1.

: At
the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The
nurse determines that which assessment finding requires intervention?

1.Tightened screws

2.Red skin areas under the jacket

3.Clean and dry lamb's wool jacket lining

4.Finger-width space between the jacket and the skin2

Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to
altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly
tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a
finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-
shirt next to the skin to help prevent itching.

2.: Aclient admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury.
In conducting the admission assessment, what is the nurse's priority action?

1.Take the temperature.

2.Listen to breath sounds.

3.Observe for dyskinesias.

4.Assess extremity muscle strength.2

Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is
the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is
ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-
injured clients unless head injury is suspected.

3.: Aclient arrives in the hospital emergency department with a closed head injury to the right side of the
head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily
for motor response deficits that involve which area?

1.The left side of the body

2.The right side of the body

3.Both sides of the body equally

4.Cranial nerves only, such as speech and pupillary response1

Motor responses such as weakness and decreased movement will be seen on the side of the body that is
opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the
pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.
4.: A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the
best nursing action?

1.Ask a family member to stay with the client at all times.

2.Ask the health care provider for a prescription for succinylcholine.

3.Encourage the client to sleep until arterial blood gas results improve.

4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.4

Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The
nurse should speak to the client calmly and provide reassurance to the anxious client. Family members also
are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask
the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular
blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results
improve does nothing to reassure or help the client.

5.: Aclient had a seizure 1 hour ago. Family members were present during the episode and reported that the
client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what
should the nurse include in the client's assessment?

1.Presence of diaphoresis

2.Loss of consciousness

3.History of prior trauma

4.Rotating eye movements

3 Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal
structural lesion in the brain, often caused by trauma, infection, or drug consumption. Options 1, 2, and 4
address signs, rather than an origin of the seizure.

6.: A
client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the
nurse should ensure that which intervention is implemented?

1.The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift.

2.The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record.

3.The suction control chamber has sterile water added every shift, and the system is kept below waist level.

4.The connection between the chest tube and the drainage system is taped, and an occlusive dressing is
maintained at the insertion site.
4

The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that
an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal
chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is
noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The
system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is
added to the suction control chamber only as needed to replace evaporation losses.
7.: A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing
the client's pain. What type of pain is consistent with this diagnosis?

1.
Burning and aching, located in the left lower quadrant and radiating to the hip
2.
Severe and unrelenting, located in the epigastric area and radiating to the back

3.
Burning and aching, located in the epigastric area and radiating to the umbilicus

4.
Severe and unrelenting, located in the left lower quadrant and radiating to the groin2

The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region,
and radiates to the back. The other options are incorrect.

8.: Aclient has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent
intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes
that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately
assesses for other signs of which condition?

1.
Right pneumothorax

2.
Pulmonary embolism

3.
Displaced endotracheal tube

4.
Acute respiratory distress syndrome1

Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical

chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause
increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and
pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too
far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side
because of the degree of curvature of the right and left mainstem bronchi.
9.: A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert
the nurse that cerebrospinal fluid is present?

1.
Fluid is clear and tests negative for glucose.

2.
Fluid is grossly bloody in appearance and has a pH of 6.

3.
Fluid clumps together on the dressing and has a pH of 7.

4.
Fluid separates into concentric rings and tests positive for glucose.4

Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be
distinguished from other body fluids because the drainage will separate into bloody and yellow concentric
rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

10.: A
client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for
which expected assessment finding?

1.
Malaise

2.
Dark stools

3.
Weight gain

4.
Left upper quadrant discomfort1

Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and
weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is
unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
11.: A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is
most commonly reported?

1.
Hot, flushed feeling

2.
Sudden chills and fever

3.
Chest pain that occurs suddenly

4.
Dyspnea when deep breaths are taken3

The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most
commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
12.: A client has suffered a head injury affecting the occipital lobe of the brain. The nurse anticipates that the
client may experience difficulty with which sense?

1.
Smell

2.
Taste

3.
Vision

4.
Hearing3
The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the
brain helps the individual to visually recognize and understand the surroundings. The other senses listed are
not a function of the occipital lobe.

13.: A
client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse
expect to note based on this diagnosis?

1.
Fatigue

2.
Pale urine

3.
Weight gain

4.
Spider angiomas1

Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is
anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens
because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider
angiomas, small, dilated blood vessels, are commonly seen in cirrhosis of the liver.
14.: A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect
the client to report about the pain?

1.
The pain is mostly around the umbilicus and comes and goes.

2.
The pain increases when the client sits up and bends forward.

3.
The pain usually increases after vomiting.

4.
Eating helps to decrease the pain.3

Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure
caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a
steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the
client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

15.: Aclient is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste
for food." What instruction should the nurse give the client to provide adequate nutrition?

1.
Select foods high in fat.

2.
Increase intake of fluids, including juices.
3.
Eat a good supper when anorexia is not as severe.

4.
Eat less often, preferably only three large meals daily.2

Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a
low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are
preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a
good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also
important.
16.: A client is hospitalized with a diagnosis of viral hepatitis. To detect any difficulty in coping with this
disease, the nurse should ask which question?

1.
"Do you have a fever?"

2.
"Are you losing weight?"

3.
"Have you enjoyed having visitors?"

4.
"Do you rest sometime during the day?"3

Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis.
They also may have a disturbance in body image related to the stigma of having a communicable disease or a
change in appearance because of jaundice. The correct option relates to the client's possible feelings of not
wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is
jaundiced.

17.: A
client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first
few hours postoperatively, what type of drainage should the nurse expect?

1.
Serous

2.
Bloody

3.
Serosanguineous

4.
Bloody, with frequent small clots2

In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes
serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow
for drainage of blood before it has the chance to clot in the chest or the tubing.
18.: A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing
which activity?
1.
Blowing the nose

2.
Isometric exercises

3.
Coughing vigorously

4.
Exhaling during repositioning4

Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the
intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing,
sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the
glottis, which prevents intrathoracic pressure from rising.
19.: A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the
client for a history of chronic use of which medication?

1.
Ibuprofen (Advil)

2.
Ranitidine (Zantac)

3.
Acetaminophen (Tylenol)

4.
Acetylsalicylic acid (aspirin)3

Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents
should be investigated whenever a client presents with signs and symptoms compatible with liver disease
(such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in options
1, 2, and 4.

20.: A
client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and
does not seem to be progressing as quickly as the client or family hoped. The nurse plans to implement
which approach as most helpful to the client and family at this time?

1.
Emphasize progress in a realistic manner.

2.
Set high goals to give the client something to "aim for."

3.
Tell the family to be extremely optimistic with the client.

4.
Inform the client and family of standardized goals of care.1
The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The
nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse
encourages the family to be realistic in their expectations and attitudes. The plan of care should be
individualized for each client.
21.: A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe
headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's
systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect?

1.
Return of spinal shock

2.
Malignant hypertension

3.
Impending brain attack (stroke)

4.
Autonomic dysreflexia (hyperreflexia)4

Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous
system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal
stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising
potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of
catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must
recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this
medical emergency could result in stroke, status epilepticus, or possibly death.

22.: Aclient who has undergone radical neck dissection for a tumor has a potential problem of obstruction
related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this
client, the nurse should implement which activities? Select all that apply.

1.
Suctioning the client as needed

2.
Encouraging coughing every 2 hours

3.
Placing the bed in low Fowler's position

4.
Supporting the neck incision when the client coughs

5.
Monitoring the respiratory status frequently as prescribed1, 2, 4, 5

The client's respiratory status is promoted by the use of high Fowler's position after this surgery. Low Fowler's
position is avoided because it could result in increased venous pressure on the surgical site and increased risk
of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2
hours, to support the neck incision when coughing, to suction periodically as needed, and to monitor the
respiratory status frequently as prescribed.
23.: A
client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The
nurse should include which measures in the care of this client? Select all that apply.

1.
Monitor the client's temperature.

2.
Use sterile technique when suctioning.

3.
Use the closed-system method of suctioning.

4.
Monitor sputum characteristics and amounts.

5.
Drain water from the ventilator tubing into the humidifier bottle.1, 2, 3, 4

Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method
of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the
ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of
acquiring infection, especially Pseudomonas.

24.: The
client with a cervical spine injury has cervical tongs applied in the emergency department. What
should the nurse avoid when planning care for this client?

1.
Using a Roto-Rest bed

2.
Removing the weights to reposition the client

3.
Assessment of the integrity of the weights and pulleys

4.
Comparing the amount of prescribed traction with the amount in use2

Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached
to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the
cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is
realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with
cervical tongs is placed on a Stryker frame or Roto-Rest bed. The nurse ensures that weights hang freely, and
the amount of weight matches the current prescription. The nurse also inspects the integrity and position of
the ropes and pulleys. The nurse does not remove the weights to administer care.
25.: A client with a chest injury has suffered flail chest. The nurse assesses the client for which most
distinctive sign of flail chest?

1.
Cyanosis

2.
Hypotension
3.
Paradoxical chest movement

4.
Dyspnea, especially on exhalation3

Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is
unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means
that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly,
during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a
characteristic sign of flail chest.

26.: Aclient with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that
the client understands suggestions for positioning to reduce pain if he or she avoids which action?

1.
Sitting up

2.
Lying flat

3.
Leaning forward

4.
Drawing the legs up to the chest2

The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located
retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall
with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs
(especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the
legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.
27.: The client with acute pancreatitis is experiencing severe pain from the disorder. Which position taken by
the client indicates there is a need for further teaching?

1.
Sitting up

2.
Lying flat

3.
Leaning forward

4.
Flexing the left leg2

Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of
the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the
pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior
peritoneal wall with these positions.
28.: A
client with an endotracheal tube attached to mechanical ventilation begins to cough, and his face
appears flushed. Which action should the nurse take first?

1.
Call respiratory therapy.

2.
Contact the health care provider.

3.
Check the client's blood pressure.

4.
Suction the client through the endotracheal tube.4

The client is choking on his secretions, which should be removed by suctioning of the endotracheal tube. There
is no need at this time to contact the health care provider or call for respiratory therapy. The nurse should
check the client's blood pressure, but suctioning is the priority.
29.: A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective
cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects
the presence of which complication?

1.
Altered breathing pattern

2.
Increased likelihood of injury

3.
Ineffective oxygen consumption

4.
Increased susceptibility to aspiration1

Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements
are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower
cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is
altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of
injury are unrelated to the focus of the question.

30.: The
client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a
blood pressure of 180/100 mm Hg. What is the priority nursing intervention?

1.
Notify the health care provider.

2.
Loosen tight clothing on the client.

3.
Place the client in a sitting position.

4.
Check the urinary catheter tubing for kinks or obstruction.3

The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological

emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Options 2
and 4 can then be done, and option 1 can be completed once initial interventions are done.
31.: A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer
care. The nurse should perform which action?

1.
Ask the family to deliver the care.

2.
Leave the client alone until ready to participate.

3.
Advise the client that rehabilitation progresses more quickly with cooperation.

4.
Acknowledge the client's anger and continue to encourage participation in care.4

Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes
that the client goes through the grieving process in adjusting to the loss and may move back and forth among
the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical
needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not
be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate.
Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

32.: A
client with a spinal cord injury expresses little interest in food and is very particular about the choice of
meals that are actually eaten. How should the nurse interpret this information?

1.
Anorexia is a sign of clinical depression, and a referral to a psychologist is needed.

2.
The client has compulsive habits that should be ignored so long as they are not harmful.

3.
The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter.

4.
Meal choices represent an area of client control and should be encouraged as much as is nutritionally
reasonable.4

Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of
appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as
much as is feasible because it is one of the few areas of control that the client has left. There is no information
in the query of the question that would indicate that the client is anorexic, obsessive-compulsive, or has a slow
metabolism.
33.: A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid
which measure to minimize the risk of occurrence?

1.
Strict adherence to a bowel retraining program
2.
Keeping the linen wrinkle-free under the client

3.
Preventing unnecessary pressure on the lower limbs

4.
Limiting bladder catheterization to once every 12 hours4

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be
done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be
checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so
maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal,
or painful stimuli. The nurse administers care to minimize risk in these areas.

34.: A
client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse
should assess for which finding as the best indicator of adequate ongoing respiratory status?

1.
Oxygen saturation of 89%

2.
Respiratory rate of 16 breaths per minute

3.
Moderate amounts of tracheobronchial secretions

4.
Small to moderate amounts of frank blood suctioned from the tube2

Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the
trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen
saturation of 89% is less than optimal. A respiratory rate of 16 breaths per minute is in the normal range.
35.: A client with chronic pancreatitis needs information on dietary modification to manage the health
problem. Which item in the diet should the nurse teach the client to limit?

1.
Fat

2.
Protein

3.
Carbohydrate

4.
Water-soluble vitamins1

The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce
the amount of carbohydrates and protein that the client must digest at any one time. The client does not need
to limit water-soluble vitamins in the diet.
36.: A
client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb
weight gain over the last 1½ weeks. The client has edema of the feet and ankles, and his abdomen is
distended, taut, and shiny with striae. Which client problem is most appropriate at this time?

1.
Difficulty with breathing

2.
Risk for skin breakdown

3.
Difficulty with sleeping

4.
Excessive body fluid volume4

The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is
especially true when the client has not demonstrated an appreciable increase in food intake or when the
weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most
appropriate problem. No data are given to support difficulty with breathing, although in some clients upward
pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower
priority because it is a risk rather than an actual problem. There is no data in the question that indicates that
the client is having difficulty with sleep.
37.: A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse
anticipate to note as a result of increased abdominal pressure? Select all that apply.

1.
Orthopnea, dyspnea

2.
Petechiae and ecchymosis

3.
Inguinal or umbilical hernia

4.
Poor body posture and balance

5.
Abdominal distention and tenderness1, 2, 3, 5

Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the
body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended
abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty,
petechiae and ecchymoses, development of hernias, abdominal distention, and tenderness. Option 4 is
unrelated to increased abdominal pressure.

38.: A
client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a
dietary consultation to limit the amount of which ingredient in the client's diet at this time?

1.
Protein
2.
Calories

3.
Minerals

4.
Carbohydrates1

Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high
serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will
prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental
status. It is not necessary to limit calories, minerals, or carbohydrates.
39.: A client with liver dysfunction exhibits low serum levels of thrombin. The nurse provides care, knowing
that this client is most at risk for which complication?

1.
Bleeding

2.
Infection

3.
Dehydration

4.
Malnutrition1

Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level
of this substance is at risk for bleeding. Options 2, 3, and 4 are incorrect and not associated with thrombin.

40.: Aclient with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time
(PT). Based on these findings, which actions should the nurse plan to promote the client's safety? Select all
that apply.

1.
Monitor serum potassium levels.

2.
Weigh client daily, and monitor trends.

3.
Monitor for symptoms of fluid retention.

4.
Provide the client with a soft toothbrush.

5.
Instruct the client to use an electric razor.

6.
Monitor all secretions for frank or occult blood.4, 5, 6
Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at
risk for bleeding. The prothrombin time is prolonged when one or more of the clotting factors (II, V, VII, or X) is
deficient, so the client's risk for bleeding is also increased. Options 4, 5, and 6 are measures that provide for
client safety and monitor for bleeding.
41.: A client with liver dysfunction is having difficulty with protein metabolism. The nurse checks the
laboratory results, expecting that the results of which serum laboratory values will be elevated?

1.
Lactase

2.
Albumin

3.
Ammonia

4.
Lactic acid3

During deamination of proteins in the liver, the amino group splits from the carbon-containing compound,
which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia
substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum
ammonia levels as a result. Options 1, 2, and 4 are incorrect.

42.: A
client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing
intervention would be most appropriate?

1.
Encourage foods that are high in protein.

2.
Monitor for fluid and electrolyte imbalance.

3.
Explain that high-fat diets usually are better tolerated.

4.
Explain that most daily calories need to be consumed in the evening hours.2

If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is
important to explain to the client that most calories should be eaten in the morning hours because nausea is
most common in the afternoon and evening. Clients should select a diet high in calories because energy is
required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat
absorption, so low-fat diets are better tolerated.
43.: A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not
sure I can avoid alcohol." What is the most appropriate nursing response?

1.
"I don't believe that."

2.
"Everything will be all right."
3.
"I'm not sure that I understand. Would you please explain?"

4.
"I think you should talk more with the health care provider (HCP) about this."3

Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the
client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction
with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's
feelings on hold by referring him or her to the HCP for further information is a block to communication.

44.: A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action?

1.
Assist the client in expressing feelings.

2.
Restrict visitors until the jaundice subsides.

3.
Perform most of the activities of daily living for the client.

4.
Provide information to the client only when he or she requests it.1

The client should be supported to explore feelings about the disease process and altered appearance so that
appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-
esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage
participation in self-care to foster independence and self-esteem. The client should be encouraged to ask
questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to
make appropriate decisions.
45.: Discharge teaching for a client with chronic pancreatitis should include which instructions?

1.
Alcohol should be consumed in moderation.

2.
Avoid caffeine, because it may aggravate symptoms.

3.
Diet should be high in carbohydrates, fats, and proteins.

4.
Frothy fatty stools indicate that enzyme replacement is working.2

Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will
direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be
avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy fatty stools
indicate that the replacement enzyme dose needs to be increased.
46.: The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall.
Which finding would indicate the presence of a pneumothorax in this client?

1.
A low respiratory rate

2.
Diminished breath sounds

3.
The presence of a barrel chest

4.
A sucking sound at the site of injury2

This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are
shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath
sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound
at the site of injury would be noted with an open chest injury.

47.: Thehealth care provider has determined that a client with hepatitis has contracted the infection from
contaminated food. The nurse understands that this client is most likely experiencing what type of
hepatitis?

1.
Hepatitis A

2.
Hepatitis B

3.
Hepatitis C

4.
Hepatitis D1

Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B,
C, and D are transmitted most commonly via infected blood or body fluids.
48.: A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should
bring which dressing materials to the bedside for the HCP's use?

1.
Telfa dressing and Neosporin ointment

2.
Petrolatum gauze and sterile 4 × 4 gauze

3.
Benzoin spray and a hydrocolloid dressing

4.
Sterile 4 × 4 gauze, Neosporin ointment, and tape2

On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 × 4 gauze is placed at the insertion
site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa, Neosporin ointment,
hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the
HCP as the tape of choice to make the dressing occlusive.
49.: A
health care provider writes a prescription to begin to wean the client from the mechanical ventilator
by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV).
The nurse determines that the process of weaning will occur by which mechanism?

1.
Gradually decreasing the respiratory rate until the client can assume the work of breathing without
ventilatory assistance

2.
Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10%
higher than the ventilator setting

3.
Providing pressure support to decrease the workload of breathing and increase the client's ability to initiate
spontaneous breathing efforts

4.
Removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously
for a predetermined amount of time1

IMV/SIMV is one of the methods used for weaning. With this method the respiratory rate is gradually
decreased until the client assumes all of the work of breathing on his or her own. This method works
exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in
clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly
basis until the client is weaned and is ready for extubation. Therefore options 2, 3, and 4 are incorrect.
50.: The home care nurse is making a visit to a client who is wheelchair bound after a spinal cord injury
sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has
been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?

1.
Updating the home safety sheet

2.
Leaving the client in an unchilled area of the room

3.
Noting a bowel movement on the client progress note

4.
Recording the amount of urine obtained with catheterization2

The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage
or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly
pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or
pressure on paralyzed body parts and that the client will be sufficiently warm.

51.: Thehome care nurse is making extended follow-up visits to a client discharged from the hospital after a
moderately severe head injury. The family states that the client is behaving differently than before the
accident. The client is more fatigued and irritable and has some memory problems. The client, who was
previously very even-tempered, is prone to outbursts of temper now. The nurse counsels the family on the
basis of an understanding that these behaviors are indicative of which condition?

1.
Indicate a worsening of the original injury

2.
Will probably be a long-term sequela of the injury

3.
Will come and go as intracranial pressure changes

4.
Are short-term problems that will resolve in about 1 month2

Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these
include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The
client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and
makes appropriate referrals to respite services, support groups, and state or local chapters of the National
Head Injury Foundation.
52.: A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home
care management instructions to the client. Which client statement indicates a need for further instruction?

1.
"I will obtain adequate rest."

2.
"I will take Tylenol if I get a headache."

3.
"I should monitor my weight on a regular basis."

4.
"I need to include sufficient amounts of carbohydrates in my diet."2

Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest
and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply
sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

53.: A
hospitalized client is diagnosed with pancreatitis. The nurse plans care, knowing that production of
which substance will be elevated in blood studies for this client?

1.
Pepsin

2.
Lactase

3.
Amylase

4.
Enterokinase3

The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase
normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein
digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into
galactose and fructose, and enterokinase activates trypsin.
54.: A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of
which complete proteins to maximize the availability of essential amino acids?

1.
Nuts

2.
Meats

3.
Cereals

4.
Vegetables2

Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from
other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs.
Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

55.: Lactulose
(Chronulac) is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy.
Which assessment finding indicates that the client is responding to this medication therapy as anticipated?

1.
Vomiting occurs.

2.
The fecal pH is acidic.

3.
The client experiences diarrhea.

4.
The client is able to tolerate a full diet.2

Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic
encephalopathy. The desired effect is two or three soft stools per day with an acid fecal pH. Lactulose creates
an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to
leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive
administration of the medication. Options 1 and 4 do not determine that a desired effect has occurred.
56.: The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube.
The nurse determines that the cause for alarm activation may be which complication?

1.
Excessive secretions

2.
Kinks in the ventilator tubing

3.
The presence of a mucous plug
4.
Displacement of the endotracheal tube4

The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible
causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a
leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube,
and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure
alarm to sound.
57.: The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to
determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should
take what initial action?3

If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is
disconnected from the ventilator and manual resuscitation is used to support respirations until the problem
can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the
initial action. Although oxygen is helpful, it will not provide ventilation to the client.

58.: Thenurse assesses for one-sided chest movement on the right while a client is being intubated by the
health care provider. The nurse's action is based on the possibility that which could occur with the
endotracheal tube?

1.
It could enter the left main bronchus if inserted too far.

2.
It could enter the right main bronchus if inserted too far.

3.
It could enter the left main bronchus if not inserted far enough.

4.
It could enter the right main bronchus if not inserted far enough.2.
It could enter the right main bronchus if inserted too far.

If the endotracheal tube is inserted too far, the tube will travel past the trachea and enter the right main
bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in
a more vertical plane. The other options are incorrect.
59.: A nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should
place the client in which position?

1.
Prone

2.
Supine

3.
Left side

4.
Right side4
To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2
hours after a liver biopsy. Therefore, options 1, 2, and 3 are incorrect.

60.: The
nurse caring for a client who is mechanically ventilated is monitoring for complications of
mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

1.
Muscle weakness in the arms and legs

2.
A temperature of 98.6° F decreased from 99.0° F

3.
A blood pressure of 90/60 mm Hg decreased from 112/78 mm Hg

4.
A heart rate of 80 beats per minute decreased from 85 beats per minute3

Complications of mechanical ventilation include the following: (1) hypotension caused by application of
positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; (2)
pneumothorax or subcutaneous emphysema as a result of positive pressure; (3) gastrointestinal alterations
such as stress ulcers; (4) malnutrition if nutrition is not maintained; (5) infections; (6) muscular deconditioning;
and (7) ventilator-dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4
present normal assessment findings.
61.: The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally
disconnects from the water seal chamber. Which initial nursing action should the nurse take?

1.
Call the health care provider (HCP).

2.
Place the tube in a bottle of sterile water.

3.
Replace the chest tube system.

4.
Place a sterile dressing over the disconnection site.2.
Place the tube in a bottle of sterile water.

If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held
below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is
replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the
disconnection site will not prevent complications resulting from the disconnection.

62.: The
nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in
the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect
which occurrence?

1.
The system needs changing.

2.
Suction needs to be increased.

3.
Suction needs to be decreased.

4.
The chest tubes are obstructed.4

Fluid in the water-seal compartment should rise with inspiration and fall with expiration (tidaling). When
tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when
the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Options 1, 2, and 3 are
incorrect interpretations.
63.: The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure.
The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8
mm Hg. The nurse plans care, knowing that these results are indicative of which condition?

1.
Normal condition

2.
Increased pressure

3.
Borderline situation

4.
Compensating condition1

The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

64.: The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suction control chamber. What action is most appropriate?

1.
Do nothing, because this is an expected finding.

2.
Check for an air leak because the bubbling should be intermittent.

3.
Increase the suction pressure so that the bubbling becomes vigorous.

4.
Immediately clamp the chest tube and notify the health care provider.1

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in
the suction control chamber and not intermittent. Increasing the suction pressure only increases the rate of
evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not
done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or
when changing drainage devices (according to agency policy).

65.: The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?

1.
Rhonchi are auscultated.

2.
Pleural friction rub is heard.

3.
Fine crackles are auscultated.

4.
Pulse oximetry reading is 96%.1

Presence of rhonchi is an indication that there are secretions in the large airways. The client requires
suctioning if he or she cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A
pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into
previously deflated alveoli.
66.: The nurse determines the client with a chest tube to a closed drainage system is experiencing an air leak.
Which finding is indicative of this?

1.
Tidaling is absent.

2.
Gentle bubbling is observed in the suction control chamber.

3.
Vacillation of water in the water seal chamber occurs during respiration.

4.
Continuous bubbling is observed in the water seal during inspiration and expiration.4

Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking
into the drainage system or pleural cavity. Bubbling is an expected finding in the suction control chamber
when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be
indicative of re-expansion of the lung or obstruction or kinking of the chest tube.

67.: The
nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse
monitors the client and notes fluctuation of the fluid level in the water-seal chamber after the tube is
inserted. Based on this assessment, which action is most appropriate?

1.
Inform the HCP.

2.
Continue to monitor the client.

3.
Reinforce the occlusive dressing.

4.
Encourage the client to deep breathe.2

The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system.
With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the
tube is obstructed, if a dependent loop exists, the suction is not working properly, or the lung has re-
expanded. Because this finding is expected, it is not necessary to notify the HCP. The presence of fluctuation of
the fluid level in the water-seal chamber does not indicate that the dressing needs reinforcement. Although it
is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the
question.
68.: The nurse has assisted the health care provider and the anesthesiologist with placement of an
endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate
proper ET tube placement?

1.
Tape the ET tube in place, and note the centimeter marking at the lip line.

2.
Ask the radiology department to obtain a stat portable radiograph at the client's bedside.

3.
Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.

4.
Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume
prescribed.3

The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by
auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment,
placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or
mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of
the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure
of appropriate ET tube placement.

69.: Thenurse has been caring for a client who required a Sengstaken-Blakemore tube because other
treatment measures for esophageal varices were unsuccessful. The health care provider arrives on the
nursing unit and deflates the esophageal balloon. After deflation of the balloon, the nurse should monitor
the client most closely for which complication?

1.
Hematemesis

2.
Bloody diarrhea

3.
Swelling of the abdomen

4.
An elevated temperature and a rise in blood pressure1

A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis and ruptured
esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure
on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released
at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis.
When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as
vomiting of blood (hematemesis). Options 2, 3, and 4 are unrelated to deflating the esophageal balloon.
70.: Thenurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider
arrives on the nursing unit and deflates the esophageal balloon. Afterward, the nurse should monitor the
client most closely for which sign?

1.
Hematemesis

2.
Bloody diarrhea

3.
Swelling of the abdomen

4.
An elevated temperature and a rise in blood pressure1

A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis and ruptured esophageal
varices if other interventions are unsuccessful. The tube has an esophageal and a gastric balloon. The
esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure
of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues,
including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again
from the esophageal varices; this would be manifested by vomiting of blood (hematemesis). Options 2, 3, and
4 are not specifically associated with esophageal deflation.

71.: Thenurse has completed discharge instructions for a client with application of a halo device. Which
action indicates that the client needs further clarification of the instructions?

1.
Uses a straw for drinking

2.
Drives only during the daytime

3.
Uses caution because the device alters balance

4.
Washes the skin daily under the lamb's wool liner of the vest2

The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin
daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The
liner should be changed if odor becomes a problem. The client should have food cut into small pieces to
facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all
because the device impairs the range of vision.
72.: The nurse has given instructions to a client with hepatitis about post-discharge management during
convalescence. The nurse determines that further teaching is needed if the client makes which statement?

1.
"I need to avoid alcohol and aspirin."

2.
"I should eat a high-carbohydrate, low-fat diet."
3.
"I can resume a full activity level within 1 week."

4.
"I need to take the prescribed amounts of vitamin K."3

The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is
important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic
substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin
K may be prescribed for prolonged clotting times.

73.: The
nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for
increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should
avoid placing the client in which positions?

1.
Head midline

2.
Neck in neutral position

3.
Flat, with head turned to the side

4.
Head of bed elevated 30 to 45 degrees3

The client who is at risk for or with increased ICP should be positioned so that the head is in a neutral, midline
position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side.
The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage
from the cranium to keep ICP down.
74.: The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for
increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely
place the client in which positions? Select all that apply.

1.
Head midline

2.
Neck in neutral position

3.
Head of bed elevated 30 to 45 degrees

4.
Head turned to the side when flat in bed

5.
Neck and jaw flexed forward when opening the mouth1, 2, 3

Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from
elevating.The head of the client at risk for or with increased intracranial pressure should be positioned so that
the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse
should avoid flexing or extending the neck or turning the head from side to side.

75.: The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body
image. The nurse develops goals for the client but determines that the client has not met the outcome
criteria by discharge if the client performs which action?

1.
Wears a turban to cover the incision

2.
Indicates that facial puffiness will be a permanent problem

3.
Verbalizes that periorbital bruising will disappear over time

4.
States an intention to purchase a hairpiece until hair has grown back2

After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by
listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising,
and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming
and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a
hairpiece, to help the client adapt to the temporary change in appearance.
76.: A nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the
incidence of recurrences. The nurse should determine that the client has understood the information if the
client states that it will be necessary to control which factor?

1.
Alcohol intake

2.
Duodenal ulcer

3.
Crohn's disease

4.
Diabetes mellitus1

Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not associated with
pancreatitis.
77.: The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder
who will be taking divalproex sodium (Depakote). The nurse should instruct the client about the importance
of returning to the clinic for monitoring of which laboratory study?

1.
Electrolyte panel

2.
Liver function studies

3.
Renal function studies

4.
Blood glucose level determination2

Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client
about the importance of monitoring the results of liver function studies and ammonia level determinations.
Options 1, 3, and 4 are not studies that are required with the use of this medication.

78.: The
nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a
blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the
nose. Which nursing action is most appropriate?

1.
Insert nasal packing.

2.
Document the findings.

3.
Contact the health care provider (HCP).

4.
Monitor the client's blood pressure and check for signs of increased intracranial pressure.3

Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a
cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires
immediate intervention. Options 1, 2, and 4 are inappropriate nursing actions in this situation.
79.: The nurse is admitting a client to the hospital emergency department from a nursing home. The client is
unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected.
Which question is of the highest priority for the emergency department nurse to ask of the transferring
nurse at the nursing home?

1.
"When did the injury occur?"

2.
"Was the client awake and talking right after the injury?"

3.
"What medications has the client received since the fall?"

4.
"What was the client's level of consciousness before the injury?"2

Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during
which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with
potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is
important for the nurse to assist in the differentiation between epidural hematoma and other types of head
injuries.

80.: The
nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is
necessary to determine information about which items as part of routine assessment of seizures? Select all
that apply.

1.
Postictal status

2.
Duration of the seizure

3.
Changes in pupil size or eye deviation

4.
Seizure progression and type of movements

5.
What the client ate in the 2 hours preceding seizure activity1, 2, 3, 4

Typically seizure assessment includes the time the seizure began, parts of the body affected, type of
movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition
during the seizure, and postictal status. Option 5 is not a component of seizure assessment.
81.: The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory
distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

1.
Bilateral wheezing

2.
Inspiratory crackles

3.
Intercostal retractions

4.
Increased respiratory rate4

The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can
begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger,
retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory
crackles or diffuse coarse crackles.

82.: The
nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess
for which finding as a sign of overhydration, which would aggravate cerebral edema?

1.
Unchanged weight

2.
Shift intake 950 mL, output 900 mL

3.
Blood urea nitrogen (BUN) 10 mg/dL

4.
Serum osmolality 280 mOsm/kg H2O4

After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body
water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value
indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid
excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN
of 10 mg/dL is within normal range and does not indicate overhydration or underhydration.

83.: Thenurse is assessing the functioning of a chest tube drainage system in a client who has just returned
from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment
findings? Select all that apply.

1.
Excessive bubbling in the water seal chamber

2.
Vigorous bubbling in the suction control chamber

3.
Drainage system maintained below the client's chest

4.
50 mL of drainage in the drainage collection chamber

5.
Occlusive dressing in place over the chest tube insertion site

6.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation3.
Drainage system maintained below the client's chest

4.
50 mL of drainage in the drainage collection chamber

5.
Occlusive dressing in place over the chest tube insertion site

6.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen
when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing,
or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An
absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that
no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction
control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the
recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires health care
provider notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent
air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to
drain the pleural space.
84.: Thenurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct
the client to take which action?

1.
Exhale slowly.

2.
Stay very still.

3.
Inhale and exhale quickly.

4.
Perform the Valsalva maneuver.4.
Perform the Valsalva maneuver.

When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath,
exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An
alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
85.: The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after
sustaining a head injury. The nurse understands that the neurologist would avoid performing the
oculocephalic response (doll's-eyes maneuver) if which condition is present in the client?

1.
Dilated pupils

2.
Lumbar trauma

3.
A cervical cord injury

4.
Altered level of consciousness3

In an unconscious client, eye movements are an indication of brainstem activity and are tested by the
oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction
when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for
the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response
indicates a disruption in the processing of information through the brainstem. Contraindications to performing
this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

86.: Thenurse is caring for a client after a craniotomy and monitors the client for signs of increased
intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased
ICP?

1.
Confusion

2.
Bradycardia

3.
Sluggish pupils

4.
A widened pulse pressure1

Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in
some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary
and breathing changes. Later manifestations include a further decrease in the level of consciousness, a
widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory
pattern; pupillary sluggishness and dilatation appear in the late stages.
87.: A nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's
laboratory results, the nurse interprets that which finding will support the diagnosis?

1.
Elevated serum lipase level

2.
Elevated serum bilirubin level

3.
Decreased serum trypsin level

4.
Decreased serum amylase level1

The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels
are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is
secondary to the hepatobiliary obstructive process.

88.: The
nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should
report which sign immediately if experienced by the client?

1.
Stridor

2.
Occasional pink-tinged sputum

3.
Respiratory rate of 24 breaths/minute

4.
A few basilar lung crackles on the right1.
Stridor

Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse
reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is
heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for
airway obstruction. Although the findings identified in the remaining options require monitoring, they do not
require immediate notification of the health care provider.
89.: A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator
sounds. The nurse suspects that the most likely cause of the alarm is which finding?
1.
A disconnection of the ventilator tubing

2.
An exaggerated client inspiratory effort

3.
Accumulation of respiratory secretions

4.
Generation of extreme negative pressure by the client3

The high pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator
before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing "out of phase"
or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing,
coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary
compliance, and pneumothorax. Options 1, 2, and 4 identify causes for triggering the low-pressure alarm

90.: The
nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse
assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be
appropriate if the nurse is unable to determine the cause of ventilator alarm?

1.
Shut the alarm off and call for help.

2.
Call the respiratory therapy department to fix the problem.

3.
Call the health care provider (HCP) for further instructions.

4.
Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.4

If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the
nurse should manually ventilate the client with a resuscitation device. The nurse should never shut off the
alarm. It is not necessary to contact the HCP, although the respiratory therapist may be notified to assist in
troubleshooting the cause of the problem. However, the initial nursing action would be to manually ventilate
the client.
91.: The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by
the nurse is contraindicated?

1.
Loosening restrictive clothing

2.
Restraining the client's limbs

3.
Removing the pillow and raising padded side rails

4.
Positioning the client to the side, if possible, with the head flexed forward2
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the
pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward,
if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because
the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity
begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture
that may injure the client.

92.: The
nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The
nurse should place the client in which position postoperatively?

1.
Head of bed flat, head and neck midline

2.
Head of bed flat, head turned to the nonoperative side

3.
Head of bed elevated 30 to 45 degrees, head and neck midline

4.
Head of bed elevated 30 to 45 degrees, head turned to the operative side3

After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be
angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This promotes
venous return through the jugular veins, which will help prevent a rise in intracranial pressure.
93.: The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord
injury. The nurse minimizes the risk of compounding the injury most effectively by performing which action?

1.
Keeping the client on a stretcher

2.
Logrolling the client onto a soft mattress

3.
Logrolling the client onto a firm mattress

4.
Placing the client on a bed that provides spinal immobilization4

Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal
cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse
to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker
frame is not available, a firm mattress with a bed board under it should be used. Options 1, 2, and 3 are
incorrect and potentially harmful interventions.

94.: The
nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is
sounding. The nurse understands that which complications may cause this alarm? Select all that apply.

1.
Water or a kink in the tubing
2.
Biting on the endotracheal tube

3.
Increased secretions in the airway

4.
Disconnection or leak in the system

5.
The client stops spontaneous breathing.1, 2, 3

Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal
tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube,
or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to
spontaneously breathe are causes of a low-pressure ventilator alarm.
95.: The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care,
the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action
should the nurse take?

1.
Elevate the head of the bed.

2.
Examine the rectum digitally.

3.
Assess the client's blood pressure.

4.
Place the client in the prone position.1

Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the
syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the
source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to
elevate the head of the bed. The client would not be placed in the prone position.

96.: Anurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water
seal chamber. Which nursing action is appropriate?

1.
Reposition the client.

2.
Notify the health care provider (HCP).

3.
Change the chest tube drainage system.

4.
No action is necessary because this is a normal expected finding.2
Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the
options provided, the appropriate action is to notify the HCP. Options 1, 3, and 4 are incorrect.
97.: A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level
on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system.
Which nursing action is appropriate?

1.
Suction the client.

2.
Increase the suction.

3.
Document the findings.

4.
Encourage coughing and deep breathing.3

With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water
level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure
mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore no
action is necessary except to document the findings.

98.: The
nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus.
Which assessment data should alert the nurse to this occurrence?

1.
Inability to pass flatus

2.
Loss of anal sphincter control

3.
Severe, constant pain with rapid onset

4.
Firm, nontender mass palpable at the lower right costal margin1

An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of
nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter
control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a
more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement.
The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an
enlarged liver is not a sign of paralytic ileus or intestinal obstruction.
99.: The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus.
Which assessment data would alert the nurse to this occurrence?

1.
Inability to pass flatus

2.
Loss of anal sphincter control
3.
Severe, constant pain with rapid onset

4.
Firm, nontender mass palpable at the lower right costal margin1

An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of
nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal
sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually
presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more
likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the
physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although
this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.

100.: Thenurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-
pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm
is most likely to be due to which complication?

1.
A kink in the ventilator circuit

2.
A leak in the endotracheal tube cuff

3.
Displacement of the endotracheal tube

4.
A disconnection of the ventilator tubing1

A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset
amount. Causes of high-pressure alarm activation include excess secretions; mucous plugs; the client biting on
the endotracheal tube; kinks in the ventilator tubing; and the client coughing, gagging, or attempting to talk.
Options 2, 3, and 4 would trigger the low-pressure alarm.
101.: A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm
sounds on the ventilator. The nurse should plan to perform which action?

1.
Suction the client.

2.
Evaluate the cuff for a leak.

3.
Assess for a disconnection.

4.
Notify the respiratory therapist.1

When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The
obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucus plugging requiring
suctioning. Options 2 and 3 would cause the low-pressure alarm to sound. Option 4 delays necessary
treatment.
102.: Thenurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The
nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula
when which occurs?

1.
Suctioning is required frequently.

2.
The client's skin and mucous membranes are light pink.

3.
Aspiration of gastric contents occurs during suctioning.

4.
Excessive secretions are suctioned from the tube and stoma.3

Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and
the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing
abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this
complication.

103.: Anurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the
disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the
client has the best understanding of the material if the client states to increase intake of which food?

1.
Pork

2.
Milk

3.
Chicken

4.
Broccoli1

Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the
vitamin. Other good sources include peanuts, asparagus, and whole grain and enriched cereals.
104.: The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of
these clients is at most risk for the development of pulmonary embolism?

1.
A 25-year-old woman with diabetic ketoacidosis

2.
A 65-year-old man out of bed 1 day after prostate resection

3.
A 73-year-old woman who has just had pinning of a hip fracture

4.
A 38-year-old man with pulmonary contusion sustained in an automobile crash3
Clients frequently at risk for pulmonary embolism include clients who are immobilized. This is especially true in
the immobilized postoperative client. Other causes include those with conditions that are characterized by
hypercoagulability, endothelial disease, or advancing age.
105.: A nurse is caring for a hospitalized client who has been diagnosed with pancreatitis. The nurse checks
the laboratory results form, anticipating that which enzyme will remain normal in the client?

1.
Lipase

2.
Lactase

3.
Trypsin

4.
Amylase2

Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase,
trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins,
respectively.

106.: Thenurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse
assess for when monitoring for gastrointestinal complications?

1.
A history of diarrhea

2.
A flattened abdomen

3.
Hyperactive bowel sounds

4.
Hematest-positive nasogastric tube drainage4

Development of a stress ulcer also can occur after spinal cord injury and can be detected by Hematest-positive
nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the
absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.
107.: The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the
security of the ties. Which method is used to ensure that the ties are not too tightly placed?

1.
The ties leave no marks on the neck.

2.
The nurse places two fingers between the tie and the neck.

3.
The tracheotomy can be pulled slightly away from the neck.
4.
The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.2

The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that
there is room for two fingers to slide comfortably under the ties. Options 1, 3, and 4 are incorrect actions.
108.: The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS).
As part of the plan, the nurse will check for which item to detect an early sign of this disorder?

1.
Edema

2.
Dyspnea

3.
Frothy sputum

4.
Diminished breath sounds2

In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy
sputum would present as a later sign, after the development of pulmonary edema. Breath sounds in the early
stages of ARDS usually are clear. Edema is not directly associated with ARDS.

109.: The
nurse is developing a plan of care for a client with cirrhosis and ascites. Which nursing actions
should be included in the care plan for this client? Select all that apply.

1.
Monitor daily weight.

2.
Measure abdominal girth.

3.
Monitor respiratory status.

4.
Place the client in a supine position.

5.
Assist the client with care as needed.1, 2, 3, 5

Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the
client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on
a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions
to be included in the plan of care for the client with ascites.
110.: The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include
which information in the teaching session?

1.
The diet should be low in calories.

2.
Meals should be large to conserve energy.

3.
Activity should be limited to prevent fatigue.

4.
Alcohol intake should be limited to 2 ounces per day.3

Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid
fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several
small meals per d

111.: Thenurse is documenting nursing observations in the record of a client who experienced a tonic-clonic
seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure?

1.
Body stiffening

2.
Spasms of the entire body

3.
Sudden loss of consciousness

4.
Brief flexion of the extremities2

The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the
entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive
salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the
pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a
period of 30 seconds. Options 1, 3, and 4 identify the tonic phase of a seizure.
112.: The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock persists?

1.
Hyperreflexia

2.
Positive reflexes

3.
Flaccid paralysis

4.
Reflex emptying of the bladder3

Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous
stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
113.: The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which
assessment finding would the nurse note as an early sign of hepatic encephalopathy?

1.
Restlessness

2.
Complaints of fatigue

3.
The presence of asterixis

4.
Decreased serum ammonia levels3

Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of
this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia
levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be
noted.

114.: The
nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes
intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

1.
Check for an air leak.

2.
Document the findings.

3.
Notify the health care provider.

4.
Change the chest tube drainage system.2.

Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the
chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of
its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration
indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and
changing the chest tube drainage system are not indicated at this time.
115.: The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse
understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the
client has which coexisting problem?

1.
Fever

2.
Epilepsy

3.
Hypotension

4.
Respiratory failure3

Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse
oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the
accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although
the readings may be abnormally low.

116.: The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most
likely to include which as a common causative factor in this client's disorder?

1.
Weight gain

2.
Use of alcohol

3.
Exposure to occupational chemicals

4.
Abdominal pain relieved with food or antacids2

Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client
from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical
exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.
117.: The nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The
nurse will direct the assessment to look for which as a hallmark sign of this disorder?

1.
Hypothermia

2.
Epigastric pain radiating to the neck area

3.
Severe abdominal pain relieved by vomiting

4.
Severe abdominal pain that is unrelieved by vomiting4

Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is
severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and
duodenal contents. Fever also is a common sign but usually is mild, with temperatures less than 39° C.
Epigastric pain radiating to the neck area is not a characteristic symptom.

118.: The
nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The
nurse would expect to note which assessment finding?

1.
Bilateral loss of pain and temperature sensation

2.
Ipsilateral paralysis and loss of touch and vibration

3.
Contralateral paralysis and loss of touch, pressure, and vibration
4.
Complete paraplegia or quadriplegia, depending on the level of injury2.
Ipsilateral paralysis and loss of touch and vibration

Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss
of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost
because these fibers decussate after entering the cord. Options 1, 3, and 4 are not assessment findings in this
syndrome.
119.: A nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment
should the nurse plan to have at the bedside when the client returns from surgery?

1.
Obturator

2.
Oral airway

3.
Epinephrine (Adrenalin)

4.
Tracheostomy set with the next larger size1

A replacement tube of the same size and an obturator are kept at the bedside at all times in case the
tracheostomy tube becomes dislodged. Additionally, a curved hemostat that could be used to hold the trachea
open if dislodgement occurs should also be kept at the bedside. An oral airway and epinephrine would not be
needed.

120.: The nurse is planning to institute seizure precautions for a client who is being admitted from the
emergency department. Which measures should the nurse include in planning for the client's safety? Select
all that apply.

1.
Padding the side rails of the bed

2.
Placing an airway at the bedside

3.
Placing the bed in the high position

4.
Putting a padded tongue blade at the head of the bed

5.
Placing oxygen and suction equipment at the bedside

6.
Having intravenous equipment ready for insertion of an intravenous catheter1, 2, 5, 6

Seizure precautions may vary from agency to agency, but they generally have some common features. Usually,
an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are
padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a
readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades
is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth
during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking
the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth
fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral
airway before seizure activity begins.
121.: The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health
care provider in this procedure, which is the initial nursing action?

1.
Deflate the cuff.

2.
Suction the ET tube.

3.
Turn off the ventilator.

4.
Obtain a code cart, and place it at the bedside.2

Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain
spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is
deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and
concern in the client. Additionally, resuscitative equipment should already be available at the client's bedside.
Option 3 is not the initial action.

122.: The
nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and is
preparing to institute full seizure precautions. Which item is contraindicated for use if a seizure occurs?

1.
Oxygen source

2.
Suction machine

3.
Padded tongue blade

4.
Padding for the side rails3

Full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the
bedside, having diazepam (Valium) or lorazepam (Ativan) available, and providing an oxygen source. Objects
such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure.
123.: The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan
to place the client in which position?

1.
Prone

2.
Supine

3.
Side-lying

4.
Semi-Fowler's4

After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's bed usually is
elevated 30 degrees to promote venous outflow through the jugular veins. Options 1, 2, and 3 denote
incorrect positions after this surgery and these positions could result in edema at the surgical site and
increased intracranial pressure.
124.: The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the
supplies needed for the procedure. What is the initial nursing action?

1.
Hyperoxygenate the client.

2.
Set the suction pressure range at 150 mm Hg.

3.
Place the catheter into the tracheostomy tube.

4.
Apply suction on the catheter, and insert it into the tracheostomy tube.1

The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing
action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter
into the tracheostomy tube, suction is not applied, because applying suction at that time will cause mucosal
trauma and aspiration of the client's oxygen.

125.: The
nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the
suctioning time to a maximum of which time period?

1.
1 minute

2.
5 seconds

3.
10 seconds

4.
30 seconds3.
10 seconds

Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A
vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning
and limit the suctioning pass to 10 seconds.
126.: The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a
component of the plan of care with this type of weaning process? Select all that apply.
1.
Pressure support is added to the oxygen system.

2.
The T-piece is connected to the client's artificial airway.

3.
The client is removed from the mechanical ventilator for a short period of time.

4.
The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of
breathing on his or her own.

5.
Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher
than a ventilator setting.1, 2, 3, 5

The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short
periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is
connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a Fio2
that is 10% higher than the ventilator setting. Option 4 describes intermittent mandatory
ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open
alveoli in some clients on mechanical ventilation.

127.: A
nurse is providing a simple overview of the anatomy of the liver and gallbladder for a client
hospitalized with biliary obstruction. The nurse explains that normally the liver stores bile in the gallbladder
and that the liver and gallbladder are connected together by which passageway?

1.
Cystic duct

2.
Liver canaliculi

3.
Common bile duct

4.
Right hepatic duct1

The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from
which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the
bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the
duodenum by way of the common bile duct.
128.: The nurse is providing care for a client with a Sengstaken-Blakemore tube. The nurse suspects which
diagnosis for this client?

1.
Gastritis

2.
Bowel obstruction
3.
Small bowel tumor

4.
Esophageal varices4

A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal
varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The
esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric
balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could
harm the client. This tube is not used in clients with the conditions noted in options 1, 2, or 3.

129.: The
nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should
the nurse instruct the client to avoid?

1.
Chili

2.
Bagel

3.
Lentil soup

4.
Watermelon1

The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which
stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of
eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.
130.: The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a
tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal
respiratory functioning, and the nurse provides instructions to assist the client toward this goal. Which
client statement indicates that further instruction is needed?

1.
"I will lie on the affected side for an hour."

2.
"I can expect a chest x-ray exam to be done shortly."

3.
"I will let you know at once if I have trouble breathing."

4.
"I will notify you if I feel a crackling sensation in my chest."1

After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion.
Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax,
should be reported to the health care provider. A chest x-ray may be performed to evaluate the degree of lung
re-expansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in
the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when
palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and
constricting vital organs, such as the trachea.

131.: Thenurse is providing instructions to a client being discharged from the hospital following removal of a
chest tube that was inserted after thoracic surgery. Which statement, if made by the client, indicates a need
for further teaching?

1.
"I should avoid heavy lifting for at least 4 to 6 weeks."

2.
"I should remove the chest tube site dressing as soon as I get home."

3.
"If I have any difficulty in breathing, I should call the health care provider."

4.
"If I note any signs of infection, I should contact the health care provider (HCP)."2

When a chest tube is removed, an occlusive dressing, consisting of petrolatum gauze covered by a dry sterile
dressing, usually is placed over the chest tube site. This dressing is maintained in place until the HCP says that
it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued
wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of
infection or increased temperature.
132.: The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin
(Dilantin). Which statement, if made by the client, would indicate an understanding of the information
about this medication?

1.
"I need to perform good oral hygiene, including flossing and brushing my teeth."

2.
"I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation."

3.
"I should take my medication before coming to the laboratory to have a blood level drawn."

4.
"I should monitor for side effects and adjust my medication dose depending on how severe the side effects
are."1

The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should
see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The
client should avoid alcohol while taking this medication. The client should also be instructed that follow-up
serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid
taking the medication before the specimen is drawn. The client should not adjust medication dosages.

133.: Anurse is reading the report for a chest x-ray study in a client who has just been intubated. The report
states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse determines that the tube
is positioned above which area of the respiratory system?

1.
The first tracheal cartilaginous ring
2.
The bifurcation of the right and left main bronchi

3.
The point at which the larynx connects to the trachea

4.
The area connecting the oropharynx to the laryngopharynx2

The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an
endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the
natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect
tube placement is easily detected because only the right lung will have breath sounds and rise and fall with
ventilation. Options 1, 3, and 4 are incorrect interpretations.
134.: The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a
nursing student. The nurse would intervene and provide teaching to the student if the student included
which home care instruction?

1.
Sounds will not be heard clearly unless they are loud.

2.
Obtain assistance with ambulation if client is lightheaded.

3.
Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed.

4.
Use a check-off system for administering anticonvulsant medications to avoid missing doses.1

The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control
of environmental noise by others will be helpful for this client. Seizures are a potential complication that may
occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications.
The client and family are encouraged to keep track of the doses administered. The family should learn seizure
precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The
suture line is kept dry until sutures are removed to prevent infection.

135.: Anurse is reviewing laboratory test results for a client with liver disease and notes that the client's
albumin level is low. The nurse next assesses the client for which physiological effect of decreased
circulating albumin?

1.
Cerebral edema

2.
Peripheral edema

3.
Decreased clotting ability

4.
Reflexive increase in total protein level2
Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic
pressure is decreased, which in turn can lead to peripheral edema. The client will not experience cerebral
edema. Clotting factors produced by the liver (not albumin) are responsible for coagulation. The total protein
level may decrease if the albumin level is low.
136.: A nurse is reviewing laboratory test results for the client with liver disease and notes that the client's
albumin level is low. Which nursing action is focused on the consequence of low albumin levels?

1.
Evaluating for asterixis

2.
Inspecting for petechiae

3.
Palpating for peripheral edema

4.
Evaluating for decreased level of consciousness3

A nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin
level is low. Which nursing action is focused on the consequence of low albumin levels?
137.: A nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital
with acute pancreatitis. Which prescription should the nurse confirm?

1.
Full liquid diet

2.
Morphine sulfate for pain

3.
Nasogastric tube insertion

4.
An anticholinergic medication1

The client with acute pancreatitis is placed on an NPO (nothing by mouth) status to decrease the activity of the
pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the
administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone
(Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer
medications as necessary.

138.: Thenurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level
is elevated. Which diet does the nurse anticipate to be prescribed for this client?

1.
Low-protein diet

2.
High-protein diet

3.
Moderate-fat diet

4.
High-carbohydrate diet1

Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of
hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the
diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation
of ammonia. If the client has hepatic encephalopathy, a low
139.: The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute
pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that
apply.

1.
Administer antacids as prescribed.

2.
Encourage coughing and deep breathing.

3.
Administer anticholinergics as prescribed.

4.
Give small, frequent high-calorie feedings.

5.
Maintain the client in a supine and flat position.

6.
Give opioid analgesics as prescribed for pain.1, 2, 3, 6

The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress
gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication
is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees
drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the
abdomen and may help ease the pain. The client is susceptible to respiratory infections because the
retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal
breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and
anticholinergics may be prescribed to suppress gastrointestinal secretions.

140.: Thenurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a
history of Laennec's cirrhosis. This type of cirrhosis is most commonly caused by which long-term condition?

1.
Alcohol abuse

2.
Cardiac disease

3.
Exposure to chemicals

4.
Obstruction to biliary ducts1

Laennec's cirrhosis results from long-term alcohol abuse. Cardiac cirrhosis most commonly is caused by long-
term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections, or a metabolic disorder can
cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused
by long-term obstruction of bile ducts.
141.: The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is
documentation of the presence of asterixis. How should the nurse assess for its presence?

1.
Dorsiflex the client's foot.

2.
Measure the abdominal girth.

3.
Ask the client to extend the arms.

4.
Instruct the client to lean forward.3

Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched,
with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that
hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect
142.: The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected
hepatitis. Which laboratory finding is most associated with hepatitis requiring the nurse to contact the
health care provider?

1.
Elevated serum bilirubin level

2.
Below normal hemoglobin concentration

3.
Elevated blood urea nitrogen (BUN) level

4.
Elevated erythrocyte sedimentation rate (ESR)1

Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR
is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin
concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

143.: The
nurse is suctioning an unconscious client who has a tracheostomy. The nurse should perform which
actions when performing this procedure? Select all that apply.

1.
Keeping a supply of suction catheters at the bedside

2.
Auscultating breath sounds to determine the need for suctioning
3.
Hyperoxygenating the client before, during, and after suctioning

4.
Intermittently suctioning during insertion of the suction catheter

5.
Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed1, 2, 3

Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial
airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently as needed. The
client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia.
Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted.
Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a
rise in intracranial pressure.
144.: The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety
precautions after discharge. The nurse determines that the client needs more information if he or she states
an intention to take which action?

1.
Refrain from smoking alone.

2.
Take all prescribed medications on time.

3.
Have the spouse nearby when showering.

4.
Drink alcohol in small amounts and only on weekends.4

The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or
the alcohol could precipitate seizure activity. The client should take all medications on time to avoid decreases
in therapeutic drug levels, which could precipitate seizures. The client should not bathe in the shower or tub
without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs.

145.: The
nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will
be most helpful to the client?

1.
Shift weight every 2 hours while in a wheelchair.

2.
Change bed sheets every other week to maintain cleanliness.

3.
Place a pillow on the seat of the wheelchair to provide extra comfort.

4.
Use a mirror to inspect for redness and skin breakdown twice a week.1

To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and use a pressure
relief pad. A pillow is not sufficient to relieve the pressure. While the client is in bed, the bottom sheet should
be free of wrinkles and wetness. Sheets should be changed as needed and more frequently than every other
week. The client should use a mirror to inspect the skin twice daily (morning and evening) to assess for
redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin
care.
146.: The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should
explain to the client that the second stage of this disease is characterized by which specific assessment
findings? Select all that apply.

1.
Jaundice

2.
Flu-like symptoms

3.
Clay-colored stools

4.
Dark or tea-colored urine

5.
Elevated bilirubin levels1, 3, 4, 5

There are three stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms
only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as
elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs
when the jaundice decreases and the colors of the urine and stool return to normal.

147.: A
nurse manager is providing an educational session to nursing staff members about the phases of viral
hepatitis. The nurse manager tells the staff that which clinical manifestation(s) is/are primarily characteristic
of the preicteric phase?

1.
Pruritus

2.
Right upper quadrant pain

3.
Fatigue, anorexia, and nausea

4.
Jaundice, dark-colored urine, and clay-colored stools3

In the preicteric phase the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint
pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase,
jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.
148.: A nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure,
fluid balance, and body temperature. The nurse concludes that which area of the client's brain is functioning
adequately?

1.
Thalamus
2.
Hypothalamus

3.
Limbic system

4.
Reticular activating system2

The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure,
temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for
sensory and motor information. The limbic system is responsible for emotions. The reticular activating system
is responsible for the sleep-wake cycle.

149.: The
nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during
the acute phase of hepatitis? Select all that apply.

1.
Select foods high in protein content.

2.
Consume multiple small meals throughout the day.

3.
Select foods low in carbohydrates to prevent nausea.

4.
Allow the client to select foods that are most appealing.

5.
Eliminate fatty foods from the meal trays until nausea subsides.

6.
Eat a nutritious dinner because it is typically the best tolerated meal of the day.2, 4, 5

Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated
than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance
appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the
acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client
should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically
increases as the day goes on.
150.: The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of
portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?

1. Weak pulse

2.
Hypotension

3.
Flat neck veins
4.
Crackles on auscultation of the lungs4

Clinical signs and symptoms of portal hypertension are similar to those of heart failure and include jugular vein
distention, lung crackles, and decreased perfusion to all organs. Initially the client may have hypertension,
flushed skin, and a bounding pulse.

151.: A
nurse who is participating in a client care conference with other members of the health care team is
discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care
provider states that as a result of fluid in the alveoli, surfactant production is falling. The nurse understands
that which is the natural consequence of insufficient surfactant?

1.
Atelectasis and viral infection

2.
Bronchoconstriction and stridor

3.
Collapse of alveoli and decreased compliance

4.
Decreased ciliary action and retained secretions3

Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents
the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs
become "stiff" because of decreased compliance. Common causes of decreased surfactant production are
ARDS and atelectasis. Options 1, 2, and 4 are incorrect.
152.: The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube.
Which observation by the nursing instructor indicates an action by the student requiring the need for
further instruction?

1.Suctioning the client every hour

2.Applying suction only during withdrawal of the catheter

3.Hyperventilating the client with 100% oxygen before suctioning

4.Applying suction intermittently during withdrawal of the catheter1

The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase
secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100%
oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a
twirling motion of the catheter are used during withdrawal.

153.: A
nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-
Evac drainage system. Which intervention in the care plan indicates the need for further teaching for the
student?

1.Position the client in semi-Fowler's position.

2.Add water to the suction chamber as it evaporates.

3.Instruct the client to avoid coughing and deep breathing.

4.Tape the connection sites between the chest tube and the drainage system.3

It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in
place. This will assist in facilitating appropriate lung re-expansion. The client is positioned in semi-Fowler's
position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the
full suction level prescribed. Connections between the chest tube and the drainage system are taped to
prevent accidental disconnection.
154.: A Penrose drain is in place on the first postoperative day in a client who has undergone a
cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which
nursing intervention is most appropriate?

1.Change the dressing.

2.Continue to monitor the drainage.

3.Notify the health care provider (HCP).

4.Use a pen to circle the amount of drainage on the dressing.

1- Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24
hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the
site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would
continue to monitor the drainage, the most appropriate intervention is to change the dressing. The HCP does
not need to be notified.

155.: A
postoperative craniotomy client who sustained a severe head injury is admitted to the neurological
unit. What important nursing intervention is necessary for this client?

1.Take and record vital signs every 4 to 8 hours.

2.Prophylactically hyperventilate during the first 20 hours.

3.Treat a central fever with the administration of antipyretic medications such as acetaminophen (Tylenol).

4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or
extension of the neck and head.
4Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased
intracranial pressure. As a general rule, hyperventilation is avoided during the first 20 hours postoperatively
because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and
recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling
(hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

156.: Aregistered nurse who is orienting a new nursing graduate to the hospital emergency department
instructs the new graduate to monitor a client for one-sided chest movement on the right side while the
client is being intubated by the health care provider. This instruction is based on the understanding that the
endotracheal tube could enter which respiratory structures?

1.Left main bronchus if inserted too far

2.Right main bronchus if inserted too far

3.Left main bronchus if not inserted far enough

4.Right main bronchus if not inserted far enough

2- If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main
bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in
a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other
options are incorrect.

157.: A
sexually active 20-year-old client has developed viral hepatitis. Which client statement indicates the
need for further teaching?

1."I should avoid drinking alcohol."

2."I can go back to work right away."

3."My partner should get the vaccine."

4."A condom should be used for sexual intercourse."

2 - To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised
during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere
with recovery. Rest is especially important until laboratory studies show that liver function has returned to
normal. The client's activity is increased gradually, and the client should not return to work right away.

158.: To
promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the
nurse should place the client with an incision in the anterior or middle fossa, in which position?

1.In 15 degrees of Trendelenburg

2.Side-lying with the head of the bed flat

3.With the head of the bed elevated at least 30 degrees

4.With the head of the bed elevated no more than 10 degrees3

Positioning of the client correctly following cranial surgery is important to avoid increased intracranial
pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always
followed. The client with an incision in the anterior or middle fossa should be positioned with the head of bed
(HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the
client is positioned flat, or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap)
is performed, the client should not be positioned to the operative side. Trendelenburg position is
contraindicated in the postoperative phase following cranial surgery.

159.: Which
intervention should the nurse include in a postoperative teaching plan for a client who
underwent a spinal fusion and will be wearing a brace?

1.
Tell the client to inspect the environment for safety hazards.

2.
Inform the client about the importance of sitting as much as possible.

3.
Inform the client that lotions and body powders can be used for skin breakdown.

4.
Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each
meal.1

The client must inspect the environment for safety hazards. The client is instructed in the importance of
avoiding prolonged sitting and standing. Powders and lotions should not be used because they may irritate the
skin. The client should be taught to loosen the brace during meals and for 30 minutes after each meal. The
client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow
adequate nutritional intake and promote comfort.
160.: Which should the nurse do when caring for a client with chest tubes attached to a chest drainage
system?

1.Empty the drainage collection chamber every shift.

2.Ensure the water level in the water seal chamber is at the 2-cm level.

3.Maintain the drainage collection device at the level of the client's chest.

4.Clamp the chest tube before moving the client from the bed to the chair.

The water seal acts a one-way valve. It allows air and fluid to leave the pleural space but prevents re-entry of
atmospheric air. The minimum amount needed is 2 cm of water. A closed chest drainage system must remain
airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the
chest, there can be backflow of drainage into the pleural cavity. Chest tubes should not be clamped unless
specifically prescribed

161.: While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is
the initial nursing action?

1.Call the health care provider to reinsert the tube.

2.Grasp the retention sutures to spread the opening.

3.Call the respiratory therapy department to reinsert the tracheotomy.

4.Cover the tracheostomy site with a sterile dressing to prevent infection.2.

Grasp the retention sutures to spread the opening.

If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the
opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Calling ancillary
services or the HCP will delay treatment in this emergency situation. Covering the tracheostomy site will block
the airway.