Nursing Practice Test IV – Set B

Bed rest with immobilization of the leg promotes coagulation and healing at the puncture site of the femoral artery.

This is caused by hypervolemia and pulmonary hypotension.

Because acetaminophen has a duration of action ranging from 3 to 5 hours and a half-life ranging from 1 to 3 hours, the nurse should wait at least 4 hours after acetaminophen ingestion before drawing a blood sample to measure the client's serum acetaminophen level. Waiting less than 4 hours could yield inaccurate results.

Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing.

This is the normal range for blood glucose.

Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.

Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

This thyroid tissue is left because it may provide enough hormone for normal function; if not supplemental medication may be necessary.

GI upset and metallic taste are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headache, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.

The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apec of the heart.

A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual is exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has or will develop tuberculosis.

Once the excessive secretion of aldosterone is stopped, the blood pressure gradually drops to a near normal level.

Although all of these interventions are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the cast, as the physician orders. The client should be told not to walk on the cast without the physician's permission.

This is an early typical finding after a myocardial infarct because of the altered contractility of the heart.

Increased glucocorticoids cause sodium and water retention, hypertension, and adipose deposition resulting in a “moon-face”.

In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

Assessment of the heart’s rate and rhythm determines how the newly implanted pacemaker is functioning.

A pH of less than 7 indicates an acid solution. If the pH is 7, the solution is neutral. A pH over 7 indicates an alkaline or basic solution.

Impaired venous return causes increased pressure, with subjective symptoms of fatigue and heaviness.

Increased basal metabolic rate, increased circulation, and vasodilation result in warm moist skin.

A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction.

This occurs with low serum glucose levels because of sympathetic nervous system activity.

The failing left ventricle cannot accept blood returning from the lungs; this results in increased vascular pressure in the lungs.

Troponin I (cTnl) and Troponin T (cTnT) are proteins in the stricted cells of cardiac tissue and are therefore unique markers for cardiac damage; elevations occurs within one hour of a myocardial infarction and persist for 7 to 15 days.