Pre-Board Nursing Exam for May 2015 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 2015 NLE

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Question 1
Prevention of lung cancer includes which practice? Select all that apply.
A
Chest X-ray once a year
B
Drinking vitamins regularly
C
Pneumonectomy
D
Quit smoking
E
Radiation treatment
F
Drinking 6-8 glasses of water per day
Question 1 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 2
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
Uterine perforation is expected to occur post-procedure
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
PID and cervicitis requires the performance of this procedure
E
The procedure is contraindicated if pregnancy is suspected
F
Done usually 2-3 days before the expected menstrual flow
Question 2 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 3
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
Aspartate Aminotransferase
B
Serum sodium
C
Prothrombin time
D
Partial thromboplastin time
E
Lactic dehydrogenase
Question 3 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 4
Which child is expected to be in Piaget’s Preoperational thought stage of cognitive development? Select all that apply.
A
9-month old baby Elise
B
36 months old Dina
C
Lady Mabelle who is a toddler
D
A preschooler kid named Argel
E
Stephanie on the 6th grade
F
24-month old Roger
Question 4 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 5
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
Keep side rails up all the time.
C
Protect patient if seizure occurs.
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
Suction as needed.
Question 5 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 6
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
Nutrition
B
Health
C
Gender
D
Ordinal position in the family
E
Intelligence
F
Temperament
Question 6 Explanation: 
ANSWER: Gender ; Health ; Temperament ; Intelligence ; 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 7
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
Bruising
B
Weight gain
C
Chills
D
Adrenal failure
E
Nephrotoxicity
F
Hepatoxicity
G
Nausea and vomiting
H
Fever
Question 7 Explanation: 
ANSWER: Fever ; Chills ; Adrenal failure ; Nephrotoxicity ; RATIONALE: Amphotericin B toxic signs and symptoms include: • Fever • Chills • Adrenal failure • Nephrotoxicity • Anorexia • Headache
Question 8
Aside from ego integrity, other developmental tasks of the elderly are: Select all that apply.
A
Establishing independence to ADLs
B
Successfully adjusting to retirement
C
Adjusting to death of spouse
D
Viewing own death as an appropriate outcome of life
E
Keeping socially active
F
Building trust to people
G
Achieving aims and visions
H
Maintaining contact with friends and family members
I
Adjusting to reduced income
Question 8 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 9
Nursing diagnosis for patients with disorders of the nervous system may include which of the following? Select all that apply.
A
Self-care deficit
B
Impairment of skin integrity related to increased mobilization
C
Potential alteration in nutrition: more than body requirements
D
Alteration in bowel elimination (constipation or continence)
E
Altered tissue perfusion (cerebral)
F
Impaired verbal communication
Question 9 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 10
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
Hepatoxicity
B
Peripheral neuritis
C
Thrombocytopenia
D
Ototoxicity
E
Skin rash
F
Nausea and vomiting
G
Nephrotoxicity
H
Red orange color to body secretions
Question 10 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 11
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
Selectively attentive
C
Distorted perceptions
D
Increased rate of speech
E
Diaphoresis
F
Vertigo
G
Increased automatisms
Question 11 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 12
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
Continuous reinforcement will last long.
C
Consequences results from behavior.
D
Random intermittent reinforcement is faster to produce an increase in behavior.
E
Behavior that is rewarded with reinforces tends to recur.
F
Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur.
Question 12 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 13
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
Make sure to cut the cuticles regularly
C
Reach out into a hot oven
D
Use a thimble when sewing
E
Wear a loose rubber glove when washing dishes
F
Wristwatch or jewelries at the affected side is allowed but it has to be very light
G
Apply lanolin hand cream to prevent dryness
Question 13 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 14
Surgery done for the management of lung cancer typically includes which of the following? Select all that apply.
A
Decortication
B
Lobectomy
C
Thoracoplasty
D
Chemotherapy
E
Radiation treatment
Question 14 Explanation: 
ANSWER: Lobectomy ; Thoracoplasty ; Decortication ; RATIONALE: Chemotherapy and radiation treatment are management for cancer but do not involve surgery.
Question 15
Which of the following causes pleural effusion and pneumothorax? Select all that apply.
A
ABG studies
B
CVP line insertion
C
A positive family history
D
Thoracic surgery
E
Emphysema
F
Positive pressure ventilation
Question 15 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 16
In providing bed and bath hygiene which of the following concepts are important? Select all that apply?
A
Ensure that the temperature of the bath water is 110-115 degree Fahrenheit
B
Check the soiled linen for personal items such as eyeglasses
C
Finish care with a back using rubbing alcohol
D
Wash the client’s extremities from proximal to distal
E
Shave the client in the direction of the hair growth
Question 16 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 17
Albuminuria is detected in clients having which condition? Select all that apply.
A
Pneumonia
B
Histoplasmosis
C
Malignant hypertension
D
Hypotension
E
CHF
F
ARDS
Question 17 Explanation: 
ANSWER: Malignant hypertension ; CHF ; RATIONALE: Albuminuria is detected in clients with malignant hypertension and CHF.
Question 18
The nurse is aware about the factors that hinder defection in a hospitalized client. Select all that apply.
A
Increased activity
B
Increased fiber in the diet
C
Ignoring the urge to defecate when it occurs
D
Increased fluid intake
E
Excessive laxative use
F
Discomfort with defecation
Question 18 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 19
In the removal of the chest tube which items should the nurse prepare? Select all that apply.
A
Suture removal kit
B
Scissors
C
Petrolatum gauze
D
Adhesive tape
E
Sterile gauze
F
Forceps
Question 19 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 20
The nurse is performing a neurological check-up on a patient. Which findings would not necessitate further evaluation? Select all that apply.
A
Patient is oriented to time date and place
B
GCS of 5/15
C
Decorticate posturing is noted
D
The patient blinks when the cornea is lightly stroked
E
Pupils constrict in response to light
Question 20 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 21
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
O2 therapy: 2-3 LPM
E
Administer Morphine if client is on Positive End Expiratory Pressure (PEEP)
Question 21 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 22
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
Treat intrusive daytime thoughts
B
Treat sleep problems
C
Control flashbacks
D
Relieves the client from nightmares when sleeping
E
Decrease alcohol cravings
F
Control phobias
Question 22 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 23
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
A sterile water should be used in rinsing the mouth
B
Rinse mouth with plain water before collecting the specimen
C
The sputum to be collected is obtained before sleeping
D
If the sputum collected is for AFB staining, the specimen should be collected for 5 consecutive mornings
E
Sputum specimen for C and s is collected before the first dose of antimicrobial
Question 23 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 24
Human cancers are majorly related to environmental carcinogens. Physical environmental carcinogens include which of the following. Select all that apply.
A
Trauma
B
Ultraviolet rays
C
Cigarette smoking
D
X-rays
E
Alkylating agents
Question 24 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 25
Which of the following should be avoided by the client who underwent a breast surgery? Select all that apply.
A
Cuts
B
Pinpricks
C
Salty foods
D
Hangnails
E
Analgesia
F
Burns
G
Scratches
H
Insect bites
Question 25 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 26
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
Collect the specimen as close as possible to the client’s usual schedule of sexual activity
B
The client should abstain from sex for 1 week before semen analysis
C
Place the collected specimen in an ice box while transporting it
D
The man masturbates into a clean, dry specimen jar with a secure lid
E
The analysis may need to be repeated after 2-3 months
F
Use lubricants when collecting the specimen
G
The spermatozoa are examined within 1 hour after ejaculation
Question 26 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 27
In glaucoma which diagnostic tests can be used? Select all that apply.
A
Gonioscopy
B
Tonometry
C
Weber’s test
D
Diathermy
E
Sclera buckling
F
Perimetry
G
Visual acuity
Question 27 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 28
Teaching guidelines regarding radiation therapy includes the following. Select all that apply.
A
Avoid overexposure to sunlight
B
Inform the client that the procedure is painless
C
Vent vials to reduce internal pressure after mixing
D
Mask, gloves and gown (back-closing) is used during the therapy
E
Remind the client that the machine may move during the therapy and the procedure usually lasts for a few minutes
F
Safety precautions are necessary only during the time the client is actually receiving irradiation.
Question 28 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 29
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
Heavy bleeding during menses
B
Sore that healed for 2 weeks
C
Change in wart or mole
D
Lump in breast or elsewhere
E
Nagging cough or hoarseness
F
Fever that lasts for 2 weeks
G
Constipation
Question 29 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 30
After a Caldwell-Luc Surgery, the nurse should instruct the client to do the following. Select all that apply.
A
Caution client with oral hygiene to prevent trauma of incision
B
Dentures should not be worn for 5 days
C
Do not chew on the affected side
D
After the removal for packing, the client should not blow his or her nose for 2 weeks
E
Avoid clearing of throat
Question 30 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 31
Basic principles on pain and its assessment include the following.  Select all that apply
A
Administering pain medications will eventually lead to addition
B
IV narcotics are the longest acting pain relief technique
C
The client needs to be reassured that the nurse believes about his statement of pain
D
Each person’s expression of pain may be different and individualized
E
Client should show verbal and non-verbal signs that he is in pain
F
Pain level and tolerance can be assessed from a scale of 1 to 10
Question 31 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 32
Before thoracentesis the nurse should perform the following. Select all that apply.
A
Encouraging the client for bed rest until VS is stable
B
Instruct the client to remain still
C
Secure consent
D
Position the client upright leaning on overbed table
E
Monitor VS
Question 32 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 33
To manage the side effect of skin itching, redness and burning in radiation, the nurse must perform the following. Select all that apply.
A
Use bed cradle.
B
Use cornstarch or olive oil.
C
Encourage the patient to eat only bland foods
D
Provide client with frequent rest periods
E
Avoid use of medicated solutions, ointments or powders
F
Assess for bleeding
Question 33 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 34
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 secretion
B
Collecting specimen for biopsy
C
Determining the location of pathologic process
D
Excises lesions
E
Removing foreign objects
Question 34 Explanation: 
ANSWER: Excises lesions ; Removing foreign objects ; RATIONALE: Items in 1, 4 and 5 are diagnostic purposes of bronchoscopy.
Question 35
Nursing interventions after bronchography include which of the following. Select all that apply.
A
Securing written consent
B
Side-lying position
C
Check for allergies to seafoods
D
Instruct the client to cough and deeply breath
E
Have oxygen and antispasmodic agents ready
F
NPO for 6-8 hours
Question 35 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 36
Complications of the respiratory tract include which of the following. Select all that apply.
A
Shock
B
Infection
C
DVT
D
Pneumonia
E
Atelectasis
F
Pulmonary embolism
Question 36 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 37
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
Instructing the patient to lie on the affected side after the procedure
B
Pulling the ear canal upward and backward in a child.
C
Allowing the returning fluid to drain on the floor or chair
D
Assisting the client to a sitting position or lying position with the head tilted to the affected area
E
Making sure to straighten the ear canal for adults and children
Question 37 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 38
Central lines are used for which purposes. Select all that apply.
A
GI feeding
B
Chemotherapy
C
IV therapy
D
Blood transfusion
E
TPN administration
F
Antibiotic therapy
Question 38 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 39
A client diagnosed with COPD is instructed to follow which dietary regimen? Select all that apply.
A
Decrease protein in the diet
B
Increase protein in the diet
C
Decrease carbohydrate
D
Increase calorie
E
Increase carbohydrate
F
Bland diet
G
Low salt
Question 39 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 40
Bronchial hygienic measures include the following. Select all that apply.
A
Steam inhalation
B
Lung biopsy
C
Closed chest drainage
D
Incentive spirometry
E
Oropharyngeal suctioning
F
Aerosol inhalation
Question 40 Explanation: 
ANSWER: Oropharyngeal suctioning ; Aerosol inhalation ; Steam inhalation ; RATIONALE: Bronchial hygiene measures are: • Suctioning • Steam inhalation • Aerosol inhalation • Medimist inhalation
Question 41
Before a lumbar puncture the nurse must provide the following care. Select all that apply.
A
Have the patient empty his or her bladder
B
Force fluids.
C
Explain to the client the need to remain still.
D
Assess the sensation and movement of the lower extremities.
E
Keep the patient flat for 12-24 hours
Question 41 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 42
Which of the following is true about creatine Phosphokinase (CK-MB)? Select all that apply.
A
It is the most specific cardiac enzyme
B
Normal range in males is 50-325 mu/ml
C
It is the most sensitive indicator of myocardial damage
D
It is an accurate indicator of myocardial damage
E
Elevated level indicates tissue necrosis
Question 42 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 43
The skin of the patient with hyperthermia can be prevented from breaking down if the nurse performs which intervention? Select all that apply.
A
Observing for seizure activity and protecting patient if seizures occur
B
Turning the client every 2 hours
C
Frequently checking every hour for signs of tissue damage
D
Maintaining room temperature
E
Applying methods for inducing hypothermia
Question 43 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 44
Decreased metabolism in COPD is characterized by which of the following? Select all that apply.
A
Body malaise
B
Fatigue
C
Polycythemia
D
Chest pain
E
Alteration in LOC
F
Anorexia
G
Weight loss
Question 44 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 45
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
Epigastric pain
C
Severe nausea and vomiting
D
Difficulty sleeping
E
Increased urine output
F
Headache
Question 45 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 46
Assessment findings in a migraine attack include which of the following? Select all that apply.
A
Abrupt onset lasting for 30-90 minutes
B
Bilateral pain in the head (occurring at the back of the neck extending diffusely to the top of the head)
C
Severe throbbing pain often in the temporal or supraorbital area
D
Pallor
E
Nausea and vomiting
F
Characterized by the presence of an aura preceding the pain
Question 46 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 47
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
Mechanical overventilation
B
Barbiturate or sedative overdose
C
Weakness of respiratory muscles
D
COPD
E
Diarrhea
F
Guillain-Barre syndrome
G
Hyperventilation
Question 47 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 48
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
Elevate the head of bed about 30 to 45 degrees.
D
Keep the patient on bed rest for the next 48 hours.
E
Offer food or fluids as tolerated
Question 48 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 49
In a client with diarrhea, which outcome indicates that fluid resuscitation is successful? Select all that apply.
A
Firm skin turgor
B
Moist mucous membranes
C
Urine output of at least 30 ml/hour
D
Absence of erythema in perianal skin and mucous membranes
E
Formed stools at regular intervals
F
Decrease in stool frequency and liquidity
Question 49 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 50
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
Do valsalva maneuver
B
Ambulate within limits
C
Deep breathing and coughing exercises
D
Remain flat in bed
Question 50 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 51
Dietary recommendations against cancer include the following. Select all that apply.
A
Alcoholic beverages should be avoided
B
Cut down on total caloric intake
C
Whole grain cereals should be minimized
D
Make sure to include foods rich in vitamin A and C in the diet
E
Avoid obesity
F
Moderate consumption of salty foods should be encouraged
Question 51 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 52
A client has been suspected with air embolism. Which clinical manifestations are expected of this client? Select all that apply.
A
Edema
B
Cyanosis
C
Rise in venous pressure
D
Unconsciousness
E
Tachycardia
F
Coldness at the site
G
Swelling at the site
H
Hypertension
Question 52 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 53
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
May say vowel sounds (oh-oh)
B
Has social smile
C
Clap hands
D
Transfer objects hand to hand
E
Use palmar grasp
F
Sit with support
Question 53 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 54
For persistent intractable pain of high intensity, neurosurgical procedures for pain control are used which includes the following. Select all that apply.
A
Chordotomy
B
Sympathectomy
C
Diathermy
D
Neurectomy
E
Rhizotomy
F
Stapedectomy
G
Transcutaneous electrical nerve stimulation
Question 54 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 55
Which of the following are parts in the layer of the middle eye? Select all that apply.
A
Cornea
B
Ciliary body
C
Retina
D
Stapes
E
Anvil
F
Iris
G
Choroid
Question 55 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 56
A client is diagnosed with acute maxillary sinusitis. Which of the following clinical assessment would the nurse expect to find in this patient?
A
Headache
B
Snoring
C
General malaise
D
Sore throat
E
Fever
F
Earache
G
Pain in and around the eyes
Question 56 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 57
To assess the current health status of the patient which questions should the nurse ask? Select all that apply.
A
Is family or friends available to provide care, or is the patient alone?
B
How well is the patient progressing?
C
What level of nursing care does the patient require?
D
Has the client shown signs of progress?
E
How serious are the present signs and symptoms?
F
Is the patient capable of self-care?
Question 57 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 58
Hypertrophy of mucous membrane in pneumonia would result to which clinical manifestations? Select all that apply.
A
Dyspnea
B
Cough
C
Increase WBC
D
Hypoxemia
E
Increase sputum production
F
Rales
G
Fever
Question 58 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 59
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
Tunnel vision
B
Halos around lights
C
Flashes of light
D
Severe eye pain
E
Veil-like curtain coming across field of vision
F
Floaters
Question 59 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 60
A middle-adult’s developmental task is met if he or she achieves the following. Select all that apply.
A
Better able to juggle their various lives as a mother, office worker and group chairperson
B
Participate in far-reaching community decisions
C
Form long-lasting relationships
D
Happily accepts a late-in-life pregnancy
E
Take pride in new accomplishments and want to do everything independently
Question 60 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 61
A client is scheduled for a surgical procedure. Preoperative health teaching/care should include which of the following? Select all that apply.
A
Explaining pre and post-op procedures and any special equipment to be used.
B
Assisting patient to turn in bed every 2 hours.
C
Assuring patient that pain medications will be available post-op.
D
Reinforcing explanations given by physicians.
E
Measuring I and O
F
Application of antiembolism stockings as ordered.
Question 61 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 62
To prevent infection post-laryngectomy the nurse should perform the following. Select all that apply.
A
Use a sterile NSS to lubricate the suction catheter tip
B
Position the patient to a semi-fowler’s
C
Change dressings and ties as necessary
D
Cleanse the stoma and tracheostomy at regular basis
E
Suction the patient as necessary
Question 62 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 63
Drugs are used in attacking cancer cells in chemotherapy. Which chemotherapeutic drugs are classified as antimetabolites? Select all that apply.
A
Cisplatin
B
Chlorambucil
C
Cytoxan
D
5-Fluorouracil
E
Methotrexate
Question 63 Explanation: 
ANSWER: 5-Fluorouracil ; Methotrexate ; RATIONALE: Antimetabolites include: • Methitrexate • 5-Fluorouracil • ARA-C Mercaptopurine Thioguanine
Question 64
Predisposing factors for cancer of the larynx includes which of the following? Select all that apply.
A
Alcohol abuse
B
Acute laryngitis
C
Environmental pollutants
D
A positive family history
E
Tonsillitis recurring 5-6 times a year
Question 64 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 65
Before cardiac catheterization, the nurse should perform which of the following? Select all that apply.
A
Apply pressure dressing and a small ice bag or ice over the punctured area
B
Immobilize affected extremity
C
Assess for allergy to iodine/seafoods
D
Have the client void
E
Elevate HOB to 30-45 degrees
F
Monitor ECG
Question 65 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 66
In delegating tasks, what activities can a registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
A
Monitoring a newly admitted alcoholic client whose last drink was two days ago
B
Checking a client in soft wrist restraint
C
Recording the intake and output of a manic client
D
Assessing a hypomanic client on depression
E
Accompanying a depressed client to occupational therapy
F
Monitoring a client who is on Tricyclic antidepressant for two weeks
Question 66 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 67
Bronchodilators can be given to patients with COPD. Which of the following drugs are bronchodilators? Select all that apply.
A
Alupent (Metaproterenol)
B
Bricanyl (terbutaline)
C
Aminophylline (Theophyline)
D
Dextrometorphan
E
Benadryl (diphenhydramine)
Question 67 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 68
Which of the following cranial nerves are purely motor in function? Select all that apply.
A
Olfactory
B
Abducens
C
Optic
D
Trigeminal
E
Oculomotor
F
Trochlear
Question 68 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 69
Existential therapies include the following. Select all that apply.
A
Rational emotive therapy
B
Cognitive therapy
C
Gestalt therapy
D
Operant conditioning
E
Classical conditioning
F
Carl Roger’s client-centered therapy
G
Reality therapy
Question 69 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 70
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
Monitoring for frequent swallowing
B
Administration of acetaminophen
C
Placing an ice collar on the patient’s neck
D
Checking the client’s vomitus for blood
Question 70 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 71
Which of the following signs would suggest that a client might have a possible lung cancer? Select all that apply.
A
Unexplained fever
B
Any change in respiratory pattern
C
Persistent cough
D
Chest, shoulder and arm pain
E
Frank hemoptysis
F
Recurring episodes of tonsillitis
G
Presence of sore that does not heal
Question 71 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 72
Which of the following is expected after tonsillectomy? Select all that apply.
A
Colds
B
Heavy Bleeding
C
Fever
D
Throat discomfort
E
Black or dark stool
Question 72 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 73
Modifiable risk factors for cardiovascular disorders include which of the following? Select all that apply.
A
Exercise
B
Contraceptive pills
C
Race
D
Obesity
E
Diabetes mellitus
F
Age
G
Alcohol
H
Gender
Question 73 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 74
A client is undergoing an IV therapy. Complications of IV therapy include which of the following? Select all that apply.
A
Presbycusis
B
Circulatory overload
C
Porous bones
D
Pyrogenic reaction
E
Impaired absorption
F
Infiltration
Question 74 Explanation: 
ANSWER: Infiltration ; Pyrogenic reaction ; Circulatory overload ; RATIONALE: Complications of IV therapy includes: • Infiltration • Phlebitis • Pyrogenic reaction • Air embolism • Circulatory overload
Question 75
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
Dobutrex
B
Inotropin
C
Lithium
D
Levophed
E
Marplan
F
Praziquantel
G
Digitalis preparations
Question 75 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 76
Pulmonary function studies include the following. Select all that apply.
A
Residual volume
B
Inspiratory reserve volume
C
Tidal volume
D
Vital capacity
E
Lung scan
F
Lymph node biopsy
G
Functional reserve volume
Question 76 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 77
Which of the following should be monitored in a client with pneumonia? Select all that apply.
A
Temperature
B
Central venous pressure
C
ABG
D
Sputum
E
Chest X-ray
Question 77 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 78
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
Release the restraint and reposition the client every four hours
B
Document restraint checks and patient status every two hours
C
Educate the client’s family about restraint use
D
Provide 10 minutes of release and repositioning
E
Obtain the physician’s order renewal every 72 hours
Question 78 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.
Question 79
Which of the following would be included in the list of emergency supplies needed in case of a disaster? Select all that apply.
A
Computer components
B
One change of clothing and protective footwear
C
Candles and matches
D
Passport and birth certificate
E
Sanitation supplies
Question 79 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 80
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
Decrease LOC
B
High-pitched cry
C
Abnormal respiratory patterns
D
Rise in systolic pressure
E
Sunken fontanels
Question 80 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 81
Proliferation of cancer cells produces pain due to the following reasons. Select all that apply.
A
Effusion
B
Release of pain mediators by the tumor
C
Thrombophlebitis
D
Distention of vessels or organs
E
Pressure on nerve endings
F
Lack of O2 to tissues and organs
G
DIC
Question 81 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 82
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
Instructing the client to follow a bland diet regimen
B
Monitoring platelet count
C
Applying heat on the area
D
Administration of aspirin before meals
E
Saline rinses every 2 hours
F
Giving the client sugarless lemon drops
Question 82 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 83
Which of the following is an antineoplastic antibiotic? Select all that apply.
A
Doxorudicin (Adriamycin)
B
Fludaradine (Fludara)
C
Bleomycin (Blenoxane)
D
Methotrexate (Folex)
E
Thioguanine
Question 83 Explanation: 
ANSWER: Bleomycin (Blenoxane) ; Doxorudicin (Adriamycin) ; RATIONALE: Medications listed in 1, 2 and 4 are antimebolites.
Question 84
Which procedure requires a chest tube placement and a semi-fowler’s position or on unaffected side position post-op?
A
Lobectomy
B
Decortication
C
Pneumonectomy
D
Wedge resection
E
Segmentectomy
F
Thoracoplasty
Question 84 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 85
Cardiovascular complications include shock. Most common causes of shock during the post-op period are? Select all that apply.
A
Sepsis
B
Post-op immobilization
C
Pulmonary embolism
D
Venous stasis
E
Drug reactions
F
Myocardial infarction
G
DVT
Question 85 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 86
Common clinical manifestations of cardiovascular disorders include which of the following? Select all that apply.
A
Cystitis
B
Diarrhea
C
Weight loss
D
Edema
E
Syncope
F
Infection
G
Orthopnea
Question 86 Explanation: 
ANSWER: Orthopnea ; Edema ; Syncope ; RATIONALE: Clinical manifestations listed in 4-7 are the common side effects of radiation therapy.
Question 87
Number of fetal movements per hour varies depending on which of the following. Select all that apply.
A
Genetic predisposition
B
Maternal medical condition
C
Time of the day
D
Meal time
E
Mood of the mother
F
Position of the mother
G
Hydration status of the mother
Question 87 Explanation: 
ANSWER: Meal time ; Position of the mother ; Hydration status of the mother ; 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 88
Which of the following should the nurse watch out after bronchoscopy? Select all that apply.
A
Nausea
B
Arrhythmias
C
Jaundice
D
Dyspnea
E
Hypertension
F
Tachycardia
Question 88 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 89
Possible bedrest complications are which of the following? Select all that apply.
A
Urinary calculi
B
Pressure ulcers
C
Contractures of extremities
D
Pneumonia
E
Thrombi
F
Decreased pain
G
Diarrhea
H
Decreased dependency
Question 89 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 90
Mr. Romar has pleural effusion. Which nursing interventions are appropriate for this client? Select all that apply.
A
O2 therapy
B
Prepare for endotracheal tube insertion
C
Prepare for CVP line insertion
D
Position the client in high-fowler’s
E
Monitor for shock
Question 90 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 91
Effects of total laryngectomy include the following. Select all that apply.
A
Loss of the sense of smell
B
Inability to whistle
C
Inability to gargle
D
Tracheostomy placement for 2 weeks
E
Softer voice produced when speaking
Question 91 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 92
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 fantasize that the disaster never occur
B
Regressive behaviors will be exhibited by the students
C
Students are cheerful to answer questions
D
Students are apt to learn about the next lesson
E
Students refuse to go back to school
Question 92 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 93
Signs of infection include which of the following? Select all that apply.
A
Increased WBCs
B
Bradycardia
C
Increased RBCs
D
Increased neutrophils
E
Hypothermia
F
Increased body temperature
G
Localized pain
H
Localized edema
Question 93 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 94
Arterial blood gas studies serve for which purpose? Select all that apply.
A
To assess the pressure of blood in the vessels
B
Assess acid-base balance
C
Measure blood perfusion in the lungs
D
Assess the adequacy of collateral circulation of the hand
E
To assess ventilation
Question 94 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 95
Preoperative care for breast surgery includes the following. Select all that apply.
A
Place the client in a semi-fowler’s position with arms elevated on pillows abducted
B
Inform about wound suction drainage
C
Include husband in the care as possible.
D
Check the patient for bleeding
E
Teach arm exercises
Question 95 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 96
Late signs of bronchogenic cancer include which of the following? Select all that apply.
A
Fever
B
Anemia
C
Weight loss
D
Hacking cough with a thick blood-tinged sputum
E
Edema around the neck
F
Weakness
Question 96 Explanation: 
ANSWER: Weakness ; Anemia ; Weight loss ; RATIONALE: Late signs of bronchogenic cancer include weakness, weight loss, anorexia and anemia.
Question 97
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
Stooped posture
B
Decreased perspiration
C
More porous bones
D
Increased muscular strength
E
Atrophy of muscles
F
Relaxed joints
Question 97 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 98
Which of the following is true about TB?
A
It is an infectious disease
B
Transmitted by droplet infection
C
Anti-TB drugs must be taken on a full stomach to prevent GI irritation
D
Anti-Tb drugs must be taken in combination
E
The effectiveness of anti-Tb drugs is evaluated by the absence of cough
Question 98 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 99
To manage clients with increased ICP the nurse should be perform which nursing interventions? Select all that apply.
A
Assist with mechanical ventilation as indicated.
B
Monitor VS and perform neuro checks frequently.
C
Avoid restrain use
D
Administer antiemetics as prescribed
E
Force fluids
F
Position the patient flat on bed
Question 99 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 100
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
Taking ASA with Coumadin
B
Constipation
C
Contact sports
D
Using electric razor
E
Smoking
F
Avoiding leg massage
Question 100 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
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