Nursing Practice Test IV – Set A

For a client with an aneurysm, nursing interventions focus on stabilizing the heart rate and blood pressure, to avoid aneurysm rupture. Easing anxiety also is important because anxiety and increased stimulation may speed the heart rate and boost blood pressure, precipitating aneurysm rupture. Typically, the client with an abdominal aortic aneurysm is hypertensive, so the nurse should take measures to lower the blood pressure, such as administering antihypertensive agents, as prescribed, to prevent aneurysm rupture. To sustain major organ perfusion, a mean arterial pressure of at least 60 mm Hg should be maintained. Although mobility must be assessed individually, most clients need bed rest initially when attempting to gain stability.

Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes.

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 osteoporosis.

Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. A regular diet is incorrect. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn't be given because it increases gastric acid production, which could prolong bleeding. A liquid diet is the first diet offered after bleeding and shock are controlled.

Anemia with petechiae occurs because of bone marrow depression and rapidly proliferating leukocytes; all organs of the body are involved with the development of anorexia.

Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.

The nurse must maintain skeletal traction continuously to ensure its effectiveness. The client should be repositioned every 2 hours to prevent skin breakdown. Traction weights must hang freely to be effective; they should never be supported. The nurse should increase, not restrict, the client's fluid and fiber intake (unless contraindicated by a concurrent illness) to prevent constipation associated with complete bed rest.

Antacids decrease gastric acidity and should be continued even if the client's symptoms subside. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals.

Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men.

It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions.

A class V finding in a Pap test suggests probable cervical cancer; the client should have a biopsy as soon as possible. Only a class I finding, which is normal, requires no action. A class II finding, which indicates inflammation, calls for a repeat Pap test in 3 months. A class III finding, which indicates mild to moderate dysplasia, calls for a repeat Pap test in 6 weeks to 3 months. A class IV finding indicates possible cervical cancer; like a class V finding, it warrants a biopsy as soon as possible.

Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.

The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.

These movements include all possible range of motion for the ankle joint.

Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.

Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients in shock.

A definite confirmation of multiple myeloma can only be made through a bone marrow biopsy; this is a plasma cell malignancy with widespread bone destruction.

The priority diagnosis is Ineffective peripheral tissue perfusion resulting from the loss of circulation secondary to amputation. All the nursing diagnoses listed are appropriate for a client presenting with a traumatic amputation of an extremity.

Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although the other options are important nursing diagnoses, they can be addressed when cardiac output and myocardial contractility have been restored.

Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.

The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%.

Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.

The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.

The hypermetabolic state associated with leukemia causes more urea and uric acid (end products of metabolism) to be produced and to accumulate in the blood.

To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.

This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber.

Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.

A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

Leads V3 and V4 record electrical events in the septal region of the left ventricle. Leads I, aVL, V5, and V6 record electrical events on the lateral surface of the left ventricle. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle. Leads V1 and V2 record electrical events on the anterior surface of the right ventricle and the anterior surface of the left ventricle.

There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.

The client’s intake was (6oz x 30 ml) X 2 = 360 ml and loss was 125 ml of fluid; loss is subtracted from intake.

There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein.

A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace herself during daily activities. Option A is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Options B and D are incorrect because the client should pace herself and take frequent rests rather than doing all chores at once.

The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.

If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.

For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves on its own and doesn't require medical intervention. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure; because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition after CABG surgery that warrants immediate physician notification.

Brief pressure is generally enough to prevent bleeding.

Thrombocytes are involved in the clotting mechanism; thrombocytopenia is a reduced number of thrombocytes in the blood; hematuria is blood in the urine.

One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

This non-judgmentally on the part of the nurse points out the client’s behavior.

A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization.

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)

Diabetes mellitus predisposes the client to degenerative joint disease. It isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow.

Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis.

Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete urinary obstruction.

This protein (globulin) results from tumor cell metabolites; it is present in clients with multiple myeloma.