Pre-Board Exam for November 2014 NLE [SATA]

This Pre-Board Nursing Exam contains 100 Select All That Apply [SATA] questions. Both questions and answers were arranged randomly.

Topics that are included were: Foundation of Nursing, Nursing Research, Professional Adjustment, Leadership and Management, Maternal and Child Health, Community Health Nursing, Communicable Diseases, Integrated Management of Childhood Illness, Medical and Surgical Nursing and Psychiatric Nursing.

Pre-Board Exam for November 2014 NLE [SATA]

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Question 1
Which of the following correctly identifies the nurse’s role in crisis intervention? Select all that apply.
A
Assessing the client’s perception of problem
B
Work with client as crisis resolves
C
Offer support in resolving crisis
D
Advising client during decision making process
E
Rewarding the client for a behavior changed
Question 1 Explanation: 
ANSWER: Offer support in resolving crisis ; Assessing the client’s perception of problem ; Work with client as crisis resolves ; RATIONALE: The nurse’s role in crisis intervention: • Offer support in resolving crisis • Assessing the client’s perception of problem • Work with client as crisis resolves • Determine situational supports • Explore previous coping behaviors of the client • Enlisting help of situational supports • Encourage use of new and more effective coping behaviors • Convey hope to client that crisis can be resolved
Question 2
Prinzmetal’s angina or variant angina is described correctly by which statements? Select all that apply.
A
The attacks tend to occur in the early hours of the day
B
May result from coronary artery spasm
C
Chest pain may occur at rest
D
Associated with rapid eye movement sleep
E
Chest pain of longer duration
F
Attacks during nighttime only
Question 2 Explanation: 
ANSWER: Chest pain of longer duration ; Chest pain may occur at rest ; The attacks tend to occur in the early hours of the day ; May result from coronary artery spasm ; RATIONALE: • Chest pain of longer duration – variant angina • Chest pain may occur at rest - variant angina • Attacks during nighttime only – nocturnal angina • The attacks tend to occur in the early hours of the day - variant angina • Associated with rapid eye movement sleep - nocturnal angina • May result from coronary artery spasm - variant angina
Question 3
Enema is administered to the client. For which purpose is enema administered to patients? Select all that apply.
A
To relieve flatulence
B
To relieve diarrhea
C
To increase body temperature
D
To administer medications
Question 3 Explanation: 
ANSWER: To administer medications ; To relieve flatulence ; RATIONALE: Purposes of administering enemas: • To administer medications • To relieve flatulence • To relive constipation • To lower body temperature • To evacuate feces in preparation for diagnostic procedure or surgery
Question 4
After TEE, the nurse should watch out for which complications? Select all that apply.
A
Pharyngeal bleeding
B
Sore throat
C
Transient hypoxemia
D
Chest pain
E
Cardiac dysrhythmias
F
Dyspnea
Question 4 Explanation: 
ANSWER: Pharyngeal bleeding ; Cardiac dysrhythmias ; Transient hypoxemia ; RATIONALE: After TEE the nurse should observe for signs and symptoms of complications such as pharyngeal bleeding, cardiac dysrhythmias, vasovagal reaction and transient hypoxemia.
Question 5
Effects of calcium-channel blockers are the following. Select all that apply.
A
Has a vasoconstriction effect
B
Inhibits calcium ion transportation
C
Reduces coronary vasospasm
D
Relieves pain in Angina
Question 5 Explanation: 
ANSWER: Reduces coronary vasospasm ; Inhibits calcium ion transportation ; RATIONALE: Calcium channel blockers have vasodilation effects.
Question 6
To prevent infection in a patient with burns the nurse should do which of the following? Select all that apply.
A
Strict asepsis
B
Reverse/protective isolation
C
Administer morphine SO4
D
Avoid exposure to draft
E
Use sterile NSS to irrigate the area
Question 6 Explanation: 
ANSWER: Use sterile NSS to irrigate the area ; Strict asepsis ; Reverse/protective isolation ; RATIONALE: Administration of morphine and avoiding draft exposure is used to relieve pain and promote comfort for patients with burn.
Question 7
Diet modification is essential in the management of sliding hiatal hernia. Which of the following foods should the client avoid? Select all that apply.
A
Fruits and vegetables
B
Fatty foods
C
Increased protein
D
Chocolate
E
Alcohol
Question 7 Explanation: 
ANSWER: Fatty foods ; Alcohol ; Chocolate ; RATIONALE: The client should avoid the following foods: • Fatty foods • Cola beverages • Coffee • Tea • Chocolate • Alcohol * These foods decrease LES pressure.
Question 8
Females are more prone to urinary tract infection because of which reason? Select all that apply.
A
No prostatic fluid
B
Hormonal changes
C
Short urethra
D
Large flow of urine
E
Increase vaginal discharges
Question 8 Explanation: 
ANSWER: No prostatic fluid ; Short urethra ; RATIONALE: Females are more prone to urinary tract infection because of: • No prostatic fluid • Short urethra
Question 9
Factors the increases intrabdominal pressure are the following. Select all that apply.
A
Bending
B
Use of loose clothing
C
Heavy lifting
D
Prolonged standing
E
Straining
Question 9 Explanation: 
ANSWER: Bending ; Straining ; Heavy lifting ; RATIONALE: Factors that increase intraabdominal pressure are: • Use of constrictive clothing • Straining • Heavy lifting • Bending, stooping • Coughing
Question 10
Common gastrointestinal interventions include the following. Select all that apply.
A
NGT insertion
B
MRI
C
GI intubation
D
Ultrasonography
E
Colonoscopy
F
Total parenteral nutrition
Question 10 Explanation: 
ANSWER: GI intubation ; NGT insertion ; Total parenteral nutrition ; RATIONALE: Ultrasonography, MRI and colonoscopy are diagnostic/laboartory tests for GI system not a GI intervention.
Question 11
Physiologic principles of dialysis include which of the following? Select all that apply.
A
Diffusion
B
Ultrafiltration
C
Osmosis
D
Selective osmosis
Question 11 Explanation: 
ANSWER: Osmosis ; Diffusion ; Ultrafiltration ; RATIONALE: Osmosis, diffusion and ultrafiltration are physiologic principles of dialysis.
Question 12
The client with a diagnosis of benign prostatic hyperplasia is scheduled for a Transurethral Resection of the Prostate (TURP).  Which of the following statements is true about this procedure? Select all that apply.
A
Impotence is possible after the procedure
B
Continuous bladder irrigation is done postop
C
Incision is located over the lower abdomen and bladder
D
No incontinence is noted after the procedure
Question 12 Explanation: 
ANSWER: Continuous bladder irrigation is done postop ; No incontinence is noted after the procedure ; RATIONALE: In TURP there is no incision done. No incontinence and impotence is noted postoperatively.
Question 13
Which is an antipsychotic medication? Select all that apply.
A
Valium
B
Librium
C
Mellaril
D
Sinequan
E
Navane
F
Artane
Question 13 Explanation: 
ANSWER: Navane ; Mellaril ; RATIONALE: • Librium – antianxiety • Navane – antipsychotic • Mellaril – antipsychotic • Valium – antianxiety • Sinequan – antidepressant • Artane – anticholinergic
Question 14
To prevent the occurrence of urinary calculi, which of the following should the nurse teach the client? Select all that apply.
A
Increase fluids in the diet
B
Encourage ambulation
C
Take Allopurinol regularly
D
Increase dairy product intake
E
Take Demerol
Question 14 Explanation: 
ANSWER: Encourage ambulation ; Increase fluids in the diet ; RATIONALE: Demerol is used for pain control if renal calculi are already present. Dairy products should be limited to decrease the risk of having Ca stones. Allopurinol is used to decrease uric acid in renal calculi.
Question 15
It is important for the nurse to keep in mind the guidelines to care for the person with a chronic renal failure. Which of the following intervention helps prevent injury and infection to the patient? Select all that apply.
A
Encourage use of soft toothbrush
B
Encourage rest for fatigue
C
Provide meticulous skin care
D
Avoid aspirin products
E
Medicate the patient as needed for pain
F
Provide calm, supportive environment
Question 15 Explanation: 
ANSWER: Avoid aspirin products ; Encourage use of soft toothbrush ; Provide meticulous skin care ; RATIONALE: Interventions listed in 2, 5 and 6 promote patient comfort but does not prevent infection and injury.
Question 16
Which of the following GI tubes is single-lumen? Select all that apply.
A
Levin tube
B
Sengstaken Blakemore tube
C
Cantor tube
D
Miller-abott tube
E
Salem-sump tube
Question 16 Explanation: 
ANSWER: Levin tube ; Cantor tube ; RATIONALE: • Salem-sump tube – double-lumen • Miller-abott tube – double-lumen • Levin tube – single-lumen • Cantor tube – single-lumen • Sengstaken Blakemore tube – triple-lumen
Question 17
Contraindications of MRI are the following. Select all that apply.
A
Aneurysm clips
B
Aneurysm
C
Fever
D
Orthopedic screws
E
Pacemakers
Question 17 Explanation: 
ANSWER: Pacemakers ; Aneurysm clips ; Orthopedic screws ; RATIONALE: MRI is contraindicated to the client with an implanted: • Pacemakers • Aneurysm clips • Orthopedic screws
Question 18
The client is taking Coumadin. Which nursing interventions are appropriate for this client? Select all that apply.
A
Can be given with ASA
B
Monitor prothrombin time
C
Assess for signs and symptoms of bleeding
D
Keep protamin sulfate available
E
Increase green leafy vegetables in the diet
Question 18 Explanation: 
ANSWER: Assess for signs and symptoms of bleeding ; Monitor prothrombin time ; Coumadin is an anticoagulant and should never be given with ASA. Green leafy vegetable should be minimized in the diet as these foods contain Vitamin K. Vitamin K is the antidote of Coumadin.
Question 19
Infantile autism is characterized by which clinical findings? Select all that apply.
A
Labile moods
B
No eye contact or facial responsiveness noted in the infant
C
Ritualistic changes
D
Urinary incontinence
E
The child has persistent eating of non-nutritive substances
Question 19 Explanation: 
ANSWER: No eye contact or facial responsiveness noted in the infant ; Ritualistic changes ; Labile moods ; RATIONALE: • No eye contact or facial responsiveness noted in the infant • Ritualistic changes • Labile moods • Infant not responsive to cuddling • Impaired or nor verbal communication • Inability to tolerate change • Fascination with movement and spinning objects • Unresponsive or overresponsive to stimuli
Question 20
Which of the following is a secondary prevention? Select all that apply.
A
Early case finding
B
Health teaching about stress and its management
C
Identifying persons at risk of certain diseases
D
Drug therapy
E
Facilitate return of client to home by use of social agencies
Question 20 Explanation: 
ANSWER: Drug therapy ; Early case finding ; RATIONALE: • Drug therapy – secondary • Health teaching about stress and its management – primary • Early case finding – secondary • Identifying persons at risk of certain diseases – primary • Facilitate return of client to home by use of social agencies – tertiary
Question 21
Which assessment findings strongly support the diagnosis of UTI? Select all that apply.
A
Upper back pain
B
Nausea and vomiting
C
Urinary retention
D
Body malaise
E
Dysuria
F
Hypothermia
Question 21 Explanation: 
ANSWER: Dysuria ; Nausea and vomiting ; Body malaise ; RATIONALE: There is urinary urgency and frequency in UTI. Pain is in the suprapubic area and at the lower back. Fever not hypothermia is noted in infection.
Question 22
The client is diagnosed with nephrotic syndrome. What are possible causes of nephrotic syndrome? Select all that apply.
A
Sickle cell disease
B
Use of diuretics
C
Allergy
D
Pericarditis
E
Chronic use of corticosteroid
Question 22 Explanation: 
ANSWER: Allergy ; Pericarditis ; Sickle cell disease ; RATIONALE: Corticosteroid and diuretics are used in the treatment of nephrotic syndrome. Possible causes of this condition are: • Allergy • Circulation problems (CHF, Pericarditis) • Systemic diseases (DM, Sickle cell disease) • Infections (herpes zoster)
Question 23
Preop care for a patient who will undergo a gastric surgery would include the implementation of which interventions? Select all that apply.
A
Splinting the incision
B
Encourage early ambulation
C
Administration of analgesics before activity
D
Provide psychosocial support
E
Providing nutritional support – TPN
Question 23 Explanation: 
ANSWER: Providing nutritional support – TPN ; Provide psychosocial support ; RATIONALE: Interventions listed in 1, 4 and 5 are appropriate during the post-op period.
Question 24
Which techniques are used in myocardial scintigraphy? Select all that apply.
A
Cardiac catheterization
B
Dipyridamole-thallium-201 test
C
Holter monitoring
D
First-pass cardiac study
E
Thallium 201 scintigraphy
Question 24 Explanation: 
ANSWER: Thallium 201 scintigraphy ; First-pass cardiac study ; Dipyridamole-thallium-201 test ; RATIONALE: • Thallium 201 scintigraphy • First-pass cardiac study • Dipyridamole-thallium-201 test • Technitium 99m ventriculography
Question 25
Transesophageal echocardiography (TEE) allows ultrasonic imaging of the cardiac structures and great vessels via esophagus. Which of the following should be performed by the nurse before this procedure? Select all that apply.
A
Cardiac monitoring
B
Place the client in a lateral or semi-fowler’s position
C
Remove dentures/prosthetics
D
NPO for 4-6 hours
E
Encourage the client to cough
F
Encourage the client to void
G
Offer throat lozenges or rinses
Question 25 Explanation: 
ANSWER: Encourage the client to void ; NPO for 4-6 hours ; Remove dentures/prosthetics ; RATIONALE: • Encourage the client to cough – after TEE • Offer throat lozenges or rinses – after TEE • Place the client in a lateral or semi-fowler’s position – after TEE • Encourage the client to void – before TEE • NPO for 4-6 hours - before TEE • Remove dentures/prosthetics - before TEE
Question 26
Nursing responsibilities for a client on Disulfiram include which of the following? Select all that apply.
A
Teach the client to always carry an identification card in case of accidental alcohol ingestion
B
Instruct the client not to take cough preparations
C
Making sure that the client has not taken any alcohol 6 hours before taking Disulfiram
D
Staying with the client
E
Provide information about rehabilitation programs
F
Monitoring the effects of antianxiety drugs if being taken at the same time
Question 26 Explanation: 
ANSWER: Instruct the client not to take cough preparations ; Teach the client to always carry an identification card in case of accidental alcohol ingestion ; Monitoring the effects of antianxiety drugs if being taken at the same time ; RATIONALE: Disulfiram produces unpleasant reactions when taken with alcohol including cough medicine and foods prepared with alcohol. In case of accidental alcohol ingestion, teach the client to always carry an identification card. If Disulfiram is taken with antianxiety drugs and oral anticoagulants, thus, taking Disulfiram with these drugs at the same time should be monitored.
Question 27
To prevent bleeding and thrombophlebitis after retropubic prostatectomy, which of the following should avoided by the client? Select all that apply.
A
Sexual intercourse at least 1 month after discharge
B
Heavy lifting
C
Long trips
D
Driving at least 5 days after discharge
E
Crossing legs
Question 27 Explanation: 
ANSWER: Heavy lifting ; Crossing legs ; Long trips ; RATIONALE: To prevent bleeding and thrombophlebitis after retropubic prostatectomy, the client should avoid: • Heavy lifting • Sexual intercourse 3 weeks after discharge • Driving 2 weeks after discharge • Crossing legs • Long trips • Vigorous exercise • Straining with defecation
Question 28
The client has undergone a barium swallow/upper GI series. After the procedure, which interventions are appropriate to implement to this client? Select all that apply.
A
Inform the client that the stool is white for 5 days
B
Administer laxatives
C
Increase fluid intake
D
Instruct the patient to stand for 3 hours after the procedure
Question 28 Explanation: 
ANSWER: Increase fluid intake ; Administer laxatives ; RATIONALE: The stool of the client is white for only 24-72 hours. The patient can be assisted to any comfortable position after the procedure.
Question 29
Pain in Angina Pectoris is characterized by the following. Select all that apply.
A
Crushing and severe
B
Radiates down one or both arms, left shoulder, jaw, neck and back
C
Characterized by Levine’s sign
D
Precipitated by activity
E
Relieved by rest and morphine
Question 29 Explanation: 
ANSWER: Radiates down one or both arms, left shoulder, jaw, neck and back ; Precipitated by activity ; RATIONALE: • Crushing and severe – MI • Radiates down one or both arms, left shoulder, jaw, neck and back – Angina • Relieved by rest and morphine – Angina is relieved by rest and nitroglycerine • Precipitated by activity – angina • Characterized by Levine’s sign – MI
Question 30
If the client has uric acid stones, which foods should be avoided? Select all that apply.
A
Shellfish
B
Gravy
C
Spinach
D
Chocolate
E
Organ meat
F
Tea
Question 30 Explanation: 
ANSWER: Organ meat ; Shellfish ; Gravy ; RATIONALE: If uric acid stones are the problem, foods containing purine should be avoided such as: • Organ meat • Shellfish • Gravy • Meat soups • Legumes • Salted anchovies • Mushroom • Sardines
Question 31
Which of the following are possible causes of angina? Select all that apply.
A
Aortic regurgitation
B
Infection
C
Diabetes mellitus
D
Hypotension
E
Polycythemia vera
Question 31 Explanation: 
ANSWER: Aortic regurgitation ; Diabetes mellitus ; Polycythemia vera ; RATIONALE: Causes of angina are: atherosclerosis, hypertension, diabetes mellitus, thromboangitis obliterans, polycythemia vera and aortic regurgitation.
Question 32
Medical management of gastritis includes which of the following? Select all that apply.
A
Fluid-electrolyte replacement
B
Avoid alcohol
C
High fiber diet until pain resolves
D
Vitamin B12 supplement
E
Avoid overeating
F
Antacid administration
Question 32 Explanation: 
ANSWER: Vitamin B12 supplement ; Fluid-electrolyte replacement ; Antacid administration ; RATIONALE: • High fiber diet until pain resolves – bland or liquid diet until pain resolves • Vitamin B12 - if pernicious anemia occurs - • Avoid overeating – not a medical management but a health teaching • Fluid-electrolyte replacement – to replace loss fluids and electrolytes • Antacid administration – histamine blocker can also be administered • Avoid alcohol - not a medical management but a health teaching
Question 33
Which behaviors are expected in a 5 year old child based on Freud’s psychosexual developmental stage? Select all that apply.
A
Pleasure is through the mouth
B
Energy is used to gain new skills in social relationships and knowledge
C
Pleasure through genitals
D
Erotic attachment to parent of opposite sex is noted
E
Concern with cleanliness or being dirty
Question 33 Explanation: 
ANSWER: Erotic attachment to parent of opposite sex is noted ; Pleasure through genitals ; RATIONALE: • Pleasure is through the mouth – 0-18 months: ORAL • Erotic attachment to parent of opposite sex is noted – 3-6 years: PHALLIC • Concern with cleanliness or being dirty – 18months-3 years: ANAL • Pleasure through genitals – 3-6 years: PHALLIC • Energy is used to gain new skills in social relationships and knowledge: 6-12 years: LATENCY
Question 34
Sliding hiatal hernia is caused by which condition/event? Select all that apply.
A
Anorexia
B
Surgery
C
Aging process
D
Obesity
E
Chronic steroid use
Question 34 Explanation: 
ANSWER: Surgery ; Aging process ; Obesity ; RATIONALE: Sliding hiatal hernia is caused by muscle weakness in the esophageal hiatus which is precipitated by 1, 2 and 3.
Question 35
Which of the following drugs are classified as platelet aggregation inhibitor?
A
Heparin Sodium
B
Verapamil (Calan)
C
Dipyridamole (Persatin)
D
Ticlopidine (Ticlid)
E
Diltiazem (Cardizem)
Question 35 Explanation: 
ANSWER: Dipyridamole (Persatin) ; Ticlopidine (Ticlid) ; RATIONALE: • Dipyridamole (Persatin) – platelet aggregator inhibitor • Diltiazem (Cardizem) – calcium channel blocker • Ticlopidine (Ticlid) - platelet aggregator inhibitor • Verapamil (Calan) - calcium channel blocker • Heparin Sodium – anticoagulant
Question 36
Administration of total parenteral nutrition is indicated for which condition? Select all that apply.
A
Antacid therapy
B
Severe GI side effects of chemotherapy
C
Heart failure
D
Kidney failure
E
Severe malnutrition
F
Severe burns
Question 36 Explanation: 
ANSWER: Severe malnutrition ; Severe GI side effects of chemotherapy ; Severe burns ; RATIONALE: Indications of TPN are: • Major GI diseases: fistulas/inflammatory diseases • Severe burns/trauma • Need for extensive support for an extended period • Severe GI side effects of chemotherapy
Question 37
Which nursing interventions are appropriate to perform if the client is taking beta-adrebergic blocker?  Select all that apply.
A
Administering the drug with food
B
Withholding drug if bradycardia is present
C
Instructing the patient to gradually change his or her position
D
Assuming a sitting or supine position when taking the drug
Question 37 Explanation: 
ANSWER: Administering the drug with food ; Withholding drug if bradycardia is present ; RATIONALE: • Assuming a sitting or supine position when taking the drug – for Nitrogylcerine • Administering the drug with food – the drug may cause GI upset, hence, this must be done • Instructing the patient to gradually change his or her position – for Nitrogylcerine • Withholding drug if bradycardia is present – assess PR before administration of the drug
Question 38
Beta-adrenergic blocking agents decrease myocardial oxygen demand by performing which mechanism of action? Select all that apply.
A
Decreasing heart rate
B
Decreasing myocardial contractility
C
Decreasing BP
D
Directly relaxing the vascular smooth muscle
E
Decreasing peripheral resistance
F
Decreasing calcium output
Question 38 Explanation: 
ANSWER: Decreasing heart rate ; Decreasing BP ; Decreasing myocardial contractility ; Decreasing calcium output ; RATIONALE: Beta-adrenergic blocking agents decrease myocardial oxygen demand by: • Decreasing heart rate • Decreasing BP • Decreasing myocardial contractility • Decreasing calcium output
Question 39
Which of the following clinical findings is expected to find in a client with a dysthymic disorder? Select all that apply.
A
Excessive guilt
B
Depression worst in the morning
C
Loss of interest in activities
D
Normal moods for a period of weeks, followed by depression
E
Weight loss
F
Insomnia
G
Social withdrawal
Question 39 Explanation: 
ANSWER: Loss of interest in activities ; Social withdrawal ; Normal moods for a period of weeks, followed by depression ; Insomnia ; RATIONALE: • Depression worst in the morning – depression with melancholia • Loss of interest in activities – dysthymic disorder • Excessive guilt - depression with melancholia • Social withdrawal - dysthymic disorder • Normal moods for a period of weeks, followed by depression - dysthymic disorder • Weight loss - depression with melancholia • Insomnia - dysthymic disorder
Question 40
Common problems of tube feedings include which of the listed items? Select all that apply.
A
Constipation
B
Vomiting
C
Aspiration
D
Hypoglycemia
E
Abdominal distention
Question 40 Explanation: 
ANSWER: Abdominal distention ; Constipation ; Aspiration ; Vomiting ; RATIONALE: Common problems of tube feedings are the following: • Abdominal distention • Constipation • Aspiration • Vomiting • Hyperglycemia
Question 41
Which of the following is a correct statement about Echocardiography? Select all that apply.
A
The client has to remain still, in supine position slightly turned to the left side, with HOB elevated to 15-20 degrees.
B
It is painless and takes approximately 30-60 minutes to complete
C
The portable monitoring system is called the telemetry unit
D
No special preparations is required
E
It uses an ultrasound to assess cardiac structure and mobility
F
It is a continuous ECG monitoring
Question 41 Explanation: 
ANSWER: It uses an ultrasound to assess cardiac structure and mobility ; No special preparations is required ; It is painless and takes approximately 30-60 minutes to complete ; The client has to remain still, in supine position slightly turned to the left side, with HOB elevated to 15-20 degrees. ; RATIONALE: • It uses an ultrasound to assess cardiac structure and mobility – Echocardiography • It is a continuous ECG monitoring – holter monitoring • The portable monitoring system is called the telemetry unit – holter monitoring • No special preparations is required – Echocardiography • It is painless and takes approximately 30-60 minutes to complete – Echocardiography • The client has to remain still, in supine position slightly turned to the left side, with HOB elevated to 15-20 degrees. – Echocardiography
Question 42
Which of the following laboratory results are considered within the normal range? Select all that apply.
A
CK-MB in a female client: 250 mu/ml
B
LDH: 325 mu/ml
C
Trigycerides: 200 mg/dl
D
Calcium: 2.5 mEq/L
E
Blood uric acid level of 6 mg/dl
F
AST: 55 mu/ml
Question 42 Explanation: 
ANSWER: Blood uric acid level of 6 mg/dl ; Trigycerides: 200 mg/dl ; CK-MB in a female client: 250 mu/ml ; RATIONALE: • Blood uric acid level of 6 mg/dl – normal range: 2.5-8 mg/dl • Trigycerides: 200 mg/dl – normal range: 140-200 mg/dl • AST: 55 mu/ml – normal range: 7-40 mu/ml • Calcium: 2.5 mEq/L – normal range 4.5-5.5 mEq/L • LDH: 325 mu/ml – normal range: 100-225 mu/ml • CK-MB in a female client: 250 mu/ml – normal range: 50-250 mu/ml
Question 43
The nurse’s role group therapy includes which of the following. Select all that apply.
A
Counselor
B
Advising the members on which decision to make
C
Promote group cohesiveness
D
Encouraging participation
E
Introduce group members
F
Decide for the group
G
Setting rules and regulations
H
Setting limits
Question 43 Explanation: 
ANSWER: Introduce group members ; Setting limits ; Encouraging participation ; Promote group cohesiveness ; RATIONALE: The role of the nurse in a group therapy are: • Introduce group members • Setting limits • Encouraging participation • Promote group cohesiveness • Explain purpose and rules of group • Focus on problems of group and group process • Facilitate communication
Question 44
Hydrotherapy in burn serves for what purpose? Select all that apply.
A
Maintains adequate nutrition
B
Improves muscle tone
C
Relieves pain
D
Removes debris
Question 44 Explanation: 
ANSWER: Removes debris ; Relieves pain ; Improves muscle tone ; RATIONALE: Hydrotherapy purposes: • Removes debris • Relieves pain • Improves muscle tone • Improves circulation • Relieves pain • Promotes healing • Prevents contractions
Question 45
The nurse is assigned to care for an elderly client with dementia. In instituting safety measures which of the following should the nurse do? Select all that apply.
A
Continue to address the client by name
B
Side rails up at all times
C
Perform frequent client checks
D
Do not force the client to remember things
E
Arrange for necessary assistive devices
Question 45 Explanation: 
ANSWER: Side rails up at all times ; Perform frequent client checks ; RATIONALE: • Side rails up at all times – safety measure • Continue to address the client by name – maintaining reality orientation • Do not force the client to remember things – reality orientation • Perform frequent client checks – safety measure • Arrange for necessary assistive devices – assisting with ADLs
Question 46
Which of the following are the causes of MI?  Select all that apply.
A
Hemorrhage and shock
B
Hypertension
C
Diabetes Mellitus
D
Coronary thrombosis
E
Direct trauma
F
Aortic regurgitation
Question 46 Explanation: 
ANSWER: Coronary thrombosis ; Hemorrhage and shock ; Direct trauma ; RATIONALE: • Coronary thrombosis – MI • Hemorrhage and shock – MI • Diabetes Mellitus – angina • Hypertension – angina • Direct trauma – MI • Aortic regurgitation – angina
Question 47
Angina is precipitated by which events? Select all that apply.
A
Sleeping
B
Exposure to cold
C
Rest
D
Eating a heavy meal
E
Excitement
F
Sexual activity
Question 47 Explanation: 
ANSWER: Sexual activity ; Eating a heavy meal ; Exposure to cold ; Excitement ; RATIONALE: Precipitating events of angina are: E – Exertion: vigorous exercise done very sporadically E – Emotions: excitement, sexual activity E – Eating a heavy meal E – Environment: exposure to cold
Question 48
In chronic renal failure, body system manifestations are observed. Assessment parameters of hematopoietic system problems in chronic renal failure are which of the following? Select all that apply.
A
Assess for joint pain
B
Reflexes
C
Hemoglobin
D
Platelet count
E
Hematocrit
F
Serum calcium
G
Level of orientation
Question 48 Explanation: 
ANSWER: Hematocrit ; Hemoglobin ; Platelet count ; RATIONALE: • Hematocrit – assessment parameter of hematopoietic system problems in chronic renal failure • Hemoglobin - assessment parameter of hematopoietic system problems in chronic renal failure • Level of orientation - assessment parameter of neurologic system problems in chronic renal failure • Reflexes - assessment parameter of neurologic system problems in chronic renal failure • Platelet count - assessment parameter of hematopoietic system problems in chronic renal failure • Serum calcium - assessment parameter of skeletal system problems in chronic renal failure • Assess for joint pain - assessment parameter of skeletal system problems in chronic renal failure
Question 49
Which of the following medications are beta-adrenergic blocking agents? Select all that apply.
A
Propanolol (Inderal)
B
Amyl Nitrate
C
Nitroglycerine
D
Isosorbide
E
Pindolol (Visken)
Question 49 Explanation: 
ANSWER: Propanolol (Inderal) ; Pindolol (Visken) ; RATIONALE: Propanolol (Inderal) and Pindolol (Visken) are beta-adrenergic blocking agents.
Question 50
Which of the following contraptions are possible to be placed in the client with sliding hiatal hernia after Nissen Fundoplication (gastric wrap-around) procedure? Select all that apply.
A
Gastrostomy
B
Enema
C
NGT
D
Chest tube
E
TPN
Question 50 Explanation: 
ANSWER: NGT ; Chest tube ; RATIONALE: NGT and Chest are the possible post-op contraptions following a gastric wrap-around.
Question 51
To promote activity and rest after CABG, the nurse should implement the following interventions. Select all that apply.
A
Encourage slower activity or shorter periods of activity with more rest periods
B
Facilitate reduction in the client’s present level of anxiety
C
Plan for a regular activity program
D
Administer nitroglycerine
Question 51 Explanation: 
ANSWER: Plan for a regular activity program ; Encourage slower activity or shorter periods of activity with more rest periods ; RATIONALE: • Administer nitroglycerine – for pain relief • Plan for a regular activity program – for activity and rest promotion • Encourage slower activity or shorter periods of activity with more rest periods - for activity and rest promotion • Facilitate reduction in the client’s present level of anxiety – to decrease anxiety and promote feeling of well-being
Question 52
The client is diagnosed with appendicitis. Possible causes of this condition include which of the following? Select all that apply.
A
High intake of refined carbohydrates
B
High fiber diet
C
Obstruction of fecalith or foreign bodies, bacteria and toxins in the appendix
D
Increase fluids in diet
Question 52 Explanation: 
ANSWER: High intake of refined carbohydrates ; Obstruction of fecalith or foreign bodies, bacteria and toxins in the appendix ; RATIONALE: Inflammation of vermiform appendix is caused by either of the following: • Low fiber diet • High intake of refined carbohydrates • Obstruction of fecalith or foreign bodies, bacteria and toxins in the appendix
Question 53
Which laboratory/diagnostic test is used to diagnose renal calculi? Select all that apply.
A
ECG
B
Renal Pyelogram (RPG)
C
Urinalysis
D
Ultrasound
E
MRI
Question 53 Explanation: 
ANSWER: Ultrasound ; Renal Pyelogram (RPG) ; Urinalysis ; RATIONALE: To assess/diagnose renal calculi the following can be done: • Ultrasound • Renal Pyelogram (RPG) • Urinalysis • Cystoscopy • Intravenous pyelography
Question 54
The nurse should monitor the client with toxic shock syndrome for which condition? Select all that apply.
A
High fever
B
Diarrhea
C
Jaundice
D
Bleeding at IV sites
E
Petechiae
Question 54 Explanation: 
ANSWER: Petechiae ; Bleeding at IV sites ; RATIONALE: The nurse should observe the client for the following and immediately report to the physician: • Petechiae • Bleeding at IV sites • Hematoma • Cyanosis *diarrhea and high fever are expected assessment findings not complications that must be reported to the physician immediately.
Question 55
Ineffective communication styles are non-therapeutic approaches and tend to block therapeutic communication. Which of the following is an ineffective communication style? Select all that apply.
A
Exploring
B
Clarification
C
Probing
D
Agreeing
E
Approving
F
Focusing
Question 55 Explanation: 
ANSWER: Approving ; Agreeing ; Probing ; RATIONALE: • Focusing – therapeutic • Approving – non-therapeutic • Agreeing – non -therapeutic • Probing – non-therapeutic • Exploring – therapeutic • Clarification – therapeutic
Question 56
After a UGI Endoscopy, which of the following should the nurse assess the patient? Select all that apply.
A
Bleeding
B
Crepitus
C
Chest pain
D
Abdominal pain
E
Fever
F
Diarrhea
Question 56 Explanation: 
ANSWER: Bleeding ; Crepitus ; Fever ; RATIONALE: After UGI endoscopy, the nurse should assess the patient for the following: • Bleeding • Crepitus (neck) • Fever • Neck/throat pain • Dyspnea • Dysphagia • Back/shoulder pain
Question 57
Which of the following groups are at increased risk for suicide? Select all that apply.
A
Cigarette smokers
B
Elderly
C
Adolescents
D
Alcoholics
E
Terminally ill
F
Children
Question 57 Explanation: 
ANSWER: Alcoholics ; Elderly ; Terminally ill ; Adolescents ; RATIONALE: Groups at increased risk for suicide: • Alcoholics • Elderly • Terminally ill • Adolescents • Persons who have experienced loss • Depressed people • Minority groups
Question 58
The client is scheduled for a stress test (treadmill test). Which of the following would be an appropriate nursing intervention to this client? Select all that apply.
A
The night before the sleep, the client should get an adequate sleep
B
Instruct the patient to avoid tea, coffee and alcohol 1 week before the test
C
Nitroglycerine should be taken 2 hours before the test
D
Rest is imperative to be done after the test
E
Comfortable and loose-fitting clothes should be worn by the client during the test
Question 58 Explanation: 
ANSWER: Comfortable and loose-fitting clothes should be worn by the client during the test ; Rest is imperative to be done after the test ; The night before the sleep, the client should get an adequate sleep ; RATIONALE: • Instruct the patient to avoid tea, coffee and alcohol 1 week before the test – these items should be avoided on the day of the test • Comfortable and loose-fitting clothes should be worn by the client during the test – should be instructed to the client • Rest is imperative to be done after the test - should be instructed to the client • Nitroglycerine should be taken 2 hours before the test – this medication should NOT be taken 2 hours before the test • The night before the sleep, the client should get an adequate sleep - should be instructed to the client
Question 59
Which of the following clinical findings strongly suggests the presence of MI? Select all that apply.
A
Decreased LDH
B
Enlargement of Q wave
C
Inverted T wave
D
Elevated Ck-MB
E
Decreased AST
Question 59 Explanation: 
ANSWER: Elevated Ck-MB ; Inverted T wave ; Enlargement of Q wave ; RATIONALE: In MI there is elevated Ck-MB, elevated AST and LDH. The T wave is inverted and Q wave is enlarged.
Question 60
Care of the catheter insertion site must be done by the nurse in TPN. Which of the following should be implemented by the nurse? Select all that apply.
A
Provide good oral hygiene
B
Change the sterile dressings every two days
C
Cleanse the site with antiseptic solution
D
Practice aseptic technique
E
Monitor for signs and symptoms of infection
Question 60 Explanation: 
ANSWER: Monitor for signs and symptoms of infection ; Practice aseptic technique ; Cleanse the site with antiseptic solution ; RATIONALE: Care of the catheter insertion site include: • Monitor for signs and symptoms of infection • Practice aseptic technique • Change the sterile dressings every day • Cleanse the site with antiseptic solution
Question 61
Which of the following drugs should the client with a sliding hiatal hernia avoid? Select all that apply.
A
Indomethacin
B
Diazepam
C
Vitamin K
D
Ca-channel blockers
E
Anticholinergics
Question 61 Explanation: 
ANSWER: Diazepam ; Anticholinergics ; Ca-channel blockers ; RATIONALE: Drugs listed in these numbers lower the LES (lower esophageal sphincter) pressure.
Question 62
Which of the following would be the appropriate goal/s in caring for a client with an organic mental disorder?
A
Protect the client from injury
B
Retain the client’s optimal cognitive function
C
Minimize the client’s fear or anxiety
D
Increase the client’s confidence
Question 62 Explanation: 
ANSWER: Protect the client from injury ; Minimize the client’s fear or anxiety ; Retain the client’s optimal cognitive function ; RATIONALE: Organic Mental disorders such as delirium, dementia and organic brain syndrome should be cared for with the following goals to keep in mind: • Client will be protected from injury • Fear or anxiety is reduced • Retain the client’s optimal cognitive function and self-care abilities
Question 63
Which dietary regimen is advisable for the client with angina pectoris? Select all that apply.
A
Low sodium diet
B
High fiber diet
C
Bland diet
D
High protein diet
E
Low fat diet
Question 63 Explanation: 
ANSWER: Low sodium diet ; Low fat diet ; High fiber diet ; RATIONALE: The cleint’s diet should be low in Na, low fat and low cholesterol and high in fiber. Avoid saturated fats and always read labels before buying prepared foods.
Question 64
Which of the following is an appropriate nursing intervention for a client with a bipolar disorder in a manic episode?
A
Provide therapeutic touch
B
Use distraction to divert client from behaviors that are harmful to self or others
C
Be accepting of hostile statements
D
Assist the client in focusing on a topic
E
Use passive listening and allow the client to talk
Question 64 Explanation: 
ANSWER: Assist the client in focusing on a topic ; Be accepting of hostile statements ; Use distraction to divert client from behaviors that are harmful to self or others ; RATIONALE: In a manic episode of bipolar disorder the nurse should determine what the client is attempting to tell and use an ACTIVE form of listening. Therapeutic touch should never be provided but rather maintaining a certain distance from the client would prevent the nurse from getting hurt while not leaving the client unattended.
Question 65
Family therapy serves for which purpose? Select all that apply.
A
Resolving family issues and conflicts
B
Discussing the member’s involvement in the issue/problem
C
Self-understanding
D
Promoting family function
E
Improving relationship among family members
Question 65 Explanation: 
ANSWER: Promoting family function ; Resolving family issues and conflicts ; Improving relationship among family members ; RATIONALE: • Promoting family function – purpose of family therapy • Self-understanding – goal of group therapy • Resolving family issues and conflicts – purpose of family therapy • Discussing the member’s involvement in the issue/problem – process involved in family therapy • Improving relationship among family members – purpose of family therapy
Question 66
Humanistic theories focus on a person’s quality, capacity to change and promotion of self-esteem. According to Maslow’s hierarchy of needs self-actualization needs is a person’s of which of the following? Select all that apply.
A
Creativity
B
Self-fulfillment
C
Oxygen
D
Aesthetic needs
E
Freedom from anxiety
F
Protection
G
Spirituality
H
Freedom from sense of worthlessness
Question 66 Explanation: 
ANSWER: Aesthetic needs ; Self-fulfillment ; Creativity ; Spirituality ; RATIONALE: • Aesthetic needs – self-actualization • Freedom from sense of worthlessness – self-esteem • Oxygen – physiologic • Freedom from anxiety – safety • Self-fulfillment – self-actualization • Creativity – self- actualization • Spirituality – self-actualization • Protection – safety
Question 67
Which should be instructed to the client with a sliding hiatal hernia? Select all that apply.
A
Eat three large meals in a day – no in-between snacks are allowed
B
Dinner should be taken 4 hours before bedtime
C
Elevate HOB 6-12 inches when sleeping
D
1-2 hours before and after eating the client should assume an upright position
E
Evening snacks must not contain foods such as coffee and chocolate
Question 67 Explanation: 
ANSWER: Elevate HOB 6-12 inches when sleeping ; 1-2 hours before and after eating the client should assume an upright position ; Dinner should be taken 4 hours before bedtime ; RATIONALE: The client should have a small frequent feedings (about 4-6 meals) throughout the day. No evening snacks are allowed to these patients and dinner should be taken at least 3 hours before bedtime.
Question 68
Which of the following are possible risks of performing renal biopsy? Select all that apply.
A
Flatulence
B
Infection
C
Hematoma
D
Diarrhea
E
Bleeding
Question 68 Explanation: 
ANSWER: Bleeding ; Hematoma ; Infection ; RATIONALE: The risks of performing a renal biopsy are bleeding, hematoma and infection.
Question 69
In communicating with children, what techniques should the nurse use? Select all that apply.
A
Compare the child’s progress to other children
B
Explain what you are going to do and give reasons for it
C
Speak in a pleasant tone
D
Stand erect and look at the child downwards when talking
E
Do not lie about something you cannot keep
Question 69 Explanation: 
ANSWER: Speak in a pleasant tone ; Do not lie about something you cannot keep ; Explain what you are going to do and give reasons for it ; RATIONALE: The child’s progress should not be compared to anyone else. When talking to children bend down to meet the child on own level.
Question 70
Freud described personality based on the presence of id, ego and superego. Which of the following describes ego? Select all that apply.
A
Present at birth
B
The aggressive energy
C
Develops as the person unconsciously incorporates standards and restrictions
D
Control and regulate instinctual drive
E
Operates on pleasure principle
F
Operates on reality principle
Question 70 Explanation: 
ANSWER: Control and regulate instinctual drive ; Operates on reality principle ; RATIONALE: • Present at birth – id • Develops as the person unconsciously incorporates standards and restrictions – superego • Control and regulate instinctual drive – ego • Operates on pleasure principle – id • The aggressive energy – id • Operates on reality principle – ego
Question 71
Early signs of dumping syndrome are the following. Select all that apply.
A
Hypoglycemia
B
Constipation
C
Pallor
D
Weakness
E
Nausea
F
Bradycardia
Question 71 Explanation: 
ANSWER: Nausea ; Weakness ; Pallor ; RATIONALE: Tachycardia is noted in dumping syndrome not bradycardia. There is diarrhea (explosive), abdominal cramps not constipation. Hypoglycemia is a late sign of dumping syndrome.
Question 72
Which of the following correctly described a mild mental retardation? Select all that apply.
A
It occurs at about 80% of the cases
B
Intellectual impairment is noticeable in these children
C
The child is educable to the 2nd grade level
D
The child may be able to become self-supporting
Question 72 Explanation: 
ANSWER: It occurs at about 80% of the cases ; The child may be able to become self-supporting ; RATIONALE: Mild mental retardation occurs about 80% of all cases of MR. the child is educable until the 6th grade and is able to become self-supporting.
Question 73
Which is an opioid? Select all that apply.
A
Some appetite suppressant
B
Morphine
C
Methadone
D
Heroin
E
LSD
F
Mescaline
Question 73 Explanation: 
ANSWER: Heroin ; Morphine ; Methadone ; RATIONALE: • Some appetite suppressant - amphetamine • LSD – Hallucinogen • Heroin – opioid (narcotic) • Morphine - opioid (narcotic) • Methadone - opioid (narcotic) • Mescaline – Hallucinogen
Question 74
To disintegrate blood clot by activating the fibrinolytic process in MI, which of the following should be administered?
A
Urokinase
B
Morphine Sulfate
C
Tissue plasminogen activator (PTA)
D
Lidocaine
E
Streptokinase
Question 74 Explanation: 
ANSWER: Streptokinase ; Tissue plasminogen activator (PTA) ; Urokinase ; RATIONALE: • Morphine Sulfate – for pain relief • Streptokinase - To disintegrate blood clot by activating the fibrinolytic process • Lidocaine – for pain relief • Tissue plasminogen activator (PTA) - To disintegrate blood clot by activating the fibrinolytic process • Urokinase - To disintegrate blood clot by activating the fibrinolytic process
Question 75
One of the surgical management of angina pectoris is coronary artery bypass graft (CABG). Which of the following is a correct statement about this procedure? Select all that apply.
A
It is recommended if severe narrowing of one or more branches of the coronary arteries exist.
B
The main purpose of CABG is myocardial revascularization.
C
It is the mechanical dilatation of the coronary vessel wall by compressing the atheromatous plaque.
D
It is recommended for clients with single-vessel coronary artery disease.
Question 75 Explanation: 
ANSWER: The main purpose of CABG is myocardial revascularization. ; It is recommended if severe narrowing of one or more branches of the coronary arteries exist. ; RATIONALE: • It is the mechanical dilatation of the coronary vessel wall by compressing the atheromatous plaque. – percutaneous transluminal coronary angioplasty (PTCA) • The main purpose of CABG is myocardial revascularization. - CABG • It is recommended for clients with single-vessel coronary artery disease. - percutaneous transluminal coronary angioplasty (PTCA) • It is recommended if severe narrowing of one or more branches of the coronary arteries exist. – CABG
Question 76
To evaluate the intellectual performance of a client the nurse must asses which of the following? Select all that apply.
A
Short and long term memory
B
Loose associations
C
Amount, volume and clarity of speech
D
Content of thoughts and clarity
E
Attention and concentration
F
Ability to use abstraction
Question 76 Explanation: 
ANSWER: Ability to use abstraction ; Short and long term memory ; Attention and concentration ; RATIONALE: • Ability to use abstraction – intellect • Amount, volume and clarity of speech – speech • Short and long term memory – intellect • Loose associations – thoughts • Content of thoughts and clarity – thoughts • Attention and concentration – intellect
Question 77
Urinary antiseptics that can be used in UTI are which of the following? Select all that apply.
A
Co-trimoxazole (Bactrim)
B
Nalidixic Acid (NegGram)
C
Metheramine Mandelate (Mandelamine)
D
Sulfisoxazole (Gantrisin)
E
Cinoxacin (Cinobac)
Question 77 Explanation: 
ANSWER: Cinoxacin (Cinobac) ; Nalidixic Acid (NegGram) ; Metheramine Mandelate (Mandelamine) ; RATIONALE: • Cinoxacin (Cinobac) - Urinary antiseptic • Co-trimoxazole (Bactrim) - Sulfonamide • Nalidixic Acid (NegGram) - Urinary antiseptic • Sulfisoxazole (Gantrisin) - Sulfonamide • Metheramine Mandelate (Mandelamine) - Urinary antiseptic
Question 78
Which characteristics are expected in a client with dementia? Select all that apply.
A
Reduced awareness of environment
B
Exaggeration of former character traits
C
Speech and attention deficits
D
Inability to perform basic ADL
E
Occurs postoperatively or usually following head injury
F
May be temporary or progressive memory loss
G
Memory impairment
Question 78 Explanation: 
ANSWER: Memory impairment ; May be temporary or progressive memory loss ; Exaggeration of former character traits ; Inability to perform basic ADL ; RATIONALE: • Occurs postoperatively or usually following head injury – delirium • Memory impairment – dementia • May be temporary or progressive memory loss – dementia • Exaggeration of former character traits – dementia • Reduced awareness of environment – delirium • Speech and attention deficits – delirium • Inability to perform basic ADL – dementia
Question 79
Which of the following is expected during the orientation phase of the nurse-client relationship? Select all that apply.
A
Developing a plan of care based on appropriate nursing diagnosis
B
Termination of relationship is introduced
C
Goal evaluation
D
Employing therapeutic techniques
E
Client’s needs and problems are identified.
F
Summarization of relationship growth and progress
Question 79 Explanation: 
ANSWER: Termination of relationship is introduced ; Developing a plan of care based on appropriate nursing diagnosis ; RATIONALE: • Client’s needs and problems are identified. – working phase • Summarization of relationship growth and progress – termination • Termination of relationship is introduced – orientation • Developing a plan of care based on appropriate nursing diagnosis – orientation • Employing therapeutic techniques – working • Goal evaluation – working
Question 80
Which of the following are risk factors of bladder cancer? Select all that apply.
A
Bladder calculi
B
Hematuria
C
Chronic cystitis
D
Histoplasmosis
E
Use of cyclophosphamide
Question 80 Explanation: 
ANSWER: Chronic cystitis ; Use of cyclophosphamide ; Bladder calculi ; RATIONALE: Risk factors of bladder cancer: • Chronic cystitis • Use of cyclophosphamide • Bladder calculi • Exposure to cigarette smoke • Pelvic radiation • Schistosomiasis • Large phenacetin intake
Question 81
After cardiac catheterization using the femoral site, the nurse should perform which of the following? Select all that apply.
A
Assess for allergy to iodine/seafoods
B
Immobilize affected extremity
C
Apply pressure dressing and a small ice bag or ice over the punctured area
D
Have the client void
E
Elevate HOB to 30-45 degrees
F
Monitor ECG
Question 81 Explanation: 
ANSWER: Apply pressure dressing and a small ice bag or ice over the punctured area ; Immobilize affected extremity ; Monitor ECG ; RATIONALE: • Have the client void – before procedure • Assess for allergy to iodine/seafoods – before procedure • Apply pressure dressing and a small ice bag or ice over the punctured area – to prevent bleeding • Immobilize affected extremity – to promote adequate circulation • Elevate HOB to 30-45 degrees – do not elevate HOB to more than 30 degrees if the femoral site was used • Monitor ECG – note for dysrhythmias
Question 82
Inability of the kidneys to excrete metabolic waste products of protein through urine formation would result to which clinical findings? Select all that apply.
A
Oliguria
B
Anemia
C
Azotemia
D
Hyperkalemia
Question 82 Explanation: 
ANSWER: Oliguria ; Azotemia ; RATIONALE: Inability of the kidneys to excrete metabolic waste products of protein through urine formation would result to: • Oliguria • Azotemia • Uniferous odor of breath • Stomatitis and GI bleeding – urea is converted back into ammonia which irritates mucous membrane • Destruction of rbc, wbc and platelets • Renal encephalopathy
Question 83
Nursing interventions in MRI include which of the following? Select all that apply.
A
Inform the client that the MRI unit is very quiet, thus, she must not make any loud noises
B
Recently implanted clips or wires implanted to the client should be removed before the client undergoes MRI
C
Assess for claustrophobia
D
Secure written consent
E
Instruct the client to remain still during the procedure
Question 83 Explanation: 
ANSWER: Assess for claustrophobia ; Secure written consent ; Instruct the client to remain still during the procedure ; RATIONALE: • Inform the client that the MRI unit is very quiet, thus, she must not make any loud noises – the MRI unit makes a loud, knocking noise • Assess for claustrophobia – the client will be placed in a tunnel-like device • Secure written consent – needed to be done before the procedure • Instruct the client to remain still during the procedure – necessary during the procedure • Recently implanted clips or wires implanted to the client should be removed before the client undergoes MRI – clients with prosthetics/pacemakers or those who have recently implanted clips/wired are not eligible for MRI scans
Question 84
Nursing interventions for clients with anorexia include which of the following? Select all that apply.
A
Staying with the client during meals
B
Focusing on the food and the amount taken by the client
C
Allowing the client to rest alone after meals
D
Measuring I and O
E
Weighing the client 3 times a week at the same time
Question 84 Explanation: 
ANSWER: Measuring I and O ; Staying with the client during meals ; Weighing the client 3 times a week at the same time ; RATIONALE: The client should be accompanied to the bathroom or anywhere in the room for at least a half hour after eating to prevent self-induced vomiting. The focus should be on the client not on the food.
Question 85
Which of the following should be avoided by the client with a PUD? Select all that apply.
A
Antacids
B
Bland foods
C
Large quantities of milk
D
Fatty foods
E
Binge eating
Question 85 Explanation: 
ANSWER: Binge eating ; Fatty foods ; Large quantities of milk ; RATIONALE: Bland diet is deal for clients with PUD. Antacids are used for neutralizing HCL in PUD. Only 400 ml/day of milk is allowed in clients with PUD.
Question 86
Group therapy serves for the following purposes. Select all that apply.
A
Dealing with particular stressors
B
Increasing self-awareness
C
Increasing funds
D
Improving interpersonal relationships
E
Preventing hospitalization
Question 86 Explanation: 
ANSWER: Increasing self-awareness ; Improving interpersonal relationships ; Dealing with particular stressors ; RATIONALE: The purposes of group therapy are: • Increasing self-awareness • Improving interpersonal relationships • Dealing with particular stressors • Make changes in behavior
Question 87
An alcoholic client is admitted in a psychiatric facility. The nurse would be alerted that the client is progressing from alcohol withdrawal symptoms to delirium tremens of the following clinical manifestations are noted. Select all that apply.
A
Agitation
B
Hallucinations
C
Bradycardia
D
Confabulation
E
Ataxia
F
Delusions
G
Increased BP
H
Confusion
Question 87 Explanation: 
ANSWER: Increased BP ; Delusions ; Hallucinations ; Agitation ; RATIONALE: Signs of delirium tremens include tachycardia, increased BP, agitation, delusions and hallucinations.
Question 88
Which of the following clinical findings are observed in toxic shock syndrome? Select all that apply.
A
Acidosis
B
Red macular rash
C
Constipation
D
High fever
E
Hypertension
Question 88 Explanation: 
ANSWER: Acidosis ; Red macular rash ; High fever ; RATIONALE: Assessment findings in toxic shock syndrome: • Acidosis • Red macular rash • High fever • Hypotension • Diarrhea • Vomiting
Question 89
The client is scheduled for fecal analysis. Which of the following should the nurse instruct the client to withhold for 48 hours before the procedure? Select all that apply.
A
Steroids
B
Colchicines
C
Fiber
D
Soda
E
Calcium-channel blockers
F
Green leafy vegetables
G
Indomethacin
Question 89 Explanation: 
ANSWER: Steroids ; Indomethacin ; Colchicines ; RATIONALE: For 48 hours the client should withhold steroids, indomethacin and colchicines because these drugs may cause GI irritation thereby, bleeding. Fiber should be increased in the diet.
Question 90
The nurse is preparing the client for an ECG. Which of the following ECG changes are expected of this client if he has hypokalemia? Select all that apply.
A
Peaked T-wave
B
Pathologic Q wave
C
Short T wave
D
Elevated ST segment
E
Depressed ST segment
F
U-wave
G
Inverted T wave
H
Peaked T wave
Question 90 Explanation: 
ANSWER: U-wave ; Depressed ST segment ; Short T wave ; RATIONALE: • U-wave – hypokalemia • Peaked T-wave – hyperkalemia • Depressed ST segment – hypokalemia • Short T wave – hypokalemia • Elevated ST segment – hyperkalemia • Peaked T wave – hyperkalemia • Pathologic Q wave – MI • Inverted T wave – MI
Question 91
A client is scheduled for retrograde pyelogram. Which nursing interventions are appropriate during the preparation phase?
A
Preparing Lidocaine as anaphylactic shock is the most life threatening condition
B
Inform on discomfort of the procedure
C
Securing written consent
D
Monitoring VS
E
Assess for allergy to the dye
F
Observing the client for infection
Question 91 Explanation: 
ANSWER: Securing written consent ; Inform on discomfort of the procedure ; Assess for allergy to the dye ; RATIONALE: Interventions listed in 1 and 4 are appropriate after the procedure. Epinephrine should be prepared not Lidocaine to combat anaphylactic shock.
Question 92
NGT insertion serves for which purpose? Select all that apply.
A
For decompression
B
Administer IV fluids
C
Administer medications
D
Stomach irrigation
Question 92 Explanation: 
ANSWER: For decompression ; Stomach irrigation ; Administer medications ; RATIONALE: Purposes of NGT insertion: • For decompression • Stomach irrigation • Administer medications • To provide feeding • Administer supplemental fluids
Question 93
If the kidneys are unable to metabolize Vitamin D, which clinical findings would result? Select all that apply.
A
Hyperphosphatemia
B
Hypocalcemia
C
Renal encephalopathy
D
Renal osteodystrophy
E
Azotemia
Question 93 Explanation: 
ANSWER: Hypocalcemia ; Renal osteodystrophy ; Hyperphosphatemia ; RATIONALE: If the kidneys are unable to metabolize Vitamin D, the following will be noted: • Hypocalcemia • Renal osteodystrophy • Hyperphosphatemia
Question 94
After cystocopy, the nurse should observe the client for which abnormal signs? Select all that apply.
A
Pink-tinged urine
B
Prolonged or excessive hematoma
C
Urinary frequency
D
Signs of infection
Question 94 Explanation: 
ANSWER: Signs of infection ; Prolonged or excessive hematoma ; RATIONALE: The nurse should observe the client for: • Urine retention • Signs of infection • Prolonged or excessive hematoma
Question 95
Which of the following laboratory result should alert the nurse? Select all that apply.
A
Serum Chloride: 108 mEq/L
B
BUN: 30 mg/dl
C
Protein in urine: +1
D
Hct: 38%
E
Serum Creatinine: 3 mg/dl
Question 95 Explanation: 
ANSWER: BUN: 30 mg/dl ; Serum Creatinine: 3 mg/dl ; Protein in urine: +1 ; RATIONALE: • BUN: 30 mg/dl – normal range: 10-20 mg/dl • Serum Creatinine: 3 mg/dl – normal range: 0.4-1.2 mg/dl • Hct: 38% - normal value: 38-54% • Serum Chloride: 108 mEq/L – normal range: 98-108 mEq/L • Protein in urine: +1 – absent in urine
Question 96
Which is a component in routine urinalysis? Select all that apply.
A
Specific gravity
B
WBC
C
RBC
D
Serum Sodium
E
BUN
Question 96 Explanation: 
ANSWER: Specific gravity ; WBC ; RBC ; RATIONALE: BUN and Serum sodium are components of blood studies not routine urinalysis.
Question 97
Management of dumping syndrome includes which of the following? Select all that apply.
A
Foods from the refrigerator are allowed
B
Carbohydrates should be limited and simple sugars should be eliminated in the diet
C
Instruct the client to elevate the head of bed after meals
D
Fluids should be given after meals
E
Small frequent feedings are advised
Question 97 Explanation: 
ANSWER: Small frequent feedings are advised ; Carbohydrates should be limited and simple sugars should be eliminated in the diet ; Fluids should be given after meals ; RATIONALE: • Instruct the client to elevate the head of bed after meals – after meals the client should lie down (on the left side) • Foods from the refrigerator are allowed – very hot and cold foods should be avoided
Question 98
Which of the drugs can predispose the occurrence of a peptic ulcer disease (PUD)? Select all that apply.
A
Steroids
B
Beer
C
Caffeine
D
ASA
E
NSAIDs
F
Antibacterial drugs
Question 98 Explanation: 
ANSWER: Steroids ; ASA ; NSAIDs ; RATIONALE: Drugs that can cause PUD are those listed in 3, 4 and 5. Caffeine and alcohol (beer) can also predispose a client to having a PUD but the question’s criteria is “drugs” thus, 1 and 2 are incorrect.
Question 99
Overdose with cannabis includes which clinical manifestations? Select all that apply.
A
Suicide
B
Panic reaction
C
Violent behavior
D
Delirium
E
Nausea and vomiting
F
Respiratory arrest
G
Disorders of perception
Question 99 Explanation: 
ANSWER: Panic reaction ; Disorders of perception ; Nausea and vomiting ; RATIONALE: • Panic reaction – cannabis overdose • Disorders of perception - cannabis overdose • Nausea and vomiting - cannabis overdose • Respiratory arrest – PCP overdose • Delirium - PCP overdose • Suicide - PCP overdose • Violent behavior - PCP overdose
Question 100
Clinical findings in gastritis include which of the following? Select all that apply.
A
Constipation
B
Painful GI bleeding
C
Nausea and vomiting
D
Hypothermia
E
Epigastric pain
Question 100 Explanation: 
ANSWER: Nausea and vomiting ; Epigastric pain ; RATIONALE: S/S of gastritis: • Fever • Painless GI bleeding • Nausea and vomiting • Diarrhea, abdominal cramping • Epigastric pain • Anorexia
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