A. a gastrostomy tube that is clamped.
B. the patient coughing blood-tinged secretions from the tracheostomy.
C. the patient positioned in a lateral position with the head of the bed flat.
D. 200 ml of serosanguineous drainage in the patient's portable drainage device.
1. A 78-year-old does not want to eat
lunch and complains that the food that is serve does not taste good. Consistent
with knowledge about age-related changes to taste, the nurse may find that the
client is more willing to eat.
A) Greasy foods
B) Sour foods
C) Sweet foods
D) Salty foods.
3. The nurse is preparing a discharge plan to a
female client with peptic ulcer for the dietary modification she will need to
follow at home. Which of the following statements indicates that the client
understands the instruction of the nurse?
A) "I should not drink alcohol and caffeine."
B) "I should eat a bland, soft diet."
C) "It is important to eat six small meals a day."
D) "I should drink several glasses of milk a day."
4. A client has disabling attacks of
vertigo. The nurse suspects that the client has Meniere's disease. The nurse is
aware that the diet of the client must be modified. Which of the following is
the best diet for the client?
A) High protein
B) Low Carbohydrates
C) Low Sodium
D) Low Fat
5. Which of the following is the most common
surgical procedure for chronic otitis media?
A) Myringotomy
B) Ossiculoplasty
C) Mastoidectomy
D) Tympanoplasty
6. A community health nurse is teaching smoking
cessation program to a group of healthy adult smokers. What type of prevention
activity is this?
A) Primary
B) Secondary
C) Tertiary
D) None of the above
7. A female client with breast cancer is
currently receiving radiation therapy for treatment. The client is complaining
of apathy, hard to concentrate on something, and feeling tired despite of
having time to rest and more sleep. These complains suggest symptoms of:
A) Hypocalcemia
B) radiation pneumonitis
C) advanced breast cancer
D) fatigue
A) Hypocalcemia
B) radiation pneumonitis
C) advanced breast cancer
D) fatigue
8. The nurse is removing the client's
staples from an abdominal when the client cough continuously and the incision
splits open exposing the intestines. Which of the following is the immediate
nursing action of the nurse?
A) Call the surgeon to come to the client's room immediately
B) Have all visitors and family member leave the room
C) Press the emergency alarm to call the resuscitation team
D) Cover the abdominal organs with sterile dressing moistened with sterile normal saline.
9. Which of the following signs and symptoms would
indicate that a client has benign prostatic hypertrophy (BPH)?
A) Hematuria
B) Flank pain
C) Impotence
D) Difficulty starting the urinary stream
10. A male client is receiving chemotherapy for
lung cancer. He asks the nurse how the drug will work. Which of the following
is the correct response of the nurse?
A) "Chemotherapy affects all rapidly dividing cells."
B) "Structure of the DNA is altered."
C) "Chemotherapy encourages cancer cells to divide."
D) "Cancer cells have susceptible drug toxins
A) "Chemotherapy affects all rapidly dividing cells."
B) "Structure of the DNA is altered."
C) "Chemotherapy encourages cancer cells to divide."
D) "Cancer cells have susceptible drug toxins
11. A client will be receiving general
anesthesia. The nurse reviews the laboratory result of the client and found out
that the serum potassium level is 5.8 mEq/L. What should be the nurse's initial
response?
A) Send the client to surgery
B) Notify the anesthesiologist
C) Call the surgeon
D) Send the client to surgery
12. The nurse is instructing the unlicensed
assistant on how to care for a client with chest tubes that are connected to
water seal drainage. Which of the following instruction would be appropriate
for the nurse to give the unlicensed assistant?
A) Mark the time and amount of drainage collected in the container
B) Raise the collection apparatus to the height of the bed to measure the fluid level.
C) Milk the test tubes every 4 hours
D) Attach the chest tubes to bed linen to avoid tension of the tubing
13. After the first three dose of Paroxetine
(Paxil) 20 mg, the client complains that the medication upsets his stomach.
Which of the following instructions would the nurse give to the client?
A) "Take the medication with 4 ounces of orange juice."
B) "Take the medication an hour before breakfast."
C) "Take the medication at bedtime."
D) "Take the medication with some foods.
14. The nurse is developing a teaching plan for a
client who will undergo a stapedectomy for treatment of otosclerosis. Which
point should the plan include?
a. ringing in the ears is common after surgery
b. vertigo and dizziness are common after surgery
c. hearing should return immediately after surgery
d. excessive drainage is common after surgery
15. The nurse is caring for a client with a
diagnosis of detached retina. Which assessment sign would indicate that
bleeding has occurred as a result of the retinal detachment?
a) total loss of vision
b) a reddened conjunctiva
c) a sudden sharp pain in the eye
d) complaints of a burst of black spots or floaters
16. The client sustains a contusion of the eyeball
following a traumatic injury with a blunt object. Which intervention is
initiated immediately?
a) notify the physician
b) apply ice to the affected eye
c) irrigate the eye with cool water
d) accompany the client to the emergency room
17. The client arrives in the emergency room with a
penetrating eye injury from wood chips that occurred while cutting wood. The
nurse assesses the eye and notes a piece of wood protruding form the eye. What
is the initial nursing action?
a) apply an eye patch
b) perform visual acuity tests
c) irrigate the eye with sterile saline
d) remove the piece of wood using a sterile eye clamp
18. The client arrives in the emergency room after
sustaining a chemical eye injury from a splash of battery acid. The initial
nursing action is to:
a) begin visual acuity testing
b) cover the eye with a pressure patch
c) swab the eye with antibiotic ointment
d) irrigate the eye with sterile normal saline
19. The nurse is caring for a client after a lung
lobectomy. The nurse notes fluctuating water levels in the water-seal chamber
of the client's chest tube. What action should the nurse take?
A. Do nothing, but continue to monitor the client.
B. Call the physician immediately.
C. Check the chest tube for a loose connection.
D. Add more water to the water-seal chamber
20. A client with type 2 diabetes has a hemoglobin
A1C level of 8.8 after 6 months of oral therapy with metformin (Glucophage®).
The client tells the nurse that she often forgets to take her medication and
doesn't really follow her diet. Which of the following is the nurse's best
first response?
A. "If you don't get control of your blood sugar, you'll need to take insulin."
B. "It can be hard to get used to having a disease like diabetes. What are some of the things you find challenging about it?"
C. "Uncontrolled diabetes can lead to eye problems and kidneys problems."
D. "Many people have diabetes."
21. The nurse is teaching a client newly diagnosed
with type 1 diabetes how to self-administer subcutaneous insulin injections.
How does the nurse best evaluate the effectiveness of her teaching?
A. Have the client repeat the steps back to the nurse.
B. Give the client a written test on self-administration of insulin.
C. Ask the client to write out the steps for self-administration of insulin injections.
D. Ask the client to give a return demonstration of self-administration of insulin.
22. The nurse is writing the teaching plan for a client
undergoing a radioactive iodine uptake test to study thyroid function. Which of
the following instructions should the nurse include?
A. "You need to stay at least 4 feet (1.2 m) away from other people after the test because you'll be radioactive."
B. "You need to lie very still on a stretcher that is placed in a long tube for the scan"
C. "Don't take any iodine or thyroid medication before the test."
D. "Schedule the bone scans before your radioactive iodine uptake test."
23. A 64-year-old patient with newly diagnosed
acute myelogenous leukemia (AML) who is undergoing induction therapy with
chemotherapeutic agents tells the nurse, "I feel so sick that I don't know
if the treatment is worth completing." The nurse's best response to the patient
is
a. "I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again."
b. "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won't feel so ill."
c. "Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you."
d. "The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life.
24. The nurse is assessing a patient with
gastroesophageal reflux disease (GERD) who is experiencing increasing
discomfort. Which patient statement indicates that additional patient education
about GERD is needed?
a. "I take antacids between meals and at bedtime each night."
b. "I quit smoking several years ago, but I still chew a lot of gum."
c. "I sleep with the head of the bed elevated on 4-inch blocks."
d. "I eat small meals throughout the day and have a bedtime snack.
25. A patient with recurring heartburn receives a
new prescription for esomeprazole (Nexium). In teaching the patient about this
medication, the nurse explains that this drug
a. reduces the reflux of gastric acid by increasing the rate of gastric emptying.
b. coats and protects the lining of the stomach and esophagus from gastric acid.
c. treats gastroesophageal reflux disease by decreasing stomach acid production.
d. neutralizes stomach acid and provides
26. A nurse is performing an initial post op assessment
on a client following upper GI surgery. The client has a NG tube to low,
intermittent suction. To best assess the client for the presence of bowel
sounds, the nurse should:
A. place the stethoscope to the left of the umbilicus.
B. turn off the nasogastric suction.
C. use the bell of the stethoscope.
D. turn the suction on the NG tube to continuous.
27. A nurse is caring for a client diagnosed with
Chron's disease, who has undergone a barium enema that demonstrated the
presence of strictures in the ileum. Based on this finding, the nurse should
monitor the client closely for signs of:
A. peritonitis
B. obstruction
C. malaborsorption.
D. fluid imbalance.
28. While conducting a home visit with a client who
had a partial resection of the ileum for Chron's Disease 4 weeks previously, a
nurse becomes concerned when the client states:
A. My stools float and seem to have fat in them.
B. I have gaiend 5 pounds since I left the hospital.
C. I am still avoiding milk products.
D. I only have 2 formed stools per day.
29. A nurse is reviewing the history and physical
of a teenager admitted to a hospital with a diagnosis of ulcerative colitis.
Based on this diagnosis, which information should the nurse expect to see on
this client's medical record?
A. Abdominal pain and bloody diarrhea.
B. Weight gain and elevated blood glucose.
C. Abdominal distention and hypoactive bowel sounds.
D. Heartburn and regurgitation.
30. A RN overhears a LPN talking with a client who
is being prepared for a total colectomy with the creation of an ileoanal
reservoir for ulcerative colitis. To decrease the client's anxiety, the RN
should intervene to clarify the information given by the LPN when the LPN is
heard saying:
A. this surgery will prevent you from developing colon cancer.
B. after this surgery you will no longer have ulcerative colitis.
C. when you return from surgery you will not be able to eat solid food for several days.
D. you will have an ileostomy when you return from the surgery.
31. The nurse is assessing a client 24 hours
following a cholecystectomy. The nurse noted that the T tube has drained 750 mL
of green-brown drainage since the surgery. Which nursing intervention is
appropriate?
A. Clamp the T tube
B. Irrigate the T tube
C. Notify the physician
D. Document the findings
ANSWERS AND RATIONALES
1. C. the patient positioned in a lateral
position with the head of the bed flat. After total laryngectomy and radical
neck dissection, a patient should be placed in a semi-Fowler's position to
decrease edema and limit tension on the suture line.
2. C = the older adults' taste buds retain
their sensitivity to carbohydrates. In addition, carbohydrates. Tend to be food
items that are easy to chew. Older adults lose their sensitivity to sour and
salty foods. Older adults may find greasy foods harder to digest and therefore
may avoid them; however, preference for greasy foods is not related to changes
in taste associated with age.
3. A = caffeinated beverages and alcohol
should be avoided because they stimulate gastric acid production and irritate
gastric mucosa.
The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet.
Eating six small meals daily is no longer a common treatment for peptic ulcer disease.
Milk in large quantities is not recommended because it actually stimulates further production of gastric acids.
4. C = A low sodium diet is frequently an
effective mechanism for reducing the frequency and severity of the disease
episodes.
About three-quarters of clients with Meniere's disease respond to treatment with a low salt diet.
5. D Tympanoplasty involves
surgical reconstruction as the tympanic membrane and is done to re-establish
middle ear function, close perforation, prevent recurrent infections.
6. A = primary cancer prevention targets
healthy individuals and includes steps to avoid factors that might lead to the
development of diseases.
7. D = Fatigue is a common complaint of
individuals receiving medication therapy.
8. D = When a wound eviscerates, the nurse
should cover the open area with sterile dressing moistened with sterile normal
saline and then cover it with a dry dressing.
The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia.
9. D = the symptoms of BPH are related to
obstruction as a result of an enlarged prostate. Difficulty in starting the
urinary stream is a common symptom, along with dribbling, hesitancy and urinary
retention.
10. A = There are many mechanisms of
action for chemotherapeutic agents, but most affect the rapidly dividing
cells-both cancerous and noncancerous. Cancer cells are characterized by rapid
cell division. Chemotherapy slows cell division
11. B = the nurse should notify the anesthesiologist
because a serum potassium level of 5.8 mEq/L places the client at risk for
dysrhythmias when under general anesthesia.
12. A = It is appropriate for an
unlicensed assistant to mark the time of measurement and fluid level in the
collection container.
13. D = Nausea and gastrointestinal upset
is a common but usually temporary side effects of Paroxetine (Paxil).
Therefore, the nurse would instruct the client to take the medication with food
to minimize nausea and stomach upset.
14. B Vertigo is the most frequent
complication of stapedectomy. The patient should move slowly to avoid
triggering or worsening vertigo and should ask for assistance with ambulation.
Ringing in the ears rarely follows this surgery and should be reported to the
doctor if it does.
Hearing typically decreases after surrey bc of
ear packing and tissue swelling, but commonly returns over the next 2-6 weeks.
Usually, post-op drainage and pain are minimal
Excessive drainage should be reported.
Usually, post-op drainage and pain are minimal
Excessive drainage should be reported.
15. D Complaints of a sudden burst of
black spots or floaters indicates that bleeding has occurred as a result of the
detachment. Options A, B, and C are not signs of bleeding.
16. B Treatment for a contusion
begins at the time of injury. Ice is applied immediately. The client then
should be seen by a physician and receive a thorough eye examination to rule
out the presence of other eye injuries.
17. B
- If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place.
Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.
18. D
Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. Options B and C are not a component of initial care.
19. A
Fluctuation in the water-seal chamber is a normal finding that occurs as the client breathes. No action is required except for continued monitoring of the client. The nurse doesn't need to notify the physician. Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, such as from a loose connection in the chest tube tubing. The water-seal chamber should be filled initially to the 2 cm line, and no more water should be added.
20. B
Acknowledging that the client is going through changes and allowing her to express her concerns will help the nurse assess her needs. Hemoglobin AIC shows the average blood glucose levels over a 3-month period. Diabetes should maintain the AIC <7%. Lecturing, threatening and comparing the clients to others belittles the client and discourages discussion, but the patient must be provided adequate information in order to make informed decisions about self-care.
21. D
Asking the client to give a return demonstration of his injection technique is the best way to assess whether the client can perform the procedure. It also gives the nurse the opportunity to provide feedback. Asking the client to recite the steps, pass a written test, or write out the steps shows the nurse whether the client is able to recall the steps but doesn't show that he has the necessary motor skills or the ability to perform the procedure.
22. C
Medications such as iodine, contrast media, and
antithyroid and thyroid drugs can affect the test results and should be
withheld by the client for a week or longer, as directed by the physician.
During a radioactive iodine uptake test, the client receives radioactive iodine
by mouth or I.V. in small doses and doesn't require isolation. During magnetic
resonance imaging--not radioactive iodine uptake testing--a client needs to lie
still inside a long tube. Any test, such as a bone scan, that requires iodine
contrast media should be scheduled after the radioactive iodine uptake test
because the iodinated contrast medium can decrease uptake.
23. D
Rationale: AML is very aggressive, and survival
after diagnosis is short without treatment. Induction therapy is followed by
more chemotherapy, so the nurse should not tell the patient that he or she will
feel normal or not so ill. The survival with AML is not 80%.
24. D
Rationale: GERD is exacerbated by eating late
at night, and the nurse should plan to teach the patient to avoid eating at
bedtime. The other patient actions are appropriate to control symptoms of GERD.
25. C
Rationale: The proton pump inhibitors decrease
the rate of gastric acid secretion. Promotility drugs such as metoclopramide
(Reglan) increase the rate of gastric emptying. Cryoprotective medications such
as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid
and work rapidly.
26. B
27. B
28. A
29. A
30. D
Posts
