1.

Category: Health Promotion and Maintenance

While assessing a one-month-old infant, which of the findings warrants
further investigation by the nurse? Select all that apply.

o  A. Abdominal respirations

o  B. Irregular breathing rate

o  C. Inspiratory grunt

o  D. Increased heart rate with crying

o  E. Nasal flaring

o  F. Cyanosis

o  G. Asymmetric chest movement

Incorrect
Correct Answers: C, E, F, & G
o Option C. Grunting occurs when an infant attempts to
maintain an adequate functional residual capacity in the face
of poorly compliant lungs by partial glottic closure. As the
infant prolongs the expiratory phase against this partially
closed glottis, there is a prolonged and increased residual
volume that maintains the airway opening and also an audible
expiratory sound.
o Option E: Nasal flaring occurs when the nostrils widen while
breathing and is a sign of troubled breathing or respiratory
distress.
o Option F: Cyanosis refers to the bluish discoloration of the
skin and indicates a decrease in oxygen attached to the red
blood cells in the bloodstream.
o Option G: Asymmetric chest movement occurs when the
abnormal side of the lungs expands less and lags behind the
normal side. This indicates respiratory distress.
o Option A: Abdominal respiration is normal among infants and
young children. Since their intercostal muscles are not yet fully
 developed, they use their abdominal muscles much more to
pull the diaphragm down for breathing.
o Option B: Newborns can have irregular breathing patterns
ranging from 30 to 60 breaths per minute with short periods
of apnea (15 seconds).
o Option D: An increase in heart rate is normal for an infant
during activity (including crying). Fluctuations in heart rate
follow the changes in the newborn’s behavioral state – crying,
movement, or wakefulness corresponds to an increase in heart
rate.

2. Category: Health Promotion and Maintenance

The nurse is providing information to a client with multiple sclerosis on
performing exercises and physical activities. The nurse determines the
client needs additional teaching if the client makes which
statements? Select all that apply.

o  A. “I can lift weights and do resistance training.”

o  B. “I should exercise to the point of exhaustion.”

o  C. “I can include aerobic exercises in my routine.”

o  D. “Proper stretching should be done before starting my

routine.”

o  E. “I should exercise continuously without rest.”

Incorrect
Correct answers: B & E.
o Option B: Patients with multiple sclerosis should not exercise
to the point of fatigue as strenuous physical exercise raises
body temperature and may aggravate symptoms.
o Option E: Continuous exercise with no rest periods is
contraindicated for patients with multiple sclerosis who wants
to exercise. The patient should be advised to take short rest
periods, preferably lying down. Again, extreme fatigue may
contribute to the exacerbation of symptoms.
 o Option A: Exercises should include activities that would
strengthen weak muscles because diminishing muscle strength
is often a primary concern in multiple sclerosis. These activities
include lifting weights and resistance exercises.
o Option C: Aerobic exercises help promote muscle efficiency,
increase flexibility, improves mood, and helps eliminate stress.
o Option D: Muscle stretching should be included prior to
exercise as this helps minimize muscle spasticity and
contractures which is common in later stages of multiple
sclerosis.

3. A client has died, and a nurse asks a family member about the funeral
arrangements. The family member refuses to discuss the issue. The nurse’s
appropriate action is to? Select all that apply.

 A. Show acceptance of feelings.

 B. Provide information needed for decision making.
 C. Suggest a referral to a mental health professional.
 D. Remain with the family member without discussing funeral
arrangements.
 E. Let the family slowly acknowledge its impact.
Correct Answer: D & E.

Grief is a process that can begin long before the loss of a loved one. Similar to
the stages of dying, individuals go through a process to help them eventually
cope and be able to live with that loss. People never get over their loss, but find
ways to live with the loss and without their deceased loved one (ELNEC, 2010).

 Option A: This is an appropriate intervention for the acceptance or

reorganization and restitution stage. In this final stage of grief, the
person accepts the reality of the loss. It can’t be reversed. Although
he or she still feels sad, he or she is ready to start moving on in life.
 Option B: This may be an appropriate intervention for the
bargaining stage. During this stage, he or she dwells on what
could’ve done to counteract the loss. General thoughts are “If only…”
and “What if…”.
  Option C: This may be an appropriate intervention for depression.
Sadness sets in as the person begins to understand the loss and its
effect in life. Indications of depression include crying, sleep issues,
and a decreased appetite.
 Option D: The family member is exhibiting the first stage of grief
(denial), and the nurse should remain with the family member. One
of the biggest facilitators of this process which nurses can engage in
is active listening. By actively listening to the bereaved, it helps them
express their feelings and feel as though they are being heard.
 Option E: As the family moves through the experience and slowly
acknowledges its impact, the initial denial and disbelief fade.
Bereavement includes grief and mourning and has been considered
to be the “time period in which the survivor adjusts to their life
without their loved one” (ELNEC, 2010). This period can include the
time right after the loss or death occurs, during the funeral
proceedings, and during the grieving process afterward.

4. A client is scheduled for a myelogram, and the nurse provides a list of

instructions to the client regarding preparation for the procedure. Which
instructions should the nurse place on the list? Select all that apply.

 A. Jewelry will need to be removed.

 B. An informed consent will need to be signed.
 C. A trained x-ray technician performs the procedure.
 D. The procedure will take approximately 45 minutes.
 E. A liquid diet can be consumed on the day of the procedure.
 F. Solid food intake needs to be restricted only on the day of the
procedure.
Correct Answer: A, B, & D.

A myelogram is an X-ray exam in which a contrast agent (X-ray dye) is injected

into the spinal canal to visualize the bones, discs, muscles and nerves. A
myelogram is used to detect abnormalities of the spine such as disc problems,
tumors and bone spurs, narrowing of the spinal canal or malformations of the
spine.
  Option A: The client will need to remove jewelry and metal objects
from the chest area. Try to wear non-restrictive, comfortable clothing
and slip on shoes if possible. Remove all piercings and leave all
jewelry and valuables at home.
 Option B: An informed consent is required because the procedure is
invasive. A myelogram may be done to assess the spinal cord,
subarachnoid space, or other structures for changes or
abnormalities.
 Option C: The procedure is performed by the healthcare provider.
The technologist will verify identification and exam requests. The
technologist and radiologist will be available to answer any
questions.
 Option D: The client is told that the procedure takes about 45
minutes. The patient will lie on the stomach on the X-ray table. If the
patient cannot tolerate lying on the stomach for at least 30 minutes,
notify the doctor.
 Option E: If not on a fluid restriction, drink at least 6-8 glasses of
fluid the day before the procedure. Do not eat or drink anything for
4 hours before the exam.
 Option F: Client preparation for a myelogram includes instructing
the client to restrict food and fluids for 4 to 8 hours before the
procedure. The client is also told that pretest medications may be
prescribed for relaxation.

5. A client with carcinoma of the lung develops the syndrome of

inappropriate antidiuretic hormone (SIADH) as a complication of cancer.
The nurse anticipates that which of the following may be
prescribed? Select all that apply.

 A. Radiation
 B. Chemotherapy
 C. Increased fluid intake
 D. Serum sodium blood levels
 E. Decreased oral sodium intake
 F. Medication that is antagonistic to antidiuretic hormone (ADH)
Correct Answer: A, B, D, & F.
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of
water are reabsorbed by the kidney and put into the systemic circulation. The
increased water causes hyponatremia (decreased serum sodium levels) and some
degree of fluid retention. 

 Option A: Syndrome of inappropriate antidiuretic hormone (SIADH)

has been commonly associated with small cell carcinoma and is
often seen in these patients. However, SIADH associated with
squamous cell carcinoma has rarely been reported on, and the
mechanism for this rare association is still unknown.
 Option B: The immediate institution of appropriate cancer therapy
(usually either radiation or chemotherapy) can cause tumor
regression so that ADH synthesis and release processes return to
normal.
 Option C: Hyponatremia treatment needs to be personalized based
on severity and duration of sodium serum reduction, extracellular
fluid volume and etiology. However, literature data highlight the
importance of early correction of the serum concentration levels. To
achieve this the main options are fluid restriction, hypertonic saline,
loop diuretics, isotonic saline, tolvaptan and urea. 
 Option D: Sodium levels are monitored closely because
hypernatremia can suddenly develop as a result of treatment. Firstly,
it is recommended to detect the cause of reduced sodium
concentration, although the increase in sodium concentration levels
is likely to be the main issue in life-threatening hyponatremia.
 Option E: SIADH is managed by treating the condition and its cause,
and treatment usually includes fluid restriction, increased sodium
intake, and a medication with a mechanism of action that is
antagonistic to ADH. 
 Option F: For patients affected by SIADH, vaptans represent a new
class of drug antagonizing the V2 receptor on renal tubular cells. To
date, two molecules are approved: conivaptan and tolvaptan. The
prescription of conivaptan (intravenous use) has been authorized for
euvolemic hyponatremia due to SIADH by the United States (US)
Food and Drug Administration (FDA) but not by the European
Medicines Agency (EMA).
 6. The nurse is preparing to teach a client about the prescribed
spironolactone (Aldactone) to monitor for adverse effects of the drug. The
nurse should instruct the client about which adverse effects? Select all that
apply.

 A. Confusion.
 B. Fatigue.
 C. Hypertension.
 D. Leg cramps.
 E. Weakness.
 F. Urinary retention.
Correct Answer: A, B, & E.

Spironolactone (Aldactone) is used to treat hypertension and edema by removing

excess fluid. Aldactone is known as a potassium-sparing diuretic. Confusion,
fatigue, and weakness are signs of hyperkalemia, an adverse effect of
spironolactone. 

 Option A: One study mentions the following additional adverse

effects in order from more to less common: dehydration,
hyponatremia, gastrointestinal problems (nausea, vomiting, diarrhea
or anorexia), neurological abnormalities (headache, drowsiness,
asterixis, confusion, or coma), and skin rashes.
 Option B: Spironolactone blocks the hormone aldosterone, which
can lead to fatigue. In addition, it can lower the blood pressure, and
if this drop is sudden, the client may feel tired.
 Option C: Spironolactone is used to treat hypertension, so it would
not produce this effect. Spironolactone is recommended in patients
with resistant hypertension which is defined as uncontrolled blood
pressure despite three antihypertensive drug combinations including
a diuretic. Spironolactone is a mineralocorticoid receptor antagonist
and causes anti-androgenic side effects.
 Option D: Leg cramps are an adverse effect of hypokalemia.
Hyperkalemia is an adverse effect of spironolactone. This drug is
contraindicated in patients with hyperkalemia and in those at
increased risk of developing hyperkalemia.
  Option E: Symptoms of hypokalemia may include attacks of severe
muscle weakness, eventually leading to paralysis and possibly
respiratory failure. Muscular malfunction may result in paralysis of
the bowel, low blood pressure, muscle twitches and mineral
deficiencies (tetany).
 Option F: Urinary retention is a side effect of anticholinergics.
Medications with anticholinergic properties, such as tricyclic
antidepressants, cause urinary retention by decreasing bladder
detrusor muscle contraction.

7. The clinic nurse is assisting to perform a focused data collection process on

a client who is complaining of symptoms of a cold, a cough, and lung
congestion. Which of the following would the nurse include for this type of
data collection? Select all that apply.

Questions and rationale from Nurseslabs.com Feel free to print or share and link
back to us! For more practice questions, please visit our  Nursing Test
Bank  [https://nurseslabs.com/nursing-test-bank]

 A. Auscultating lung sounds

 B. Obtaining the client’s temperature
 C. Checking the strength of peripheral pulses
 D. Obtaining information about the client’s respirations
 E. Performing a musculoskeletal and neurological examination
 F. Asking the client about a family history of any illness or disease
Correct Answer: A, B, & D.

A focused data collection process focuses on a limited or short-term problem,

such as the client’s complaint. Because the client is complaining of symptoms of a
cold, a cough, and lung congestion the nurse would focus on the respiratory
system and the presence of an infection. 

 Option A: Auscultation of the lungs should be systematic and follow

a stepwise approach in which the examiner surveys all the lung
zones. For practical purposes, the lung can be divided into apical,
middle and basilar regions during auscultation.
  Option B: An increase in temperature may be a sign of underlying
infection. The diagnosis of a cough is an obvious clinical observation.
A cough is a symptom rather than a diagnosis of disease. As such,
many patients present for evaluation of the secondary or underlying
effects of cough rather than a cough itself.
 Option C: Checking the strength of peripheral pulses relates to a
vascular assessment, which is not related to this client’s complaints.
Otherwise, a systemic approach should be used to identify any
coexisting illness, which may be the origin or compounding factor of
a cough.
 Option D: During the inspection, the examiner should pay attention
to the pattern of breathing: thoracic breathing, thoracoabdominal
breathing, costal markings, and use of accessory breathing muscles.
The use of accessory breathing muscles (i.e., scalenes,
sternocleidomastoid muscle, intercostal muscles) could point to
excessive breathing effort caused by pathologies.
 Option E: A musculoskeletal and neurological examination also is
not related to this client’s complaints. However, the strength of
peripheral pulses and a musculoskeletal and neurological
examination would be included in a complete data collection.
 Option F: A complete data collection includes a complete health
history and physical examination and forms a baseline database.
Likewise, asking the client about a family history of any illness or
disease would be included in a complete assessment.

8. A community health nurse is conducting a teaching session about

terrorism with members of the community and discussing information
regarding anthrax. The nurse tells those attending that anthrax can be
transmitted via which route(s)? Select all that apply.

 A. Skin
 B. Kissing
 C. Inhalation
 D. Gastrointestinal
 E. Direct contact with an infected individual
 F. Sexual contact with an infected individual
Correct Answer: A, C, & D.
Anthrax is caused by Bacillus anthracis, and it can be contracted through
the digestive system, abrasions in the skin, or inhalation. It cannot be spread from
person to person.

 Option A: Skin contact results in cutaneous anthrax. Cutaneous

anthrax results from inoculation of B. anthracis spores through the
abraded skin into subcutaneous tissues. The bacteria subsequently
germinate and multiply locally and begin toxin production.  This
leads to the characteristic edema and cutaneous ulceration. 
 Option B: Viruses responsible for diseases such as hepatitis viruses,
herpesvirus infections (e.g., with Herpes simplex types 1 and 2,
Epstein-Barr virus, Cytomegalovirus, and Kaposi syndrome
herpesvirus), and papillomaviruses can be conveyed by kissing—as
can potentially other viruses present in saliva such as Ebola and Zika
viruses.
 Option C: Inhalation or ingestion of the spores leads to inhalational
or gastrointestinal (GI) anthrax. Inhalational anthrax leads to
accumulation of B. anthracis spores within the lung alveoli. The
spores are engulfed by immune cells (macrophages, neutrophils,
dendritic cells) and transported to regional lymph nodes where the
bacteria germinate, multiply, and begin toxin production.
 Option D: Human transmission occurs via contact with infected
animals through butchering and working with hides or ingestion of
raw or undercooked meat. GI anthrax occurs due to ingestion of
contaminated meat, with spores introduced into the gastrointestinal
tract, causing bacterial replication, mucosal ulcerations, and
bleeding. 
 Option E: Anthrax is acquired from animals; there are no reports of
direct human to human transmission.
 Option F: More than 30 different bacteria, viruses and parasites are
known to be transmitted through sexual contact. Eight of these
pathogens are linked to the greatest incidence of sexually
transmitted disease. Of these 8 infections, 4 are currently curable:
syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are
viral infections which are incurable: hepatitis B, herpes simplex virus
(HSV or herpes), HIV, and human papillomavirus (HPV).
 9. The emergency room nurse is providing discharge teaching to the parents
of a 2-year-old child who sustained burns from a hot cup of coffee that
had been left on the kitchen counter. The nurse evaluates that the parents
have correctly understood the teaching when they state which of the
following? Select all that apply.

 A. “We will be sure to not leave hot liquids unattended.”

 B. “I guess my child needs to understand what the word ‘hot’
means.”
 C. “We will be sure that our child stays in his room when we work in
the kitchen.”
 D. “We will install a safety gate as soon as we get home so that our
child can’t get into the kitchen.”
 E. “We will not put adhesive bandages over the affected area.”
Correct Answer: A & E.

Toddlers, with their increased mobility and developing motor skills, can reach hot
water, open fires, or hot objects placed on counters and stoves above their eye
level. Pot handles should be turned inward and toward the middle of the stove.
Options 2, 3, and 4 do not reflect an adequate understanding of the principles of
safety.

 Option A: Hot liquids should never be left unattended, and the

toddler should always be supervised. Don’t cook, drink, or carry hot
beverages or foods while holding a child. Keep hot foods and liquids
away from table and counter edges. Don’t use tablecloths or place
mats, which young children can pull down.
 Option B: Store items designed to get hot, such as clothes irons or
curling irons, unplugged and out of reach. Be careful with food or
liquids warmed in a microwave, which might heat foods unevenly.
 Option C: Don’t leave the stove unattended when cooking. Parents
should be encouraged to remain in the kitchen when preparing a
meal and reminded to use the back burners on the stove.
 Option D: Block access to the stove, fireplace, space heaters and
radiators. Don’t leave a child unattended in a room when these items
are in use.
  Option E: Parents should not put adhesive bandages on very young
kids, though, as these can be a choking hazard if they get loose. 

10.A licensed practical nurse is planning the client assignments for the day.
Which of the following is the most appropriate assignment for the nursing
assistant? Select all that apply.

 A. A client who requires wound irrigation

 B. A client who requires frequent ambulation
 C. A client who is receiving continuous tube feedings
 D. A client who requires frequent vital signs after a cardiac
catheterization
 E. A client who needs to be turned or repositioned in bed
Correct Answer: B and E.

The nurse must determine the most appropriate assignment on the basis of the
skills of the staff member and the needs of the client.

 Option A: Wound irrigations and tube feedings are not performed

by unlicensed personnel. The staff members’ levels of education,
knowledge, past experiences, skills, abilities, and competencies are
also evaluated and matched with the needs of all of the patients in
the group of patients that will be cared for.
 Option B: In general, simple, routine tasks such as making
unoccupied beds, supervising patient ambulation, assisting with
hygiene, and feeding meals can be delegated. But if the patient is
morbidly obese, recovering from surgery, or frail, work closely with
the UAP or perform the care yourself.
 Option C: Care of the client receiving continuous tube feedings
should be delegated to another registered nurse because it requires
monitoring. Scopes of practice are also considered prior to the
assignment of care. All states have scopes of practice for
advanced nurse practitioners, registered nurses, licensed practical
nurses and unlicensed assistive personnel like nursing assistants and
patient care technicians.
 Option D: The client who had a cardiac catheterization will require
specific monitoring in addition to that of the vital signs. Based on the
 basic entry educational preparation differences among these
members of the nursing team, care should be assigned according to
the level of education of the particular team member.
 Option E: In this case, the most appropriate assignment for a
nursing assistant would be to care for the client who requires client
repositioning. The nursing assistant is skilled in these tasks.

11.A nurse develops a plan of care for a client following a lumbar puncture.
Which interventions should be included in the plan? Select all that apply.

 A. Monitor the client’s ability to void.

 B. Maintain the client in a flat position.
 C. Restrict fluid intake for a period of 2 hours.
 D. Monitor the client’s ability to move the extremities.
 E. Inspect the puncture site for swelling, redness, and drainage.
 F. Maintain the client on a nothing-by-mouth (NPO) status for 24
hours.
Correct Answer: A, B, D, & E.

Lumbar puncture, also known as a spinal tap, is an invasive procedure where a

hollow needle is inserted into the space surrounding the subarachnoid space in
the lower back to obtain samples of cerebrospinal fluid (CSF) for qualitative
analysis.

 Option A: The nurse should monitor the client’s ability to void. Take
vital signs, measure intake and output, and assess neurologic status
at least every 4 hours for 24 hours to allow further evaluation of the
patient’s condition.
 Option B: Following a lumbar puncture, the client remains flat in bed
for 6 to 24 hours, depending on the health care provider’s
prescriptions. He or she may turn from side to side as long as the
head is not elevated.
 Option C: A liberal fluid intake is encouraged to replace
cerebrospinal fluid removed during the procedure unless
contraindicated by the client’s condition. An increased amount of
fluid intake (up to 3,000 ml in 24 hours) will replace CSF removed
during the lumbar puncture.
  Option D: The nurse should monitor the client’s ability to move the
extremities. A feeling of tingling sensation and numbness in the
lower back and legs is felt temporarily.
 Option E: The nurse checks the puncture site for redness and
drainage. Signs of CSF leakage include positional headaches, nausea
and vomiting, neck stiffness, photophobia (sensitivity to light), sense
of imbalance, tinnitus (ringing in the ear), and phonophobia
(sensitivity to sound).

12.A nurse is developing a care plan for a client with an injury to the
frontal lobe of the brain. Which nursing interventions should be
included as part of the care plan? Select all that apply.

 A. Keep instructions simple and brief because the client will have
difficulty concentrating.
 B. Speak clearly and slowly because the client will have difficulty
hearing.
 C. Assist with bathing because the client will have vision
disturbances.
 D. Orient the client to person, place, and time as needed because of
memory problems.
 E. Assess vital signs frequently because vital bodily functions are
affected.
Correct Answer: A & D.

Damage to the frontal lobe affects personality, memory, reasoning,

concentration, and motor control of speech. The cortex of the frontal lobe is the
largest of the four, and in many ways the lobe which participates most in making
us human.

 Option A: The prefrontal cortex is known to be the higher-order

association center of the brain as it is responsible for decision
making, reasoning, personality expression, maintaining social
appropriateness, and other complex cognitive behaviors. 
 Option B: Damage to the temporal lobe, not the frontal lobe, causes
hearing and speech problems. Another study divides the temporal
area into 4 major subregions: a) dorsal, mostly language and
 auditory/somatosensory networks b) ventromedial, mostly visual
network c) medial, connected to paralimbic structures and d)
anterolateral, associated with a default-semantic network. These
areas have many important functions such as processing of
language, social cues, and emotions, facial recognition (auditory and
visual aspects), emotional processing of different stimuli (auditory,
olfactory and visual) and theory of mind.
 Option C: Damage to the occipital lobe causes vision disturbances.
The occipital lobe is the visual processing area of the brain. It is
associated with visuospatial processing, distance and depth
perception, color determination, object and face recognition, and
memory formation.
 Option D: Research has proven that the dominant (left) superior
frontal gyrus is a key component in the neural network of working
memory as well as spatial processing.Research has proven that the
dominant (left) superior frontal gyrus is a key component in the
neural network of working memory as well as spatial processing.
 Option E: Damage to the brain stem affects vital functions. The
brainstem is the structure that connects the cerebrum of the brain to
the spinal cord and cerebellum. It is composed of four sections in
descending order: the diencephalon, midbrain, pons, and medulla
oblongata. It is responsible for many vital functions of life, such as
breathing, consciousness, blood pressure, heart rate, and sleep.

13.A nurse has reinforced instructions to the client with hyperparathyroidism

regarding home care measures related to exercise. Which statement by the
client indicates a need for further instruction? Select all that apply.

 A. “I enjoy exercising but I need to be careful.”

 B. “I need to pace my activities throughout the day.”
 C. “I need to limit playing football to only the weekends.”
 D. “I should gauge my activity level by my energy level.”
 E. “I should exercise in the evening to encourage a good sleep
pattern.”
Correct Answer: C & E.
Primary hyperparathyroidism (PHPT) is a disorder of one or more of
the parathyroid glands . The parathyroid gland(s) becomes overactive and
secretes excess amounts of parathyroid hormone (PTH). As a result, the blood
calcium rises to a level that is higher than normal (called hypercalcemia). An
elevated calcium level can cause many short-term and long-term complications.

 Option A: The client should plan for at least 30 minutes of walking

each day to support calcium movement into the bones. Every person
is different in terms of their fitness level and the severity of their
disease. That’s why it is important to start slowly and gradually
increase the intensity of the exercise routine over time.
 Option B: The client with hyperparathyroidism should pace activities
throughout the day and plan for periods of uninterrupted rest.
 Option C: The client should be instructed to avoid high-impact
activity or contact sports such as football. Research has shown that
PTH levels tend to increase following either high-intensity exercise
over a long period (greater than 50 minutes) or low-intensity
exercise over a very long period (around five hours).
 Option D: The client should be instructed to use energy levels as a
guide to activity. Data suggested that short-duration exercise at high
levels of exertion, or low-intensity exercise over a moderate time
period (50 minutes), did not appear to affect PTH levels.
 Option E: Exercising late in the evening may interfere with restful
sleep. However, it can aid with sleeping and increasing the energy
levels, as long as it isn’t overdone and if done at the right time.

14.A nurse in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles, and
the nurse suspects pulmonary edema. The nurse immediately notifies the
registered nurse and expects which interventions to be prescribed? Select
all that apply.

 A. Administering oxygen
 B. Inserting a Foley catheter
 C. Administering furosemide (Lasix)
 D. Administering morphine sulfate intravenously
 E. Transporting the client to the coronary care unit
  F. Placing the client in a low Fowler’s side-lying position
Correct Answer: A, B, C, & D.

A pulmonary edema is a life-threatening event that can result from severe heart
failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and
pressure increases in the lungs because of the accumulated blood. 

 Option A: Oxygen is always prescribed. Supplemental oxygen

increases oxygen availability to the myocardium and can help relieve
symptoms of hypoxemia, ischemia, and subsequent activity
intolerance (Giordano, 2005; Haque et al., 1996). The need is based
on the degree of pulmonary congestion and resulting hypoxia.
 Option B: A Foley catheter is inserted to accurately measure output.
Urine output may be scanty and concentrated (especially during the
day) because of reduced renal perfusion. Recumbency favors
diuresis; therefore, urine output may be increased at night and/or
during bed rest.
 Option C: Furosemide, a rapid-acting diuretic, will eliminate
accumulated fluid. Evaluate urine output in response to diuretic
therapy. The focus is on monitoring the response to the diuretics
rather than the actual amount voided.
 Option D: Intravenously administered morphine sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of
breathing. The use of morphine should be reserved for patients with
myocardial ischemia who are refractory to drugs that favorably alter
myocardial oxygen supply and demand.
 Option E: Transporting the client to the coronary care unit is not a
priority intervention. In fact, this may not be necessary at all if the
client’s response to treatment is successful.
 Option F: The client is placed in a high Fowler’s position to ease the
work of breathing. Allows for better chest expansion, thereby
improving pulmonary capacity. In this position, the venous return to
the heart is reduced, pulmonary congestion is alleviated, and
pressure on the diaphragm is minimized.
15.Mr. Hasakusa is in end-stage liver failure. Which interventions should the
nurse implement when addressing hepatic encephalopathy? Select all that
apply.

  A. Assessing the client's neurologic status every 2 hours

  B. Monitoring the client's hemoglobin and hematocrit levels

  C. Evaluating the client's serum ammonia level

  D. Monitoring the client's handwriting daily

  E. Preparing to insert an esophageal tamponade tube

  F. Making sure the client's fingernails are short

Incorrect
Correct Answers: A, C, & D
Hepatic encephalopathy results from an increased ammonia level due to
the liver’s inability to convert ammonia to urea, which leads to neurologic
dysfunction and possible brain damage. Hepatic encephalopathy (HE) is a
reversible syndrome observed in patients with advanced liver dysfunction.
The syndrome is characterized by a spectrum of neuropsychiatric
abnormalities resulting from the accumulation of neurotoxic substances in
the bloodstream (and ultimately in the brain).
 Option A: The nurse should monitor the client’s neurologic
status. Symptoms typically include confusion, personality
changes, disorientation, and a depressed level of
consciousness. The earliest stage is often characterized by an
inverted sleep-wake pattern wherein patients are found to be
sleeping during the day and awake throughout the night.
 Option B: Monitoring the client’s hemoglobin and hematocrit
levels address esophageal bleeding. A diagnosis of HE should
involve a thorough evaluation of the patient’s vital signs and
airway followed by classification of the symptoms according to
the West-Haven Criteria.
 Option C: The nurse should monitor the client’s serum
ammonia level. Elevated blood ammonia levels are often seen
 in patients with hepatic encephalopathy. It is more useful,
however, to assess the clinical improvement or deterioration
of a patient undergoing treatment rather than monitor serial
arterial blood ammonia measurements.
 Option D: The nurse should monitor the client’s handwriting.
During the intermediate stages of HE, a characteristic jerking
movement of the limbs is often observed (e.g., asterixis) when
the patient attempts to hold arms outstretched with hands
bent upward at the wrist.
 Option E: Insertion of an esophageal tamponade tube
addresses esophageal bleeding. Treatment for HE involves
proper identification and treatment of the underlying cause.
Antibiotics (e.g., rifaximin)
neomycin/paromomycin/metronidazole, or vancomycin) are
often given empirically due to the frequency of infection as an
underlying cause.
 Option F: Keeping fingernails short addresses jaundice.
Protein restriction is only of use in patients with acute flare-
ups and is not justified in chronic cases. These patients need
nutrition as they have a high catabolic rate and severe wasting.