BASIC NEEDS
CARDIO
PULMONARY
BONUS
ENDOCRINE/METABOLIC
100
Which should be the initial intervention for a client with external bleeding? 1. Elevation of the extremity 2. Pressure point control 3. Direct pressure 4. Application of a tourniquet
What is 3
100
The nurse is teaching a client how to take nitroglycerin to treat angina pectoris. The client verbalizes an understanding of the need to take up to three sublingual nitroglycerin (Nitrostat) tablets at 5-minute intervals, if necessary, and to notify the physician immediately if chest pain doesn't subside within 15 minutes. The nurse knows that nitroglycerin may cause: 1. Nausea, vomiting, depression, fatigue, and impotence; 2. sedation, nausea, vomiting, constipation, and respiratory depression; 3. Headache, hypotension, dizziness, and flushing; 4. flushing, dizziness, headache, and pedal edema.
What is 3. RATIONALE: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator.
100
The nurse recognizes that a client with tuberculosis needs further teaching when the client states:1. I'll have to take these medications for 9 to 12 months." 2. "It won't be necessary for the people I work with to take medication." 3. "I'll need to have scheduled lab tests while I'm on the medication." 4. "The people I have contact with at work should be checked regularly."
What is 4. RATIONALE: Casual contacts such as people at work needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. Coworkers' not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements.
100
Which of the following is the recommended immunization schedule for diphtheria, tetanus, and pertussis (DTP)? 1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years 4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years
What is 3. RATIONALES: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school).
100
The adrenal cortex is responsible for producing which substances? 1. Glucocorticoids and androgens 2. Catecholamines and epinephrine 3. Mineralocorticoids and catecholamines 4. Norepinephrine and epinephrine
What is 1. RATIONALES: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine.
200
A client's blood test results are as follows: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal would be most important for this client? 1.Promote fluid balance 2.Prevent infection 3. Promote rest 4. Prevent injury
What is #2
200
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? Romberg's, Phalen's, Rinne, OR Homans'
What is HOMAN'S. RATIONALES: A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Romberg's test assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.
200
What is the normal pH range for arterial blood? 1. 7 to 7.49 2. 7.35 to 7.45 3. 7.50 to 7.60 4. 7.55 to 7.65
What is 2 RATIONALES: Normal pH ranges from 7.35 to 7.45. A pH less than 7.35 is indicative of acidosis; a pH higher than 7.45 indicates alkalosis.
200
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 1. 9%, 2. 18%, 3. 27%, 4. 36%
What is 3. RATIONALES: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
200
The client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions? 1. Take daily weight. 2. Restrict fluids. 3. Assess urine specific gravity. 4. Encourage intake of coffee or tea. 5. Monitor intake and output.
What is 1,3,5 RATIONALES: Tumors of the pituitary gland can lead to diabetes insipidus due to deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, weigh the client daily, measure urine specific gravity, and monitor intake and output. Encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect should be avoided.
300
On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values, the nurse should formulate which nursing diagnosis for this client? Risk for deficient fluid volume, Deficient fluid volume, Impaired gas exchange, Metabolic acidosis
What is 3. RATIONALES: The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.
300
The nurse is performing a 12-lead electrocardiogram (ECG) on a client who's complaining of chest pain. Identify the area where lead V6 should be placed.
What is the 5th ICS. RATIONAL: The V6 lead is placed at the 5th intercostal space at the midaxillary line. Correct placement of the leads is essential when performing a 12-lead ECG to accurately document the electrical potential of the heart. V6 is one of the precordial leads and, in combination with the other leads, records potential in the horizontal plane.
300
A positive Mantoux test indicates that the client: 1. is actively immune to tuberculosis. 2. has produced an immune response. 3. will develop full-blown tuberculosis. 4. has an active case of tuberculosis.
What is 2. RATIONALES: Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis.
300
A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? 1. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output 2. Checking the client's medical records for health history information 3. Attempting to contact the client's family to obtain more information about the client 4. Restricting fluids and leaving the client alone to "sleep off" the episode
What is 1. RATIONALES: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the care plan. Fluids are typically increased unless contraindicated by a preexisting medical condition.
300
After taking an overdose of amitriptyline (Elavil), a client is brought to the emergency department. Immediate care for this client should include: 1. giving syrup of ipecac to induce vomiting. 2. administering activated charcoal every 4 hours for 24 hours. 3. giving large boluses of enteral saline. 4. lavaging the stomach with a small-gauged gastric tube.
What is 2. RATIONALES: After appropriate lavage of the stomach, activated charcoal is given every 4 hours for 24 hours. The charcoal binds with amitriptyline and inactivates it. Inducing vomiting is contraindicated because the client's mental status may rapidly deteriorate and pose the risk of aspiration. Large boluses of enteral saline can force the drug into the small intestine, where it will be absorbed. A large tube should be used for gastric lavage so that intact pills can be removed.
400
A client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause: 1. palpitations. 2. dizziness. 3. diarrhea. 4. a metallic taste.
What is 3. RATIONALES: Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn't associated with palpitations, dizziness, or a metallic taste.
400
The nurse is performing a cardiac assessment. Identify where the nurse places the stethoscope to best auscultate the pulmonic valve.
What is The pulmonic area is best heard at the second intercostal space, just left of the sternum.
400
A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding? 1. Bronchophony 2. Tactile fremitus 3. Crepitation 4. Egophony
What is 1 RATIONALES: Bronchophony is an increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. Over normal lung tissue, the words are unintelligible; however, over areas of tissue consolidation, such as with pneumonia, the words are clear because the tissue enhances the sounds. Tactile fremitus is the vibration felt when the client speaks while the nurse holds her hand against his chest. Crepitation is a crackling sound heard in certain diseases, such as pneumonia. Egophony is an abnormal change in tone heard when the client speaks normally as the nurse auscultates his chest.
400
The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature? 1. 39° C 2. 47° C 3. 38.9° C 4. 40.1° C
What is 3. RATIONALES: To convert Fahrenheit degrees to Centigrade, use this formula: °C = (°F – 32) ÷ 1.8 °C = (102 – 32) ÷ 1.8 °C = 70 ÷ 1.8 °C = 38.9
400
A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8° F (38.2° C). What effect may this have on his need for insulin? 1. It will have no effect. 2. It will decrease the need for insulin. 3. It will increase the need for insulin. 4. It will cause wide fluctuations in the need for insulin.
What is 3 RATIONALES: Insulin requirements are increased by growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.
500
The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would: 1. keep the area covered with the warm soaks continuously, 2. remove the warm compress after 20 minutes for at least 15 minutes, 3.alternate warm compresses with cold compresses, 4. question the order because heat increases edema.
What is 2. RATIONALES: Because heat and cold can injure the skin, either should be applied only for a limited time. Warm compresses increase circulation and promote absorption of fluid in the infiltrated area. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction.
500
DAILY DOUBLE! A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: 1. place a heating pad around the affected calf. 2. elevate the affected leg as high as possible. 3. keep the affected leg level or slightly dependent. 4. shave the affected leg in anticipation of surgery.
What is 3. RATIONALES: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks.
500
For a client with impaired gas exchange, which position is best? 1. Lateral decubitus 2. High Fowler's 3. Supine 4. Semi-Fowler's
What is 2 RATIONALES: For a client with impaired gas exchange, high Fowler's is the best position because it allows maximal chest expansion. If the client can't tolerate high Fowler's position, semi-Fowler's is the next best choice because it increases comfort and allows chest expansion. The lateral decubitus and supine positions don't promote chest expansion.
500
Which source of information helps the nurse formulate nursing diagnoses for a specific client? 1. Research articles 2. Essential assessment data 3. Outcome criteria 4. Admission criteria
What is 2.
500
The nurse prepares to administer medication by the buccal route. Where should the nurse place this medication? 1. On the client's skin 2. Between the client's cheek and gum 3. Under the client's tongue 4. In the client's conjunctival sac
What is 2 RATIONALES: The nurse should place medication administered by the buccal route in the client's upper or lower buccal pouch, between the cheek and gum. A topical medication is applied on the client's skin; a sublingual medication, under the tongue; and an eye (ocular) medication, in the conjunctival sac.
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