PNLE IV for Care of Clients with

Physiologic and Psychosocial

Alterations (Part 2)

1. Randy has undergone kidney transplant, what assessment would prompt

Nurse Katrina to suspect organ rejection?
A. Sudden weight loss
B. Polyuria
C. Hypertension
D. Shock
2. The immediate objective of nursing care for an overweight, mildly
hypertensive male client with ureteral colic and hematuria is to decrease:
A. Pain
B. Weight
C. Hematuria
D. Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a
subtotal thyroidectomy is performed. The nurse is aware that this medication
is given to:
A. Decrease the total basal metabolic rate.
B. Maintain the function of the parathyroid glands.
C. Block the formation of thyroxine by the thyroid gland.
D. Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute
hypoglycemia also can develop in the client who is diagnosed with:
A. Liver disease
B. Hypertension
C. Type 2 diabetes
D. Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of metastatic
carcinoma. Nurse Ruby should monitor the client for the systemic side effect
of:
A. Ascites
B. Nystagmus
C. Leukopenia
D. Polycythemia
6. Norma, with recent colostomy expresses concern about the inability to
control the passage of gas. Nurse Oliver should suggest that the client plan to:
A. Eliminate foods high in cellulose.
B. Decrease fluid intake at meal times.
C. Avoid foods that in the past caused flatus.
D. Adhere to a bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform colostomy
irrigations. The nurse would evaluate that the instructions were understood
when the client states, “I should:
A. Lie on my left side while instilling the irrigating solution.”
B. Keep the irrigating container less than 18 inches above the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to
stimulate evacuation of the bowel.”
D. Insert the irrigating catheter deeper into the stoma if
cramping occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing
fluid and electrolyte imbalances. The client is somewhat confused and
complains of nausea and muscle weakness. As part of the prescribed therapy
to correct this electrolyte imbalance, the nurse would expect to:
A. Administer Kayexalate
B. Restrict foods high in protein
C. Increase oral intake of cheese and milk.
D. Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2
liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10
gtt/ml. The nurse should set the flow to provide:
A. 18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
 D. 36 gtt/min
10.Terence suffered form burn injury. Using the rule of nines, which has the
largest percent of burns?
A. Face and neck
B. Right upper arm and penis
C. Right thigh and penis
D. Upper trunk
11. Herbert, a 45 year old construction engineer is brought to the hospital
unconscious after falling from a 2-story building. When assessing the client,
the nurse would be most concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial
pacemaker. Which information given by the nurse shows her knowledge
deficit about the artificial cardiac pacemaker?
A. take the pulse rate once a day, in the morning upon awakening
B. May be allowed to use electrical appliances
C. Have regular follow up care
D. May engage in contact sports
13.The nurse is ware that the most relevant knowledge about oxygen
administration to a male client with COPD is
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing.
B. Hypoxia stimulates the central chemoreceptors in the medulla that
makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.
14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy.
Chest tubes are inserted, and one-bottle water-seal drainage is instituted in
the operating room. In the postanesthesia care unit Tonny is placed in
Fowler’s position on either his right side or on his back. The nurse is aware
that this position:
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
 C. Equalize pressure in the pleural space.
D. Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to
expect afterward, the nurse’s highest priority of information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The nurse
should expect hypertonic glucose, insulin infusions, and sodium bicarbonate
to be used to treat:
A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata (genital
warts). What information is appropriate to tell this client?
A. This condition puts her at a higher risk for cervical cancer; therefore,
she should have a Papanicolaou (Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
D. The human papillomavirus (HPV), which causes condylomata
acuminata, can’t be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem and is being
examined in the emergency department. When palpating the her kidneys, the
nurse should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm
(¾” to 1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The
nurse is aware that the diagnostic test are consistent with CRF if the result is:
 A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/
dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP)
excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting
that she read her chart while the nurse was out of the room, Katrina asks what
dysplasia means. Which definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that don’t
resemble cells of the tissues of their origin.
B. Increase in the number of normal cells in a normal arrangement in a
tissue or an organ.
C. Replacement of one type of fully differentiated cell by another in
tissues where the second type normally isn’t found.
D. Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client with
acquired immunodeficiency syndrome (AIDS) for signs and symptoms of
cancer. What is the most common AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma
22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans
to use a spinal (subarachnoid) block during surgery. In the operating room, the
nurse positions the client according to the anesthesiologist’s instructions.
Why does the client require special positioning for this type of anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now complaining of
abdominal pressure and nausea. The first nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this test
initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an ileostomy. On
the first day after surgery, Nurse Oliver notes that the client’s stoma appears
dusky. How should the nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention helps prevent
contractures?
A. Applying knee splints
B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-degree
burns on the face, arms, and chest. Which finding indicates a potential
problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too
weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia
should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a female client
who has dermatitis over the anterior chest. How should the nurse apply this
topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected
area
C. In long, even, outward, and downward strokes in the direction of hair
growth
D. In long, even, outward, and upward strokes in the direction opposite
hair growth
30.Nurse Kate is aware that one of the following classes of medication
protect the ischemic myocardium by blocking catecholamines
and sympathetic nerve stimulation is:
A. Beta -adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
31.A male client has jugular distention. On what position should the nurse
place the head of the bed to obtain the most accurate reading of jugular vein
distention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
32.The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by increasing
ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL) level and
an elevated low-density lipoprotein (LDL) level. Which of the following dietary
modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories form fat
 C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2
days ago with an acute myocardial infarction. Which of the following actions
would breach the client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry
unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a change in the
client’s condition
C. The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress.
D. At the client’s request, the CCU nurse updates the client’s wife on his
condition
35. A male client arriving in the emergency department is receiving
cardiopulmonary resuscitation from paramedics who are giving ventilations
through an endotracheal (ET) tube that they placed in the client’s home.
During a pause in compressions, the cardiac monitor shows narrow QRS
complexes and a heart rate of beats/minute with a palpable pulse. Which of
the following actions
should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cardarone), 300 mg
L.V. over 10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg.
Nurse Katrina determines that mean arterial pressure (MAP) is which of the
following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg
37. A female client arrives at the emergency department with chest and
stomach pain and a report of black tarry stool for several months. Which of
the following order should the nurse Oliver anticipate?
 A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase
levels
B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin
split product values.
C. Electrocardiogram, complete blood count, testing for occult blood,
comprehensive serum metabolic panel.
D. Electroencephalogram, alkaline phosphatase and aspartate
aminotransferase levels, basic serum metabolic panel
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago.
Which of the following conditions is suspected by the nurse when a decrease
in platelet count from 230,000 ul to 5,000 ul is noted?
A. Pancytopenia
B. Idiopathic thrombocytopemic purpura (ITP)
C. Disseminated intravascular coagulation (DIC)
D. Heparin-associated thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve
the platelet count in a male client with idiopathic thrombocytopenic purpura
(ITP)?
A. Acetylsalicylic acid (ASA)
B. Corticosteroids
C. Methotrezate
D. Vitamin K
40. A female client is scheduled to receive a heart valve replacement with a
porcine valve. Which of the following types of transplant is this?
A. Allogeneic
B. Autologous
C. Syngeneic
D. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following
actions shows the initial response to the injury in the extrinsic pathway?
A. Release of Calcium
B. Release of tissue thromboplastin
C. Conversion of factors XII to factor XIIa
D. Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE) would
include information about which of the following blood dyscrasias?
 A. Dressler’s syndrome
B. Polycythemia
C. Essential thrombocytopenia
D. Von Willebrand’s disease
43. The nurse is aware that the following symptoms is most commonly an
early indication of stage 1 Hodgkin’s disease?
A. Pericarditis
B. Night sweat
C. Splenomegaly
D. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions
must frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM)
usually involve which of the following body system?
A. Brain
B. Muscle spasm
C. Renal dysfunction
D. Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
A. Less than 5 years
B. 5 to 7 years
C. 10 years
D. More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs
of disseminated intravascular coagulation (DIC). Which of the following
laboratory findings is most consistent with DIC?
A. Low platelet count
B. Elevated fibrinogen levels
C. Low levels of fibrin degradation products
D. Reduced prothrombin time
48. Mario comes to the clinic complaining of fever, drenching night sweats,
and unexplained weight loss over the past 3 months. Physical examination
reveals a single enlarged supraclavicular lymph node. Which of the following
is the most probable diagnosis?
A. Influenza
B. Sickle cell anemia
C. Leukemia
D. Hodgkin’s disease
49. A male client with a gunshot wound requires an emergency blood
transfusion. His blood type is AB negative. Which blood type would be the
safest for him to receive?
A. AB Rh-positive
B. A Rh-positive
C. A Rh-negative
D. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL)
and beginning chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy
treatments. Which statement of Stacy’s mother indicated that she
understands when she will contact the physician?
A. “I should contact the physician if Stacy has difficulty in sleeping”.
B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
C. “My physician should be called if Stacy is irritable and unhappy”.
D. “Should Stacy have continued hair loss, I need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is:
A. “Stacy looks very nice wearing a hat”.
B. “You should not worry about her hair, just be glad that she is alive”.
C. “Yes it is upsetting. But try to cover up your feelings when you are
with her or else she may be upset”.
D. “This is only temporary; Stacy will re-grow new hair in 3-6 months,
but may be different in texture”.
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the
nurse in-charge should:
A. Provide frequent mouthwash with normal saline.
 B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy agents, Nurse Oliver observed
that the IV site is red and swollen, when the IV is touched Stacy shouts in pain.
The first nursing action to take is:
A. Notify the physician
B. Flush the IV line with saline solution
C. Immediately discontinue the infusion
D. Apply an ice pack to the site, followed by warm compress.
54. The term “blue bloater” refers to a male client which of the following
conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
55. The term “pink puffer” refers to the female client with which of the
following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
56. Jose is in danger of respiratory arrest following the administration of a
narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would
expect the paco2 to be which of the following values?
A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2
80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respirator y alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes after she
takes the drug, she develops chest tightness and becomes short of breath and
tachypneic. She has a decreased level of consciousness. These signs indicate
which of the following conditions?
A. Asthma attack
B. Pulmonary embolism
C. Respiratory failure
D. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and
jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
A. Decreased red blood cell count
B. Decreased serum acid phosphate level
C. Elevated white blood cell count
D. Elevated serum aminotransferase
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr.
Gonzales is at increased risk for excessive bleeding primarily because of:
A. Impaired clotting mechanism
B. Varix formation
C. Inadequate nutrition
D. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical
manifestation is most common with this condition?
A. Increased urine output
B. Altered level of consciousness
C. Decreased tendon reflex
D. Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of
Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best
action would be:
A. “I’ll see if your physician is in the hospital”.
B. “Maybe your reacting to the drug; I will withhold the next dose”.
C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4
stools a day”.
D. “Frequently, bowel movements are needed to reduce sodium level”.
63. Which of the following groups of symptoms indicates a ruptured
abdominal aortic aneurysm?
A. Lower back pain, increased blood pressure, decreased re blood cell
(RBC) count, increased white blood (WBC) count.
B. Severe lower back pain, decreased blood pressure, decreased RBC
count, increased WBC count.
C. Severe lower back pain, decreased blood pressure, decreased RBC
count, decreased RBC count, decreased WBC count.
D. Intermitted lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of
blood under his buttocks. Which of the following steps should the nurse take
first?
A. Call for help.
B. Obtain vital signs
C. Ask the client to “lift up”
D. Apply gloves and assess the groin site
65. Which of the following treatment is a suitable surgical intervention for a
client with unstable angina?
A. Cardiac catheterization
B. Echocardiogram
C. Nitroglycerin
D. Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe reduced
cardiac output and perfusion impairment due to ineffective pumping of the
heart is:
A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause blood
pressure to drop to normal levels?
A. Kidneys’ excretion to sodium only.
B. Kidneys’ retention of sodium and water
C. Kidneys’ excretion of sodium and water
D. Kidneys’ retention of sodium and excretion of water
68. Nurse Rose is aware that the statement that best explains why furosemide
(Lasix) is administered to treat hypertension is:
A. It dilates peripheral blood vessels.
B. It decreases sympathetic cardioacceleration.
C. It inhibits the angiotensin-coverting enzymes
D. It inhibits reabsorption of sodium and water in the loop of Henle.
69. Nurse Nikki knows that laboratory results supports the diagnosis of
systemic lupus erythematosus (SLE) is:
A. Elavated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA) titer
D. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
70. Arnold, a 19-year-old client with a mild concussion is discharged from the
emergency department. Before discharge, he complains of a headache. When
offered acetaminophen, his mother tells the nurse the headache is severe and
she would like her son to have something stronger. Which of the following
responses by the nurse is appropriate?
A. “Your son had a mild concussion, acetaminophen is strong enough.”
B. “Aspirin is avoided because of the danger of Reye’s syndrome in
children or young adults.”
C. “Narcotics are avoided after a head injury because they may hide a
worsening condition.”
D. Stronger medications may lead to vomiting, which increases the
intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a subdural
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following
responses best describes the result?
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP)
B. Emergent; the client is poorly oxygenated
C. Normal
D. Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the nurse
Olivia assess first?
A. A 17-year-old clients 24-hours postappendectomy
 B. A 33-year-old client with a recent diagnosis of Guillain-Barre
syndrome
C. A 50-year-old client 3 days postmyocardial infarction
D. A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to know why colchicine is
used in the treatment of gout. Which of the following actions of colchicines
explains why it’s effective for gout?
A. Replaces estrogen
B. Decreases infection
C. Decreases inflammation
D. Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
A. Osteoarthritis is rarely debilitating
B. Osteoarthritis is a rare form of arthritis
C. Osteoarthritis is the most common form of arthritis
D. Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets
to take her thyroid replacement medicine. The nurse understands that
skipping this medication will put the client at risk for developing which of the
following lifethreatening complications?
A. Exophthalmos
B. Thyroid storm
C. Myxedema coma
D. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which
observation should the nurse report to the physician immediately?
A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to
the intensive care unit. Thirty-six hours later, the client’s urine output suddenly
rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus.
Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
A. Above-normal urine and serum osmolality levels
 B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal serum osmolality
level
D. Below-normal urine osmolality level, above-normal serum osmolality
level
78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS) is stabilized and prepared for discharge. When preparing
the client for discharge and home management, which of the following
statements indicates that the client understands her condition and how to
control it?
A. “I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink, or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I should drink a
glass of soda that contains sugar.”
C. “I will have to monitor my blood glucose level closely and notify the
physician if it’s constantly elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in
carbohydrates.”
79. A 66-year-old client has been complaining of sleeping more, increased
urination, anorexia, weakness, irritability, depression, and bone pain that
interferes with her going outdoors. Based on these assessment findings, the
nurse would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about
the need to take fludrocortisone acetate and hydrocortisone at home. Which
statement by the client indicates an understanding of the instructions?
A. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right after I wake
up.”
C. “I’ll take two-thirds of the dose when I wake up and one-third in the
late afternoon.”
D. “I’ll take the entire dose at bedtime.”
81. Which of the following laboratory test results would suggest to the nurse
Len that a client has a corticotropin-secreting pituitary adenoma?
 A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal hypophysectomy to
remove a pituitary tumor. Preoperatively, the nurse should assess for
potential complications by doing which of the following?
A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for which he receives 8 U of regular
insulin. Nurse Mariner should expect the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism in a
female client with classic signs and symptoms of this disorder. Which test
result would confirm the diagnosis?
A. No increase in the thyroid-stimulating hormone (TSH) level after 30
minutes during the TSH stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the TSH
stimulation test
D. Below-normal levels of serum triiodothyronine (T3) and serum
thyroxine (T4) as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100
isophane insulin suspension (NPH) to be taken before breakfast. When
teaching the client how to select and rotate insulin injection sites, the nurse
should provide which instruction?
 A. “Inject insulin into healthy tissue with large blood vessels and
nerves.”
B. “Rotate injection sites within the same anatomic region, not among
different regions.”
C. “Administer insulin into areas of scar tissue or hypotrophy whenever
possible.”
D. “Administer insulin into sites above muscles that you plan to
exercise heavily later that day.”
86. Nurse Sarah expects to note an elevated serum glucose level in a client
with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other
laboratory finding should the nurse anticipate?
A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
D. Below-normal serum potassium level
87. For a client with Graves’ disease, which nursing intervention promotes
comfort?
A. Restricting intake of oral fluids
B. Placing extra blankets on the client’s bed
C. Limiting intake of high-carbohydrate foods
D. Maintaining room temperature in the low-normal range
88. Patrick is treated in the emergency department for a Colles’ fracture
sustained during a fall. What is a Colles’ fracture?
A. Fracture of the distal radius
B. Fracture of the olecranon
C. Fracture of the humerus
D. Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
development of this disorder?
A. Calcium and sodium
B. Calcium and phosphorous
C. Phosphorous and potassium
D. Potassium and sodium
90. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the
incident, requiring intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
 A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia
91. A 67-year-old client develops acute shortness of breath and progressive
hypoxia requiring right femur. The hypoxia was probably caused by which of
the following conditions?
A. Asthma attack
B. Atelectasis
C. Bronchitis
D. Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds
on the right side, from the apex to the base. Which of the following conditions
would best explain this?
A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an
unrestrained driver. He’s now in the emergency department complaining of
difficulty of breathing and chest pain. On auscultation of his lung field, no
breath sounds are present in the upper lobe. This client may have which of the
following conditions?
A. Bronchitis
B. Pneumonia
C. Pneumothorax
D. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic
cavity?
A. The space remains filled with air only
B. The surgeon fills the space with a gel
C. Serous fluids fills the space and consolidates the region
D. The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism
because of which of the following reasons?
A. Alveolar damage in the infracted area
 B. Involvement of major blood vessels in the occluded area
C. Loss of lung parenchyma
D. Loss of lung tissue
96. Aldo with a massive pulmonary embolism will have an arterial blood gas
analysis performed to determine the extent of hypoxia. The acid-base disorder
that may be present is?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted
with a pneumothorax. The surgeon inserts a chest tube and attaches it to a
chest drainage system. Bubbling soon appears in the water seal chamber.
Which of the following is the most likely cause of the bubbling?
A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours.
The IV infusion set has a drop factor of 10 drops per milliliter. The nurse
should regulate the client’s IV to deliver how many drops per minute?
A. 18
B. 21
C. 35
D. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The
bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the
following statements, if made by the client, indicates to the nurse that the
teaching was successful?
A. “I will wear the stockings until the physician tells me to remove
them.”
B. “I should wear the stockings even when I am sleep.”
C. “Every four hours I should remove the stockings for a half hour.”
D. “I should put on the stockings before getting out of bed in the
morning.”
Answers and Rationales
1. Answer: (C) Hypertension. Hypertension, along with fever, and
tenderness over the grafted kidney, reflects acute rejection.
2. Answer: (A) Pain. Sharp, severe pain (renal colic) radiating toward
the genitalia and thigh is caused by uretheral distention and smooth
muscle spasm; relief form pain is the priority.
3. Answer: (D) Decrease the size and vascularity of the thyroid
gland. Lugol’s solution provides iodine, which aids in decreasing
the vascularity of the thyroid gland, which limits the risk of
hemorrhage when surgery is performed.
4. Answer: (A) Liver Disease. The client with liver disease has a
decreased ability to metabolize carbohydrates because of a
decreased ability to form glycogen (glycogenesis) and to form
glucose from glycogen.
5. Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is a
systemic effect of chemotherapy as a result of myelosuppression.
6. Answer: (C) Avoid foods that in the past caused flatus. Foods that
bothered a person preoperatively will continue to do so after a
colostomy.
7. Answer: (B) Keep the irrigating container less than 18 inches above
the stoma.” This height permits the solution to flow slowly with little
force so that excessive peristalsis is not immediately precipitated.
8. Answer: (A) Administer Kayexalate. Kayexalate,a potassium
exchange resin, permits sodium to be exchanged for potassium in
the intestine, reducing the serum potassium level.
9. Answer:(B) 28 gtt/min. This is the correct flow rate; multiply the
amount to be infused (2000 ml) by the drop factor (10) and divide
the result by the amount of time in minutes (12 hours x 60 minutes)
10. Answer: (D) Upper trunk. The percentage designated for each
burned part of the body using the rule of nines: Head and neck 9%;
Right upper extremity 9%; Left upper extremity 9%; Anterior trunk
18%; Posterior trunk 18%; Right lower extremity 18%; Left lower
extremity 18%; Perineum 1%.
11. Answer: (C) Bleeding from ears. The nurse needs to perform a
thorough assessment that could indicate alterations in cerebral
function, increased intracranial pressures, fractures and bleeding.
Bleeding from the ears occurs only with basal skull fractures that
can easily contribute to increased intracranial pressure and brain
herniation.
12. Answer: (D) may engage in contact sports. The client should be
advised by the nurse to avoid contact sports. This will prevent
trauma to the area of the pacemaker generator.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic
stimulus for breathing. COPD causes a chronic CO2 retention that
renders the medulla insensitive to the CO2 stimulation for breathing.
The hypoxic state of the client then becomes the stimulus for
breathing. Giving the client oxygen in low concentrations will
maintain the client’s hypoxic drive.
14. Answer: (B) Facilitate ventilation of the left lung. Since only a
partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the client on the
opposite unoperated side.
15. Answer: (A) Food and fluids will be withheld for at least 2
hours. Prior to bronchoscopy, the doctors sprays the back of
the throat with anesthetic to minimize the gag reflex and thus
facilitate the insertion of the bronchoscope. Giving the client food
and drink after the procedure without checking on the return of the
gag reflex can cause the client to aspirate. The gag reflex usually
returns after two hours.
16. Answer: (C) hyperkalemia. Hyperkalemia is a common
complication of acute renal failure. It’s life-threatening if immediate
action isn’t taken to reverse it. The administration of glucose and
regular insulin, with sodium bicarbonate if necessary, can
temporarily prevent cardiac arrest by moving potassium into the
cells and temporarily reducing serum potassium
levels. Hypernatremia, hypokalemia, and hypercalcemia don’t usually
 occur with acute renal failure and aren’t treated with glucose, insulin,
or sodium bicarbonate.
17. Answer: (A) This condition puts her at a higher risk for cervical
cancer; therefore, she should have a Papanicolaou (Pap) smear
annually. Women with condylomata acuminata are at risk for cancer
of the cervix and vulva. Yearly Pap smears are very important for
early detection. Because condylomata acuminata is a virus, there is
no permanent cure. Because condylomata acuminata can occur on
the vulva, a condom won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right
one. The left kidney usually is slightly higher than the right one.
An adrenal gland lies atop each kidney. The average kidney
measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼”)
wide, and 2.5 cm (1″) thick. The kidneys are located retroperitoneally,
in the posterior aspect of the abdomen, on either side of the
vertebral column. They lie between the 12th thoracic and 3rd lumbar
vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23 mg/dl; the
normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test
results in option C are abnormally elevated, reflecting CRF and the
kidneys’ decreased ability to remove nonprotein nitrogen waste from
the blood. CRF causes decreased pH and increased hydrogen ions —
not vice versa. CRF also increases serum levels of potassium,
magnesium, and phosphorous, and decreases serum levels of
calcium. A uric acid analysis of 3.5 mg/dl falls within the normal
range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the
normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization
of differentiated cells. Dysplasia refers to an alteration in the size,
shape, and organization of differentiated cells. The presence of
completely undifferentiated tumor cells that don’t resemble cells of
the tissues of their origin is called anaplasia. An increase in the
number of normal cells in a normal arrangement in a tissue or an
organ is called hyperplasia. Replacement of one type of fully
differentiated cell by another in tissues where the second type
normally isn’t found is called metaplasia.
21. Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most
common cancer associated with AIDS. Squamous cell carcinoma,
multiple myeloma, and leukemia may occur in anyone and aren’t
associated specifically with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The
client receiving a subarachnoid block requires special positioning to
prevent CSF leakage and headache and to ensure proper anesthetic
distribution. Proper positioning doesn’t help prevent
confusion, seizures, or cardiac arrhythmias.
23. Answer: (A) Auscultate bowel sounds. If abdominal distention is
accompanied by nausea, the nurse must first auscultate bowel
sounds. If bowel sounds are absent, the nurse should suspect
gastric or small intestine dilation and these findings must be
reported to the physician. Palpation should be avoided
postoperatively with abdominal distention. If peristalsis is absent,
changing positions and inserting a rectal tube won’t relieve the
client’s discomfort.
24. Answer: (B) Lying on the left side with knees bent. For a
colonoscopy, the nurse initially should position the client on the left
side with knees bent. Placing the client on the right side with legs
straight, prone with the torso elevated, or bent over with
hands touching the floor wouldn’t allow proper visualization of the
large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted. An
ileostomy stoma forms as the ileum is brought through
the abdominal wall to the surface skin, creating an artificial opening
for waste elimination. The stoma should appear cherry red,
indicating adequate arterial perfusion. A dusky stoma suggests
decreased perfusion, which may result from interruption of the
stoma’s blood supply and may lead to tissue damage or necrosis. A
dusky stoma isn’t a normal finding. Adjusting the ostomy bag
wouldn’t affect stoma color, which depends on blood supply to the
area. An intestinal obstruction also wouldn’t change stoma color.
26. Answer: (A) Applying knee splints. Applying knee splints prevents
leg contractures by holding the joints in a position of function.
Elevating the foot of the bed can’t prevent contractures because this
action doesn’t hold the joints in a position of function.
Hyperextending a body part for an extended time is
inappropriate because it can cause contractures. Performing
 shoulder range-of-motion exercises can prevent contractures in the
shoulders, but not in the legs.
27. Answer: (B) Urine output of 20 ml/hour. A urine output of less
than 40 ml/hour in a client with burns indicates a fluid volume
deficit. This client’s PaO2 value falls within the normal range (80 to
100 mm Hg). White pulmonary secretions also are normal. The
client’s rectal temperature isn’t significantly elevated and probably
results from the fluid volume deficit.
28. Answer: (A) Turn him frequently. The most important intervention
to prevent pressure ulcers is frequent position changes, which
relieve pressure on the skin and underlying tissues. If pressure isn’t
relieved, capillaries become occluded, reducing circulation and
oxygenation of the tissues and resulting in cell death and ulcer
formation. During passive ROM exercises, the nurse moves each
joint through its range of movement, which improves joint mobility
and circulation to the affected area but doesn’t prevent
pressure ulcers. Adequate hydration is necessary to maintain
healthy skin and ensure tissue repair. A footboard prevents plantar
flexion and footdrop by maintaining the foot in a dorsiflexed
position.
29. Answer: (C) In long, even, outward, and downward strokes in
the direction of hair growth. When applying a topical agent, the nurse
should begin at the midline and use long, even, outward, and
downward strokes in the direction of hair growth. This application
pattern reduces the risk of follicle irritation and skin inflammation.
30. Answer: (A) Beta -adrenergic blockers. Beta-adrenergic blockers
work by blocking beta receptors in the myocardium, reducing the
response to catecholamines and sympathetic nerve stimulation.
They protect the myocardium, helping to reduce the risk of another
infraction by decreasing myocardial oxygen demand. Calcium
channel blockers reduce the workload of the heart by decreasing the
heart rate. Narcotics reduce myocardial oxygen demand, promote
vasodilation, and decrease anxiety. Nitrates reduce
myocardial oxygen consumption bt decreasing left ventricular end
diastolic pressure (preload) and systemic vascular resistance
(afterload).
31. Answer: (C) Raised 30 degrees. Jugular venous pressure is
measured with a centimeter ruler to obtain the vertical distance
between the sternal angle and the point of highest pulsation with the
 head of the bed inclined between 15 to 30 degrees. Increased
pressure can’t be seen when the client is supine or when the head of
the bed is raised 10 degrees because the point that marks the
pressure level is above the jaw (therefore, not visible). In
high Fowler’s position, the veins would be barely discernible above
the clavicle.
32. Answer: (D) Inotropic agents. Inotropic agents are administered
to increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output.
Beta-adrenergic blockers and calcium channel blockers decrease
the heart rate and ultimately decreased the workload of the heart.
Diuretics are administered to decrease the overall vascular volume,
also decreasing the workload of the heart.
33. Answer: (B) Less than 30% of calories form fat. A client with low
serum HDL and high serum LDL levels should get less than 30% of
daily calories from fat. The other modifications are appropriate for
this client.
34. Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s progress. The
emergency department nurse is no longer directly involved with the
client’s care and thus has no legal right to information about his
present condition. Anyone directly involved in his care (such as the
telemetry nurse and the on-call physician) has the right to
information about his condition. Because the client requested that
the nurse update his wife on his condition, doing so doesn’t breach
confidentiality.
35. Answer: (B) Check endotracheal tube placement. ET tube
placement should be confirmed as soon as the client arrives in the
emergency department. Once the airways is secured, oxygenation
and ventilation should be confirmed using an end-tidal
carbon dioxide monitor and pulse oximetry. Next, the nurse should
make sure L.V. access is established. If the client experiences
symptomatic bradycardia, atropine is administered as ordered 0.5 to
1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should
try to find the cause of the client’s arrest by obtaining an ABG
sample. Amiodarone is indicated for ventricular tachycardia,
ventricular fibrillation and atrial flutter – not symptomatic
bradycardia.
36. Answer: (C) 95 mm Hg. Use the following formula to calculate
MAP
▪ MAP = systolic + 2 (diastolic) /3
▪ MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
▪ MAP=286 mm HG/ 3
▪ MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel. An
electrocardiogram evaluates the complaints of chest
pain, laboratory tests determines anemia, and the stool test for
occult blood determines blood in the stool. Cardiac monitoring,
oxygen, and creatine kinase and lactate dehydrogenase levels are
appropriate for a cardiac primary problem. A basic metabolic panel
and alkaline phosphatase and aspartate aminotransferase levels
assess liver function. Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split products are measured to verify bleeding
dyscrasias, An electroencephalogram evaluates brain electrical
activity.
38. Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG surgery due
to heparin use during surgery. Although DIC and ITP cause platelet
aggregation and bleeding, neither is common in a client after
revascularization surgery. Pancytopenia is a reduction in all blood
cells.
39. Answer: (B) Corticosteroids. Corticosteroid therapy can decrease
antibody production and phagocytosis of the antibody-coated
platelets, retaining more functioning platelets. Methotrexate can
cause thrombocytopenia. Vitamin K is used to treat an excessive
anticoagulate state from warfarin overload, and ASA decreases
platelet aggregation.
40. Answer: (D) Xenogeneic. An xenogeneic transplant is between is
between human and another species. A syngeneic transplant is
between identical twins, allogeneic transplant is between two
humans, and autologous is a transplant from the same individual.
41. Answer: (B). Tissue thromboplastin is released when damaged
tissue comes in contact with clotting factors. Calcium is released to
assist the conversion of factors X to Xa. Conversion of factors XII to
XIIa and VIII to VIII a are part of the intrinsic pathway.
42. Answer: (C) Essential thrombocytopenia. Essential
thrombocytopenia is linked to immunologic disorders, such as SLE
and human immunodeficiency vitus. The disorder known as von
Willebrand’s disease is a type of hemophilia and isn’t linked to
SLE. Moderate to severe anemia is associated with SLE, not
polycythermia. Dressler’s syndrome is pericarditis that occurs after
a myocardial infarction and isn’t linked to SLE.
43. Answer: (B) Night sweat. In stage 1, symptoms include a single
enlarged lymph node (usually), unexplained fever, night sweats,
malaise, and generalized pruritis. Although splenomegaly may be
present in some clients, night sweats are generally more prevalent.
Pericarditis isn’t associated with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly and pericarditis aren’t
symptoms. Persistent hypothermia is associated with Hodgkin’s but
isn’t an early sign of the disease.
44. Answer: (D) Breath sounds. Pneumonia, both viral and fungal, is
a common cause of death in clients with neutropenia, so frequent
assessment of respiratory rate and breath sounds is required.
Although assessing blood pressure, bowel sounds, and heart
sounds is important, it won’t help detect pneumonia.
45. Answer: (B) Muscle spasm. Back pain or paresthesia in the lower
extremities may indicate impending spinal cord compression from a
spinal tumor. This should be recognized and treated promptly as
progression of the tumor may result in paraplegia. The other
options, which reflect parts of the nervous system, aren’t usually
affected by MM.
46. Answer: (C)10 years. Epidermiologic studies show the average
time from initial contact with HIV to the development of AIDS is 10
years.
47. Answer: (A) Low platelet count. In DIC, platelets and clotting
factors are consumed, resulting in microthrombi and excessive
bleeding. As clots form, fibrinogen levels decrease and the
prothrombin time increases. Fibrin degeneration products increase
as fibrinolysis takes places.
48. Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically
causes fever night sweats, weight loss, and lymph mode
enlargement. Influenza doesn’t last for months. Clients with sickle
cell anemia manifest signs and symptoms of chronic anemia with
pallor of the mucous membrane, fatigue, and decreased tolerance
 for exercise; they don’t show fever, night sweats, weight loss
or lymph node enlargement. Leukemia doesn’t cause lymph
node enlargement.
49. Answer: (C) A Rh-negative. Human blood can sometimes
contain an inherited D antigen. Persons with the D antigen have
Rh-positive blood type; those lacking the antigen have Rh-negative
blood. It’s important that a person with Rhnegative blood receives
Rh-negative blood. If Rh-positive blood is administered to an
Rh-negative person, the recipient develops anti-Rh agglutinins, and
sub sequent transfusions with Rh-positive blood may cause serious
reactions with clumping and hemolysis of red blood cells.
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting
and diarrhea”. Persistent (more than 24 hours) vomiting, anorexia,
and diarrhea are signs of toxicity and the patient should stop the
medication and notify the health care provider. The other
manifestations are expected side effects of chemotherapy.
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair
in 3-6 months, but may be different in texture”. This is the
appropriate response. The nurse should help the mother how to
cope with her own feelings regarding the child’s disease so as not to
affect the child negatively. When the hair grows back, it is still of the
same color and texture.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as
needed. Stomatitis can cause pain and this can be relieved by
applying topical anesthetics such as lidocaine before mouth care.
When the patient is already comfortable, the nurse can proceed with
providing the patient with oral rinses of saline solution mixed with
equal part of water or hydrogen peroxide mixed water in 1:3
concentrations to promote oral hygiene. Every 2-4 hours.
53. Answer: (C) Immediately discontinue the infusion. Edema or
swelling at the IV site is a sign that the needle has been dislodged
and the IV solution is leaking into the tissues causing the edema.
The patient feels pain as the nerves are irritated by pressure and the
IV solution. The first action of the nurse would be to discontinue
the infusion right away to prevent further edema and other
complication.
54. Answer: (C) Chronic obstructive bronchitis. Clients with chronic
obstructive bronchitis appear bloated; they have large barrel chest
and peripheral edema, cyanotic nail beds, and at times, circumoral
 cyanosis. Clients with ARDS are acutely short of breath and
frequently need intubation for mechanical ventilation and
large amount of oxygen. Clients with asthma don’t exhibit
characteristics of chronic disease, and clients with emphysema
appear pink and cachectic.
55. Answer: (D) Emphysema. Because of the large amount of energy
it takes to breathe, clients with emphysema are usually cachectic.
They’re pink and usually breathe through pursed lips, hence the term
“puffer.” Clients with ARDS are usually acutely short of breath.
Clients with asthma don’t have any particular characteristics, and
clients with chronic obstructive bronchitis are bloated and cyanotic
in appearance.
56. Answer: D 80 mm Hg. A client about to go into respiratory arrest
will have inefficient ventilation and will be retaining carbon dioxide.
The value expected would be around 80 mm Hg. All other values are
lower than expected.
57. Answer: (C) Respiratory acidosis. Because Paco2 is high at 80
mm Hg and the metabolic measure, HCO3- is normal, the client has
respiratory acidosis. The pH is less than 7.35, academic, which
eliminates metabolic and respiratory alkalosis as possibilities. If the
HCO3- was below 22 mEq/L the client would have metabolic
acidosis.
58. Answer: (C) Respiratory failure. The client was reacting to the
drug with respiratory signs of impending anaphylaxis, which could
lead to eventually respiratory failure. Although the signs are also
related to an asthma attack or a pulmonary embolism, consider the
new drug first. Rheumatoid arthritis doesn’t manifest these signs.
59. Answer: (D) Elevated serum aminotransferase. Hepatic cell
death causes release of liver enzymes alanine aminotransferase
(ALT), aspartate aminotransferase (AST) and lactate dehydrogenase
(LDH) into the circulation. Liver cirrhosis is a chronic and irreversible
disease of the liver characterized by generalized inflammation and
fibrosis of the liver tissues.
60. Answer: (A) Impaired clotting mechanism. Cirrhosis of the liver
results in decreased Vitamin K absorption and formation of clotting
factors resulting in impaired clotting mechanism.
61. Answer: (B) Altered level of consciousness. Changes in behavior
and level of consciousness are the first sins of hepatic
encephalopathy. Hepatic encephalopathy is caused by liver failure
 and develops when the liver is unable to convert protein
metabolic product ammonia to urea. This results in accumulation of
ammonia and other toxic in the blood that damages the cells.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes
only 2 to 4 stools a day”. Lactulose is given to a patients with
hepatic encephalopathy to reduce absorption of ammonia in the
intestines by binding with ammonia and promoting more frequent
bowel movements. If the patient experience diarrhea, it indicates
over dosage and the nurse must reduce the amount of medication
given to the patient. The stool will be mashy or soft. Lactulose is
also very sweet and may cause cramping and bloating.
63. Answer: (B) Severe lower back pain, decreased blood
pressure, decreased RBC count, increased WBC count.Severe
lower back pain indicates an aneurysm rupture, secondary to
pressure being applied within the abdominal cavity. When ruptured
occurs, the pain is constant because it can’t be alleviated until the
aneurysm is repaired. Blood pressure decreases due to the loss
of blood. After the aneurysm ruptures, the vasculature is interrupted
and blood volume is lost, so blood pressure wouldn’t increase. For
the same reason, the RBC count is decreased – not increased. The
WBC count increases as cell migrate to the site of injury.
64. Answer: (D) Apply gloves and assess the groin site. Observing
standard precautions is the first priority when dealing with any blood
fluid. Assessment of the groin site is the second priority. This
establishes where the blood is coming from and determineshow
much blood has been lost. The goal in this situation is to stop
the bleeding. The nurse would call for help if it were warranted after
the assessment of the situation. After determining the extent of the
bleeding, vital signs assessment is important. The nurse should
never move the client, in case a clot has formed. Moving can disturb
the clot and cause rebleeding.
65. Answer: (D) Percutaneous transluminal coronary angioplasty
(PTCA). PTCA can alleviate the blockage and restore blood flow
and oxygenation. An echocardiogram is a noninvasive diagnosis
test. Nitroglycerin is an oral sublingual medication. Cardiac
catheterization is a diagnostic tool – not a treatment.
66. Answer: (B) Cardiogenic shock. Cardiogenic shock is shock
related to ineffective pumping of the heart. Anaphylactic shock
results from an allergic reaction. Distributive shock results from
 changes in the intravascular volume distribution and is usually
associated with increased cardiac output. MI isn’t a shock
state, though a severe MI can lead to shock.
67. Answer: (C) Kidneys’ excretion of sodium and water. The kidneys
respond to rise in blood pressure by excreting sodium and excess
water. This response ultimately affects sysmolic blood pressure by
regulating blood volume. Sodium or water retention would only
further increase blood pressure. Sodium and water travel
together across the membrane in the kidneys; one can’t travel
without the other.
68. Answer: (D) It inhibits reabsorption of sodium and water in the
loop of Henle. Furosemide is a loop diuretic that inhibits sodium and
water reabsorption in the loop Henle, thereby causing a decrease in
blood pressure. Vasodilators cause dilation of peripheral blood
vessels, directly relaxing vascular smooth muscle and decreasing
blood pressure. Adrenergic blockers decrease sympathetic
cardioacceleration and decrease blood pressure.
Angiotensin-converting enzyme inhibitors decrease blood pressure
due to their action on angiotensin.
69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA)
titer. Laboratory findings for clients with SLE usually
show pancytopenia, elevated ANA titer, and decreased serum
complement levels. Clients may have elevated BUN and creatinine
levels from nephritis, but the increase does not indicate SLE.
70. Answer: (C) Narcotics are avoided after a head injury because
they may hide a worsening condition. Narcotics may mask changes
in the level of consciousness that indicate increased ICP and
shouldn’t acetaminophen is strong enough ignores the mother’s
question and therefore isn’t appropriate. Aspirin is contraindicated in
conditions that may have bleeding, such as trauma, and for children
or young adults with viral illnesses due to the danger of
Reye’s syndrome. Stronger medications may not necessarily lead to
vomiting but will sedate the client, thereby masking changes in his
level of consciousness.
71. Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). A normal Paco2 value is 35 to
45 mm Hg CO2 has vasodilating properties; therefore, lowering
Paco2 through hyperventilation will lower ICP caused by dilated
cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen
 saturation. Alveolar hypoventilation would be reflected in an
increased Paco2.
72. Answer: (B) A 33-year-old client with a recent diagnosis of
Guillain-Barre syndrome . Guillain-Barre syndrome is characterized
by ascending paralysis and potential respiratory failure. The order of
client assessment should follow client priorities, with disorder of
airways, breathing, and then circulation. There’s no information to
suggest the postmyocardial infarction client has an arrhythmia or
other complication. There’s no evidence to suggest hemorrhage or
perforation for the remaining clients as a priority of care.
73. Answer: (C) Decreases inflammation. Then action of colchicines
is to decrease inflammation by reducing the migration of leukocytes
to synovial fluid. Colchicine doesn’t replace estrogen, decrease
infection, or decrease bone demineralization.
74. Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis and can
be extremely debilitating. It can afflict people of any age, although
most are elderly.
75. Answer: (C) Myxedema coma. Myxedema coma, severe
hypothyroidism, is a life-threatening condition that may develop if
thyroid replacement medication isn’t taken. Exophthalmos,
protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid
storm is life-threatening but is caused by severe
hyperthyroidism. Tibial myxedema, peripheral mucinous edema
involving the lower leg, is associated with hypothyroidism but isn’t
life-threatening.
76. Answer: (B) An irregular apical pulse. Because Cushing’s
syndrome causes aldosterone overproduction, which increases
urinary potassium loss, the disorder may lead to hypokalemia.
Therefore, the nurse should immediately report signs and symptoms
of hypokalemia, such as an irregular apical pulse, to the physician.
Edema is an expected finding because aldosterone overproduction
causes sodium and fluid retention. Dry mucous membranes and
frequent urination signal dehydration, which isn’t associated with
Cushing’s syndrome.
77. Answer: (D) Below-normal urine osmolality level, above-normal
serum osmolality level. In diabetes insipidus, excessive polyuria
causes dilute urine, resulting in a below-normal urine osmolality
level. At the same time, polyuria depletes the body of water, causing
 dehydration that leads to an above-normal serum osmolality level.
For the same reasons, diabetes insipidus doesn’t cause
above-normal urine osmolality or below-normal serum osmolality
levels.
78. Answer: (A) “I can avoid getting sick by not becoming dehydrated
and by paying attention to my need to urinate, drink, or eat more
than usual.” Inadequate fluid intake during hyperglycemic episodes
often leads to HHNS. By recognizing the signs of hyperglycemia
(polyuria, polydipsia, and polyphagia) and increasing fluid intake, the
client may prevent HHNS. Drinking a glass of nondiet soda would be
appropriate for hypoglycemia. A client whose diabetes is controlled
with oral antidiabetic agents usually doesn’t need to monitor blood
glucose levels. A highcarbohydrate diet would exacerbate the
client’s condition, particularly if fluid intake is low.
79. Answer: (D) Hyperparathyroidism. Hyperparathyroidism is most
common in older women and is characterized by bone pain and
weakness from excess parathyroid hormone (PTH). Clients also
exhibit hypercaliuria-causing polyuria. While clients with diabetes
mellitus and diabetes insipidus also have polyuria, they don’t have
bone pain and increased sleeping. Hypoparathyroidism
is characterized by urinary frequency rather than polyuria.
80. Answer: (C) “I’ll take two-thirds of the dose when I wake up and
one-third in the late afternoon.” Hydrocortisone, a glucocorticoid,
should be administered according to a schedule that closely reflects
the body’s own secretion of this hormone; therefore, two-thirds of
the dose of hydrocortisone should be taken in the morning and
one-third in the late afternoon. This dosage schedule reduces
adverse effects.
81. Answer: (C) High corticotropin and high cortisol levels. A
corticotropin-secreting pituitary tumor would cause
high corticotropin and high cortisol levels. A high corticotropin level
with a low cortisol level and a low corticotropin level with a low
cortisol level would be associated with hypocortisolism. Low
corticotropin and high cortisol levels would be seen if there was a
primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every 4
hours. The nurse should perform capillary glucose testing every
4 hours because excess cortisol may cause insulin resistance,
placing the client at risk for hyperglycemia. Urine ketone testing isn’t
 indicated because the client does secrete insulin and, therefore, isn’t
at risk for ketosis. Urine specific gravity isn’t indicated because
although fluid balance can be compromised, it usually isn’t
dangerously imbalanced. Temperature regulation may be affected
by excess cortisol and isn’t an accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4
p.m.. Regular insulin, which is a short-acting insulin, has an onset
of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse
gave the insulin at 2 p.m., the expected onset would be from 2:15
p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone
(TSH) level after 30 minutes during the TSH stimulation test. In the
TSH test, failure of the TSH level to rise after 30 minutes confirms
hyperthyroidism. A decreased TSH level indicates a pituitary
deficiency of this hormone. Below-normal levels of T3 and T4,
as detected by radioimmunoassay, signal hypothyroidism. A
below-normal T4 level also occurs in malnutrition and liver disease
and may result from administration of phenytoin and certain other
drugs.
85. Answer: (B) “Rotate injection sites within the same anatomic
region, not among different regions.” The nurse should instruct the
client to rotate injection sites within the same anatomic region.
Rotating sites among different regions may cause excessive
day-to-day variations in the blood glucose level; also, insulin
absorption differs from one region to the next. Insulin should be
injected only into healthy tissue lacking large blood vessels, nerves,
or scar tissue or other deviations. Injecting insulin into areas of
hypertrophy may delay absorption. The client shouldn’t inject insulin
into areas of lipodystrophy (such as hypertrophy or atrophy); to
prevent lipodystrophy, the client should rotate injection sites
systematically. Exercise speeds drug absorption, so the client
shouldn’t inject insulin into sites above muscles that will be
exercised heavily.
86. Answer: (D) Below-normal serum potassium level. A client with
HHNS has an overall body deficit of potassium resulting from
diuresis, which occurs secondary to the
hyperosmolar, hyperglycemic state caused by the relative insulin
deficiency. An elevated serum acetone level and serum ketone
 bodies are characteristic of diabetic ketoacidosis. Metabolic
acidosis, not serum alkalosis, may occur in HHNS.
87. Answer: (D) Maintaining room temperature in the low-normal
range. Graves’ disease causes signs and symptoms
of hypermetabolism, such as heat intolerance, diaphoresis,
excessive thirst and appetite, and weight loss. To reduce heat
intolerance and diaphoresis, the nurse should keep the client’s room
temperature in the low-normal range. To replace fluids lost via
diaphoresis, the nurse should encourage, not restrict, intake of oral
fluids. Placing extra blankets on the bed of a client with heat
intolerance would cause discomfort. To provide needed energy and
calories, the nurse should encourage the client to
eat high-carbohydrate foods.
88. Answer: (A) Fracture of the distal radius. Colles’ fracture is a
fracture of the distal radius, such as from a fall on an outstretched
hand. It’s most common in women. Colles’ fracture doesn’t refer to a
fracture of the olecranon, humerus, or carpal scaphoid.
89. Answer: (B) Calcium and phosphorous. In osteoporosis, bones
lose calcium and phosphate salts, becoming porous, brittle, and
abnormally vulnerable to fracture. Sodium and potassium aren’t
involved in the development of osteoporosis.
90. Answer: (A) Adult respiratory distress syndrome (ARDS). Severe
hypoxia after smoke inhalation is typically related to ARDS. The
other conditions listed aren’t typically associated with
smoke inhalation and severe hypoxia.
91. Answer: (D) Fat embolism. Long bone fractures are correlated
with fat emboli, whichcause shortness of breath and hypoxia. It’s
unlikely the client has developed asthma or bronchitis without a
previous history. He could develop atelectasis but it typically doesn’t
produce progressive hypoxia.
92. Answer: (D) Spontaneous pneumothorax. A spontaneous
pneumothorax occurs when the client’s lung collapses, causing an
acute decreased in the amount of functional lung used in
oxygenation. The sudden collapse was the cause of his chest
pain and shortness of breath. An asthma attack would show
wheezing breath sounds, and bronchitis would have rhonchi.
Pneumonia would have bronchial breath sounds over the area of
consolidation.
93. Answer: (C) Pneumothorax. From the trauma the client
experienced, it’s unlikely he has bronchitis, pneumonia, or TB;
rhonchi with bronchitis, bronchial breath sounds with TB would be
heard.
94. Answer: (C) Serous fluids fills the space and consolidates the
region. Serous fluid fills the space and eventually
consolidates, preventing extensive mediastinal shift of the heart and
remaining lung. Air can’t be left in the space. There’s no gel that can
be placed in the pleural space. The tissue from the other lung can’t
cross the mediastinum, although a temporary mediastinal shift exits
until the space is filled.
95. Answer: (A) Alveolar damage in the infracted area. The infracted
area produces alveolar damage that can lead to the production of
bloody sputum, sometimes in massive amounts. Clot formation
usually occurs in the legs. There’s a loss of lung parenchyma and
subsequent scar tissue formation.
96. Answer: (D) Respiratory alkalosis. A client with massive
pulmonary embolism will have a large region and blow off large
amount of carbon dioxide, which crosses the unaffected
alveolar-capillary membrane more readily than does oxygen and
results in respiratory alkalosis.
97. Answer: (A) Air leak. Bubbling in the water seal chamber of a
chest drainage system stems from an air leak. In pneumothorax an
air leak can occur as air is pulled from the pleural space. Bubbling
doesn’t normally occur with either adequate or inadequate suction
or any preexisting bubbling in the water seal chamber.
98. Answer: (B) 21. 3000 x 10 divided by 24 x 60.
99. Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4
ml.
100. Answer: (D) “I should put on the stockings before getting out of
bed in the morning. Promote venous return by applying external
pressure on veins.