Nursing Practice Test IV – Set A
by Admin · May 15, 2009
A 50-item quiz on Medical Surgical Nursing.
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Nursing Practice Test IV - Set A
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Question 1 |
Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. Nurse Julia notes that the catheter drainage has stopped. The nurse’s initial action should be to:
A | Irrigate the catheter with saline |
B | Milk the catheter tubing |
C | Remove the catheter |
D | Notify the physician |
Question 1 Explanation:
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.
Question 2 |
The nurse is aware that the routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:
A | 400 Kilocalories |
B | 600 Kilocalories |
C | 800 Kilocalories |
D | 1000 Kilocalories |
Question 2 Explanation:
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.
Question 3 |
A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. Nurse Monette should be aware that this pattern will alter his arterial blood gases by:
A | Increasing HCO3 |
B | Decreasing PCO2 |
C | Decreasing pH |
D | Decreasing PO2 |
Question 3 Explanation:
Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.
Question 4 |
Nurse Jon performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:
A | Flexion, extension and left and right rotation |
B | Abduction, flexion, adduction and extension |
C | Pronation, supination, rotation, and extension |
D | Dorsiflexion, plantar flexion, eversion and inversion |
Question 4 Explanation:
These movements include all possible range of motion for the ankle joint.
Question 5 |
Nurse Blessy is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
A | Testicular cancer is a highly curable type of cancer. |
B | Testicular cancer is very difficult to diagnose. |
C | Testicular cancer is the number one cause of cancer deaths in males. |
D | Testicular cancer is more common in older men. |
Question 5 Explanation:
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.
Question 6 |
Rafael is admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
A | "Continue to take antacids even if your symptoms subside." |
B | "You may take antacids with other medications." |
C | "Avoid taking magnesium-containing antacids if you develop a heart problem." |
D | "Be sure to take antacids with meals." |
Question 6 Explanation:
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.
Question 7 |
When assessing a client during a routine checkup, nurse Rose reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitisis is best described as:
A | A canker sore of the oral soft tissues. |
B | An acute stomach infection. |
C | Acid indigestion. |
D | An early sign of peptic ulcer disease. |
Question 7 Explanation:
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.
Question 8 |
Minerva refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should
A | call the MD to change the dressing so Minerva can see the incision |
B | recognize that Minerva is experiencing denial, a normal stage of the grieving process |
C | reinforce Minerva’s belief for several days until her body can adjust to stress of surgery. |
D | remind Minerva that she needs to accept her diagnosis so that she can begin rehabilitation exercises. |
Question 8 Explanation:
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.
Question 9 |
Nurse Gina would know that a post-TURP client understood his discharge teaching when he says “I should:”
A | Get out of bed into a chair for several hours daily |
B | Call the physician if my urinary stream decreases |
C | Attempt to void every 3 hours when I’m awake |
D | Avoid vigorous exercise for 6 months after surgery |
Question 9 Explanation:
Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete urinary obstruction.
Question 10 |
The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. Nurse Pia understands that this diet contains approximately:
A | 2200 calories |
B | 2000 calories |
C | 2800 calories |
D | 1600 calories |
Question 10 Explanation:
There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein.
Question 11 |
When obtaining a health history from a young female client with probable acute lymphocytic leukemia (ALL), the clinical manifestations nurse Ron should expect to be present are:
A | Petechiae, alopecia |
B | Anorexia, insomia |
C | Anorexia, petechiae |
D | Alopecia, bleeding gums |
Question 11 Explanation:
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.
Question 12 |
Mang Jose a retired farmer has been admitted with a diagnosis of acute lymphoblastic leukemia. When he is receiving chemotherapy, nurse Leng should assess for the development of life-threatening thrombocytopenia by monitoring the client for:
A | Fever |
B | Diarrhea |
C | Headache |
D | Hematuria |
Question 12 Explanation:
Thrombocytes are involved in the clotting mechanism; thrombocytopenia is a reduced number of thrombocytes in the blood; hematuria is blood in the urine.
Question 13 |
During and 8 hour shift, Ryan drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:
A | +55 ml |
B | +137 ml |
C | +235 ml |
D | +485 ml |
Question 13 Explanation:
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.
Question 14 |
Nurse Marianne applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:
A | Inhibit bacterial growth |
B | Relieve pain from the burn |
C | Prevent scar tissue formation |
D | Provide chemical debridement |
Question 14 Explanation:
Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes.
Question 15 |
Kristina is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:
A | 4.5% |
B | 9% |
C | 18 % |
D | 22.5% |
Question 15 Explanation:
The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%.
Question 16 |
Mr. F, jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:
A | “Your laugher is a cover for your fear.” |
B | “He who laughs on the outside, cries on the inside.” |
C | “Why are you always laughing?” |
D | “Does it help you to joke about your illness?” |
Question 16 Explanation:
This non-judgmentally on the part of the nurse points out the client’s behavior.
Question 17 |
Nurse May is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
A | Regular diet |
B | Skim milk |
C | Nothing by mouth |
D | Clear liquids |
Question 17 Explanation:
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.
Question 18 |
A postoperative female client is receiving heparin (Heparin sodium injection) after developing thrombophlebitis. Nurse Myrna monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
A | phytonadione (vitamin K) |
B | protamine sulfate |
C | thrombin |
D | plasma protein fraction |
Question 18 Explanation:
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.
Question 19 |
Mrs. Cruz has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
A | It's normal and requires no action. |
B | It calls for a repeat Pap test in 3 months. |
C | It calls for a repeat Pap test in 6 weeks. |
D | It calls for a biopsy as soon as possible. |
Question 19 Explanation:
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.
Question 20 |
Delia, with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer?
A | "Do all your chores in the morning, when pain and stiffness are least pronounced." |
B | "Do all your chores after performing morning exercises to loosen up." |
C | "Pace yourself and rest frequently, especially after activities." |
D | "Do all your chores in the evening, when pain and stiffness are least pronounced." |
Question 20 Explanation:
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.
Question 21 |
Nurse Oliver would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
A | Food low in fiber so that there is less stool |
B | Everything he ate before the operation but will avoid those foods that cause gas |
C | Bland foods so that his intestines do not become irritated |
D | Soft foods that are more easily digested and absorbed by the large intestines |
Question 21 Explanation:
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.
Question 22 |
Julius is admitted to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, the nurse formulates interventions with which goal in mind?
A | Decreasing blood pressure and increasing mobility |
B | Increasing blood pressure and reducing mobility |
C | Stabilizing the heart rate and blood pressure and easing anxiety |
D | Increasing blood pressure and monitoring fluid intake and output |
Question 22 Explanation:
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.
Question 23 |
The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:
A | Changing the abdominal dressing |
B | Maintaining patency of the cystotomy tube |
C | Maintaining patency of a three-way Foley catheter for cystoclysis |
D | Observing for hemorrhage and wound infection |
Question 23 Explanation:
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.
Question 24 |
Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. Nurse Jasmine should set the flow to provide:
A | 18 gtt/min |
B | 28 gtt/min |
C | 32 gtt/min |
D | 36 gtt/min |
Question 24 Explanation:
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)
Question 25 |
Mr. F who is suspected of having leukemia has a bone marrow aspiration. Immediately following the procedure, Nurse Olive should:
A | Apply brief pressure to the site. |
B | Ask the client to lie on the affected side |
C | Swab the site with an antiseptic solution |
D | Monitor the vital signs every hour for 4 hours |
Question 25 Explanation:
Brief pressure is generally enough to prevent bleeding.
Question 26 |
What laboratory finding is the primary diagnostic indicator for pancreatitis?
A | Elevated blood urea nitrogen (BUN) |
B | Elevated serum lipase |
C | Elevated aspartate aminotransferase (AST) |
D | Increased lactate dehydrogenase (LD) |
Question 26 Explanation:
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.
Question 27 |
Which of the following is a priority nursing diagnosis for a male client with an amputated extremity?
A | Impaired skin integrity related to effects of the injury |
B | Anticipatory grieving related to the loss of a limb |
C | Disturbed body image related to changes in the structure of a body part |
D | Ineffective peripheral tissue perfusion related to injury and amputation |
Question 27 Explanation:
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.
Question 28 |
An electrocardiogram (ECG) taken during a routine checkup reveals that a male client has had a silent myocardial infarction. On a 12-lead ECG, which leads record electrical events in the septal region of the left ventricle?
A | Leads I, aVL, V5, and V6 |
B | Leads II, III, and aVF |
C | Leads V1 and V2 |
D | Leads V3 and V4 |
Question 28 Explanation:
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.
Question 29 |
Mr. Y, who has had bone pains of insidious onset for 4 months is suspected of having multiple myeloma. Nurse Anna understands that one of the diagnostic findings specific for multiple myeloma would be:
A | Low serum calcium levels. |
B | Bence-Jones protein in urine. |
C | Occult and frank blood in the stool. |
D | Positive bacterial culture of sputum. |
Question 29 Explanation:
This protein (globulin) results from tumor cell metabolites; it is present in clients with multiple myeloma.
Question 30 |
A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, Nurse Tanya learns that the client was diagnosed with diabetes mellitus at age 12. The nurse knows that this disease predisposes the client to which musculoskeletal disorder?
A | Degenerative joint disease |
B | Muscular dystrophy |
C | Scoliosis |
D | Paget's disease |
Question 30 Explanation:
Diabetes mellitus predisposes the client to degenerative joint disease. It isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.
Question 31 |
When a post-thyroidectomy client returns from surgery, Nurse Eve assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:
A | Observing for signs of tetany |
B | Checking her throat for swelling |
C | Asking her to state her name out loud |
D | Palpating the side of her neck for blood seepage |
Question 31 Explanation:
If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.
Question 32 |
On a post-thyroidectomy client’s discharge, Nurse Sandy teaches her to observe for signs of surgically induced hypothyroidism. Nurse Sandy would know that the client understands the teaching when she states she should notify the physician if she develops:
A | Intolerance to heat |
B | Dry skin and fatigue |
C | Progressive weight loss |
D | Insomnia and excitability |
Question 32 Explanation:
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.
Question 33 |
Health teachings to be given to a female client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include:
A | Oral tablets of Vitamin B12 will control her symptoms |
B | IM injections are required for daily control |
C | IM injections once a month will maintain control |
D | Weekly Z-track injections provide needed control |
Question 33 Explanation:
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.
Question 34 |
Nurse Melody is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the:
A | upper half of the sternum |
B | upper third of the sternum |
C | lower half of the sternum |
D | lower third of the sternum |
Question 34 Explanation:
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.
Question 35 |
Mr. Reyes weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:
A | 0.5 L |
B | 1.0 L |
C | 2.0 L |
D | 3.5 L |
Question 35 Explanation:
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.
Question 36 |
Mr. Sy, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. Nurse Angela concludes that his pulse rate is most likely the result of the:
A | Diuretic |
B | Vasodilator |
C | Bed-rest regimen |
D | Cardiac glycoside |
Question 36 Explanation:
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.
Question 37 |
Nurse Katrina includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan?
A | Wash, dry, and inspect the stump daily. |
B | Treat superficial abrasions and blisters promptly. |
C | Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. |
D | Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool). |
Question 37 Explanation:
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.
Question 38 |
Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:
A | Limit discomfort |
B | Provide hemostasis |
C | Reduce bladder spasms |
D | Promote urinary drainage |
Question 38 Explanation:
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.
Question 39 |
The laboratory results of the client with leukemia indicate bone marrow depression. Nurse Nina should encourage the client to:
A | Increase his activity level and ambulate frequently |
B | Sleep with the head of his bed slightly elevated |
C | Drink citrus juices frequently for nourishment |
D | Use a soft toothbrush and electric razor |
Question 39 Explanation:
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.
Question 40 |
Which of the following activities is not encouraged in a female patient after an eye surgery?
A | sneezing, coughing and blowing the nose |
B | straining to have a bowel movement |
C | wearing tight shirt collars |
D | sexual intercourse |
Question 40 Explanation:
To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.
Question 41 |
A chest tube with water seal drainage is inserted to a male client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to
A | Prepare for chest tube removal |
B | Milk the tube toward the collection container as ordered |
C | Arrange for a stat Chest x-ray film |
D | Clam the tube immediately |
Question 41 Explanation:
This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber.
Question 42 |
When observing an ostomate do a return demonstration of the colostomy irrigation, Nurse Henry notes that he needs more teaching if he:
A | Stops the flow of fluid when he feels uncomfortable |
B | Lubricates the tip of the catheter before inserting it into the stoma |
C | Hangs the bag on a clothes hook on the bathroom door during fluid insertion |
D | Discontinues the insertion of fluid after only 500 ml of fluid has been instilled |
Question 42 Explanation:
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.
Question 43 |
In the evaluation of a male client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:
A | Urinary output is 30 ml in an hour |
B | Central venous pressure reading of 2 cm H2O |
C | Pulse rates of 120 and 110 in a 15 minute period |
D | Blood pressure readings of 50/30 and 70/40 within 30 minutes |
Question 43 Explanation:
A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.
Question 44 |
Which of the following interventions would be included in the care of plan in a female client with cervical
implant?
A | Frequent ambulation |
B | Unlimited visitors |
C | Low residue diet |
D | Vaginal irrigation every shift |
Question 44 Explanation:
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.
Question 45 |
After a traumatic back injury, a male client requires skeletal traction. When caring for this client, Nurse Jen must:
A | change the client's position only if ordered by the physician. |
B | maintain traction continuously to ensure its effectiveness. |
C | support the traction weights with a chair or table to prevent accidental slippage. |
D | restrict the client's fluid and fiber intake to reduce the movement required for bedpan use. |
Question 45 Explanation:
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.
Question 46 |
Linda 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 |
Question 46 Explanation:
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.
Question 47 |
Mr. Garcia is recovering from coronary artery bypass graft (CABG) surgery. Nurse Trish knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common, spontaneously resolving symptom?
A | Depression |
B | Ankle edema |
C | Memory lapses |
D | Dizziness |
Question 47 Explanation:
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.
Question 48 |
On admission, the blood work of a young male client with leukemia indicates an elevated blood urea nitrogen (BUN) and uric acid. Nurse Bea is aware that these laboratory results may be related to:
A | Lymphadenopathy |
B | Thrombocytopenia |
C | Hypermetabolic state |
D | Hepatic encephalopathy |
Question 48 Explanation:
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.
Question 49 |
Nurse Tina understands that the most definitive test to confirm a diagnosis of multiple myeloma is:
A | Bone marrow biopsy. |
B | Serum test for hypercalcemia. |
C | Urine test for Bence-Jones protein. |
D | X-ray films of the ribs, spine, and skull. |
Question 49 Explanation:
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.
Question 50 |
For a male client with cardiomyopathy, the most important nursing diagnosis is:
A | Decreased cardiac output related to reduced myocardial contractility. |
B | Excessive fluid volume related to fluid retention and altered compensatory mechanisms. |
C | Ineffective individual coping related to fear of debilitating illness. |
D | Anxiety related to actual threat to health status. |
Question 50 Explanation:
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.
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