SENSORY/NEURO
CARDIO
MUSC/SKELETAL
PULMONARY
GI/GU
100
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? 1. Administering zolpidem tartrate (Ambien) 2. Assessing laboratory test results as ordered 3. Placing the client in Trendelenburg's position 4. Monitoring the patency of an indwelling urinary catheter
What is 4. RATIONALES: Because a full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
100
The nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? 1. Notched T-wave 2. Presence of a U-wave 3. T-wave inversion 4. Prolonged PR-interval 5. ST-segment elevation 6. Pathologic Q-wave
What ARE 3,4,5
100
After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client? 1. With the affected hip flexed acutely 2. With the leg on the affected side abducted 3. With the leg on the affected side adducted 4. With the affected hip rotated externally
What is 2 RATIONALES: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.
100
A client with a suspected pulmonary embolus is brought to the emergency department. She complains of shortness of breath and chest pain. Which other signs and symptoms would support this diagnosis? 1. Low-grade fever 2. Thick, green sputum 3. Bradycardia 4. Frothy sputum 5. Tachycardia 6. Blood-tinged sputum
What is 1,5,6. RATIONALES: In addition to pleuritic chest pain and dyspnea, a client with a pulmonary embolus may also present with a low-grade fever, tachycardia, and blood-tinged sputum. Thick, green sputum would indicate infection, and frothy sputum would indicate pulmonary edema. A client with a pulmonary embolus is tachycardic (to compensate for decreased oxygen supply), not bradycardic.
100
A client with suspected renal insufficiency is scheduled for a comprehensive diagnostic workup. After the nurse explains the diagnostic tests, the client asks which part of the kidney "does the work." Which answer is correct? 1. The glomerulus 2. Bowman's capsule 3. The nephron 4. The tubular system
What is 3. RATIONALES: The nephron is the functioning unit of the kidney. The glomerulus, Bowman's capsule, and tubular system are components of the nephron.
200
A client is experiencing problems with balance, as well as fine and gross motor function. Which area of the brain is malfunctioning?
What is the cerebellum RATIONALE: The cerebellum is the portion of the brain that controls balance and fine and gross motor function.
200
The nurse assessing Erb's point recognizes its location as
What is the 3rd ICS (intracostal space) Left. RATIONALE: Erb's point is located at the third left intercostal space, close to the sternum. Murmurs of both aortic and pulmonic origin may be heard at Erb's point.
200
A client with gout is receiving probenecid (Benemid). When caring for this client, the nurse should monitor which laboratory value? 1. Red blood cell count 2. Serum uric acid level 3. Hemoglobin level 4. Serum potassium level
What is 2 RATIONALES: In gout, joint inflammation results from deposits of uric acid crystals. Probenecid relieves this inflammation by reducing the uric acid level in the blood. To assess the drug's efficacy, the nurse should monitor the client's serum uric acid level. The other options don't reflect the action or effectiveness of probenecid.
200
The maximum transfusion time for a unit of packed red blood cells (RBCs) is: 6 hours. 4 hours. 2 hours. 1 hour.
What is 4 hours RATIONALES: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy.
200
The nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? 1. Encouraging intake of at least 2 L of fluid daily 2. Giving the client a glass of soda before bedtime 3. Taking the client to the bathroom twice per day 4. Consulting with a dietitian
What is 1. RATIONALES: By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
300
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? 1. Diencephalon 2. Medulla 3. Midbrain 4. Cortex
What is 3. RATIONALES: Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.
300
Systole and diastole are represented by which heart sounds?
What are S1 and S2
300
A client is diagnosed with osteoporosis. Which statements should the nurse include when teaching the client about the disease? 1. "It's common in females after menopause." 2. "It's a degenerative disease characterized by a decrease in bone density." 3. "It's a congenital disease caused by poor dietary intake of milk products." 4. "It can cause pain and injury." 5. "Passive range-of-motion exercises can promote bone growth." 6. "Weight-bearing exercise should be avoided."
What is 1,2,4 RATIONALES: Osteoporosis is a degenerative metabolic bone disorder in which the rate of bone resorption accelerates and the rate of bone formation decelerates, thus decreasing bone density. Postmenopausal women are at increased risk for this disorder because of the loss of estrogen. The decrease in bone density can cause pain and injury. Osteoporosis isn't a congenital disorder; however, low calcium intake does contribute to the disorder. Passive range-of-motion exercises may be performed but they won't promote bone growth. The client should be encouraged to participate in weight-bearing exercise because it promotes bone growth.
300
The nurse is performing a respiratory assessment on a client with left lower lobe atelectasis. Identify the area where the nurse may hear fine crackles associated with this condition.
What is RATIONALES: To auscultate the left lower lobe from the anterior chest, use the landmarks of the left anterior axillary line, between the fifth and sixth intercostal spaces.
300
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: 1.water and sodium retention secondary to a severe decrease in the glomerular filtration rate. 2. a decreased serum phosphate level secondary to kidney failure. 3. an increased serum calcium level secondary to kidney failure. 4. metabolic alkalosis secondary to retention of hydrogen ions.
What is 1. RATIONALES: A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
400
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: 1.provide instructions on eye patching. 2.assess the client's visual acuity. 3.demonstrate eyedrop instillation. 4.teach about intraocular lens cleaning.
What is 3. RATIONALES: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.
400
During a physical examination, the nurse asks a client to hold the breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding is normal when auscultating over these arteries? 1.No sounds heard over either carotid artery, 2. Faint swishing sounds heard over both carotid arteries, 3. Throbbing pulsations heard bilaterally, 4. Louder sounds heard over the right carotid artery than over the left carotid artery
What is 1. RATIONALE: Absence of sounds over either carotid artery indicates unobstructed blood flow. Auscultation of any sounds (bruits) is abnormal.
400
Which of the following cells are involved in bone resorption? 1. Chondrocytes 2. Osteoblasts 3. Osteoclasts 4. Osteocytes
What is 3 RATIONALES: Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue.
400
The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: 1. suctioning the tracheostomy tube frequently. 2. using a cuffed tracheostomy tube. 3. using the minimal air leak technique with cuff pressure less than 25 cm H2O. 4. keeping the tracheostomy tube plugged.
What is 3 RATIONALES: To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
400
DAILY DOUBLE: For a client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: 1. prevent respiratory alkalosis. 2. lower arterial pH. 3. promote carbon dioxide elimination. 4. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.
What is 3 RATIONALES: The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
500
DAILY DOUBLE! A client recently had a right total hip replacement. As a result of intraoperative blood loss, postoperative serum hemoglobin levels and hematocrit are low. The physician prescribes two units of packed red blood cells. During the infusion of the first unit of blood, the client develops a transfusion reaction and experiences urticaria, itching, and bronchospasm. The nurse discontinues the transfusion and notifies the physician. Which antihistamine would the physician most likely prescribe to treat this type I hypersensitivity reaction? 1. tripelennamine citrate (PBZ) 2. astemizole (Hismanal) 3. cyclizine (Marezine) 4. chlorpheniramine maleate (Chlor-Trimeton)
What is 4 RATIONALES: The parenteral form of chlorpheniramine maleate is used to relieve symptoms of anaphylaxis and allergic reactions to blood or plasma. Tripelennamine citrate (PBZ) antihist used to treat sneezing; runny nose; itching, watery eyes; hives; rashes; itching; and other symptoms of allergies and the common cold, astemizole, and cyclizine aren't used to treat blood transfusion reactions.
500
DAILY DOUBLE A client who is receiving procainamide an electrocardiogram (ECG) tracing that shows torsades de pointes. The nurse anticipates that the physician will prescribe which drug? quinidine sulfate (Cin-Quin), lidocaine (Xylocaine), procainamide (Pronestyl), magnesium sulfate
What is magnesium sulfate
500
The nurse should monitor the client with a pelvic fracture receiving an opium derivative, such as morphine, for what common adverse reaction? 1. Respiratory depression 2. Diarrhea 3. High fever 4. Pupil dilation
What is 1 RATIONALES: One of the most common adverse reactions to opium derivatives is decreased rate and depth of respiration, which worsens as the dosage is increased. This may cause periodic, irregular breathing or precipitate asthmatic attacks in susceptible clients. Opium derivatives also can cause constipation and pupil constriction. A high fever isn't an adverse reaction associated with opium derivatives.
500
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? 1. Endotracheal suctioning 2. Encouragement of coughing 3. Use of cooling blanket 4. Incentive spirometry
What is 1 RATIONALES: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
500
DAILY DOUBLE. A client with amebiasis, an intestinal infection, is prescribed metronidazole (Flagyl). When teaching the client about adverse reactions to this drug, the nurse should mention:metallic taste, tinnitus, blurred vision, loss of smell.
What is metallic taste. RATIONALE: Metronidazole commonly causes a metallic taste
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