffeine since they trigger the release of gastrin. Although milk and dairy products may initially have a soothing effect because they coat the stomach, they also trigger the release of gastric acid and should be avoided. Dietary management of gastric ulcers is controversial, but the client should avoid foods that may trigger symptoms.
Question 53.
The nurse is caring for a client with veno-occlusive disease. Which manifestations of this condition would the nurse expect to find? Select all that apply.
(a) jaundice
(b) weight loss
(c) weight gain
(d) right lower quadrant pain
(e) enlargement of the spleen
(f) right upper quadrant pain
Answer:
(a) jaundice
(c) weight gain
(f) right upper quadrant pain
Rationale:
Veno-occlusive disease is the blockage of blood vessels in the liver and is a complication of bone marrow transplant, also known as hematopoietic stem cell transplant. Manifestations include jaundice, weight gain, and right upper quadrant pain. Liver enlargement is another sign of veno-occlusive disease.
Question 54.
The nurse is preparing to remove a client's abdominal stitches as ordered by the health care provider. Which is the correct action by the nurse?
(a) clean the stitches with soap and water before removing
(b) wash the hands and use gloves while removing the stitches
(c) wash the hands and use sterile technique when removing the stitches
(d) wear a gown, gloves, a mask, an eye shield, and shoe covers during the procedure
Answer:
(c) wash the hands and use sterile technique when removing the stitches
Rationale:
Removing stitches is a sterile procedure. The nurse should wash her hands and use sterile technique when removing stitches. Soap and water is not sufficient for cleaning the stitches prior to removal. Washing the hands and using regular gloves is not sterile. The sterile field must be maintained during the procedure, which contraindicates the use of regular gloves. It is not necessary to wear a gown, a mask, gloves, an eye shield, and shoe covers unless the client is on contact precautions. Nothing in this question indicates that the client is on contact precautions.
Question 55.
The ED nurse receives a client who is bleeding profusely from a gunshot wound. Which action by the nurse will best help this client avoid complications of extreme blood loss?
(a) draw a type and match
(b) administer type O blood
(c) administer type AB+ blood
(d) ask the family to donate blood
Answer:
(b) administer type O blood
Rationale:
In an emergency situation, type O blood can be given because it is the universal donor. There is not enough time to draw a type and match before the client bleeds out. Type AB+ blood is the universal recipient. There is not enough time to ask the family to donate blood for the client.
Question 56.
The nurse is assessing a client with Graves' disease. Which assessment finding would the nurse expect in this client?
(a) bradycardia
(b) constipation
(c) exophthalmos
(d) recent weight gain
Answer:
(c) exophthalmos
Rationale:
Exophthalmos, or a "startled" look, is caused by edema in the extraocular muscles. Clients may report difficulty in focusing, dry eyes, or photophobia. Graves' disease causes tachycardia, not bradycardia. The client may report an increase in bowel movements. Unplanned weight loss is also common.
Question 57.
The nurse is caring for a client who is HIV-positive. The nurse understands which of the following to be true regarding HIV and AIDS?
(a) Viral load testing monitors disease progression and evaluates effectiveness of treatment.
(b) The Western blot test is positive if antibodies to at least three major HIV antigens are present.
(c) Patients with AIDS present with a white blood cell (WBC) count between 5,000 and 10,000 cells/mm3.
(d) An enzyme-linked immunosorbent assay (ELISA) test can detect the presence of antibodies within 2 weeks of exposure.
Answer:
(a) Viral load testing monitors disease progression and evaluates effectiveness of treatment.
Rationale:
Viral load testing measures the level of HIV RNA or other viral proteins and monitors disease progression and evaluates effectiveness of treatment. The Western blot test is positive if antibodies to at least two major HIV antigens are present. Clients with AIDS are frequently leukopenic, with a WBC less than 3,500 cells/mm3. The ELISA test cannot detect antibodies before 3 weeks to 3 months. The client can test negative although HIV infection is present until sufficient antibodies are made.
Question 58.
The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus?
(a) cold intolerance
(b) chest pain and anxiety
(c) decreased respirations
(d) hypertension and widening pulse pressure
Answer:
(b) chest pain and anxiety
Rationale:
Signs of air embolus include chest pain, anxiety, changes in sensorium, and decreased oxygen saturation. Cold intolerance is not an indication of air embolus. Tachypnea, dyspnea, and hypotension are other findings.
Question 59.
The nurse is teaching a client about peritoneal dialysis. Which complication of this treatment would the nurse instruct the client to report?
(a) bone pain
(b) confusion
(c) muscle cramps
(d) cloudy outflow
Answer:
(d) cloudy outflow
Rationale:
Cloudy outflow is a sign of peritonitis, which is life-threatening if left untreated. Other signs include distention, pain, fever, and tenderness. The classic sign is a rigid, boardlike abdomen. Bone pain is a sign of dialysis encephalopathy. Confusion and muscle cramps occur with disequilibrium syndrome.
Question 60.
The nurse is caring for a 9-year-old boy who presented to the ED after a penetrating injury from a BB gun. The client is diagnosed with a hyphema. The nurse proceeds to place the client in which position?
(a) fiat in bed
(b) semi-Fowler's
(c) Trendelenburg's
(d) lateral on the unaffected side
Answer:
(b) semi-Fowler's
Rationale:
The client should be in a semi-Fowler's position to keep the hyphema away from the cornea's optical center. Positioning the client flat in bed or in Trendelenburg's increases pressure on the site. The lateral position should be avoided until after the hyphema resolves.
Question 61.
The nurse is caring for a client at risk for postpartum hemorrhage. Which early sign of hemorrhage should the nurse monitor for this client?
(a) coma
(b) hypotension
(c) restlessness
(d) cool, clammy skin
Answer:
(c) restlessness
Rationale:
Restlessness is one of the first signs of shock. Coma is a late sign of shock. Hypotension occurs later in shock. Skin may appear pale early in shock, but coolness manifests later if shock is not corrected. The presenting signs vary slightly depending on which type of shock the client is experiencing. Middle and late signs may overlap, or progress differently in the client depending on previous health history. With hemorrhagic shock, acute bleeding is obvious and the client can quickly enter the late stages of shock if blood loss is fast enough or high volume loss persists.
Question 62.
The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results:
pH 7.32
PaCO2 47 mm Hg
HCO3 24 mEq/L
PaO2 91 mm Hg
Which clinical manifestation would the nurse anticipate, based on these findings?
(a) confusion
(b) nausea and vomiting
(c) deep, rapid respirations
(d) hypoventilation with hypoxia
Answer:
(d) hypoventilation with hypoxia
Rationale:
These ABGs indicate acute respiratory acidosis. Common signs of respiratory acidosis include hypoventilation with hypoxia, disorientation, and dizziness. Untreated respiratory acidosis can progress to ventricular fibrillation, low blood pressure, seizures, and coma. The other options are signs of metabolic acidosis. If metabolic acidosis is severe, it can cause nausea and vomiting.
Question 63.
The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention?
(a) complaints of yellow-tinted vision
(b) sudden onset of frothy, pink sputum
(c) urinary output of 75 mL/hr. per urinary catheter
(d) complaints of sudden and severe back pain and shortness of breath
Answer:
(d) complaints of sudden and severe back pain and shortness of breath
Rationale:
Sudden back pain and shortness of breath indicate rupture of the aneurysm, which is an emergency. The nurse should notify the health care provider, monitor neurological and vital signs, and remain with the client. Yellow-tinted vision is a finding of digitalis toxicity. Frothy, pink sputum is a sign of pulmonary edema. Urinary output of 75 mL/hr. is a normal urinary output.
Question 64.
The nurse is caring for a client who has been diagnosed with pulseless electrical activity (PEA). Following effective CPR and administration of epinephrine, which is the next priority nursing action?
(a) check for a pulse
(b) insert a urinary catheter
(c) prepare to shock the client
(d) administer a bolus of sodium bicarbonate
Answer:
(a) check for a pulse
Rationale:
Following CPR, the most important priority is to check the client for a pulse. Often the cardiac monitor may display normal sinus rhythm when there is no pulse present. A urinary catheter would not be the first priority. PEA is never shocked. Once airway is established, the client should be monitored for a pulse, regardless whether the monitor displays an organized rhythm or not.
Question 65.
The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.
(a) hypertension; slow, labored breathing
(b) decreased urine output; warm, pink skin
(c) increased urine output; cool, clammy skin
(d) hypotension; weak pulse; cool, clammy skin
Answer:
(d) hypotension; weak pulse; cool, clammy skin
Rationale:
Classic signs of cardiogenic shock include a rapid pulse that weakens; cool, clammy skin; and decreased urine output. Hypotension is another classic sign.
Question 66.
The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm x 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?
(a) Stage I
(b) Stage II
(c) Stage III
(d) unstageable
Answer:
(d) unstageable
Rationale:
A full-thickness wound covered with black collagen, known as eschar, is unstageable. Wounds covered in eschar or slough cannot be staged because the full depth of the wound is not visible.
Question 67.
The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client's risk of skin breakdown?
(a) high risk
(b) mild risk
(c) severe risk
(d) moderate risk
Answer:
(d) moderate risk
Rationale:
This client is at moderate risk for skin breakdown. The Braden scale is a tool used to assess client's risk of skin breakdown. A score of 15 - 16 indicates mild risk, 12-14 indicates moderate risk, and a score of less than 11 indicates severe risk.
Question 68.
The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client?
(a) 9
(b) 10
(c) 11
(d) 12
Answer:
(b) 10
Rationale:
The Glasgow coma scale ranges from 3 to 15 and is a measure of neurological function. Based on the findings for this client, the score is 10.
Question 69.
The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?
(a) calcium 9.8 mg/dL
(b) sodium 137 mEq/L
(c) chloride 104 mEq/L
(d) potassium 3.1 mEq/L
Answer:
(d) potassium 3.1 mEq/L
Rationale:
Normal potassium ranges from 3.5 to 5 mEq/L. Hypokalemia can manifest with weak peripheral pulses, orthostatic hypotension, diminished breath sounds, lethargy, confusion, and coma. EKG changes include ST depression and T wave changes. Severe hypokalemia (less than 2.5 mEq/L) can cause death without emergent treatment. The health care provider should be notified for orders. The other laboratory findings are within normal limits.