Health Promotion & Maintenance
Reduction of Risk Potential
Physio Adaptation
Pharmacology
Basic Care & Comfort
100
A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds?
What is 2?
Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where the main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage.
100
A client who has undergone renal biopsy complains of pain at the biopsy site, radiating to the front of the abdomen. For which finding would the nurse assess the client?
Bleeding
Increased temperature
Renal colic
Infection at the site
What is Bleeding?
Rationale: Bleeding would be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs/symptoms of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic.
100
The nurse notes that a client’s serum potassium level is 5.8 mEq/L. What does the nurse interpret this expected finding to be related to? (ref range 3.5-5)
Addison disease
Diarrhea
Heart failure being treated with loop diuretics
Wound drainage
What is Addison disease?
Rationale: Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia, and the nurse would report the finding to the primary healthcare provider. Other common causes of hyperkalemia include tissue damage such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia.
100
The primary healthcare provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number.)
What is 31 gtt/min?
Rationale: Use the IV flow rate formula:
100
A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that they will plan to eat foods that are low in which substance?
Carbohydrates
Vitamins
Fats
Potassium
What is Potassium?
Rationale: Most excretion of potassium and control of potassium balance are carried out by the kidneys. In the client with AKI, potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis. Vitamins, carbohydrates, and fats are not normally restricted in the client with AKI.
200
A client complains that their skin is redder than normal. The nurse assesses the client’s skin, documents hyperemia, and explains to the client that this condition is caused by which?
Excess blood in the dilated superficial capillaries
Diminished perfusion of the surrounding tissues
A reduced amount of bilirubin in the blood
Contraction of the underlying blood vessels
What is Excess blood in the dilated superficial capillaries?
Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. A reduced amount of bilirubin in the blood, diminished perfusion of the surrounding tissues, and contraction of the underlying blood vessels are all incorrect explanations for hyperemia.
200
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action would the nurse take first?
Call a code.
Administer a bronchodilator.
Contact the primary healthcare provider.
Disconnect the suction source from the catheter.
What is Disconnect the suction source from the catheter?
Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the client’s symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction source from the catheter but leaves the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The primary healthcare provider is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.
200
The nurse assists in developing a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan?
A dosimeter badge must be placed on the client’s bedside stand.
Visitors must be limited to one half-hour per day.
The client may be maintained in a semi-private room as long as the client uses a commode.
Visitors must remain at least 2 feet (61 cm) from the client.
What is Visitors must be limited to one half-hour per day?
Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet (1.8 meters) from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual’s exposure to radiation and would be used by only one person and is not left in the client’s room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation.
200
The primary healthcare provider prescribes an intramuscular dose of 200,000 units of penicillin G benzathine for an adult client. The label on the 10-mL ampule sent from the pharmacy reads, “Penicillin G benzathine, 300,000 units/mL.” How many milliliters of medication does the nurse prepare to ensure administration of the correct dose? (Round to the nearest tenth.)
What is 0.7mL?
Rationale: Use the medication formula:
200
A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client’s bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown?
Right heel
Left heel
Scapulae
Back of the head
What is the right heel?
Rationale: Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the unaffected leg, which is used as a brace when the client pushes up from the bed). Other such pressure points include the ischial tuberosity, popliteal space, and Achilles tendon.
300
An adult client tells the clinic nurse they are susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?
Exposure to cigarette smoke
Use of power tools
Loud music
Occupational noise
What is Exposure to cigarette smoke?
Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include youth (otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Loud music, the use of power tools, and occupational noise can all cause hearing loss. Hearing loss may occur as a result of an acute loud noise (acoustic trauma) or long-term exposure to loud noise (noise-induced hearing loss).
300
A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what would the nurse assess first?
The amount of drainage
The client’s lung sounds
The client’s vital signs
The chest tube connections
What is The chest tube connections?
Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires surgeon intervention. Although the interventions identified in the other options would also be taken in this situation, they would be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's signs/symptoms would resolve.
300
The nurse is educating a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. What does the nurse tell the client to do?
Wear a patch on the affected eye.
Wear eyeglasses 24 hours a day.
Turn the head to scan the lost visual field.
Keep all objects in the impaired field of vision.
What is Turn the head to scan the lost visual field?
Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision but it is not necessary to wear the glasses 24 hours a day. The client needs to keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision.
300
The primary healthcare provider’s prescription for an adult client reads, “Potassium chloride 15 mEq by mouth.” The label on the medication bottle reads, “20 mEq potassium chloride/15 mL.” How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round to the nearest whole number.)
What is 11mL?
Rationale: Use the medication formula:
300
A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication?
Rhubarb
Prunes
Cranberries
Oranges
What is Rhubarb?
Rationale: When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be instructed to consume an acid-ash diet. Rhubarb reduces the acidity of the urine and would be avoided when acidic urine is required. Prunes, oranges, and cranberries are acceptable foods.
400
A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding in which way?
Abnormal vesicular breath sounds
Abnormal bronchophony
Normal whispered pectoriloquy
Normal egophony
What is Abnormal bronchophony?
Rationale: The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client’s chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly. Vesicular breath sounds are heard over peripheral lung fields where air flows through smaller bronchioles and alveoli. In egophony, the client’s chest is auscultated while the client phonates a long "ee-ee-ee-ee" sound. Normally the nurse hears "eeeeee" through the stethoscope. In whispered pectoriloquy, the client is asked to whisper a phrase such as "one-two-three" as the nurse listens to the chest. The normal response is a muffled, almost inaudible sound.
400
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional teaching for the test?
“I ate breakfast this morning.”
“I didn’t shampoo my hair.”
“I didn’t take my anticonvulsant today.”
“It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.”
What is “I didn’t shampoo my hair.”?
Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.
400
The nurse reinforces home care instructions to a client with Ménière disease about measures to control and treat vertigo. What would the nurse tell the client to do?
Limit sodium in the diet.
Increase fluid intake to at least 3000 mL/day.
Lie down when vertigo occurs and keep a light on in the room.
Move the head from the right to the left when vertigo occurs to determine the extent of its effects.
What is Limit sodium in the diet?
Rationale: Limiting sodium and fluids in the diet will help reduce the amount of endolymphatic fluid, which is excessive in Ménière disease. The client’s room needs to be darkened to reduce the acute signs/symptoms of vertigo. The client needs to limit head movement to prevent worsening of the signs/symptoms of vertigo.
400
The primary healthcare provider prescribes 1000 mL of 5% dextrose in water to be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number.)
What is 42 gtt/min?
Rationale: Use the IV flow rate formula:
400
A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client?
Low protein
Moderate amount of fats
High carbohydrates
High in fluids
What is Low Protein?
Rationale: A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, resulting in the formation of ammonia. Therefore, the client would benefit from a low-protein diet.
500
At a health screening clinic, a nurse is educating a young client about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when the client makes which statement?
-BSE must be performed every other month.
-Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.
-Monthly BSE is the only way to ensure early detection of breast cancer.
-BSE is performed on the day menstruation begins.
What is Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down?
Rationale: BSE is performed monthly and would be carried out after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. A client who is not having menstrual periods would select a specific day of the month and perform BSE on that day each month. BSE is not the only way to detect early breast cancer. Clients need to get regular physical examinations and mammograms as prescribed. The client is taught to inspect the breasts while standing in front of a mirror, palpate the breasts while in the shower (because soap and water assist in palpation), and finally, perform palpation while lying supine.
500
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse would reinforce which information to the client about the test?
The test will need to be confirmed with the use of a Western blot.
A positive test is a normal result and does not mean that the client is infected with HIV.
HIV infection has been confirmed.
The client probably has an opportunistic infection.
What is The test will need to be confirmed with the use of a Western blot?
Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be confirmed with the use of the Western blot. The other options are incorrect.
500
During a client’s yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. What does the nurse tell the client?
-That the intraocular pressure in both eyes is normal
-That they have glaucoma in the left eye
-That they need to increase fluid intake because the pressure in the right eye is low
-That they have glaucoma in the right eye
What is That the intraocular pressure in both eyes is normal?
Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore, this client’s intraocular pressure is normal. Increased intake of fluids is unrelated to increasing intraocular pressure.
500
The primary healthcare provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number.)
What is 21 gtt/min?
Rationale: Use the IV flow rate formula:
500
A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection?
Urethra
Nephron
Glomerulus
Ureterovesical junction
What is the Ureterovesical junction?
Rationale: The ureterovesical junction is the point where the ureters enter the bladder. At this junction, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This pathway prevents the reflux of urine back into the ureter; in essence, acting as a valve to prevent urine from traveling back into the ureter and up to the kidney. The urethra extends from the bladder to the opening of the body where urine is excreted. The nephrons and glomeruli are located in the kidneys.