Pre-Board Nursing Exam for May 2014 NLE [SATA]

This Pre-Board Nursing Exam contains 100 Select all That Apply 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 May 2014 NLE [SATA]

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Question 1
Human cancers are majorly related to environmental carcinogens. Physical environmental carcinogens include which of the following. Select all that apply.
A
Cigarette smoking
B
Alkylating agents
C
Trauma
D
X-rays
E
Ultraviolet rays
Question 1 Explanation: 
ANSWER: Trauma ; Ultraviolet rays ; X-rays ; RATIONALE: Majority (over 80%) of human cancers related to environmental carcinogens. The types of environmental carcinogens are: Physical • Radiation: x-rays, radium, nuclear explosion or waste, UV • Trauma or chronic irritation Chemical • Nitrites and food additives, alkylating agents • Drugs: arsenicals, stilbesterol • Cigarrete smoke • Hormones
Question 2
Which child is expected to be in Piaget’s Preoperational thought stage of cognitive development? Select all that apply.
A
24-month old Roger
B
A preschooler kid named Argel
C
36 months old Dina
D
Stephanie on the 6th grade
E
9-month old baby Elise
F
Lady Mabelle who is a toddler
Question 2 Explanation: 
ANSWER: 24-month old Roger ; Lady Mabelle who is a toddler ; A preschooler kid named Argel ; 36 months old Dina ; RATIONALE: Preoperational thought stage of Piaget’s cognitive development is from 2 years old to 7 years of age.
Question 3
In a client with diarrhea, which outcome indicates that fluid resuscitation is successful? Select all that apply.
A
Absence of erythema in perianal skin and mucous membranes
B
Formed stools at regular intervals
C
Moist mucous membranes
D
Firm skin turgor
E
Urine output of at least 30 ml/hour
F
Decrease in stool frequency and liquidity
Question 3 Explanation: 
ANSWER: Firm skin turgor ; Moist mucous membranes ; Urine output of at least 30 ml/hour ; RATIONALE: Because of the criteria in the question, FLUID RESUSCITATION, the diagnosis for diarrhea in this case is narrowed to Deficient Fluid Volume related to excessive fluid loss in stool. Thus, fluid resuscitation is needed and expected outcomes of successful intervention include: • Firm skin turgor • Moist mucous membranes • Urine output of at least 30 ml/hr The client also has a nursing diagnosis of diarrhea with the following expected outcomes: • Passage of formed stools at regular intervals • Decrease in stool frequency and liquidity
Question 4
A client is scheduled for a sputum exam. Which of the following teaching is appropriate to instruct to the client? Select all that apply.
A
The sputum to be collected is obtained before sleeping
B
If the sputum collected is for AFB staining, the specimen should be collected for 5 consecutive mornings
C
Rinse mouth with plain water before collecting the specimen
D
Sputum specimen for C and s is collected before the first dose of antimicrobial
E
A sterile water should be used in rinsing the mouth
Question 4 Explanation: 
ANSWER: Rinse mouth with plain water before collecting the specimen ; A sterile water should be used in rinsing the mouth ; Sputum specimen for C and s is collected before the first dose of antimicrobial ; RATIONALE: The sputum should be collected early in the morning. If the sputum collected is for AFB staining, the specimen should be collected for 3 NOT 5 consecutive mornings.
Question 5
Which of the following would be included in the list of emergency supplies needed in case of a disaster? Select all that apply.
A
Passport and birth certificate
B
Sanitation supplies
C
Computer components
D
Candles and matches
E
One change of clothing and protective footwear
Question 5 Explanation: 
ANSWER: Candles and matches ; One change of clothing and protective footwear ; Sanitation supplies ; RATIONALE: All items except the passport or birth certificate and computer components should be listed as needed in case of a disaster.
Question 6
Dietary recommendations against cancer include the following. Select all that apply.
A
Moderate consumption of salty foods should be encouraged
B
Cut down on total caloric intake
C
Avoid obesity
D
Make sure to include foods rich in vitamin A and C in the diet
E
Alcoholic beverages should be avoided
F
Whole grain cereals should be minimized
Question 6 Explanation: 
ANSWER: Avoid obesity ; Make sure to include foods rich in vitamin A and C in the diet ; Moderate consumption of salty foods should be encouraged ; RATIONALE: Total intake of fat should be cut down. Whole grain cereals should be increased in the diet to increase fiber intake. Alcoholic beverage intake should be moderated not avoided.
Question 7
A client with a cardiovascular disorder is scheduled for a blood coagulation test. Which of the following laboratory tests is a blood coagulation test? Select all that apply.
A
Lactic dehydrogenase
B
Aspartate Aminotransferase
C
Serum sodium
D
Partial thromboplastin time
E
Prothrombin time
Question 7 Explanation: 
ANSWER: Partial thromboplastin time ; Prothrombin time ; RATIONALE: • Partial thromboplastin time – blood coagulation test • Serum sodium – serum electrolytes • Lactic dehydrogenase – enzyme studies • Prothrombin time – blood coagulation test • Aspartate Aminotransferase – enzyme studies
Question 8
A client has been suspected with air embolism. Which clinical manifestations are expected of this client? Select all that apply.
A
Unconsciousness
B
Coldness at the site
C
Hypertension
D
Rise in venous pressure
E
Edema
F
Cyanosis
G
Tachycardia
H
Swelling at the site
Question 8 Explanation: 
ANSWER: Cyanosis ; Tachycardia ; Unconsciousness ; Rise in venous pressure ; RATIONALE: In air embolism the expected clinical manifestations are cyanosis, hypotension, tachycardia, rise in venous pressure and unconsciousness.
Question 9
To maintain a clean and patent airway in an unconscious patient, which interventions should be performed by the nurse? Select all that apply.
A
Check respiratory rate, depth and quality every 1-2 hours and as needed.
B
Protect patient if seizure occurs.
C
Suction as needed.
D
Place patient in a side-lying position.
E
Auscultate breath sounds for rales, rhonchi or absent breath sounds every 4 hours and before and after suctioning.
F
Keep side rails up all the time.
Question 9 Explanation: 
ANSWER: Suction as needed. ; Place patient in a side-lying position. ; Check respiratory rate, depth and quality every 1-2 hours and as needed. ; Auscultate breath sounds for rales, rhonchi or absent breath sounds every 4 hours and before and after suctioning. ; RATIONALE: Interventions listed in 2 and 4 are important in providing client safety but is not essential in maintaining a clear and patent airway.
Question 10
Which procedure requires a chest tube placement and a semi-fowler’s position or on unaffected side position post-op?
A
Wedge resection
B
Decortication
C
Segmentectomy
D
Lobectomy
E
Pneumonectomy
F
Thoracoplasty
Question 10 Explanation: 
ANSWER: Lobectomy ; Segmentectomy ; Wedge resection ; Decortication ; Thoracoplasty ; RATIONALE: Placement of chest tube and placing the client in a semi-fowler’s position or on the unaffected side to allow expansion of the affected lung is done postoperatively in the procedures listed in 2-6. Fully side-lying position is avoided after pneumonectomy to prevent mediastinal shift. In general, no chest tube is placed after this procedure.
Question 11
Late signs of bronchogenic cancer include which of the following? Select all that apply.
A
Fever
B
Weakness
C
Edema around the neck
D
Hacking cough with a thick blood-tinged sputum
E
Anemia
F
Weight loss
Question 11 Explanation: 
ANSWER: Weakness ; Anemia ; Weight loss ; RATIONALE: Late signs of bronchogenic cancer include weakness, weight loss, anorexia and anemia.
Question 12
Basic principles on pain and its assessment include the following. Select all that apply
A
Administering pain medications will eventually lead to addition
B
Client should show verbal and non-verbal signs that he is in pain
C
Each person’s expression of pain may be different and individualized
D
Pain level and tolerance can be assessed from a scale of 1 to 10
E
The client needs to be reassured that the nurse believes about his statement of pain
F
IV narcotics are the longest acting pain relief technique
Question 12 Explanation: 
ANSWER: Each person’s expression of pain may be different and individualized ; Pain level and tolerance can be assessed from a scale of 1 to 10 ; The client needs to be reassured that the nurse believes about his statement of pain ; RATIONALE: Each person’s expression of pain may be different. In expressing the pain, the client needs to know that the nurse believes what they are saying. Pain level and pain tolerance can be assessed using a scale of 1-10.
Question 13
A middle-adult’s developmental task is met if he or she achieves the following. Select all that apply.
A
Form long-lasting relationships
B
Take pride in new accomplishments and want to do everything independently
C
Happily accepts a late-in-life pregnancy
D
Better able to juggle their various lives as a mother, office worker and group chairperson
E
Participate in far-reaching community decisions
Question 13 Explanation: 
ANSWER: Better able to juggle their various lives as a mother, office worker and group chairperson ; Participate in far-reaching community decisions ; Happily accepts a late-in-life pregnancy ; RATIONALE: The developmental task of middle age is to establish a sense of generativity versus stagnation. People extend their concern from just themselves and their families to the community and world. They become politically active, are self-confident and can juggle their various lives/roles as a mother, office worker and group chairperson. Women without a sense of generativity may have more difficulty than others accepting a late-in-life pregnancy and a new role of childbearing and childrearing.
Question 14
Which of the following should the nurse watch out after bronchoscopy? Select all that apply.
A
Dyspnea
B
Hypertension
C
Jaundice
D
Nausea
E
Arrhythmias
F
Tachycardia
Question 14 Explanation: 
ANSWER: Tachycardia ; Arrhythmias ; Dyspnea ; RATIONALE: After bronchoscopy, the nurse should watch out for cyanosis,hypotension, tachycardia, arrhythmias, hemoptysis and dyspnea. These signs and symptoms indicate performation of the bronchial tree.
Question 15
Radiation therapy has side effects. One of these expected side effects is stomatitis.  Nursing interventions for stomatitis includes which of the following? Select all that apply.
A
Giving the client sugarless lemon drops
B
Saline rinses every 2 hours
C
Monitoring platelet count
D
Instructing the client to follow a bland diet regimen
E
Administration of aspirin before meals
F
Applying heat on the area
Question 15 Explanation: 
ANSWER: Instructing the client to follow a bland diet regimen ; Saline rinses every 2 hours ; Giving the client sugarless lemon drops ; RATIONALE: Stomatitis is the ulceration of oral mucous membrane which is managed by performing the following: • Administer analgesics before meals • Bland diet/no smoking/alcohol • Saline rinses every 2 hours/ good oral hygiene • Sugarless lemon drops/mint to increase salivation
Question 16
A male client is scheduled for a semen analysis. Instructions to be given to this client should include which of the following? Select all that apply.
A
The client should abstain from sex for 1 week before semen analysis
B
The spermatozoa are examined within 1 hour after ejaculation
C
The analysis may need to be repeated after 2-3 months
D
The man masturbates into a clean, dry specimen jar with a secure lid
E
Use lubricants when collecting the specimen
F
Place the collected specimen in an ice box while transporting it
G
Collect the specimen as close as possible to the client’s usual schedule of sexual activity
Question 16 Explanation: 
ANSWER: The spermatozoa are examined within 1 hour after ejaculation ; The analysis may need to be repeated after 2-3 months ; The man masturbates into a clean, dry specimen jar with a secure lid ; Collect the specimen as close as possible to the client’s usual schedule of sexual activity ; RATIONALE: For a semen analysis, after 2-4 days of sexual abstinence, the man ejaculates by masturbation into a clean dry container with a secure lid. Lubricant use should be avoided when collecting the specimen and it should be kept at body temperature while transporting for analysis.
Question 17
The nurse is performing a neurological check-up on a patient. Which findings would not necessitate further evaluation? Select all that apply.
A
Pupils constrict in response to light
B
GCS of 5/15
C
The patient blinks when the cornea is lightly stroked
D
Decorticate posturing is noted
E
Patient is oriented to time date and place
Question 17 Explanation: 
ANSWER: Patient is oriented to time date and place ; Pupils constrict in response to light ; The patient blinks when the cornea is lightly stroked ; RATIONALE: Decorticate posture may suggest damage to corticospinal tracts and a GCS score of only 5 from a scale of 15 needs further evaluation.
Question 18
Effects of total laryngectomy include the following. Select all that apply.
A
Inability to gargle
B
Tracheostomy placement for 2 weeks
C
Inability to whistle
D
Loss of the sense of smell
E
Softer voice produced when speaking
Question 18 Explanation: 
ANSWER: Loss of the sense of smell ; Inability to whistle ; Inability to gargle ; RATIONALE: After laryngectomy a permanent tracheostomy is placed. Loss of voice is also noted together with the effects listed in 1, 2 and 5.
Question 19
A client had undergone a simple mastectomy. Which of the following should be instructed to this client after the procedure? Select all that apply.
A
Always carry a purse with either arms when walking
B
Apply lanolin hand cream to prevent dryness
C
Reach out into a hot oven
D
Make sure to cut the cuticles regularly
E
Wear a loose rubber glove when washing dishes
F
Use a thimble when sewing
G
Wristwatch or jewelries at the affected side is allowed but it has to be very light
Question 19 Explanation: 
ANSWER: Wear a loose rubber glove when washing dishes ; Apply lanolin hand cream to prevent dryness ; Use a thimble when sewing ; RATIONALE: Don’ts after a simple mastectomy: (on the affected side) • Carry purse/ anything heavy • Wear wristwatch/ jewelry • Pick at/ cut cuticles • Work near thorny plant or dig in garden • Reach into a hot oven • Hold a cigarette • Injections, withdrawal of blood, BP-taking
Question 20
Common clinical manifestations of cardiovascular disorders include which of the following? Select all that apply.
A
Diarrhea
B
Orthopnea
C
Weight loss
D
Edema
E
Cystitis
F
Infection
G
Syncope
Question 20 Explanation: 
ANSWER: Orthopnea ; Edema ; Syncope ; RATIONALE: Clinical manifestations listed in 4-7 are the common side effects of radiation therapy.
Question 21
The following principles of operant conditioning described by Skinner form the basis for behavior techniques today. Select all that apply.
A
All behavior is learned.
B
Behavior that is rewarded with reinforces tends to recur.
C
Continuous reinforcement will last long.
D
Consequences results from behavior.
E
Random intermittent reinforcement is faster to produce an increase in behavior.
F
Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur.
Question 21 Explanation: 
ANSWER: All behavior is learned. ; Behavior that is rewarded with reinforces tends to recur. ; Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. ; Consequences results from behavior. ; RATIONALE: The following principles of operant conditioning described by Skinner form the basis for behavior techniques today: • All behavior is learned. • Random intermittent reinforcement is slower to produce an increase in behavior. • Behavior that is rewarded with reinforces tends to recur. • Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. • Continuous reinforcement will not last long after the reward ceases. • Consequences results from behavior.
Question 22
Albuminuria is detected in clients having which condition? Select all that apply.
A
Malignant hypotension
B
Pneumonia
C
ARDS
D
CHF
E
Histoplasmosis
F
Hypotension
Question 22 Explanation: 
ANSWER: Malignant hypotension ; CHF ; RATIONALE: Albuminuria is detected in clients with malignant hypertension and CHF.
Question 23
To prevent infection post-laryngectomy the nurse should perform the following. Select all that apply.
A
Cleanse the stoma and tracheostomy at regular basis
B
Position the patient to a semi-fowler’s
C
Change dressings and ties as necessary
D
Suction the patient as necessary
E
Use a sterile NSS to lubricate the suction catheter tip
Question 23 Explanation: 
ANSWER: Cleanse the stoma and tracheostomy at regular basis ; Change dressings and ties as necessary ; RATIONALE: To prevent infection the nurse must practice cleansing the stoma and tracheostomy ate regular basis and change the ties and dressings as needed.
Question 24
To assess the current health status of the patient which questions should the nurse ask? Select all that apply.
A
Has the client shown signs of progress?
B
Is the patient capable of self-care?
C
What level of nursing care does the patient require?
D
How well is the patient progressing?
E
Is family or friends available to provide care, or is the patient alone?
F
How serious are the present signs and symptoms?
Question 24 Explanation: 
ANSWER: Has the client shown signs of progress? ; How well is the patient progressing? ; How serious are the present signs and symptoms? ; RATIONALE: Current health status: How well is the patient progressing? How serious are the present signs and symptoms? Has the patient shown signs of progressing as expected, or does it seem that recovery will be delayed?
Question 25
Predisposing factors for cancer of the larynx includes which of the following? Select all that apply.
A
Acute laryngitis
B
Environmental pollutants
C
Alcohol abuse
D
A positive family history
E
Tonsillitis recurring 5-6 times a year
Question 25 Explanation: 
ANSWER: Alcohol abuse ; A positive family history ; Environmental pollutants ; RATIONALE: Predisposing factors of laryngitis: • Cigarette smoking • Alcohol abuse • Voice abuse • Environmental pollutants • Chronic laryngitis • (+) family history
Question 26
Complications of the respiratory tract include which of the following. Select all that apply.
A
Shock
B
Atelectasis
C
DVT
D
Infection
E
Pneumonia
F
Pulmonary embolism
Question 26 Explanation: 
ANSWER: Atelectasis ; Pneumonia ; RATIONALE: Common post-op complications of respiratory tract are atelectasis and pneumonia. Pulmonary embolism is a cardiovascular system post-op complication.
Question 27
Teaching guidelines regarding radiation therapy includes the following. Select all that apply.
A
Avoid overexposure to sunlight
B
Safety precautions are necessary only during the time the client is actually receiving irradiation.
C
Remind the client that the machine may move during the therapy and the procedure usually lasts for a few minutes
D
Vent vials to reduce internal pressure after mixing
E
Mask, gloves and gown (back-closing) is used during the therapy
F
Inform the client that the procedure is painless
Question 27 Explanation: 
ANSWER: Safety precautions are necessary only during the time the client is actually receiving irradiation. ; Inform the client that the procedure is painless ; Remind the client that the machine may move during the therapy and the procedure usually lasts for a few minutes ; RATIONALE: Avoiding overexposure to sunlight is a way to prevent cancer. Guidelines in 3 and 6 are ways to handle chemotherapeutic agents safely.
Question 28
The nurse is aware about the factors that hinder defection in a hospitalized client. Select all that apply.
A
Ignoring the urge to defecate when it occurs
B
Increased activity
C
Increased fiber in the diet
D
Excessive laxative use
E
Discomfort with defecation
F
Increased fluid intake
Question 28 Explanation: 
ANSWER: Excessive laxative use ; Ignoring the urge to defecate when it occurs ; Discomfort with defecation ; Increased fluid intake ; RATIONALE: Chronic use of laxatives causes the large intestine to lose muscle tone and becomes less responsive to stimulation by laxatives. Anything that prevents a person from responding to the urge to defecate and disrupts regular habits can cause possible alterations such as constipation. Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool contents.
Question 29
Bronchoscopy is the direct inspection and observation of the larynx, trachea and bronchi. Which of the following is the therapeutic use of bronchoscopy? Select all that apply.
A
Collecting specimen for biopsy
B
Excises lesions
C
Collecting secretion
D
Determining the location of pathologic process
E
Removing foreign objects
Question 29 Explanation: 
ANSWER: Excises lesions ; Removing foreign objects ; RATIONALE: Items in 1, 4 and 5 are diagnostic purposes of bronchoscopy.
Question 30
Central lines are used for which purposes. Select all that apply.
A
TPN administration
B
Blood transfusion
C
Chemotherapy
D
IV therapy
E
Antibiotic therapy
F
GI feeding
Question 30 Explanation: 
ANSWER: TPN administration ; Antibiotic therapy ; Chemotherapy ; IV therapy ; RATIONALE: Central lines are used for TPN administration, CVP measurement, IV therapy when suitable peripheral veins are not available, long-term antibiotic therapy and chemotherapy.
Question 31
During the third trimester of her pregnancy, the client has mild preeclampsia. She is discharged home with instructions to remain on bed rest. She should also be instructed to call her doctor if she experiences which symptoms? Select all that apply.
A
Blurred vision
B
Headache
C
Difficulty sleeping
D
Severe nausea and vomiting
E
Increased urine output
F
Epigastric pain
Question 31 Explanation: 
ANSWER: Epigastric pain ; Headache ; Blurred vision ; Severe nausea and vomiting ; RATIONALE: Signs of mild preeclampsia includes epigastric pain, headache, blurred vision and severe nausea and vomiting.
Question 32
Proliferation of cancer cells produces pain due to the following reasons. Select all that apply.
A
DIC
B
Release of pain mediators by the tumor
C
Distention of vessels or organs
D
Effusion
E
Pressure on nerve endings
F
Lack of O2 to tissues and organs
G
Thrombophlebitis
Question 32 Explanation: 
ANSWER: Pressure on nerve endings ; Lack of O2 to tissues and organs ; Release of pain mediators by the tumor ; Distention of vessels or organs ; RATIONALE: Proliferation of Ca cells produces pain as a result of: • Pressure on nerve endings • Lack of O2 to tissues and organs • Release of pain mediators by the tumor • Distention of vessels or organs
Question 33
The effectiveness of monoamine oxidase inhibitors (MAOI) drug therapy in a client with posttraumatic disorder can be demonstrated by which of the following? Select all that apply.
A
Control flashbacks
B
Treat sleep problems
C
Control phobias
D
Decrease alcohol cravings
E
Treat intrusive daytime thoughts
F
Relieves the client from nightmares when sleeping
Question 33 Explanation: 
ANSWER: Treat sleep problems ; Treat intrusive daytime thoughts ; Relieves the client from nightmares when sleeping ; RATIONALE: MAOIs are used to treat sleep problems, nightmares and intrusive daytime thought in individuals with posttraumatic disorder. MAOIs inhibitors are not used to help control flashbacks or phobias or to decrease the craving for alcohol.
Question 34
Which of the following should be monitored in a client with pneumonia? Select all that apply.
A
Chest X-ray
B
Central venous pressure
C
ABG
D
Temperature
E
Sputum
Question 34 Explanation: 
ANSWER: Sputum ; Chest X-ray ; Temperature ; RATIONALE: In pneumonia the nurse should monitor for the client’s sputum, chest x-ray and temperature.
Question 35
Warning signs of cancer should be taught to the client for early diagnosis and prompt diagnosis and treatment. Which of the following are warning signals of cancer? Select all that apply.
A
Change in wart or mole
B
Heavy bleeding during menses
C
Lump in breast or elsewhere
D
Constipation
E
Nagging cough or hoarseness
F
Fever that lasts for 2 weeks
G
Sore that healed for 2 weeks
Question 35 Explanation: 
ANSWER: Change in wart or mole ; Nagging cough or hoarseness ; Lump in breast or elsewhere ; RATIONALE: Warning signs of cancer: • Change in bowel or bladder habits • Sore that doesn’t heal • Lump in breast or elsewhere • Unusual bleeding or discharge • Indigestion or dysphagia • Change in wart or mole • Nagging cough or hoarseness
Question 36
A primary excess of carbonic acid in the extracellular fluid leading to decreased in pH, elevated pCO2 and bicarbonate (if renal compensation is present) is caused by which of the following. Select all that apply.
A
Weakness of respiratory muscles
B
Hyperventilation
C
Barbiturate or sedative overdose
D
COPD
E
Diarrhea
F
Guillain-Barre syndrome
G
Mechanical overventilation
Question 36 Explanation: 
ANSWER: COPD ; Guillain-Barre syndrome ; Barbiturate or sedative overdose ; Weakness of respiratory muscles ; RATIONALE: Respiratory Acidosis, a primary excess of carbonic acid in the extracellular fluid leading to decreased in pH, elevated pCO2 and bicarbonate (if renal compensation is present), may be caused by: • COPD • Barbiturate or sedative overdose • Acute airway obstruction • Weakness of respiratory muscles • Guillain-Barre syndrome
Question 37
The mother of a 6-month old baby girl is asking about her daughter’s developmental milestones. An infant by this age is able to perform which activity? Select all that apply.
A
Use palmar grasp
B
May say vowel sounds (oh-oh)
C
Clap hands
D
Transfer objects hand to hand
E
Sit with support
F
Has social smile
Question 37 Explanation: 
ANSWER: Sit with support ; Use palmar grasp ; May say vowel sounds (oh-oh) ; RATIONALE: A 6-month old baby can do the following: • Turn both ways • Moro reflex fading • Uses palmar grasp • May say vowel words (oh-oh) • Enjoy bathtub toys and rubber ring for teeth • Starts to sit without support
Question 38
A client is scheduled for a surgical procedure. Preoperative health teaching/care should include which of the following? Select all that apply.
A
Application of antiembolism stockings as ordered.
B
Explaining pre and post-op procedures and any special equipment to be used.
C
Measuring I and O
D
Assisting patient to turn in bed every 2 hours.
E
Assuring patient that pain medications will be available post-op.
F
Reinforcing explanations given by physicians.
Question 38 Explanation: 
ANSWER: Explaining pre and post-op procedures and any special equipment to be used. ; Assuring patient that pain medications will be available post-op. ; Reinforcing explanations given by physicians. ; RATIONALE: Preoperative health teachings include those listed in 1, 2 and 3. Activities listed in numbers 4, 5 and 6 are applicable during the post-operative period.
Question 39
Signs of infection include which of the following? Select all that apply.
A
Increased body temperature
B
Localized pain
C
Increased WBCs
D
Hypothermia
E
Increased neutrophils
F
Increased RBCs
G
Bradycardia
H
Localized edema
Question 39 Explanation: 
Answer: Localized pain ; Localized edema ; Increased WBCs ; Increased neutrophils ; Increased body temperature ; RATIONALE: Localized pain is due to swelling of inflamed tissue resulting to increase pressure on nerve endings. Localized edema occurs as fluid, protein and cells enter the interstitial spaces. WBC level is elevated as the body’s response to infection. Specialized WBCs, neutrophils and monocytes, ingest and destroy microorganism through phagocytosis. Fever is caused by phagocytic release of pyrogen from bacterial cells that cause a rise in hypothalamic set point.
Question 40
After a Caldwell-Luc Surgery, the nurse should instruct the client to do the following. Select all that apply.
A
Avoid clearing of throat
B
Dentures should not be worn for 5 days
C
After the removal for packing, the client should not blow his or her nose for 2 weeks
D
Do not chew on the affected side
E
Caution client with oral hygiene to prevent trauma of incision
Question 40 Explanation: 
ANSWER: Do not chew on the affected side ; After the removal for packing, the client should not blow his or her nose for 2 weeks ; Caution client with oral hygiene to prevent trauma of incision ; RATIONALE: Dentures should not be worn for at least 10 days. Clearing of throat should be avoided after a tonsillectomy not Caldwell-Luc Surgery.
Question 41
Surgery done for the management of lung cancer typically includes which of the following? Select all that apply.
A
Thoracoplasty
B
Decortication
C
Radiation treatment
D
Lobectomy
E
Chemotherapy
Question 41 Explanation: 
ANSWER: Lobectomy ; Thoracoplasty ; Decortication ; RATIONALE: Chemotherapy and radiation treatment are management for cancer but do not involve surgery.
Question 42
A client is diagnosed with retinal detachment. The nurse would expect the client to be noted with which assessment findings? Select all that apply.
A
Veil-like curtain coming across field of vision
B
Severe eye pain
C
Tunnel vision
D
Halos around lights
E
Flashes of light
F
Floaters
Question 42 Explanation: 
ANSWER: Floaters ; Halos around lights ; Flashes of light ; RATIONALE: A tunnel vision, impairment of peripheral vision (tunnel vision) and severe eye pain are NOT experienced by clients with retinal detachment but those with glaucoma.
Question 43
Arterial blood gas studies serve for which purpose? Select all that apply.
A
To assess the pressure of blood in the vessels
B
To assess ventilation
C
Measure blood perfusion in the lungs
D
Assess the adequacy of collateral circulation of the hand
E
Assess acid-base balance
Question 43 Explanation: 
ANSWER: To assess ventilation ; Assess acid-base balance ; RATIONALE: Blood pressure in the vessels is obtained using a sphygmomanometer. Perfusion of blood in the lungs is measured in lung scan. Assessing the adequacy of collateral circulation of the hand is done through Allen’s test.
Question 44
A client is diagnosed with acute maxillary sinusitis. Which of the following clinical assessment would the nurse expect to find in this patient?
A
Sore throat
B
Fever
C
Headache
D
Pain in and around the eyes
E
Snoring
F
General malaise
G
Earache
Question 44 Explanation: 
ANSWER: General malaise ; Headache ; Pain in and around the eyes ; RATIONALE: In maxillary sinusitis there is pain in the cheek and upper teeth. Sore throat, earache and snoring are clinical manifestations of tonsillitis.
Question 45
Genetic inheritance and environmental influence are two primary factors affecting growth and development. Genetic influences on a child’s pattern of growth and development includes which of the following? Select all that apply.
A
Ordinal position in the family
B
Health
C
Intelligence
D
Gender
E
Temperament
F
Nutrition
Question 45 Explanation: 
ANSWER: Gender ; Health ; Temperament ; Intelligence ; RATIONALE: On average girls are born lighter and shorter than boys. A child who inherits a genetically transmitted disease may not grow as rapidly or develop fully as a healthy child, depending on the type of illness and the therapy or care available for the disease. Children with high intelligence do not generally grow faster than other children, but they do tend to advance faster in skills. Temperament is an inborn characteristic set at birth.
Question 46
Mr. Slone is experiencing shock. The nurse should obtain a physician’s order of which possible medication to treat shock? Select all that apply.
A
Digitalis preparations
B
Lithium
C
Levophed
D
Marplan
E
Inotropin
F
Praziquantel
G
Dobutrex
Question 46 Explanation: 
ANSWER: Inotropin ; Dobutrex ; Digitalis preparations ; Levophed ; RATIONALE: Drugs used to treat shock: • Dopamine (Inotropin) – stimulates myocardial contractility; increases urine output • Dobutamine (Dobutrex) – similar to dopamine • Digitalis preparations – improve cardiac performances • Norepinephrine (Levophed) – symphatomimetic; produces vasoconstriction in all vascular beds and improves cardiac contractility.
Question 47
Which of the following are parts in the layer of the middle eye? Select all that apply.
A
Ciliary body
B
Retina
C
Anvil
D
Choroid
E
Cornea
F
Stapes
G
Iris
Question 47 Explanation: 
ANSWER: Ciliary body ; Choroid ; Iris ; RATIONALE: Choroid is a highly vascular layer that nourishes the retina. The ciliary body secretes the aqueous humor and the iris is the pigmented membrane behind the cornea giving color to the eye.
Question 48
Decreased metabolism in COPD is characterized by which of the following? Select all that apply.
A
Chest pain
B
Anorexia
C
Alteration in LOC
D
Fatigue
E
Weight loss
F
Body malaise
G
Polycythemia
Question 48 Explanation: 
ANSWER: Body malaise ; Fatigue ; Anorexia ; Weight loss ; RATIONALE: The given items are all noted in COPD but decreased metabolism in COPD is characterized by signs and symptoms listed in 1, 4, 5 and 7.
Question 49
In providing bed and bath hygiene which of the following concepts are important? Select all that apply?
A
Finish care with a back using rubbing alcohol
B
Ensure that the temperature of the bath water is 110-115 degree Fahrenheit
C
Check the soiled linen for personal items such as eyeglasses
D
Wash the client’s extremities from proximal to distal
E
Shave the client in the direction of the hair growth
Question 49 Explanation: 
ANSWER: Check the soiled linen for personal items such as eyeglasses ; Ensure that the temperature of the bath water is 110-115 degree Fahrenheit ; Shave the client in the direction of the hair growth ; RATIONALE: Rubbing alcohol is drying and may cause skin breakdown. Washing extremities distal to proximal stimulates venous return.
Question 50
Ear irrigations are used to introduce fluid into the external auditory canal for cleaning purposes. The nurse is performing the procedure correctly if she does the following. Select all that apply.
A
Pulling the ear canal upward and backward in a child.
B
Instructing the patient to lie on the affected side after the procedure
C
Making sure to straighten the ear canal for adults and children
D
Assisting the client to a sitting position or lying position with the head tilted to the affected area
E
Allowing the returning fluid to drain on the floor or chair
Question 50 Explanation: 
ANSWER: Making sure to straighten the ear canal for adults and children ; Assisting the client to a sitting position or lying position with the head tilted to the affected area ; Instructing the patient to lie on the affected side after the procedure ; RATIONALE: The auricle is pulled upward and backward in children not the ear canal. Returning fluids are allowed to drain in a collecting basin.
Question 51
In delegating tasks, what activities can a registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
A
Recording the intake and output of a manic client
B
Assessing a hypomanic client on depression
C
Monitoring a client who is on Tricyclic antidepressant for two weeks
D
Accompanying a depressed client to occupational therapy
E
Monitoring a newly admitted alcoholic client whose last drink was two days ago
F
Checking a client in soft wrist restraint
Question 51 Explanation: 
ANSWER: Recording the intake and output of a manic client ; Accompanying a depressed client to occupational therapy ; RATIONALE: Non-nuring activities, such as those listed in 2 and 5 are safe to be delagted to the UAP as long as there has been prior education.
Question 52
Nursing diagnosis for patients with disorders of the nervous system may include which of the following? Select all that apply.
A
Potential alteration in nutrition: more than body requirements
B
Impairment of skin integrity related to increased mobilization
C
Altered tissue perfusion (cerebral)
D
Self-care deficit
E
Impaired verbal communication
F
Alteration in bowel elimination (constipation or continence)
Question 52 Explanation: 
ANSWER: Alteration in bowel elimination (constipation or continence) ; Self-care deficit ; Impaired verbal communication ; Altered tissue perfusion (cerebral) ; RATIONALE: Skin integrity impairment in patients with nervous system disorder is related to immobility (not increased mobilization) or sensory deficits. Potential alteration in nutrition: less than body requirements is also noted.
Question 53
A client is diagnosed with TB. He is now taking anti-TB drugs. Side effects of Rifampicin include which of the following? Select all that apply.
A
Red orange color to body secretions
B
Ototoxicity
C
Skin rash
D
Peripheral neuritis
E
Hepatoxicity
F
Thrombocytopenia
G
Nephrotoxicity
H
Nausea and vomiting
Question 53 Explanation: 
ANSWER: Nausea and vomiting ; Red orange color to body secretions ; Thrombocytopenia ; Hepatoxicity ; RATIONALE: Side effects of Rifampicin: red orange color to body secretions, hepatoxicity, nausea and vomiting and thrombocytopenia.
Question 54
Which of the following is true about TB?
A
Anti-TB drugs must be taken on a full stomach to prevent GI irritation
B
The effectiveness of anti-Tb drugs is evaluated by the absence of cough
C
It is an infectious disease
D
Anti-Tb drugs must be taken in combination
E
Transmitted by droplet infection
Question 54 Explanation: 
ANSWER: Transmitted by droplet infection ; It is an infectious disease ; Anti-Tb drugs must be taken in combination ; RATIONALE: The effectiveness of anti-Tb drugs is evaluated by sputum culture for acid fast bacilli. Drugs should be taken on an empty stomach for a better absorption.
Question 55
If assessments do not reveal the cause of infertility, uterine endometrial biopsy may be scheduled for a woman. Which statements are true about this surgical procedure? Select all that apply.
A
Done usually 2-3 days before the expected menstrual flow
B
A small amount of vaginal spotting is normal after the procedure
C
The woman will feel sharp pain as a thin probe and biopsy forceps are introduced into the cervix
D
The procedure is contraindicated if pregnancy is suspected
E
PID and cervicitis requires the performance of this procedure
F
Uterine perforation is expected to occur post-procedure
Question 55 Explanation: 
ANSWER: Done usually 2-3 days before the expected menstrual flow ; The procedure is contraindicated if pregnancy is suspected ; Uterine perforation is expected to occur post-procedure ; A small amount of vaginal spotting is normal after the procedure ; RATIONALE: There may be a moment of sharp pain as the biopsy specimen is taken from the anterior or posterior uterine wall. Mild to moderate discomfort is felt by the woman as thin probe and biopsy forceps are introduced into the cervix. If an infection such as PID or cervicitis is present this procedure should never be performed.
Question 56
Possible bedrest complications are which of the following? Select all that apply.
A
Diarrhea
B
Pressure ulcers
C
Contractures of extremities
D
Urinary calculi
E
Decreased pain
F
Pneumonia
G
Thrombi
H
Decreased dependency
Question 56 Explanation: 
ANSWER: Pneumonia ; Urinary calculi ; Thrombi ; Contractures of extremities ; Pressure ulcers ; RATIONALE: Urinary calculi due to stasis or urine, contractures of extremities because of the disuse of the muscles and joints, pneumonia due to pulmonary stasis, pressure ulcers due to increased pressure on bony prominences and thrombi due to venous stasis are all possible complications of bed rest.
Question 57
The skin of the patient with hyperthermia can be prevented from breaking down if the nurse performs which intervention? Select all that apply.
A
Maintaining room temperature
B
Turning the client every 2 hours
C
Applying methods for inducing hypothermia
D
Frequently checking every hour for signs of tissue damage
E
Observing for seizure activity and protecting patient if seizures occur
Question 57 Explanation: 
ANSWER: Frequently checking every hour for signs of tissue damage ; Turning the client every 2 hours ; RATIONALE: Nursing care listed in 3 and 4 can prevent skin breakdown to patients with hyperthermia.
Question 58
Before cardiac catheterization, 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
Elevate HOB to 30-45 degrees
E
Have the client void
F
Monitor ECG
Question 58 Explanation: 
ANSWER: Have the client void ; Assess for allergy to iodine/seafoods ; 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 (after procedure) • Immobilize affected extremity – to promote adequate circulation (after) • Elevate HOB to 30-45 degrees – do not elevate HOB to more than 30 degrees if the femoral site was used (after) • Monitor ECG – note for dysrhythmias (after)
Question 59
Bronchial hygienic measures include the following. Select all that apply.
A
Oropharyngeal suctioning
B
Steam inhalation
C
Lung biopsy
D
Incentive spirometry
E
Closed chest drainage
F
Aerosol inhalation
Question 59 Explanation: 
ANSWER: Oropharyngeal suctioning ; Aerosol inhalation ; Steam inhalation ; RATIONALE: Bronchial hygiene measures are: • Suctioning • Steam inhalation • Aerosol inhalation • Medimist inhalation
Question 60
Aside from ego integrity, other developmental tasks of the elderly are: Select all that apply.
A
Keeping socially active
B
Successfully adjusting to retirement
C
Establishing independence to ADLs
D
Achieving aims and visions
E
Adjusting to death of spouse
F
Viewing own death as an appropriate outcome of life
G
Building trust to people
H
Maintaining contact with friends and family members
I
Adjusting to reduced income
Question 60 Explanation: 
ANSWER: Adjusting to reduced income ; Viewing own death as an appropriate outcome of life ; Keeping socially active ; Adjusting to death of spouse ; Successfully adjusting to retirement ; RATIONALE: Other elderly developmental tasks: • Adjusting to reduced income • Viewing own death as an appropriate outcome of life • Keeping socially active • Establishing independence to ADLs • Adjusting to death of spouse • Successfully adjusting to retirement • Making satisfactory living arrangements
Question 61
Bronchodilators can be given to patients with COPD. Which of the following drugs are bronchodilators? Select all that apply.
A
Benadryl (diphenhydramine)
B
Alupent (Metaproterenol)
C
Bricanyl (terbutaline)
D
Aminophylline (Theophyline)
E
Dextrometorphan
Question 61 Explanation: 
ANSWER: Aminophylline (Theophyline) ; Alupent (Metaproterenol) ; Bricanyl (terbutaline) ; RATIONALE: 1. Aminophylline (Theophyline) – bronchodilator 2. Dextrometorphan – antitussives 3. Benadryl (diphenhydramine) – antihistamine 4. Alupent (Metaproterenol) – bronchodilator 5. Bricanyl (terbutaline) – bronchodilator
Question 62
Which of the following behaviors are expected of an elementary teacher to her students whose school was located in an area where a recent flood disaster that destroyed the homes and displaced the families took place? Select all that applies.
A
Students are apt to learn about the next lesson
B
Students are cheerful to answer questions
C
Regressive behaviors will be exhibited by the students
D
Students fantasize that the disaster never occur
E
Students refuse to go back to school
Question 62 Explanation: 
ANSWER: Students refuse to go back to school ; Students are apt to learn about the next lesson ; Students fantasize that the disaster never occur ; RATIONALE: Exhibiting behaviors of regression, having fantasies that nothing occurred and the inability to concentrate are the common behaviors after a disaster trauma.
Question 63
In glaucoma which diagnostic tests can be used? Select all that apply.
A
Diathermy
B
Gonioscopy
C
Weber’s test
D
Tonometry
E
Sclera buckling
F
Perimetry
G
Visual acuity
Question 63 Explanation: 
ANSWER: Perimetry ; Tonometry ; Visual acuity ; Gonioscopy ; RATIONALE: Tonometry reading of 24-32 mmHg suggests glaucoma and may be 50 mmHg or more in acute (closed-angle) glaucoma. Perimetry reveals defects in visual fields. Visual acuity is reduced in glaucoma and gonioscopy examines the angle of anterior chamber.
Question 64
Which of the following is true about creatine Phosphokinase (CK-MB)? Select all that apply.
A
Elevated level indicates tissue necrosis
B
It is the most specific cardiac enzyme
C
It is the most sensitive indicator of myocardial damage
D
Normal range in males is 50-325 mu/ml
E
It is an accurate indicator of myocardial damage
Question 64 Explanation: 
ANSWER: It is the most specific cardiac enzyme ; Normal range in males is 50-325 mu/ml ; It is an accurate indicator of myocardial damage ; RATIONALE: • It is the most specific cardiac enzyme – CK-MB • Elevated level indicates tissue necrosis – aspartate aminotransferase • It is the most sensitive indicator of myocardial damage – lactic dehydrogenase • Normal range in males is 50-325 mu/ml – CK- MB • It is an accurate indicator of myocardial damage – CK-MB
Question 65
Pulmonary function studies include the following. Select all that apply.
A
Residual volume
B
Inspiratory reserve volume
C
Tidal volume
D
Lymph node biopsy
E
Lung scan
F
Vital capacity
G
Functional reserve volume
Question 65 Explanation: 
ANSWER: Tidal volume ; Inspiratory reserve volume ; Residual volume ; Vital capacity ; RATIONALE: Functional residual capacity is a component of pulmonary studies not functional reserve volume.
Question 66
A client is undergoing an IV therapy. Complications of IV therapy include which of the following? Select all that apply.
A
Circulatory overload
B
Impaired absorption
C
Porous bones
D
Presbycusis
E
Pyrogenic reaction
F
Infiltration
Question 66 Explanation: 
ANSWER: Infiltration ; Pyrogenic reaction ; Circulatory overload ; RATIONALE: Complications of IV therapy includes: • Infiltration • Phlebitis • Pyrogenic reaction • Air embolism • Circulatory overload
Question 67
Number of fetal movements per hour varies depending on which of the following. Select all that apply.
A
Mood of the mother
B
Genetic predisposition
C
Position of the mother
D
Meal time
E
Hydration status of the mother
F
Maternal medical condition
G
Time of the day
Question 67 Explanation: 
ANSWER: Meal time ; Position of the mother ; Hydration status of the mothe r; Time of the day ; RATIONALE: Generally, at least three fetal movements in one hour are considered normal. Procedure varies with time of the day, reference to mealtime, maternal position and hydration. Often a baby is more active after a meal.
Question 68
The nurse is assigned to an elderly client. Physical changes of aging in musculoskeletal system expected in this client include which of the following? Select all that apply.
A
Increased muscular strength
B
Relaxed joints
C
More porous bones
D
Stooped posture
E
Atrophy of muscles
F
Decreased perspiration
Question 68 Explanation: 
ANSWER: More porous bones ; Stooped posture ; Atrophy of muscles ; RATIONALE: Musculoskeletal system changes due to aging are the following: • Atrophy of muscles with decreased strength, endurance and agility • Bones more porous and lighter through calcium loss • Enlarged stiff joints • Stooped posture
Question 69
Which of the following can be performed to manage a client with Adult Respiratory Distress syndrome? Select all that apply.
A
Bronchogram
B
Biophysical profile
C
CPT
D
Administer Morphine if client is on Positive End Expiratory Pressure (PEEP)
E
O2 therapy: 2-3 LPM
Question 69 Explanation: 
ANSWER: CPT ; Administer Morphine if client is on Positive End Expiratory Pressure (PEEP) ; RATIONALE: If client is on PEEP Morphine/Ativan/Diprivan is administered to reduce resistance to PEEP. CPT is done for adults with ARDS and O2 therapy is regulated to flow of about 8-10 LPM.
Question 70
Cardiovascular complications include shock. Most common causes of shock during the post-op period are? Select all that apply.
A
Post-op immobilization
B
Drug reactions
C
DVT
D
Venous stasis
E
Myocardial infarction
F
Pulmonary embolism
G
Sepsis
Question 70 Explanation: 
ANSWER: Pulmonary embolism ; Sepsis ; Myocardial infarction ; Drug reactions ; RATIONALE: Most common causes of shock during the post-op period include: • Hemorrhage • Sepsis • MI and cardiac arrest • Drug reactions • Transfusion reactions • Pulmonary embolism • Adrenal failure
Question 71
Assessment findings in a migraine attack include which of the following? Select all that apply.
A
Severe throbbing pain often in the temporal or supraorbital area
B
Abrupt onset lasting for 30-90 minutes
C
Nausea and vomiting
D
Characterized by the presence of an aura preceding the pain
E
Pallor
F
Bilateral pain in the head (occurring at the back of the neck extending diffusely to the top of the head)
Question 71 Explanation: 
ANSWER: Characterized by the presence of an aura preceding the pain ; Severe throbbing pain often in the temporal or supraorbital area ; Nausea and vomiting ; Pallor ; RATIONALE: Clinical manifestations listed in 2, 3, 4 and 6 are experienced by patients with migraine headaches.
Question 72
Prevention of lung cancer includes which practice? Select all that apply.
A
Radiation treatment
B
Quit smoking
C
Chest X-ray once a year
D
Drinking 6-8 glasses of water per day
E
Pneumonectomy
F
Drinking vitamins regularly
Question 72 Explanation: 
ANSWER: Quit smoking ; Chest X-ray once a year ; RATIONALE: Prevention of lung cancer would include quitting on smoking and having a chest x-ray once a year.
Question 73
Nursing interventions after bronchography include which of the following. Select all that apply.
A
Instruct the client to cough and deeply breath
B
Have oxygen and antispasmodic agents ready
C
NPO for 6-8 hours
D
Side-lying position
E
Check for allergies to seafoods
F
Securing written consent
Question 73 Explanation: 
ANSWER: Side-lying position ; Instruct the client to cough and deeply breath ; RATIONALE: The client is on NPO after bronchography until cough and gag reflexes return. Interventions listed in 2, 3 5 and 6 are appropriate before bronchogram.
Question 74
A client has closed chest drainage with a two bottle system not attached to a suction apparatus. The nurse in this case should encourage the client to do which of the following to promote drainage? Select all that apply.
A
Ambulate within limits
B
Deep breathing and coughing exercises
C
Remain flat in bed
D
Do valsalva maneuver
Question 74 Explanation: 
ANSWER: Deep breathing and coughing exercises ; Ambulate within limits ; RATIONALE: Valsalva maneuver is encouraged if the chest tube is to be removed. The client should be turning to sides at a regular basis to promote drainage.
Question 75
Which of the following causes pleural effusion and pneumothorax? Select all that apply.
A
A positive family history
B
Emphysema
C
Positive pressure ventilation
D
ABG studies
E
Thoracic surgery
F
CVP line insertion
Question 75 Explanation: 
ANSWER: Thoracic surgery ; Positive pressure ventilation ; CVP line insertion ; Emphysema ; RATIONALE: Causes of pleural effusion and pneumothorax: 1. Thoracic surgery 2. Positive pressure ventilation 3. CVP line insertion 4. Emphysema 5. Thoracentesis 6. Trauma
Question 76
A client diagnosed with Histoplasmosis is taking amphotericin B. Signs of toxicity of this taking this drug include which of the following? Select all that apply.
A
Chills
B
Hepatoxicity
C
Adrenal failure
D
Weight gain
E
Nephrotoxicity
F
Bruising
G
Fever
H
Nausea and vomiting
Question 76 Explanation: 
ANSWER: Fever ; Chills ; Adrenal failure ; Nephrotoxicity ; RATIONALE: Amphotericin B toxic signs and symptoms include: • Fever • Chills • Adrenal failure • Nephrotoxicity • Anorexia • Headache
Question 77
Drugs are used in attacking cancer cells in chemotherapy. Which chemotherapeutic drugs are classified as antimetabolites? Select all that apply.
A
Methotrexate
B
Cytoxan
C
Chlorambucil
D
5-Fluorouracil
E
Cisplatin
Question 77 Explanation: 
ANSWER: 5-Fluorouracil ; Methotrexate ; RATIONALE: Antimetabolites include: • Methitrexate • 5-Fluorouracil • ARA-C Mercaptopurine Thioguanine
Question 78
The client is suffering from moderate anxiety. The nurse expects to observe which clinical manifestations in the client. Select all that apply.
A
Alert
B
Diaphoresis
C
Vertigo
D
Distorted perceptions
E
Increased rate of speech
F
Selectively attentive
G
Increased automatisms
Question 78 Explanation: 
ANSWER: Increased automatisms ; Selectively attentive ; Diaphoresis ; Increased rate of speech ; RATIONALE: Moderate anxiety clinical manifestations: • Selectively attentive • Perceptual field limited to the immediate task • Can be redirected • Cannot connect thoughts or events independently • Muscle tension • Diaphoresis • Pounding pulse • Headache • Dry mouth • Higher voice pitch • Increased rate of speech • GI upset • Frequent urination • Increased automatisms (nervous mannerisms)
Question 79
Which of the following cranial nerves are purely motor in function? Select all that apply.
A
Optic
B
Oculomotor
C
Trochlear
D
Trigeminal
E
Abducens
F
Olfactory
Question 79 Explanation: 
ANSWER: Oculomotor ; Trochlear ; Abducens ; RATIONALE: The oculomotor nerve supplies motor fibers to four of the six muscles that direct the eyeball to the eyelid. Trochlear cranial nerve supplies motor fibers for one external eye muscle. Abducens supplies motor nerve fibers to the lateral rectus muscle which rolls the eye laterally.
Question 80
To manage clients with increased ICP the nurse should be perform which nursing interventions? Select all that apply.
A
Avoid restrain use
B
Assist with mechanical ventilation as indicated.
C
Administer antiemetics as prescribed
D
Force fluids
E
Monitor VS and perform neuro checks frequently.
F
Position the patient flat on bed
Question 80 Explanation: 
ANSWER: Monitor VS and perform neuro checks frequently. ; Assist with mechanical ventilation as indicated. ; Avoid restrain use ; Administer antiemetics as prescribed ; RATIONALE: The interventions listed in 2, 3 5 and 6 are essential in the nursing management of increased ICP. Fluid balance should be maintained by restricting 1200-1500 ml/day of fluids. The ehad of bed should be elevated to 35-45 degrees and neck should be in a neutral position to improve venous drainage from brain.
Question 81
A 16-year old client after an accident is noted with an increased ICP. Assessment findings for this patient would include which of the following? Select all that apply.
A
Abnormal respiratory patterns
B
Decrease LOC
C
Sunken fontanels
D
Rise in systolic pressure
E
High-pitched cry
Question 81 Explanation: 
ANSWER: Decrease LOC ; Rise in systolic pressure ; Abnormal respiratory patterns ; RATIONALE: Sunken fontanels and a high-pitched cry are noted if the patient is an infant.
Question 82
A client diagnosed with COPD is instructed to follow which dietary regimen? Select all that apply.
A
Bland diet
B
Decrease carbohydrate
C
Increase calorie
D
Increase protein in the diet
E
Increase carbohydrate
F
Low salt
G
Decrease protein in the diet
Question 82 Explanation: 
ANSWER: Increase calorie ; Increase protein in the diet ; Decrease carbohydrate ; RATIONALE: High caloric diet provides source of energy. High protein diet helps maintain integrity of alveolar walls. Low carbohydrate diet limit carbon dioxide production (natural end product) since the client has difficulty exhaling carbon.
Question 83
After the injection of air directly into the ventricles via the burr hole or craniotomy flap (Ventriculography), followed by x-rays, the nurse should perform which of the following? Select all that apply.
A
Use icebags for headaches or administer analgesics
B
Use aspetic technique
C
Keep the patient on bed rest for the next 48 hours.
D
Elevate the head of bed about 30 to 45 degrees.
E
Offer food or fluids as tolerated
Question 83 Explanation: 
ANSWER: Offer food or fluids as tolerated ; Use aspetic technique ; Use icebags for headaches or administer analgesics ; RATIONALE: The head of bed should be elevated at about 15-20 degrees and patient should be kept on bed rest for the next 24 hours only.
Question 84
To manage the side effect of skin itching, redness and burning in radiation, the nurse must perform the following. Select all that apply.
A
Encourage the patient to eat only bland foods
B
Avoid use of medicated solutions, ointments or powders
C
Provide client with frequent rest periods
D
Use bed cradle.
E
Assess for bleeding
F
Use cornstarch or olive oil.
Question 84 Explanation: 
ANSWER: Avoid use of medicated solutions, ointments or powders ; Use cornstarch or olive oil. ; Use bed cradle. ; RATIONALE: Clients should avoid use of medicated solutions, ointments or powders that contain heavy metals such as zinc oxide. Cornstarch or olive oil can be used for itching. Talcum powder should never be used. To prevent pressure, trauma and infection to skin bed cradle should be used.
Question 85
Which of the following should be avoided by the client who underwent a breast surgery? Select all that apply.
A
Scratches
B
Cuts
C
Analgesia
D
Pinpricks
E
Insect bites
F
Burns
G
Hangnails
H
Salty foods
Question 85 Explanation: 
ANSWER: Cuts ; Scratches ; Pinpricks ; Hangnails ; Insect bites ; Burns ; RATIONALE: To prevent lymphedema the client should avoid the following: • Cuts • Scratches • Pinpricks • Hangnails • Insect bites • Burns • Strong detergents
Question 86
Patient teaching to a client with pulmonary embolism would include teaching him or her not to do which of the following? Select all that apply.
A
Avoiding leg massage
B
Smoking
C
Contact sports
D
Constipation
E
Using electric razor
F
Taking ASA with Coumadin
Question 86 Explanation: 
ANSWER: Smoking ; Taking ASA with Coumadin ; Constipation ; Contact sports ; RATIONALE: Patient teaching in Pulmonary Embolism – DON’T’s: • Smoking • Taking ASA with Coumadin • Constipation • Contact sports • Restrictive clothing on legs • Prolonged sitting or standing
Question 87
Post-op care after tonsillectomy includes the promotion of comfort. In doing so, the nurse should perform which of the following? Select all that apply.
A
Administration of acetaminophen
B
Checking the client’s vomitus for blood
C
Placing an ice collar on the patient’s neck
D
Monitoring for frequent swallowing
Question 87 Explanation: 
ANSWER: Placing an ice collar on the patient’s neck ; Administration of acetaminophen ; RATIONALE: Placing an ice collar and administering acetaminophen promotes client comfort.
Question 88
Before a lumbar puncture the nurse must provide the following care. Select all that apply.
A
Assess the sensation and movement of the lower extremities.
B
Force fluids.
C
Keep the patient flat for 12-24 hours
D
Have the patient empty his or her bladder
E
Explain to the client the need to remain still.
Question 88 Explanation: 
ANSWER: Explain to the client the need to remain still. ; Have the patient empty his or her bladder ; RATIONALE: Nursing care listed in 1, 2 and 4 are applicable after lumbar puncture is done.
Question 89
Mr. Romar has pleural effusion. Which nursing interventions are appropriate for this client? Select all that apply.
A
O2 therapy
B
Monitor for shock
C
Prepare for endotracheal tube insertion
D
Prepare for CVP line insertion
E
Position the client in high-fowler’s
Question 89 Explanation: 
ANSWER: Position the client in high-fowler’s ; O2 therapy ; Monitor for shock ; RATIONALE: CVP line insertion should never be performed as it causes pleural effusion.
Question 90
Which of the following is an antineoplastic antibiotic? Select all that apply.
A
Thioguanine
B
Fludaradine (Fludara)
C
Bleomycin (Blenoxane)
D
Methotrexate (Folex)
E
Doxorudicin (Adriamycin)
Question 90 Explanation: 
ANSWER: Bleomycin (Blenoxane) ; Doxorudicin (Adriamycin) ; RATIONALE: Medications listed in 1, 2 and 4 are antimebolites.
Question 91
Preoperative care for breast surgery includes the following. Select all that apply.
A
Check the patient for bleeding
B
Place the client in a semi-fowler’s position with arms elevated on pillows abducted
C
Inform about wound suction drainage
D
Include husband in the care as possible.
E
Teach arm exercises
Question 91 Explanation: 
ANSWER: Include husband in the care as possible. ; Teach arm exercises ; Inform about wound suction drainage ; RATIONALE: Psychosocial support is promoted when the husband is included in the care as necessary. Arm exercises are taught during the preop period to prevent lymphedema.
Question 92
Existential therapies include the following. Select all that apply.
A
Rational emotive therapy
B
Cognitive therapy
C
Carl Roger’s client-centered therapy
D
Classical conditioning
E
Reality therapy
F
Operant conditioning
G
Gestalt therapy
Question 92 Explanation: 
ANSWER: Gestalt therapy ; Reality therapy ; Rational emotive therapy; Cognitive therapy ; RATIONALE: Existential therapies include: cognitive therapy, rational emotive therapy, logotherapy, gestalt, and reality therapy.
Question 93
For persistent intractable pain of high intensity, neurosurgical procedures for pain control are used which includes the following. Select all that apply.
A
Transcutaneous electrical nerve stimulation
B
Diathermy
C
Neurectomy
D
Rhizotomy
E
Sympathectomy
F
Chordotomy
G
Stapedectomy
Question 93 Explanation: 
ANSWER: Neurectomy ; Chordotomy ; Rhizotomy ; Sympathectomy ; RATIONALE: Neurosurgical procedures for pain control involves surgical destruction of nerve pathways to block transmission of pain which includes neurectomy, rhizotomy, chordotomy and sympathectomy.
Question 94
In the removal of the chest tube which items should the nurse prepare? Select all that apply.
A
Petrolatum gauze
B
Sterile gauze
C
Scissors
D
Adhesive tape
E
Suture removal kit
F
Forceps
Question 94 Explanation: 
ANSWER: Petrolatum gauze ; Suture removal kit ; Scissors ; Sterile gauze ; RATIONALE: Removal of chest tube is done by the physician. It is the nurse’s responsibility to prepare the following items: • Petrolatum gauze • Suture removal kit • Adhesive tape • Sterile gauze
Question 95
Modifiable risk factors for cardiovascular disorders include which of the following? Select all that apply.
A
Alcohol
B
Exercise
C
Contraceptive pills
D
Diabetes mellitus
E
Age
F
Gender
G
Race
H
Obesity
Question 95 Explanation: 
ANSWER: Alcohol ; Obesity ; Contraceptive pills ; Exercise ; Diabetes mellitus ; RATIONALE: Modifiable risk factors include: • Alcohol • Obesity • Contraceptive pills • Exercise • Diabetes mellitus • Diet • Stress • Cigarette smoking • Hypertension • Hyperlipidemia • Personality type
Question 96
Before thoracentesis the nurse should perform the following. Select all that apply.
A
Instruct the client to remain still
B
Position the client upright leaning on overbed table
C
Encouraging the client for bed rest until VS is stable
D
Monitor VS
E
Secure consent
Question 96 Explanation: 
ANSWER: Secure consent ; Position the client upright leaning on overbed table ; Instruct the client to remain still ; RATIONALE: Obtaining initial VS is done pre-procedure while monitoring VS is done post-procedure. Bed rest until Vs are stable is applicable post-op.
Question 97
Which of the following is expected after tonsillectomy? Select all that apply.
A
Heavy Bleeding
B
Colds
C
Black or dark stool
D
Fever
E
Throat discomfort
Question 97 Explanation: 
ANSWER: Throat discomfort ; Black or dark stool ; RATIONALE: After tonsillectomy throat discomfort between 4th and 8th post op day is expected due to sloughing off of mucous membrane at the operative site. The stool is black or dark for a few days due to swallowed blood during the procedure.
Question 98
Hypertrophy of mucous membrane in pneumonia would result to which clinical manifestations? Select all that apply.
A
Rales
B
Fever
C
Increase sputum production
D
Cough
E
Dyspnea
F
Hypoxemia
G
Increase WBC
Question 98 Explanation: 
ANSWER: Dyspnea ; Increase sputum production ; Rales ; Cough ; RATIONALE: • Dyspnea – due to hypertrophy of mucous membrane • Fever – protective mechanism of the body with infection • Increase WBC – protective mechanism of the body with infection • Increase sputum production – due to hypertrophy of mucous membrane • Rales – due to hypertrophy of mucous membrane • Hypoxemia – due to increased capillary permeability • Cough – due to hypertrophy of mucous membrane
Question 99
Which of the following signs would suggest that a client might have a possible lung cancer? Select all that apply.
A
Frank hemoptysis
B
Any change in respiratory pattern
C
Chest, shoulder and arm pain
D
Unexplained fever
E
Presence of sore that does not heal
F
Recurring episodes of tonsillitis
G
Persistent cough
Question 99 Explanation: 
ANSWER: Persistent cough ; Frank hemoptysis ; Chest, shoulder and arm pain ; Any change in respiratory pattern ; RATIONALE: Warning signs of lung cancer: • Persistent cough • Frank hemoptysis • Sputum streaked with blood • Rust colored or purulent sputum • Chest, shoulder and arm pain • Recurring episodes of bronchitis, pneumonia and pleural effusion • Any change in respiratory pattern • Dyspnea, unexplained or out of proportion
Question 100
The nurse is assigned to care for a patient in a continuous mitten restraint. Which of the following should be included in the client’s plan of care? Select all that apply.
A
Educate the client’s family about restraint use
B
Release the restraint and reposition the client every four hours
C
Document restraint checks and patient status every two hours
D
Obtain the physician’s order renewal every 72 hours
E
Provide 10 minutes of release and repositioning
Question 100 Explanation: 
ANSWER: Document restraint checks and patient status every two hours ; Educate the client’s family about restraint use ; Provide 10 minutes of release and repositioning ; RATIONALE: Restrain standards states that documentation must occur at least every two hours. It is important for the family to understand the purpose of restraint. Standard states that restraint orders are to be renewed ever 24 hours when a restraint is used continuously. Release and positioning should be provided for a minimum of 10 minutes at least every two hours.
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