1. After the lungs, the kidneys work to maintain body pH. The best explanation of how the kidneys accomplish regulation of pH is that they
a. Secrete hydrogen ions and sodium.
b. Secrete ammonia.
c. Exchange hydrogen and sodium in the kidney tubules.
d. Decrease sodium ions, hold on to hydrogen ions, and then secrete sodium bicarbonate.
Rationale: By decreasing NA+ ions, holding onto hydrogen ions, and secreting sodium bicarbonate, the kidneys can regulate pH. Therefore, this is the most complete answer, and while this buffer system is the slowest, it can completely compensate for acid-base imbalance.
3. The nurse explains to a client who has just received the diagnosis of Noninsulin-Dependent Diabetes Mellitus (NIDDM) that sulfonylureas, one group of oral hypoglycemic agents, act by
a. Stimulating the pancreas to produce or release insulin
b. Making the insulin that is produced more available for use
c. Lowering the blood sugar by facilitating the uptake and utilization of glucose
d. Altering both fat and protein metabolism
Rationale: Sulfonylurea drugs, Orinase for example, lowers the blood sugar by stimulating the beta cells of the pancreas to synthesize and release insulin.
4. Myasthenic crisis and cholinergic crisis are the major complications of myasthenia gravis. Which of the following is essential nursing knowledge when caring for a client in crisis?
a. Weakness and paralysis of the muscles for swallowing and breathing occur in either crisis
b. Cholinergic drugs should be administered to prevent further complications associated with the crisis
c. The clinical condition of the client usually improves after several days of treatment
d. Loss of body function creates high levels of anxiety and fear
Rationale: The client cannot handle his own secretions, and respiratory arrest may be
imminent. Atropine may be administered to prevent crisis. Anticholinergic drugs are administered to increase the levels of acetylcholine at the myoneural junction. Cholinergic drugs mimic the actions of the parasympathetic nervous system and would not be used.
5. A 54-year-old client was put in Quinidine (a drug that decreases myocardial excitability) to prevent atrial fibrillation. He also has kidney disease. The nurse is aware that this drug, when given to a client with kidney disease, may
a. Cause cardiac arrest
b. Cause hypotension
c. Produce mild bradycardia
d. Be very toxic even in small doses
Rationale: Kidney disease interferes with metabolism and excretion of Quinidine, resulting in higher drug concentrations in the body. Quinidine can depress myocardial excitability enough to cause cardiac arrest.
6. A client is about to be discharged on the drug bishydroxycoumarin (Dicumarol). Of the principles below, which one is the most important to teach the client before discharge?
a. He should be sure to take the medication before meals
b. He should shave with an electric razor
c. If he misses a dose, he should double the dose at the next scheduled time
d. It is the responsibility of the physician to do the teaching for this medication
Rationale: Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals. Due to danger of bleeding, missed doses should not be made up.
7. A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to
a. Wait until the client's lab work is done
b. Not administer oxygen unless ordered by the physician
c. Administer oxygen at 2 liters flow per minute
d. Administer oxygen at 10 liters flow per minute and check the client's nail beds
Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function
8. A client with a diagnosis of gout will be taking colchicine and allopurinol bid to prevent recurrence. The most common early sign of colchicine toxicity that the nurse will assess for is
a. Blurred vision
Rationale: Diarrhea is by far the most common early sign of colchicine toxicity. When
given in the acute phase of gout, the dose of colchicine is usually 0.6 mg (PO) q hr
(not to exceed 10 tablets) until pain is relieved or gastrointestinal symptoms ensue.
9. A client has chronic dermatitis involving the neck, face and antecubital creases. She has a strong family history of varied allergy disorders. This type of dermatitis is probably best described as
a. Contact dermatitis
b. Atopic dermatitis
d. Dermatitis medicamentosa
Rationale: Atopic dermatitis is chronic, pruritic and allergic in nature. Typically it has a longer course than contact dermatitis and is aggravated by commercial face or body lotions, emotional stress, and, in some instances, particular foods.
12. The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment?
a. High serum creatinine levels
b. Low hemoglobin
Rationale: High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients.
13. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid?
a. Obtain a culture of the specimen using sterile swabs and send to the laboratory
b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood
c. Suction the nose gently with a bulb syringe and send specimen to the laboratory
d. Insert sterile packing into the nares and remove in 24 hours
Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of a
head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result.
14. A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that
a. Edema has resulted from a low pH state
b. Acidosis has caused vasoconstriction of cerebral arterioles
c. Cerebral edema has resulted from a low oxygen state
d. Cerebral blood flow has decreased
Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg.
16. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is
a. That it is reversible
b. Amnesia will occur
c. Loss of consciousness may be transient
d. Laceration of the brain may occur
Rationale: Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible.
17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide). Which one of the following diagnostic tests would be inaccurate if the client is receiving the drug?
a. Liver function test
b. Gall bladder studies
c. Thyroid function studies
d. Blood glucose
Rationale: Liver function tests can be elevated in clients taking pyrazinamide. This drug is used when primary and secondary antitubercular drugs are not effective. Urate levels may be increased and there is a chemical interference with urine ketone levels if these tests are done while the client is on the drug.
18. Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear?
a. Artificial nails
d. Movement of the head
Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate reading of oxygen saturation. Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent.
19. While on a camping trip, a friend sustains a snake bite from a poisonous snake. The most effective initial intervention would be to
a. Place a restrictive band above the snake bite
b. Elevate the bite area above the level of the heart
c. Position the client in a supine position
d. Immobilize the limb
Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in
containing the venom and minimizing lymphatic and superficial venous return. Elevation of the limb or immobilization would not be effective interventions.
20. There is a physician's order to irrigate a client's bladder. Which one of the following nursing measures will ensure patency?
a. Use a solution of sterile water for the irrigation
b. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent
c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to remain for 10 hour, and then siphon it out
d. Irrigate with 20mL's of normal saline to establish patency
Rationale: Normal saline is the fluid of choice for irrigation. It is never advisable to force fluids into a tubing to check for patency. Sterile water and aqueous Zephiran will affect the pH of the bladder as well as cause irritation.
21. A female client has orders for an oral cholecystogram. Prior to the test, the nursing intervention would be to
a. Provide a high fat diet for dinner, then NPO
b. Explain that diarrhea may result from the dye tablets
c. Administer the dye tablets following a regular diet for dinner
d. Administer enemas until clear
Rationale: Diarrhea is a very common response to the dye tablets. A dinner of tea and toast is usually given to the client. Each dye tablet is given at 5 minute intervals, usually with 1 glass of water following each tablet. The number of tablets prescribed will vary, because it is based on the weight of the client.
22. The physician has just completed a liver biopsy. Immediately following the procedure, the nurse will position the client
a. On his right side to promote hemostasis
b. In Fowler's position to facilitate ventilation
c. Supine to maintain blood pressure
d. In Sims' position to prevent aspiration
Rationale: Placing the client on his right side will allow pressure to be placed on the puncture site, thus promoting hemostasis and preventing hemorrhage. The other positions will not be effective in achieving these goals.
23. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be
a. Assisting in inserting a Miller-Abbott tube
b. Assisting in inserting an arterial pressure line
c. Inserting a nasogastric tube
d. Inserting an IV
Rationale: An NG tube insertion is the most appropriate intervention because it will determine
the presence of active gastrointestinal bleeding. A Miller-Abbott tube is a weighted, mercury-filled ballooned tube used to resolve bowel obstructions. There is no evidence of shock or fluid overload in the client; therefore, an arterial line is not appropriate at this time and an IV is optional.
25. In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include
a. Walking several times each day as a part of an exercise routine
b. Keeping the heat up so that the environment is warm
c. Wearing TED hose during the day
d. Using hydrotherapy for increasing oxygenation
Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in preventing vasoconstriction, but TED hose would not be therapeutic. Walking will most likely increase pain.
26. When a client asks the nurse why the physician says he "thinks" he has tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take several weeks to confirm. Which of the following statements supports this answer?
a. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis, even if one negative sputum is obtained
b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the bacillus
c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be repeated during several consecutive weeks
d. A client with a positive smear will have to have a positive culture to confirm the diagnosis
Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even very small lesions can be seen on x-rays due to the natural contrast of the air in the lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may have positive smears but negative cultures if they have been on medication (d). A positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active disease (a).
27. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to
c. Retrolental fibroplasia
Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness.
28. A nursing assessment for initial signs of hypoglycemia will include
a. Pallor, blurred vision, weakness, behavioral changes
b. Frequent urination, flushed face, pleural friction rub
c. Abdominal pain, diminished deep tendon reflexes, double vision
d. Weakness, lassitude, irregular pulse, dilated pupils
Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia.
29. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then
a. Discarded, then the collection begins
b. Saved as part of the 24-hour collection
c. Tested, then discarded
d. Placed in a separate container and later added to the collection
Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.
30. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician will use Crutchfield tongs. The purpose of these tongs is to
a. Hypoextend the vertebral column
b. Hyperextend the vertebral column
c. Decompress the spinal nerves
d. Allow the client to sit up and move without twisting his spine
Rationale: The purpose of the tongs is to decompress the vertebral column through
hyperextending it. Both (a) and (c) are incorrect because they might cause further damage.
(d) is incorrect because the client cannot sit up with the tongs in place; only the head of the bed can be elevated.
31. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to
a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown
b. Set alarms on the oximeter to at least 100 percent
c. Identify if the client has had a recent diagnostic test using intravenous dye
d. Remove the sensor between oxygen saturation readings
Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings.
32. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to
a. Check that a hemostat is at the bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a regular basis
Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.
33. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The client's activity at this time should be
a. Ambulation as desired
b. Bedrest in supine position
c. Up ad lib and right side-lying position in bed
d. Bedrest in Fowler's position
Rationale: The pain of pancreatitis is made worse by walking and supine positioning. The client is more comfortable sitting up and leaning forward.
34. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is
a. pH 7.49, HCO3 24, PCO2 46
b. pH 7.49, HCO3 14, PCO2 30
c. pH 7.26, HCO3 24, PCO2 46
d. pH 7.26, HCO3 14, PCO2 30
Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg.
35. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to
a. Correct the hyperglycemia that occurs with acute renal failure
b. Facilitate the intracellular movement of potassium
c. Provide calories to prevent tissue catabolism and azotemia
d. Force potassium into the cells to prevent arrhythmias
Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed.
This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion.
38. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes this client for complications in the postoperative period. Which of the following symptoms indicates an unexpected outcome and requires priority care?
a. Edema of the stoma
b. Mucus in the drainage appliance
c. Redness of the stoma
d. Feces in the drainage appliance
Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. The proximal and distal ileal borders can be resumed. Feces should not be draining from the conduit. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period, as is mucus from the stoma.
39. A nursing care plan for a client with a suprapubic cystostomy would include
a. Placing a urinal bag around the tube insertion to collect the urine
b. Clamping the tube and allowing the client to void through the urinary meatus before removing the tube
c. Catheter irrigations every 4 hours to prevent formation of
d. Limiting fluid intake to 1500 mL per day
Rationale: Allowing the client to void naturally will be done prior to removal of the
catheter to ensure adequate emptying of the bladder. Irrigations are not recommended,
as they increase the chances of the client developing a urinary tract infection. Any time a client has an indwelling catheter in place, fluids should be encouraged (unless contraindicated) to prevent stone formation.
40. For a client who has ataxia, which of the following tests would be performed to assess the ability to ambulate?
Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction, is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.
41. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which of the following neurological checks will give the nurse the best information about the extent of bleeding?
a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system
Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced by blood, tumor, etc.
42. Assessing for immediate postoperative complications, the nurse knows that a complication likely to occur following unresolved atelectasis is
d. Pulmonary embolism
Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not related to this condition. Pulmonary embolism could result from deep vein thrombosis.
43. A young client is in the hospital with his left leg in Buck's traction. The
team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to
a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot
Rationale: The purpose of the footplate is to prevent footdrop while the client is immobilized in traction. This will not anchor the traction, keep the client from sliding down in bed, or prevent pressure areas.
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