1

Which of the following is an important component of a teaching plan for the client
recently diagnosed with peptic ulcer disease?
Incorrect: Antacids should not be taken concurrently with other ulcer drugs such
as H2 blockers because they will decrease drug absorption by 10% to 20%.Correct: The
GI complications of NSAID use are strongly linked to mucosal injury and the
development of gastric ulcers.Incorrect: Although milk-based diets may provide symptom
relief, research has shown they do not influence healing and in fact actually act to
increase acid secretion. Diet plays no defined role in ulcer development and current
management of ulcers.Incorrect: The individual with an ulcer does not need to restrict
activity to enhance healing. Most clients are able to continue usual activities, although
adequate rest is encouraged.
Antacids and H2 receptor antagonists can be taken together.
Avoid the use of NSAIDs for pain control.
Increase milk products in the diet to enhance healing.
Limit physical activity to reduce stomach acid.
2

A nurse admits a 42-year-old female with the following characteristics: excessive

sleeping, fatigue, constipation, weight gain, and complaint of intolerance to cold. These
signs and symptoms are most consistent with:
Incorrect: Although some of the symptoms mentioned would be consistent with
acute renal failure (i.e. fatigue, weight gain), there is no mention of the classic symptoms
of acute renal failure. These would include signs and symptoms of fluid overload and
electrolyte imbalance such as hypertension, neck vein distention, low urine output,
confusion.Incorrect: Although fatigue is consistent with aplastic anemia, the remaining
symptoms are not. Aplastic anemia results from impaired erythrocyte production and is
manifested by pale skin color, fatigue, exertional dyspnea, palpations, low hemoglobin,
and signs of bleeding tendency such as petechiae and ecchymosis.Correct: This client
presents with some of the classic characteristics of hypothyroidism. Recall that a lack of
thyroid hormone results in a general depression of the basal metabolic rate. A typical
clinical picture includes fatigue, weakness, intolerance to cold, constipation, menstrual
irregularities, reduced appetite, dry skin, edema.Incorrect: The hallmark of diabetes is
insulin deficiency manifested by hyperglycemia, polyuria, polydipsia, polyphagia, visual
blurring, fatigue, and weight loss. This client does not present with this symptom
combination.
acute renal failure.
aplastic anemia.
hypothyroidism.
diabetes mellitus.
3

A client newly diagnosed with HIV says to the nurse, "I can't believe this is happening.
There must be some new treatments that can help." The most appropriate nursing
diagnosis for this client based on his comments would be:
 Incorrect: The defining characteristics of altered family processes include verbal
hostility between family members and a general lack of communication and respect
between family members. Although this may be a problem for the client with HIV, more
data is needed to formulate this nursing diagnosis in this situation.Incorrect: The client
has not expressed a feeling of aloneness or verbalized discomfort in social situations,
which are characteristics of social isolation. Although clients with a diagnosis of HIV or
AIDS may experience social isolation, there is insufficient data to validate this as a
problem for this individual.Correct: The client's statement is most consistent with
anticipatory grieving which is characterized by the normal grief response including anger,
denial, disbelief, and guilt.Incorrect: The defining characteristics of ineffective individual
coping include verbalization of the inability to cope, inability to problem-solve, altered
social participation, inability to meet basic needs and role expectations and inappropriate
use of defense mechanisms to mention a few. Although the client is expressing disbelief,
there is insufficient data to support a nursing diagnosis of ineffective individual coping.
altered family processes.
social isolation.
anticipatory grieving.
ineffective individual coping.
4

The nature of systemic lupus erythematosus (SLE) requires the nurse to teach the patient
and family:
Incorrect: Pregnancy is not necessarily contraindicated in clients with SLE.
Although pregnancy does not induce SLE exacerbations, pregnancy should be planned
with the client's primary care provider.Correct: Factors such as fatigue, sun exposure,
stress, and infection can exacerbate systemic lupus erythematosus. Nursing interventions
should include teaching the client and family measures to reduce stress and cope with the
chronic disease.Incorrect: Neither discoid nor systemic lupus erythematosus is a
contagious disease. Both are thought to be autoimmune disorders.Incorrect: The lesions
of SLE are well demarcated and are relatively benign in nature. The rash is generally
confined to the face, scalp, and neck. Although other parts of the body may be involved
(i.e. mucous membranes), the rash does not actually spread like an allergic dermatitis (i.e.
when an irritant or allergen is spread by the hands to another body part as in poison ivy).
birth control measures to prevent pregnancy.
strategies to prevent and cope with stress.
measures to prevent spread of the disease.
methods to diminish spread of skin lesions.
5

A Type I diabetic is prescribed to take Regular and NPH insulin before breakfast. The
client administers his insulin at 6:00 a.m. prior to breakfast. The nurse should teach the
client to:
Incorrect: The onset of NPH insulin is approximately 1-2 hours with peak effect
between 6-12 hours. Therefore a snack eaten between breakfast and lunch, when the NPH
insulin is beginning to reach it's peak action would be important to prevent hypoglycemia
before lunch. In addition, regular or quick acting insulin requires that a supplemental
snack of 15 g of carbohydrate be given to match the peak action of the insulin. Since
regular insulin is peaking at 2-4 hours post administration, a 10:00 a.m. snack would be
recommended.Incorrect: Because the NPH insulin will still be peaking from
approximately 12:00 p.m. to 6:00 p.m., delaying the evening meal (dinner) until after 6:00
p.m. would put the client at risk for hypoglycemia.Incorrect: Carbohydrate intake must be
coordinated with the peak action of insulin. Therefore, the client should be taught to
consistently eat carbohydrates at meals, ranging from 45-60% of the total caloric
intake.Correct: The peak time of NPH insulin is 4-12 hours. If the client takes the NPH
insulin at 6:00 a.m., the insulin will be peaking between 12:00 p.m. and 6:00 p.m.
Therefore it is important that food be scheduled between this time period to prevent
hypoglycemia.
avoid any snacks between breakfast and lunch.
delay dinner until after 6:00 p.m..
eat a low carbohydrate lunch at noon.
schedule a snack at 3:00 p.m..
6

A client with a fractured femur was recently admitted to the orthopedic unit in traction. In
planning care to minimize the risk for fat embolism, the nurse should implement which
intervention?
Correct: Immobilization, surgery or trauma to the skeletal system, poor hydration
and low tidal volume in the lung are predisposing factors to fat embolism syndrome.
Nursing interventions to reduce the risk of fat embolism include good respiratory care,
adequate hydration, and stable traction. Other measures include: the use of intermittent
pneumatic compression, leg elevation, elastic stockings, and medications (anticoagulant,
anti-platelet agents).Incorrect: Fat embolism is not related to diet. The use of
supplementary oxygen may require an order, particularly to the client with chronic
obstructive pulmonary disease. Range of motion is not recommended for the affected
leg.Incorrect: A liquid diet is not necessary for the client in traction. Physical therapy is
essential in the rehabilitative phase.Incorrect: Sedation and analgesia are not related to the
prevention of fat emboli.
The client is encouraged to move the unaffected extremities to reduce the
risk of fat embolism syndrome, pressure-related skin injury, and muscle soreness.
Provide a low-fat, high-carbohydrate diet, give oxygen, and encourage
range of motion in the affected leg.
Keep the client on a liquid diet, and have physical therapy start the client
on an exercise program for upper body strengthening.
Maintain sedation and administer intravenous fluids and medications for
pain as needed.
7

The nurse is caring for a client who has just developed ventricular tachycardia following
a myocardial infarction. The nurse anticipates the client will immediately be given which
of the following medications?
Incorrect: Atropine sulfate is an anticholinergic drug used to increase the heart
rate in symptomatic bradycardia (defined as 40 beats per minute).Incorrect: Epinephrine
is an adrenergic agent that increases the heart rate. This drug would be contraindicated in
fast-rate dysrhythmias. It is one of the first line drugs administered during CPR. By
constricting peripheral blood vessels, epinephrine shunts blood to the central circulation
and increases blood flow to the heart and brain. It is also given for asystole to stimulate
electrical and mechanical activity to produce myocardial contraction.Correct: The first
line drug for management of serious ventricular dysrhythmias is lidocaine, which
decreases myocardial irritability (automaticity) in the ventricles.Incorrect:
Nitroglycerin is used to dilate coronary arteries and improve blood flow. It has no
antidysrhythmic effect.
Atropine sulfate
Epinephrine
Lidocaine
Nitroglycerin
8

During a home visit the nurse determines that the client is experiencing dumping
syndrome following his recent total gastrectomy. Which dietary recommendation should
the nurse convey to the client?
Incorrect: Oral vitamins will have no effect on dumping syndrome. Further, they
are of no benefit to the client following total gastrectomy due to loss of intrinsic factor
normally secreted by the parietal cells of the stomach. Intrinsic factor is essential for the
absorption of vitamin B12. Monthly injection of vitamin B12 will prevent the
development of pernicious anemia.Incorrect: Malabsorption of fat may occur after
gastrectomy from reduced acid secretion and availability of pancreatic enzymes required
for fat absorption. Dumping syndrome occurs because of the rapid entry of hypertonic
food into the upper small intestine without undergoing the usual breakdown and dilution
in the stomach. This stimulates motility and diarrhea. Preventive measures include a
moderate-fat, high-protein diet with limited carbohydrates.Correct: Fluids with meals are
discouraged because they increase total volume and further promote diarrhea.Incorrect:
Rest on the left side for 20-30 minutes after eating is thought to delay gastric emptying
and may be helpful for some individuals.
Begin taking a vitamin B complex supplement.
Eat a high carbohydrate, low fat, low protein diet.
Decrease fluid intake with meals.
Go for a slow, short walk after eating.
9

A client with asthma goes into status asthmaticus. Which clinical signs, if present, would
indicate that intubation and mechanical ventilation are needed?
Incorrect: Both hyperresonance (air-trapping) and tachypnea are characteristic of
an acute asthma attack.Incorrect: Severe inspiratory and expiratory wheezing is consistent
with an acute asthma attack. Clients with status asthmaticus may be moving minimal
amounts of air into and out of the lungs therefore audible wheezing may NOT be
present.Correct: These blood gas values indicate respiratory acidosis and hypoxemia. This
occurs as a result of a prolonged attack where respiratory muscle exhaustion causes
hypoventilation. If respiratory acidosis and hypoxemia are present, intubation and
ventilatory assistance may be required if oxygen and other treatment measures are
ineffective.Incorrect: Tachycardia and an elevated blood pressure are expected findings
during an acute asthma attack. However, clients with status asthmaticus may exhibit
pulsus paradoxus. Pulsus paradoxus is an accentuation of the normal decrease in systolic
arterial pressure with inspiration. This is a result of changes in intrapleural pressure
during respiration that occurs in obstructive airway disease.
Hyperresonance and tachypnea
Severe inspiratory and expiratory wheezing
pH 7.32, PCO2 55 mm Hg, PO2 74 mm Hg
Pulse 110/minute, BP 150/88
10

Which nursing intervention is the priority for care of the client during the acute phase of a
cerebrovascular accident (CVA)?
Incorrect: Following a CVA clients are at risk for a variety of complications
associated with immobility and subsequent disuse such as contractures and skin
breakdown. While preventive nursing care measures are incorporated into the daily
routine, during the acute phase of a stroke, the immediate priority is maintaining a patent
airway and adequate oxygenation to support cerebral perfusion.Correct: During the acute
phase of a cerebrovascular accident it is essential to assess respiratory function and
maintain a patent airway to support oxygenation and cerebral perfusion. Because of motor
of sensory deficits, the client with a CVA is at risk of aspiration of food, fluid, and
secretions.Incorrect: The effects of a CVA are life altering. The emotional changes and
physical limitations that commonly occur, challenge the coping abilities of the client and
family. Although a nursing care plan would be incomplete without addressing the coping
needs of the client and family, the immediate priority post CVA is respiratory and
neurological assessment and promotion of oxygenation to the brain.Incorrect: Problems
with urinary incontinence are common after stroke and the plan of care during
hospitalization and rehabilitation will include measures to restore continence. However,
the immediate care priority in the acute phase of stroke is airway, oxygenation, and
cerebral perfusion.
Decrease the complications of disuse.
Monitor the status of respiratory function.
Maintain effective coping by the family.
Assess for bladder distention.

11

Of the following nursing diagnoses, which one would most effectively address primary
prevention as it relates to drug management in the elderly population?
Incorrect: The nursing diagnosis that most effectively guides primary prevention
of drug reactions and interactions involves identifying the risk and taking measures to
prevent adverse reactions, self-care deficit, and/or injuries. Although elderly clients
taking multiple drugs are at greater risk for adverse reactions because of complex drug
regimens and age-related physiological changes, a diagnosis of 'self-care deficit related to
adverse reactions to prescribed drugs' addresses an actual problem with drug
management.Incorrect: The prevention of drug mismanagement, adverse reactions and
side effects is best addressed using a potential nursing diagnosis that identifies risk factors
in the elderly population. The other answer options are nursing diagnosis that
address 'actual' problems.Incorrect: Although elderly clients may be noncompliant with
the drug regimen due to lack of sufficient knowledge regarding drug administration, this
diagnosis does not focus on problem prevention.Correct: Because elders consume
disproportionately more of all kinds of drugs than do middle-aged adults, 'risk for injury
related to polypharmacy' is the nursing diagnosis that would focus on prevention of
complications for this group of individuals.
Self-care deficits related to adverse reactions to prescribed drugs
Body image disturbance related to drug side effects
Noncompliance related to knowledge deficit
Risk for injury related to polypharmacy
12

The nurse is planning care for a 48-year-old female following a total hysterectomy.
Which of the following interventions would be contraindicated?
Incorrect: Frequent ambulation is encouraged as the most reliable means of
stimulating peristalsis. In addition, ambulation supports oxygenation through natural deep
breathing and assists in the elimination of residual anesthetic.Incorrect: The risk of
thromboembolism is significant in the post-hysterectomy client because of venous
pooling and pelvic congestion. Nursing interventions to prevent thromboembolism
include compression stockings and leg/foot flexion and extension exercises.Incorrect:
Pain relief should be promoted not only for comfort but to promote frequent turning,
coughing and deep breathing, and early ambulation. Narcotic analgesics are the most
effective in relieving pain during the immediate postoperative period and should be
encouraged to prevent severe pain and enhance activity.Correct: Venous pooling and
pelvic congestion are common complications after hysterectomy, especially if the
lithotomy position was used. Efforts should be taken to avoid positioning the client with
the knees bent since this promotes pelvic congestion.
Early ambulation
Compression stockings
Narcotic analgesics
Pillows under the knees
13

The nurse is teaching an asthmatic client how to treat episodes of acute

bronchoconstriction. Of the following inhaled agents, if prescribed, the nurse should
teach the client to immediately take the:
Incorrect: The anticholinergic Atrovent is ineffective in acute bronchospasm when
a rapid response is required. It is used in maintenance therapy in chronic,
bronchoconstrictive conditions such as chronic bronchitis and emphysema.Correct: The
1st drug of choice in an acute asthma attack is a short-acting inhaled beta2-adrengergic
agonist such as albuterol sulfate (Proventil) or metaproterenol sulfate (Alupent). These
drugs cause smooth muscle relaxation and bronchodilation and start to act within 10
minutes.Incorrect: Inhaled steroids do not play a role in acute situations. Corticosteroids
primarily work by suppressing inflammation in the airways, thereby decreasing mucus
secretion and edema. Another important action is to increase the number and sensitivity
of beta2-adrenergic receptors, which increases the effectiveness of beta2-adrengergic
bronchodilators. In maintenance therapy, it should be noted that the inhaled beta2-agonist
should be given first to open the airway; followed by the inhaled steroid, which will be
more effective when inhaled deeper into the lung.Incorrect: Cromolyn (Intal) is used to
prevent acute asthma attacks in clients with chronic asthma. The drugs in this category
are used only for prophylaxis and are not effective in acute bronchospasm. Mast cell
stabilizers prevent the release of bronchoconstrictive and inflammatory substances when
mast cells are confronted with allergens.
anticholinergic (Atrovent).
beta2-adrenergic agonist (Albuterol).
corticosteroid (Azmacort).
mast cell stabilizer (Cromolyn).
14

A client is admitted to the Intensive Care Unit following a femoral-popliteal bypass graft.
Which intervention provides the most relevant data about graft patency?
Incorrect: This activity evaluates neurological status and would not provide any
significant data regarding graft patency, circulation, and perfusion.Incorrect: Monitoring
ECG activity is a critical nursing intervention because clients with vascular disease
commonly have problems with CAD or hypertension. However, palpating arterial pulses
gives the most information about the patency of the graft and perfusion of blood to areas
below the bypass.Incorrect: Because coronary artery disease and hypertension are
common in clients with vascular disease, dysrhythmias or cardiac failure are potential
complications of vascular surgery. Therefore, accurate documentation of I & O is also
essential to quality nursing care to detect alterations in cardiac output and renal perfusion.
However, palpating arterial pulses gives the most information about the patency of the
graft and perfusion of blood to areas below the bypass.Correct: Graft patency is a priority
concern in the postoperative client because the risk of reocclusion from thrombosis,
restenosis, or debris is significant. The nurse should monitor the client's peripheral pulses
and limb temperature, as well as the degree of pain, pallor, sensation, and movement.
Check the equality of the client's hand grasps.
Check the electrocardiogram every four hours.
Record the client's intake and output.
Palpate all arterial pulse sites as frequently as every hour.
15

A preoperative order is written for meperidine 50 mg IM. Which desired effects can the
nurse anticipate following drug administration?
Incorrect: Anticholinergic agents such as Robinul are often given preoperatively
to inhibit salivation and excessive respiratory secretions.Correct: Meperidine (Demerol) is
an opioid analgesic. Meperidine binds to opiate receptors in the central nervous system
resulting in altered perception of and response to painful stimuli. As a secondary
response, the client's blood pressure can be expected to decrease as pain diminishes. It
should be noted that hypotension can be an adverse reaction.Incorrect: Meperidine is not
known to have any antiemetic or GI stimulant effects. A drug expected to have these
effects would be metoclopramide (Reglan). Recall that opioids can have a constipating
effect.Incorrect: The therapeutic effects described are characteristic of Versed, a sedative/
hypnotic that induces short-term sedation and postoperative amnesia.
Decreased salivation and mucous production
Pain reduction and decreased blood pressure
Reduced nausea and increased peristalsis
Sedation and amnesia following the surgical procedure

21

When treating clients with chronic obstructive pulmonary disease (COPD) who are
hypoxemic, the standard of care is to:
Correct: Breathing very high concentrations of O2 for prolonged periods is
associated with acute respiratory distress syndrome. A firm general principle is to use the
lowest amount of O2 that will achieve an acceptable PO2.Incorrect: It is true that
precautions must be taken when giving O2 to clients with COPD. These persons
chronically retain carbon dioxide; low O2 levels produce the drive to breathe.Incorrect:
This is a common misunderstanding by clients requiring O2 therapy. Studies have shown
that clients receive the most benefit from O2 therapy if the oxygen is used
continuously.Incorrect: Clients with COPD who are carbon dioxide retainers must receive
supplemental O2 by controlled O2 delivery devices. When low-flow O2 is desired,
oxygen is given by nasal cannula. The Venturi mask can also be used to deliver O2 at
controlled levels.
administer the least amount of O2 that achieves an acceptable PO2.
maintain low-flow O2 under all circumstances.
institute O2 therapy only when dyspnea occurs.
use a nasal cannula rather than a facial mask.
22

A client is being treated for pulmonary edema secondary to congestive heart failure.
Which signs/symptoms, if present, would suggest to the nurse the onset of acute
respiratory failure?
Incorrect: Although acute dyspnea will occur as a result of hypoxemia, alone it is
not a criterion for diagnosing acute respiratory failure.Incorrect: An irregular apical pulse
in this situation may be associated with the client's congestive heart failure, commonly
associated with dysrhythmias such as atrial fibrillation. An irregular apical pulse is not a
component of the physiological criteria used to diagnose acute respiratory
failure.Incorrect: Jugular vein distention is a clinical manifestation of the client's
congestive heart failure.Correct: Acute respiratory failure is defined as any rapid change
in respiration resulting in hypoxemia, hypercarbia, or both. Physiological criteria for
acute respiratory failure include sudden onset of PO2 50 mmHg or less, PCO2 50 mm Hg
or more, and pH 7.35 or less.
Acute dyspnea
Irregular apical pulse
 Jugular vein distention
PO2 < 50 mm Hg, PCO2 > 50 mm Hg
23

The primary care provider prescribes levodopa for a 68-year-old male diagnosed with
Parkinson's disease. The nurse knows that this drug helps reduce rigidity by:
Incorrect: A deficient amount of norepinephrine is thought to be a contributing
factor in depression. Some of the antidepressants such as the monoamine oxidase
inhibitors (MAO) act by facilitating release of norepinephrine in nerve terminals.
Parkinson's disease does not involve this neurotransmitter.Incorrect: Parkinson's disease
involves deficient amounts of dopamine. Insufficient dopamine allows large numbers of
excitatory acetylcholine (ACh) secreting neurons to remain active, creating an imbalance
between excitatory and inhibitory neuronal activity. This results in the characteristic
excessive excitation of neurons that occurs in Parkinson's disease interfering with control
or initiation of voluntary. Anticholinergic agents, such as Cogentin, are often prescribed
to decrease the excitatory effects of ACh.Incorrect: A deficiency of norepinephrine and/or
serotonin is thought to be a component of depression. Selective serotonin reuptake
inhibitors (SSRI) are antidepressants that increase the amounts of these neurotransmitters
in the CNS. Parkinson's disease does not involve this neurotransmitter.Correct:
Parkinson's disease results from degeneration of the substantia nigra, leading to a
decrease in the amount of dopamine, resulting in loss of the ability to refine voluntary
movement. Levodopa is converted to dopamine in the central nervous system.
enhancing the release of norepinephrine.
increasing the action of acetylcholine.
inhibiting the reuptake of serotonin.
restoring deficient dopamine.
24

When evaluating serial electrocardiograms (ECGs) for a client with coronary artery
disease, the nurse knows that this diagnostic tool is important because the ECG:
Incorrect: Although ECG characteristics may lend support to the diagnosis of
angina and/or infarction, it does not give definitive data that would help distinguish
between stable and unstable angina. The client's history often distinguishes between types
of angina (i.e. provocative factors, what relieves the pain, duration etc.).Incorrect: Blood
studies are equally important but can take longer to analyze. Injured myocardial cells
release several enzymes that are important indicators of acute myocardial
infarction.Incorrect: Stress testing is an important diagnostic tool different from the 12-
lead ECG. An exercise stress test demonstrates the significance of coronary artery
blockages and can indicate areas of the myocardium that do not receive adequate
perfusion at peak exercise.Correct: ST segment elevation is the hallmark of acute
myocardial ischemia leading to infarction. Because ECG findings correlate to anatomical
locations, it can indicate which type of infarction has occurred. Therefore, the ECG is an
important diagnostic tool.
can help distinguish between stable and unstable angina.
is a more reliable diagnostic tool than blood studies.
replaces the need for stress testing.
 wave abnormalities can signal injury and/or infarction.
25

Acute respiratory distress syndrome (ARDS) can be detected early in high-risk clients.
Which of the following are early manifestations of ARDS?
Incorrect: These are late signs of ARDS. As alveoli collapse and gas exchange is
impaired, signs of hypoxia occur including cyanosis and tachycardia. The client becomes
fatigued as the work of breathing increases as evidenced by intercostal retractions.

Incorrect: Early in the course of ARDS chest auscultation is clear. As the leakage of
fluid into the interstitial and intra-alveolar spaces increases, terminal airways become
filled with fluid and adventitious breath sounds are auscultated. Grunting respirations and
shallow breathing are also late signs as respiratory fatigue and hypoxia occur.
Incorrect: Generally, blood-tinged or frothy sputum occur with pulmonary edema. This
occurs as a result of increased pulmonary capillary pressures and RBCs entering the
alveoli.
Correct: Although clinical presentation will vary depending on the pathophysiology
contributing to ARDS, early indicators include dyspnea, restlessness, hyperventilation,
cough, and labored breathing.
Late: Tachycardia, cyanosis, intercostal retractions
Late: Adventitious breath sounds, grunting respirations, shallow breathing
Pulm edema: A productive cough with bloody or frothy sputum
Dyspnea, restlessness, and hyperventilation

26

A client is admitted to the emergency department with diabetes mellitus and a blood
sugar of 620 mg/dl. Her skin is flushed and warm, mucous membranes are dry,
respirations are rapid and deep, and she is irritable. Arterial blood gas (ABG) values
reveal pH 7.18, PCO2 12 mmHg, HCO3 12 mEq/L. The ABG results confirm the client
is in:
Incorrect: Although the pH does indicate acidosis, the PCO2 does not indicate
respiratory acidosis. Recall that CO2 when combined with H2O forms H2CO3 or
carbonic acid. Therefore, if the PCO2 is low, then less carbonic acid is formed.
Respiratory acidosis would be reflected in an elevated PCO2 when carbon dioxide is
retained and more carbonic acid is formed.Incorrect: Although the low PCO2 is
consistent with respiratory alkalosis, the pH indicates acidosis. Therefore, we can
eliminate alkalosis as a correct choice.Correct: The imbalance is metabolic acidosis
suggested immediately by the client's history and clinical manifestations. Diabetic
ketoacidosis occurs most often in clients with type I IDDM who experience illness,
infection, or trauma. The insulin deficiency prevents normal utilization of serum glucose
by the cells. The body is forced to break down fat and protein stores for energy resulting
in ketone bodies accumulating in the blood. Ketones cause the blood pH to drop. The pH
is acidotic (< 7.35). The client's low PCO2 does not match with acidosis. In other words,
the low PCO2 is not the cause of the acidosis but is decreased, indicating CO2 is being
blown-off as a result of the client's rapid and deep respirations, referred to as Kussmaul's
respirations. This is a compensatory response to the metabolic acidosis indicated by the
low HCO3. The HCO3 is low in proportion to the increase in fixed acids in the blood (in
this case ketones). The metabolic acidosis is only partially compensated as indicated by
the abnormal pH.Incorrect: The pH is consistent with acidosis since it is less than 7.35.
Therefore, we can immediately eliminate alkalosis as a correct interpretation.
respiratory acidosis, partially compensated.
respiratory alkalosis, uncompensated.
metabolic acidosis, partially compensated.
metabolic alkalosis, fully compensated.
27

The nurse is evaluating central venous pressure (CVP) measurements for a client with
multi-system injuries who was recently admitted to the intensive care unit. The nurse
determines the most recent CVP measurement to be very low. This reading indicates:
Incorrect: The CVP does not give any direct information about pressure in the
arterial system. However, it does provide information about fluid volume and therefore
could indirectly suggest blood pressure changes. In the case of a low CVP reading,
hypovolemia is the likely cause and blood pressure would be decreased.Correct: CVP is
the measurement of systemic venous pressure at the level of the right atrium. Because
60% of the blood volume is in the venous system, the CVP is valuable in assessing fluid
volume excess or deficit. Usually, decreased CVP is caused by hypovolemia.Incorrect:
The CVP does not give any information about oxygenation. Arterial blood gas analysis
can be obtained via an arterial catheter for assessment of oxygenation status.Incorrect:
Aside from direct observation, the best tool for analyzing ventilation status is arterial
blood gas analysis. The CVP does not provide information about ventilation.
hypertension.
hypovolemia.
hypoxia.
hyperventilation.
28

Which of the following individuals has the most risk factors for developing hypertensive
disease? A/an:
Incorrect: Based on the data, this client is at low risk since her weight is within
ideal range for her height. Obesity is an important risk factor in the incidence of
hypertension. She does not have any risk factors listed.Incorrect: This client's age
represents a risk factor. However, persons of Hispanic culture have been noted to be at
higher risk. Although elevated cholesterol and triglyceride levels are correlated with
coronary artery disease and hypertension, this client's cholesterol level is at the upper
edge of normal. This client has two risk factors.Correct: Age is the primary risk factor for
hypertension. It is more common among men than women until after menopause, and is
twice as prevalent and more severe among African Americans. Smoking and excess
alcohol use are also risk factors. This client has five risk factors.Incorrect: Although this
female is the oldest of the four choices, her culture does not place her at high risk.
Heredity also plays a role in hypertensive disease. This client has two risk factors.
42-year-old white female, 5 feet, 9 inches, weight 145 lbs.
 64-year-old Hispanic male, cholesterol 180 mg/dl.
76-year-old black male, 40 pack year history of smoking, alcoholic.
80-year-old Asian female whose mother had coronary artery disease.
29

A client in the rehabilitative phase of a burn injury is having difficulty with pain
management. The nurse planning this client's care should consider which intervention for
pain control?
Incorrect: The client with burn injury experiences pain that requires analgesia,
usually narcotics in the acute phase. Non-pharmacologic treatments, such as relaxation
technique, distraction, music therapy, guided imagery and hypnosis, are also effective in
the reduction of perceived pain. Sedation promotes drowsiness and does not relieve pain.

Incorrect: The nurse may teach the client with chronic pain the use of various non-
pharmacologic therapies for pain management. The techniques of guided imagery,
distraction, progressive relaxation, music therapy, and hypnosis that are used as an
adjunct to analgesia may be more effective than medication alone.

Correct: Pain relief with analgesic agents, such as narcotics or non-steroidal anti-
inflammatory agents, may be obtained through the oral or intravenous routes.
Intramuscular administration is contraindicated due to the erratic and diminished
circulation to muscle tissue. Non-pharmacologic treatments, such as relaxation technique,
distraction, music therapy, guided imagery and hypnosis, are also effective in the
reduction of perceived pain.Incorrect: Methods to control pain, either analgesic or non-
pharmacologic therapies, are most effective if used at or just below the pain threshold.
A cascade of physiologic responses occurs that contribute to the increased difficulty in
controlling the perception of pain. A more effective strategy for pain management is to
intervene before it escalates.
Request that the primary care provider prescribe sedative medication.
Ask the primary care provider to order a patient-controlled analgesic pump.
Encourage the use of analgesia and non-pharmacologic methods of pain
control.
Teach the client to minimize the use of analgesia to prevent a tolerance
effect.
30

As part of the collaborative plan of care, which class of medications would the nurse
expect the practitioner to prescribe for the client with newly diagnosed glaucoma?
Correct: Recall that in glaucoma, intraocular pressure rises as a result of structural
resistance (open-angle) or complete obstruction (closed-angle) to the outflow of aqueous
humor through the chamber located between the iris and cornea. Pressure is placed on the
optic nerve and blindness can result. Miotics (direct-acting cholinergics) such as
pilocarpine hydrochloride are commonly used to treat glaucoma. These drugs constrict
the pupil so that the ciliary muscle is contracted which allows better circulation of
aqueous humor.Incorrect: Antibacterial agents such as tobramycin or gentamicin sulfate
are prescribed as anti-infective agents and are not routinely given to clients with
glaucoma unless surgical intervention is required.Incorrect: Systemic anticholinergics
such as atropine would be contraindicated, especially in the client with closed or narrow-
angle glaucoma, because of the anticholinergic effects (mydriasis or pupillary dilation).
Ophthalmic atropine solution is classified as a cycloplegic mydriatic causing pupillary
dilation. These drugs are hazardous in glaucoma.Incorrect: Systemic corticosteroids can
raise intraocular pressure and even cause glaucoma. Therefore, corticosteroids decrease
the effects of all drugs used for glaucoma. However, an ocular steroid may be prescribed
following laser surgery.
Direct-acting miotic agent
Ophthalmic antibacterial agent
Systemic Anticholinergic
Corticosteroid

31

The nurse is obtaining a health history from the client scheduled for a transurethral
resection of the prostate (TURP) in the morning. Which question should the nurse ask
that is essential to the safety of the client prior to surgery?
Correct: Since bleeding can be a common postoperative problem the nurse must
carefully assess the client's medication history. The use of over-the-counter medications
that impair clotting, such as ASA and NSAIDs should be documented.Incorrect:
Although important to the overall assessment of the client with prostatic dysfunction,
determining degree of nocturia is not the most essential piece of preoperative
information.Incorrect: This would be an essential question to ask the client immediately
prior to surgery. Although assessing voiding patterns is important in the client with
prostatic disease, the question regarding aspirin therapy is essential to the client's
safety.Incorrect: Again, this would be an important question to ask the client the morning
of surgery. Questions regarding over-the-counter drugs and prescribed anticoagulants are
essential to the client's safety.
"Do you take aspirin or any blood thinners?"
"How often do you get up during the night to urinate?"
"How much did you urinate last time you voided?"
"When did you last take your medications?"
32

A client with Acquired Immunodeficiency Syndrome (AIDS) develops shingles on the

trunk. Which is the most likely rationale for this client to develop herpes zoster infection?
Incorrect: Shingles, caused by the herpes zoster virus, occurs after exposure to the
varicella-zoster virus (chickenpox).Correct: Shingles, caused by the herpes zoster virus, is
an infection of the dorsal nerve root ganglion. Increased incidence of herpes zoster occurs
in clients with AIDS, lymphoma, and leukemia because of the impaired immunologic
response.Incorrect: Herpes zoster, also known as shingles, is a viral infection not related
to a vaccination for measles, mumps or rubella.Incorrect: Herpes zoster is a viral
infection, known as shingles.
The client never had chicken pox as a child.
Shingles frequently occurs in the host with immunosuppression.
 Client received a recent measles, mumps, and rubella vaccination.
Herpes zoster is an allergic reaction to medication.
33

A client has a chest tube following a chest injury. Continuous bubbling in the water-seal
chamber of the closed drainage system would alert the nurse to which of the following?
Incorrect: Absence of tidaling of fluid in the water-seal chamber could suggest
that the tubing is obstructed by a kink or dependent fluid has filled a loop of tubing. It
also may suggest lung re-expansion. In the presence of a pneumothorax, tidaling or
fluctuation in the water-seal chamber will occur. The water level will rise on inspiration
and fall on expiration.Incorrect: Continuous bubbling in the water-seal chamber is not an
indication that the drainage system is properly functioning. As described below, excessive
bubbling may indicate a leak in the system.Correct: Unexpected or continuous bubbling
in the water-seal chamber indicates an air leak in the closed system. During forceful
expiration or coughing, bubbling is expected because air in the chest is being expelled.
Efforts must be made to identify the source of the leak.Incorrect: Tidaling of fluid in the
tubing and/or water-seal chamber will occur as long as a pneumothorax is present to any
degree. As described above, continuous bubbling suggests a leak in the system.
The affected lung is now fully expanded.
The water-seal drainage is properly functioning.
An air leak may be present in the closed system.
The pneumothorax is expanding.
34

To prevent vessel and/or tissue injury during intravenous infusion of a concentrated

potassium solution to the client with severe hypokalemia the nurse should:
Incorrect: Intravenous potassium is extremely irritating to blood vessels and
subcutaneous tissue. Potassium should NEVER be given IV push. The potassium would
be insufficiently diluted, and if infiltration occurred during administration, severe tissue
injury could occur. In addition, without proper dilution severe cardiac dysrhythmias could
result.Incorrect: Intravenous potassium should be diluted in large quantities of solution.
The recommended dilution is a solution that contains no more than 60 mEq/L in clients
with a K+ < 2.0 mEq/L and ECG abnormalities; and 30 mEq/L for clients with less severe
hypokalemia (i.e. 2.5 mEq/L) and no ECG manifestations. In clients unable to tolerate
large fluid volumes, more concentrated K+ solutions are used such as 10-20 mEq/100
mL.Incorrect: For the same reasons as discussed above, potassium should NEVER be
given as a bolus.Correct: To minimize irritation of the peripheral vein, a concentrated
KCl solution should be piggybacked into a running primary line to help dilute the
solution. To avoid fluid overload, a small volume of sodium chloride (i.e. 100 - 250 ml)
could be initiated as the primary line to facilitate the potassium infusion and then
discontinued after drug therapy. NOTE: if the client is not on a fluid restriction, and the
situation is not emergent, the best way to safely administer potassium IV is to dilute the
potassium in large volumes (i.e. 40 mEq/liter).
administer the infusion IV push slowly over 5 minutes.
dilute the potassium preparation in at least 20 mL sodium chloride.
give the potassium as a bolus preparation.
 piggyback the solution into a primary line.
35

An adult client has been vomiting persistently for 3 days. On admission he weighed 155
pounds. He states he weighed 167 pounds one week ago. Serum sodium is 155 mEq/L.
Which signs/symptoms would the nurse expect to find on assessment?
Incorrect: A bounding pulse is characteristic of hypervolemia when excess fluid is
in the vascular space. Hand veins that are slow to empty, or remain engorged when
elevated above the heart is also indication of fluid volume excess.Incorrect: A reduction
in urine specific gravity and serum osmolality indicate dilution of the vascular space as
would occur in fluid volume excess. Dehydration would cause the blood and urine to be
concentration with a resultant increase in urine specific gravity and serum
osmolality.Correct: The client is exhibiting clinical manifestations of dehydration due to
severe diarrhea occurring with inadequate volume replacement or fluid replacement with
hyperosmolar solution. Both a fluid volume deficit and hypernatremia are present. Fluid
volume deficit is manifested by postural hypotension (a key sign), tachycardia, dry
mucous membranes, elevated body temperature, weight loss, reduced urine output and
increased specific gravity. As the serum sodium rises due to loss of water, symptoms
include extreme thirst and dry, sticky mucous membranes, rough dry tongue, increased
serum osmolality, and behavioral changes such as restlessness and agitation.Incorrect: A
combination of cough, dyspnea, and peripheral edema suggest fluid volume excess with
accumulation of fluid in the lungs.
Bounding pulse and hand veins are slow to empty
Decreased urine specific gravity and serum osmolality
Postural hypotension and thirst
Cough, dyspnea, and peripheral edema

36

The client experiencing an acute myocardial infarction can be given Morphine sulfate IV
every 2-3 hours prn chest pain. The primary function of Morphine sulfate in this situation
is to:
Incorrect: Increases in oxygenation of myocardial tissue occur through the use of
vasodilators such as the nitrates. In addition, the most effective immediate intervention to
increase myocardial oxygen supply is via supplemental oxygen.Correct: Morphine sulfate
has a vasodilating effect on peripheral vessels thereby causing venous pooling and
decreasing venous return (preload). This helps to reduce the workload of the heart. The
analgesic effect of morphine also helps reduce the client's anxiety as chest pain is reduced
or eliminated. The primary function of morphine is to decrease pain and the associated
deleterious effects of pain (i.e. increased myocardial oxygen demand).Incorrect: Coronary
artery vasodilators work by increasing blood flow to the myocardium. Morphine is not a
coronary artery vasodilator.Incorrect: Antiplatelet agents such as aspirin work by
inhibiting platelet aggregation resulting in reduced clot formation. Morphine does not
have any affect on platelet aggregation.
increase oxygenation of myocardial tissue.
 decrease anxiety and reduce cardiac workload.
increase blood flow to the myocardium.
inhibit platelet aggregation.
37

A post-menopausal female diagnosed with cervical cancer is admitted for placement of a

radioactive implant. More teaching is required if the client states:
Incorrect: A foul-smelling vaginal discharge is expected from destruction and
sloughing of cells.Incorrect: Radiation precautions for internal radiotherapy include the
principles of time and distance. Visitors will be held to the same precautions as staff,
including the limitation of time at the bedside.Correct: This statement indicates the need
for more teaching since the client with a cervical implant should select a low-residue diet
to prevent abdominal distention. During treatment with an intracavity implant, it is
important that all untreated tissues remain in their normal position and not come in
contact with the radioactive device. The bowel is cleansed before therapy and a low-
residue diet is maintained during treatment to prevent bowel distention.Incorrect: The
client must be kept in bed and as flat as possible to prevent dislodgement of the
radioactive substance. Turning from side to side is permitted for comfort.
"I can expect a foul-smelling vaginal discharge."
"I realize time for visitors will be restricted."
"I will select high fiber foods throughout the treatment."
"I will remain in bed while the implant is in place."
38

In planning nursing care for the client with a left hemisphere stroke, the nurse develops
the following interventions. Which one addresses the problem of unilateral neglect?
Incorrect: This nursing intervention is aimed at addressing the problem of fluent
aphasia where the individual has difficulty comprehending speech but may be able to
speak fluently.Incorrect: This nursing intervention is aimed at addressing the problem of
hemianopsia (loss of vision in a portion of the visual field).Correct: Unilateral neglect
involves a distortion in body image in which the individual ignores the affected side of
the body. Teaching the client to monitor the position of the right side will help the person
be aware of that side and promote safety.Incorrect: This intervention is aimed at
addressing the problems of agnosia/apraxia. Agnosia is the inability to recognize familiar
objects, and apraxia is the inability to properly use objects or carry out a learned sequence
of movements.
Face the client and speak slowly and distinctly.
Place objects within the client's visual field.
Teach the client to monitor position of the right side.
Verbally cue the client about correct use of objects.
39

While caring for a postoperative client the nurse checks the most recent arterial blood
gas (ABG) values which reveal a pH 7.37, PCO2 of 40 mmHg and HCO3 of 24 mEq/L.
What conclusion can the nurse make?
Incorrect: These ABG values are within normal range. If the kidneys were
retaining fixed acids there would be evidence of metabolic acidosis with a lowered pH
and HCO3.Correct: Normally, the body maintains a ratio of carbonic acid (CO2 plus
H2O) and bicarbonate at 1:20. This ratio keeps the pH within normal limits. Since the
client's PCO2 and HCO3 levels are within normal range one can infer that the carbonic
acid/bicarbonate ratio is normal.Incorrect: Since the pH, PCO2 and HCO3 levels are all
within normal range, there is neither acidosis nor alkalosis. If respiratory alkalosis were
present, the pH would be elevated and the PCO2 would be below normal.Incorrect: If the
client were hyperventilating the PCO2 would most likely be low since carbon dioxide
would be blown off.
Kidneys are retaining fixed acids.
Carbonic acid/bicarbonate ratio is normal.
Respiratory alkalosis is present.
The client is hyperventilating.
40

In planning the care of an adult client with acute renal failure (ARF) caused by a drug
overdose, the nurse is aware that the recovery phase of the nephrons occurs when:
Correct: During the recovery phase of acute renal failure, the BUN and creatinine
levels stabilize.Incorrect: A reduction of the glomerular filtration rate occurs in the
oliguric phase when the kidney is unable to excrete metabolic wastes. This is manifested
by increased serum urea nitrogen (BUN) and creatinine levels.Incorrect: During the
recovery phase of ARF the client's energy levels generally improve but may continue to
decrease. Fatigue may last from 3-12 months.Incorrect: A marked increase in urine output
occurs in the diuretic phase of acute renal failure due to a decline in the concentrating
ability of the renal tubules and the osmotic diuretic effect of a high BUN.
BUN and creatinine levels stabilize.
glomerular filtration rate decreases.
the client's energy level returns.
urine output increases by 3 to 5 liters per day.

41

Which clinical manifestation is the most reliable indicator for a fluid imbalance?
Incorrect: Blood pressure changes often do occur with fluid and electrolyte
disturbances, however many other factors raise or lower blood pressure (i.e. coronary
artery disease, stress).Correct: Daily weight, at the same time, in similar clothing is the
most reliable means of estimating fluid gains/losses.Incorrect: Urine output only
measures the integrity of the urinary system. Intake AND output should be assessed to
determine fluid gains/losses. However, I & O is not considered the most reliable indicator
of fluid gains or losses because accuracy is hampered by many factors such as failure to
(a) explain I & O to the client and family, (b) consider that parenteral fluid bottles are
overfilled, (c) estimate fluid lost as perspiration, 'uncaught' emesis or wound exudate, (d)
record intake or output.Incorrect: Skin turgor is not considered a reliable indicator of
hydration especially in the elderly because of changes in skin elasticity. In addition, skin
color changes do not typically occur in fluid or electrolyte imbalances.
Blood pressure
Daily weight
 Hourly urinary output
Skin turgor and color
42

A client is admitted to the emergency department with a diagnosis of diabetic

ketoacidosis. Which presenting sign/symptom would the nurse expect the physician to
give highest priority?
Incorrect: Although the serum potassium level is low, it is not the highest priority.
IV potassium will be replaced once rehydration is achieved and renal output is
established.Correct: A priority intervention in treating the client with diabetic
ketoacidosis (DKA) is rehydration. Recall that hyperglycemia causes an osmotic diuresis
resulting in dehydration. Priorities in management of DKA center on rehydration and IV
insulin to control gluconeogensis and ketogenesis.Incorrect: Although the arterial pH
indicates mild acidemia, treatment with sodium bicarbonate is not indicated unless pH is
< 7.0 and client is exhibiting shock or dysrhythmia. The pH is low because in the
presence of insulin deficiency the liver will produce excessive ketones that are acidic.
This can lead to metabolic acidosis because ketones are acidic and they are retained in the
presence of dehydration and decreased urine output. However, this client's arterial pH
does not indicate severe acidosis. The priority focus should be on rehydration.Incorrect:
Although it is important to determine if the client with DKA is septic, the client's WBC is
only slightly elevated and may represent leukocytosis commonly seen in DKA.
Serum potassium 3.2 mEq/L
Dehydration
Arterial pH 7.34
WBC 11,000/mm3
43

A young male client had a positive ELISA and Western blot test for HIV three years
ago. He has been admitted to the medical unit with a diagnosis of Pneumocystis carinii
pneumonia. This client would be categorized as having/being:
Correct: In the past, clinicians used an informal staging system categorizing
clients who have experienced an opportunistic infection as having AIDS. Pneumocystis
carinii pneumonia is the most common opportunistic infection associated with HIV
infection.Incorrect: In this informal staging system, those clients classified as having
AIDS-related complex exhibited constitutional symptoms including persistent generalized
lymphadenopathy, persistent fevers, involuntary weight loss or diarrhea.Incorrect: In this
staging system, HIV positive referred to those clients who were completely asymptomatic
but HIV positive.Incorrect: Although the end result may be similar, immunosuppression
is different from immunodeficiency. AIDS is a syndrome involving immunodeficiency
from depletion of T4 helper cells resulting in a dramatic loss of the protective immune
response. On the other hand, immunosuppression involves an inhibition of the formation
of antibodies to antigens that may be present.
AIDS.
AIDS-related complex.
HIV positive.
immunosuppression.
44

Which is an appropriate nursing care goal for the client with Cushing syndrome?
Incorrect: Fluid volume excess is the primary concern in clients with Cushing's
syndrome. Recall that this syndrome involves an excess of cortisol that has
mineralocorticoid activity resulting in excessive retention of sodium and water.Correct:
Clients with Cushing's syndrome are at increased risk for infection because cortisol
excess results in decreased lymphocytes and cell-mediated immunity, and altered
antibody activity. These changes make persons vulnerable to viral and fungal
infections.Incorrect: Clients with cortisol excess are usually overweight as a result of
changes in fat metabolism. The nurse should assist the client in restricting
calories.Incorrect: Although rest and careful management of energy levels is important,
the goal is to maintain the client's current activity level and gradually increase activity
tolerance.
Control fluid volume deficit
Prevent infection
Promote weight gain
Restrict activity
45

A client with COPD is prescribed to take ipratropium (Atrovent) via a metered-dose

inhaler with spacer. The client asks the nurse why the spacer is necessary. The most
accurate response by the nurse is that the spacer:
Incorrect: The correct use of an inhaler with a spacer entails positioning the
nebulizer in the mouth WITHOUT sealing the lips around it.Correct: Because large
droplets of the aerosol fall on the walls of the spacer, and finer droplets disperse more
fully within the spacer and can be delivered deeper into the airways, each dose is used
more efficiently.Incorrect: Although it is not necessary to coordinate breathing as
carefully as it is with the standard inhaler, a deep breath should be taken while releasing a
puff of medication into the spacer.Incorrect: The metered dose inhaler delivers a
prescribed dose into the spacer. The spacer itself does not determine the dose to be given.
helps clients form a tight seal with the mouth.
ensures each dose is used more efficiently.
eliminates the need to coordinate breathing with the inhaler.
delivers medication at a prescribed dosage.

46

A client is on ventilatory assistance in the intensive care unit. Which of the following
measures should the nurse implement to prevent pneumonia in the intubated client?
Incorrect: Aspiration pneumonia can be prevented by inflating the endotracheal or
tracheostomy cuff before feeding.Incorrect: Family visitation is important to every client,
especially those individuals in the intensive care unit. Visitation is often limited in this
environment to promote rest for the acutely ill client; however, family visitation should
not be restricted to once per shift for the purposes of preventing pneumonia. Rather,
visitors should be screened for colds/flu that may be transmitted to the client and
staff.Correct: Individuals requiring mechanical ventilation for 48 hours or more have a
10% to 20% chance of developing pneumonia. One method to diminish the risk is to drain
condensation in the ventilator equipment into the designated reservoir, NOT back into the
liquid reservoir, and by changing respiratory equipment every 24 hours.Incorrect: In the
hospital environment, all tracheostomy and endotracheal airways should be managed
using sterile technique.
Maintain cuff deflation at all times.
Restrict family visitation to once per shift.
Drain tube condensation into the external reservoir.
Use clean technique when suctioning.
47

Data related to which of the following assessments would be essential prior to

administration of an aminoglycoside, such as Gentamicin?
Correct: Because aminoglycosides are nephrotoxic and ototoxic, laboratory
reports of renal function and hearing are essential baseline data. The most serious adverse
reaction is nephrotoxicity. Risks of kidney damage can be minimized by detecting early
signs of renal impairment, using cautiously in clients with impaired renal function-
including the elderly-and keeping clients well hydrated.Incorrect: There are not serious
pulmonary side effects to this category of drugs.Incorrect: The aminoglycosides are not
known to cause cardiac or coagulation problems.Incorrect: Serum electrolytes and acid-
base balance may be altered in the client who receives an aminoglycoside and
experiences nephrotoxicity. However, the essential baseline data should be direct tests of
renal function such as BUN and creatinine.
Audiometry, BUN/creatinine
Chest x-ray, pulmonary function tests
Electrocardiogram, coagulation studies
Serum electrolytes, arterial blood gases
48

For the client with chronic renal failure, one of the goals of diet therapy is to:
Incorrect: Because potassium retention occurs in chronic renal failure due to
reduction in the nephrons excretory ability, a diet low in potassium is recommended. This
includes reducing intake of foods high in potassium such as citrus fruits, green leafy
vegetables, and salt substitutes.Incorrect: Ample calories are required for growth and
repair and should be obtained from carbohydrates and fats because they do not require
renal excretion of metabolic by-products.Incorrect: Although sufficient calories are
required for growth and repair of the kidney, too many calories can place an increased
excretory demand on the kidney.Correct: A key goal of the diet for clients with chronic
renal failure is reducing the quantity of metabolic waste that requires excretion by the
kidney (i.e. protein). Therefore, protein intake is restricted to 1-1.5 g/kg of ideal body
weight. This is sufficient to promote healing but also limits excretory demands on the
kidney.
increase the intake of foods high in potassium to promote electrolyte
balance.
limit carbohydrates and fats to reduce excretory demands.
 maximize caloric intake to promote healing.
restrict protein intake to decrease metabolic waste.
49

A client is scheduled to have a thoracentesis to remove excessive pleural fluid. The nurse
helps prepare the client for this procedure by explaining that:
Incorrect: During a thoracentesis it is important to emphasize to the client the
importance of NOT moving during the procedure to avoid damage to the pleura and lung.
Therefore, sedation is not administered since the cooperation of the client is
essential.Correct: Coughing is also avoided during the procedure to avoid damage to the
pleura of the lung.Incorrect: Supplemental oxygen should NOT be discontinued during
the procedure especially in the client who is having difficulty breathing.Incorrect: The
best position to facilitate removal of pleural fluid is to have the client lean over the
bedside table with the head and crossed arms resting on several pillows, and the feet
supported by a footstool.
a sedative will be given prior to the exam.
coughing should be avoided during the procedure.
oxygen is temporarily discontinued.
positioning will involve lying on the affected side.
50

During a health assessment of a post-menopausal female, the nurse documents the client's
complaint that she "frequently loses urine." The nurse suspects stress incontinence.
Which additional information should the nurse gather?
Incorrect: Alcohol generally acts as a diuretic and increases urine output. The
exact nature of alcohol consumption is not relevant to the incidence of stress
incontinence.Incorrect: Medications, such as hypnotics, tranquilizers, sedatives, and
diuretics, are contributing factors to “urge” incontinence.Incorrect: Stress incontinence is
seen primarily in women who have relaxed pelvic muscles. Diet has not been implicated
in the etiology of incontinence.Correct: Stress incontinence involves a loss of 50 ml or
less of urine following an activity that increases intraabdominal pressure on the bladder
such as lifting, coughing, sneezing, or laughing.
Alcohol consumption
Current medications
Diet history
Precipitating factors

51

An emergency room nurse is asked to develop a plan of care for clients who experience
eye trauma. Which intervention should be included in those plans?
Incorrect: Irrigation with copious amounts of a nontoxic solution such as water or
saline would be appropriate if the visible foreign object was a loose substance such as dirt
or an insect, or if the client sustained a chemical burn to the eye. In the case of an
embedded or penetrating object, it is essential that an ophthalmologist evaluate the client's
eye before any treatment is initiated. Blindness could occur if the injury is
mistreated.Incorrect: Penetrating objects should not be removed. The eye should be
protected with a shield such as a paper cup, the uninjured eye should be covered to
prevent excess movement of the injured eye, and medical assistance obtained.Incorrect:
To avoid further trauma, both eyes are patched. A pressure dressing is avoided to prevent
further trauma.Correct: It is important to establish a baseline and evaluate vision before
initiating treatment (as well as after). The exception is chemical burns to the eye, in which
case flushing with saline irrigations is begun immediately.
Immediately irrigate all injuries with a saline solution.
Gently remove any penetrating objects.
Cover the injured eye immediately with a pressure dressing.
Briefly assess visual acuity prior to treatment.
52

As part of the treatment plan for the client with gastroesophageal reflux disease (GERD),
the physician has prescribed omeprazole (Prilosec). This drug acts primarily by:
Incorrect: The prokinetic agents such as cisapride (Propulsid) act by enhancing GI
motility.Incorrect: The prokinetic agents (i.e. Propulsid) increase strength of esophageal
peristalsis and increase lower esophageal sphincter pressure to prevent reflux.Incorrect:
Antacids are given to neutralize gastric acids or buffer it's effects.Correct: Omeprazole
(Prilosec) is classified as a proton pump inhibitor and acts by inhibiting gastric parietal
cells and suppressing gastric acid secretion by more than 90%. The histamine (H2)
receptor antagonists such as cimetidine (Tagamet) and ranitidine (Zantac) also reduce
gastric acid secretion.
enhancing GI motility.
increasing lower esophageal sphincter pressure.
neutralizing gastric acid.
suppressing gastric acid secretion.
53

The nurse is conducting a stop smoking clinic and includes a discussion of laryngeal
cancer. Participants should be informed that a classic, early symptom of laryngeal cancer
is:
Incorrect: Signs of metastases of laryngeal cancer to other parts of the larynx
include pain in the Adam's apple that radiates to the ear.Correct: Chronic hoarseness,
especially in an individual who smokes is the most common presenting symptoms of
laryngeal cancer. This is often associated with dysphagia. If treatment is initiated when
hoarseness first appears a cure is usually possible.Incorrect: Enlarged cervical lymph
nodes are considered late manifestations of laryngeal cancer as a result of
metastases.Incorrect: Airway obstruction is a sign of advanced laryngeal cancer.
pain in the ear.
chronic hoarseness.
enlarged cervical nodes.
airway obstruction.
54
The nurse who provides health care maintenance care to a group of elderly women in a
low-income apartment setting recognizes which assessment sign is related to the presence
of osteoporosis in this population?
Incorrect: The loss of appetite and muscle tissue wasting can occur in many
disease states or use of various types of medications. Osteoporosis is a condition in which
bone demineralization causes a reduction in bone density and mass.Correct: Osteoporosis
is a common age-related metabolic bone disease in which there is reduced skeletal bone
mass. The risk of fracture is caused by the bone fragility, especially in the hip, wrist and
vertebrae. The clinical expression of post-menopausal osteoporosis may be the “dowager
hump” and reduced height.Incorrect: A limitation in range of motion of the elbow and
knee joints is most likely related to the pain associated with arthritic changes.Incorrect:
An unstable gait and frequent falls signal neurological disease or stroke.
Loss of appetite and wasting of muscle tissue
Loss of height and a "humped" appearance to the upper back
Inability to straighten the elbows and knees
Unstable gait and frequent falls
55

In the client who is receiving a combination of furosemide and digoxin, the nurse should
give high priority to assessing for digoxin toxicity when:
Incorrect: These GI effects commonly occur with digoxin therapy. Although the
presence of these symptoms raises suspicion of digitalis toxicity, many other conditions
may cause anorexia and nausea. These symptoms may be side effects of other drugs such
as diuretics. The priority assessment indicator is hypokalemia.Incorrect: Digoxin has a
low therapeutic index. Concurrent treatment with other drugs affecting the heart, such as
quinidine, verapamil, or nifedipine can contribute to digoxin toxicity. Opioids are not
known to enhance digoxin toxicity.Incorrect: The desired effects of digoxin therapy are: a
reduction in heart rate (negative chronotropic effect), and an increase in myocardial
contractility (positive ionotropic effect). However, bradycardia may indicate digoxin
toxicity.Correct: Electrolyte imbalances such as hypokalemia, hypomagnesemia, and
hypercalcemia are known factors in promoting digoxin toxicity. The most common
electrolyte disturbance is hypokalemia because potassium-losing diuretics are often given
concurrently with digitalis preparations in the treatment of congestive heart failure.
Hypokalemia increases cardiac excitability and increases the risk of digoxin toxicity.
anorexia and nausea occur.
given concurrently with opioids.
pulse rate drops from 90 to 68 bpm.
serum potassium falls.

56

Increased intracranial pressure (ICP) can occur due to a variety of diseases or injuries.
Which physical assessment finding is an early sign of ICP in a client with a head injury?
Correct: Increased intracranial pressure (ICP) is the pressure exerted in the
cranium by the pressure of blood, edema, and impaired flow of cerebral spinal fluid
(obstruction or infection.) The first and most sensitive indicators of ICP are the subtle
changes in orientation and level of consciousness. Behavioral changes may include:
restlessness, irritability, confusion, and decreased score on the Glasgow Coma
Scale.Incorrect: The nurse may assess bradycardia and irregular respiratory pattern
(Cheyenne Stokes) in the client in the later phases of increased intracranial
pressure.Incorrect: The nurse may assess pupils that are fixed and dilated in the client
experiencing the later phase of ICP. Sluggish papillary reactions or blurred vision occur
in the earlier response to ICP.Incorrect: A sign that a client has developed ICP in an
advanced phase is decreased motor activity or paralysis.
Change in orientation and level of consciousness
Bradycardia and tachypnea
Fixed and dilated pupils
Decreased motor activity or paralysis
57

Following a left, radical mastectomy the nurse assesses the wound and positions the left
arm on pillows so that the hand is higher than the elbow and the elbow is higher than the
shoulder. The primary reason this position is important is because it:
Correct: This position prevents venous pooling in the hand and forearm by
increasing venous return, promoting lymphatic flow, and prevent lymphedema. In the
client who had a large number of lymph nodes dissected, lymphedema can occur and lead
to infection. Clients must be taught how to prevent lymphedema through positioning and
exercise.Incorrect: Elevating the arm would increase venous return - a desired goal in the
management of lymphedema following radical mastectomy.Incorrect: Shoulder problems
can occur if the client does not adhere to the prescribed exercise regimen. Performance of
arm exercises helps restore full range of motion to the arm and shoulder, preventing
a 'frozen shoulder' from lack of normal movement. However, the reason the arm is
elevated is to promote lymphatic drainage.Incorrect: Although this position may enhance
comfort, the primary reason for keeping the affected arm elevated is to promote lymphatic
flow.
enhances lymphatic drainage.
decreases venous return.
prevents shoulder subluxation.
reduces pain.
58

In planning care for the client with renal calculi, the most appropriate outcome would be
to expect the client to:
Incorrect: Clients with renal stones typically are not febrile. However, the
presence of renal calculi can lead to an increased risk for infection in susceptible
individuals. Pain or renal colic is the primary symptom in an acute episode of renal
calculi. Hematuria may be present if the stone has rough edges.Incorrect: An intake of
1000 mL daily is too low. Adequate hydration involves at least 2500 mL/day or more to
help prevent urinary stasis that can lead to stone formation and UTI.Correct: Because
stones can obstruct the ureters, the most important goal or outcome is to ensure urinary
elimination by measuring I & O.Incorrect: The client may or may not need to acidify the
urine based on the mineral composition of the stones. For example, phosphate calculi
develop in alkaline urine, therefore prevention depends on keeping the urine acidic. On
the other hand, uric acid stones tend to develop in acidic urine, therefore alkalinizing the
urine is helpful. To facilitate treatment, a 24-hour urine collection is performed to
determine urine pH and elements such as calcium, phosphorus, and uric acid levels.
demonstrate a reduction in fever.
consume at least 1000 mL of fluids/day.
maintain urine output equal to intake.
verbalize ways to acidify the urine.
59

The nurse teaches nursing assistants to recognize and notify the nurse when traction is
interrupted for clients in Russell's traction. Which finding indicates a need to notify the
client's nurse?
Incorrect: As long as traction is maintained, the head of the bed may be
elevated.Incorrect: The elevation of the foot of the bed may be used at times for counter
traction.Correct: Russell's traction is a modification of Buck's traction. This type of
traction adds a vertical pull by placing a sling under the leg above the knee. For effective
use of traction, it is essential that the weights are hanging freely.Incorrect: The client is
encouraged to move the unaffected extremities to reduce the risk of fat embolism
syndrome, pressure-related skin injury, and muscle soreness.
Head of the bed is elevated
Foot of the bed is elevated
Weights are not hanging freely
Client is moving the unaffected leg
60

While a client is receiving a blood transfusion, the nurse continually assesses for the most
common symptoms of a nonhemolytic transfusion reaction. These symptoms include:
Correct: The characteristic symptoms of a febrile, nonhemolytic transfusion
reaction are sudden chills and fever, headache, flushing and anxiety. This type of reaction
occurs when the recipient becomes sensitized to the donor's WBC, platelets, or
plasma.Incorrect: Urticaria, wheezing, and hypotension, chest tightness, and signs of
shock are clinical manifestations of an anaphylactic reaction to blood
components.Incorrect: Flushing, itching, and urticaria are typically symptoms of a mild
allergic reaction to transfusion therapy caused by sensitivity of the recipient to foreign
plasma proteins.Incorrect: Dyspnea, jugular vein distention, and hypertension are some of
the signs/symptoms of circulatory overload that may occur if blood is given to rapidly or
in the client with congestive heart or renal failure.
sudden onset of chills and fever.
urticaria, wheezing and hypotension.
flushing, itching, and urticaria.
dyspnea, jugular vein distention, and hypertension.
61

Immediately following the application of a cast to a client's fractured forearm, the nurse
needs to closely monitor the:
 Incorrect. Although management of the airway and breathing are always the
priority for care, no information is presented in the stem to suggest that the airway or
breathing has been compromised at the time of the cast application.Incorrect. Nutritional
status is not a priority for nursing care at the time of cast application, but will require
attention later. The assessment of the color, movement of distal fingers and toes, swelling,
pulses distal to cast, and sensation indicates adequacy of the neurovascular status of the
extremity.Incorrect. The psychosocial response to injury is not a priority for the care of a
client with a newly applied cast. The assessment of the color, movement of distal fingers
and toes, swelling, pulses distal to cast, and sensation indicates adequacy of the
neurovascular status of the extremity.Correct. A cast is a temporary device used for: 1)
immobilization, 2) prevention or correction of a deformity, 3) bone realignment, or 4)
promotion of healing, which allows for weight bearing and ambulation. Thorough
assessment and prompt intervention are essential to prevent cast-related complications.
The assessment of the color, movement of distal fingers and toes, swelling, pulses distal
to cast, and sensation indicates adequacy of the neurovascular status of the extremity.
client's airway and breathing.
nutritional status of the client.
client's psychosocial response to injury.
neurovascular status of the injured arm.
62

A client arrives in the emergency department with an acute head injury suspected to be an
intracranial hemorrhage. The nurse includes which intervention as a priority in the plan
for care?
Correct: The neurologic assessment (Glasgow Coma Scale) provides more data
regarding the status of the client with acute head injury. The components of the scale
includes: eye, motor and verbal response. The cranial nerve exam is performed in the
assessment of the components: papillary response, extra-ocular movements, tracking,
blink and gag reflexes, facial muscles, speech patterns, and any other pertinent neurologic
findings.Incorrect: Measurement of the intake and output volumes is not priority care
measures in the care of the client with a suspected intracranial hemorrhage. The
neurologic assessment (Glasgow Coma Scale) provides more data regarding the status of
the client with acute head injury.Incorrect: The vital sign assessment may change
(bradycardia, abnormal respiratory pattern, increased systolic blood pressure and widened
pulse pressure), however, subtle changes in level of consciousness usually precedes
alterations in cardiorespiratory status.Incorrect: There may not be any external signs of
bleeding with an acute head injury.
Make frequent neurological assessments.
Measure the client's intake and output.
Monitor the client's vital signs frequently.
Observe for signs of bleeding form the ears.
63

An adult client with cirrhosis of the liver has developed ascites. The serum sodium is 145
mEq/L and potassium is 3.2 mEq/L. Which of the following primary care provider orders
should the nurse question?
 Incorrect: Although sodium restriction is often based on a 24-hour urine collection
to determine sodium loss, sodium is generally restricted to 1 g (1000 mg) daily for clients
with ascites.Correct: An intravenous infusion of 0.9% sodium chloride would be
contraindicated in the client who is retaining sodium and water. This order should be
questioned by the nurse.Incorrect: Fluids are restricted if hyponatremia is caused by fluid
retention. A restriction of 1500 ml/24 hours is reasonable for the dilutional effect. A
severe fluid restriction, coupled with diuretic therapy could lead to decreased output and
renal failure.Incorrect: If bedrest and sodium restriction do not improve ascites, diuretics
may be used. Spironolactone (aldactone) is often the first diuretic chosen because it
promotes potassium retention. Note the client's K+ level is low, a common finding in
clients with cirrhosis because aldosterone metabolism is impaired. Although thiazide
diuretics may be used, they may worsen hypokalemia.
1000 mg of sodium per day.
0.9% NaCl to infuse IV at 50 cc/hr
1500 mL/24 hour fluid restriction
Spironolactone 25 mg bid
64

While conducting an assessment for a client following a craniotomy, the nurse observes
yellowish drainage on the dressing. The nurse should:
Incorrect: Yellowish drainage should be immediately reported to the surgeon
because it may indicate a cerebrospinal fluid (CSF) leak. After notifying the surgeon, the
nurse should mark the drainage area with a pen in order to determine additional drainage
at a later assessment.Incorrect: It would be inappropriate to delay reporting this finding to
the surgeon since the yellow drainage may indicate leakage of CSF. Dressing
reinforcement is generally appropriate when excessive drainage is expected and the
original dressing is not to be removed. In this case, it would be important to evaluate the
extent of drainage over time by marking the area on the original dressing and continue to
observe.Incorrect: Surgeons generally have individual preferences regarding changing
head dressings. Assessing the incision would not provide a further data regarding the
yellow drainage. The presence of yellow drainage on a head dressing signals a possible
CSF leak and should be immediately reported.Correct: Surgeons generally have
individual preferences regarding changing head dressings. Assessing the incision would
not provide a further data regarding the yellow drainage. Yellow drainage could signal a
CSF leak and should be immediately reported.
outline the drainage area and reassess in one hour.
reinforce the dressing, document, and continue to observe.
remove the dressing and assess the incision.
report this finding immediately to the surgeon.
65

During a follow-up assessment after discharge from the hospital, a client diagnosed with
epilepsy verbalizes to the nurse, "I'm constantly worried that I'll have a seizure and lose
control. I'm afraid to go back to work or see my friends anymore." Which is the most
appropriate nursing diagnosis for this client?
Incorrect: The nursing diagnosis 'ineffective management of the therapeutic
regimen” relates to the medication schedule and therapeutic drug levels and not the
client's self-concept or adaptation to the illness.Incorrect: The nursing
diagnosis “impaired verbal communication” relates to the expressive or receptive aspects
of language. The client with epilepsy does not experience impairment to the language
center except during the seizure event.Incorrect: The nursing diagnosis “risk for injury
due to seizures” relates to the physical risk of injury during a seizure event. This situation
pertains to the client's response to the condition and perceived self-concept as a
result.Correct: The nursing diagnosis “self esteem disturbance related to the diagnosis of
epilepsy” relates to the client's feelings and perceptions of self that has occurred as a
result of the change in health status. Many clients who are diagnosed with epilepsy fear
the onset of a seizure in a public setting.
Ineffective management of therapeutic regimen
Impaired verbal communication
Risk for injury due to seizures
Self-concept disturbance related to diagnosis of epilepsy

66

A client diagnosed with acute pancreatitis has a history of alcoholism and opioid abuse.
Morphine 10-15 mg IV prn q 3-4 hours is ordered. Three hours after an initial dose the
client is crying and asking for more morphine. Which intervention is indicated for the
care of the client?
Correct: The nurse should administer morphine. Nurses often fear giving
prescribed analgesics will increase addiction and therefore under-medicate the client.
Keeping the client in pain may actually contribute to a relapse of the addiction. In
addition, it is common for the drug-addicted individual to require higher doses of
analgesics than the average person.Incorrect: Placebos are unethical unless part of a
research protocol where client consent has been obtained.Incorrect: Although non-
pharmacological strategies are effective in diminishing the perception of pain; medication
should not be withheld, especially when the request for the analgesic is within the
prescribed time frame.Incorrect: Again, the client should not be penalized by withholding
pain medication. The client should receive pain medication for only as long as s/he
requires it.
Administer morphine 15 mg as prescribed.
Give a saline placebo.
Substitute distraction techniques for opioid administration.
Withhold the drug for another hour.
67

After administering a calcium channel blocker, which of the following desired outcomes
does the nurse expect?
Correct: Through coronary vasodilation, calcium channel blockers result in
decreased frequency and severity of anginal attacks.Incorrect: Calcium channel blockers
such as verapamil cause systemic vasodilation resulting in decreased blood
pressure.Incorrect: The calcium channel blockers do not have any diuretic effect. It
should be noted that these agents are contraindicated in clients with congestive heart
failure since they may reduce contractility and cardiac output.Incorrect: Although calcium
channel blockers have a vasodilating effect, they are not known to relieve the pain
associated with arterial occlusion. Agents prescribed for intermittent claudication, such as
pentoxifylline (Trental) improve blood flow by decreasing blood viscosity rather than by
vasodilation.
Decreased frequency and severity of angina
Increased blood pressure
Reduction in peripheral edema
Relief of intermittent claudication
68

The nurse supervising care of clients with Alzheimer's disease in an adult day care
identifies which of the following as the priority nursing diagnosis:
Correct: The client's safety is always paramount to the plan of care. Because
clients with Alzheimer's disease are prone to wandering, agitation, confusion, and
seizures, risk for injury is high. Memory loss, impaired judgment, inability to make
decisions, and decreased attention span all contribute to the risk for injury.Incorrect: The
cognitive and biochemical changes in Alzheimer's disease affect personality and
behavior. The client may begin to withdraw from friends and social events as memory
impairments and personality changes become more apparent. While it is important for the
nurse to minimize the impact of social isolation, the priority care concern is
safety.Incorrect: In the early stages of Alzheimer's disease when memory and cognitive
impairments are mild, clients may feel anxious and frustrated as they realize cognitive
changes are occurring. As social interactions decrease, the client may feel alienated and
powerless to do anything about it.Incorrect: Although this nursing diagnosis is extremely
relevant to the care of clients with Alzheimer's disease, matters of safety take priority.
One could argue that altered thought processes are the etiology of risk for injury, and that
the diagnosis of altered thought processes is indeed a priority. However, the plan of care
for the diagnosis of altered thought processes focuses primarily on promoting effective
communication and reality orientation.
safety due to memory loss and impaired judgment.
social isolation due to diminishing social relationships.
anxiety due to perceived powerlessness.
altered thought processes due to dementia.
69

The biopsy report for the client after a colon resection indicates a grade 3, stage 3
adenocarcinoma. In planning care for this client, the nurse understands that the tumor:
Correct: Grade 3 neoplasms are poorly differentiated (extensive structural changes
from tissue of origin). Loss of differentiation means a higher degree of malignancy. Stage
3 lesions involve extensive local and regional spread.Incorrect: Well-differentiated
neoplasms retain characteristics similar to the parent tissue and therefore are less
invasive. This is characteristic of grade 1 lesions.Incorrect: Neoplasms that are localized
without spread to adjacent tissue or other organs are classified as stage 2
lesions.Incorrect: Benign neoplasms are often encapsulated and therefore have limited
growth potential.
 has metastasized to regional tissue.
is similar to normal tissue and slow growing.
was confined to the intestinal wall.
was encapsulated and completely removed.
70

The nurse administers the MMR vaccine to a child in the health clinic. Which type of
immunity will this child possess?
Correct: Active artificial immunity is acquired through administration of antigens
(vaccines or toxoids) to stimulate antibody production.Incorrect: Active natural immunity
is acquired by the body's own efforts to form antibodies in the presence of active
infection. An example is the individual who has had any of the childhood diseases such as
chickenpox, measles, or the mumps.Incorrect: Passive artificial immunity is acquired by
administering an antibody from an animal or another human. An example is
administration of immune globulin to the person exposed to hepatitis B, or administration
of tetanus immune globulin for prophylaxis against tetanus.Incorrect: Passive natural
immunity is acquired when antibodies are transferred naturally from an immune mother
to her baby through the placenta or in colostrum.
Active artificial immunity
Active natural immunity
Passive artificial immunity
Passive natural immunity

71

A 32-year-old female complains of having 10-12 diarrhea stools per day that contain
bloody mucus and left-sided abdominal cramping prior to each stool. She states she has
little desire to eat and has lost approximately 10 pounds in the last 2 weeks. Based on this
data, which is the most likely cause of the client's symptoms?
Incorrect: Cholecystitis is characterized by sudden onset of pain in the RUQ that
often radiates to the right scapula or shoulder, and may be associated with eating a large
or fatty meal. Bowel sounds may be decreased or absent and anorexia, nausea, and
possibly vomiting may be present.Incorrect: Crohn's disease and ulcerative colitis are
classified as inflammatory bowel disease. Although anorexia and weight loss often occur
in both types of inflammatory bowel disease, symptoms of Crohn's disease differ from
ulcerative colitis in that stools are large, semisolid, fewer in number (3-5/day), and rarely
contain blood. Diffuse, colicky abdominal pain or localized pain in the right lower
quadrant is characteristic of Crohn's disease. Symptoms may resemble those of
appendicitis.Incorrect: The clinical manifestations of diverticulitis include crampy lower
left quadrant pain, low-grade fever (a classic sign), feeling of bloating, nausea and
vomiting.Correct: One of the distinguishing clinical manifestations between Crohn's
disease and ulcerative colitis is bloody diarrhea. Clients with ulcerative colitis often
experience profuse diarrhea (15-20 stools per day) containing a mixture of blood, mucus,
and possibly pus. Left-sided abdominal cramping can be present prior to the bowel
movement and is relieved by emptying the bowel. Significant losses of fluids and
electrolytes can occur as well as weight loss.
Cholecystitis
Crohn's disease
Diverticulitis
Ulcerative colitis
72

A client inadvertently takes too many Coumadin tablets. The nurse anticipates the
practitioner will order which of the following as an antidote?
Incorrect: Acetyocysteine is the antidote for acetaminophen.Incorrect: Naloxone is
the antidote for opioid analgesics.Incorrect: Protamine sulfate is the antidote for
heparin.Correct: Vitamin K is the antidote for warfarin (Coumadin).
Acetyocysteine
Naloxone
Protamine sulfate
Vitamin K
73

The nurse is planning care for a client with hepatitis A. The nurse includes measures to
prevent secondary transmission of the virus. Which intervention would most effectively
achieve this goal?
Correct: Hepatitis A virus is transmitted by the fecal-oral route, often through
food contaminated by infected food handlers. Preventing spread of infection must include
enteric precautions (wearing gloves when handling feces/urine).Incorrect: A private room
is necessary only if the client cannot implement self-care measures for disposal of feces
and urine (i.e. confusion, incontinence).Incorrect: Hepatitis B virus is transmitted through
blood and body fluids.Incorrect: Contact precautions are used for clients known to have
diseases easily transmitted by direct client contact. Contact precautions would be
appropriate with hepatitis A in the client who is diapered or incontinent.
Enteric precautions
Private room
Wearing gloves when handling blood
Contact precautions
74

Which assessment data is essential to evaluate the effectiveness of oxygen therapy?

Incorrect: Although the carbon dioxide level in arterial would be helpful
information in evaluating the client's gas exchange and overall oxygenation status, it is
not essential in evaluating O2 therapy. The PCO2 is a measurement of ventilation but is
most essential in evaluating acid-base status since the PCO2 is the respiratory component
in acid-base determinations.Incorrect: Although skin color is an important component in
assessing tissue oxygenation, it is not a reliable indicator since pallor may be difficult to
determine in clients with darker skin tones. The same is true in assessing cyanosis. Color
changes must be assessed in a variety of places such as buccal mucosa, conjunctiva, lips,
nail beds, and palate based on underlying skin tones.Correct: Either the PO2 or the
oxygen saturation gives the most accurate information about arterial oxygenation. The
PO2 is an indirect measure of O2 content of arterial blood. O2 saturation is an indication
of the percentage of hemoglobin saturated with O2. Since the partial pressure of oxygen
(PO2) is the driving force behind O2 saturation, both are useful in evaluating the
effectiveness of O2 therapy. Pulse oximetry is a common method of measuring O2
saturation.Incorrect: Hemoglobin levels are essential to maximize the blood's oxygen-
carrying capacity since oxygen attaches to the hemoglobin molecule. However, the
client's hemoglobin level does not provide data about the effectiveness of oxygen therapy.
Arterial CO2 level
Skin color
Oxygen saturation
Hemoglobin level
75

A client with a deep vein thrombosis has been receiving heparin therapy for two days.
The morning APTT is 40 seconds. Which intervention should the nurse anticipate?
Incorrect: The APTT value is at the low end of therapeutic range. In addition, the
client has only been receiving heparin therapy for two days. A standard protocol calls for
administration of a continuous infusion of heparin for at least 5 days.Correct: The normal
control value for the activated partial thromboplastin time (APTT) is 25-35 seconds.
During heparin therapy, the APTT should be maintained at about 1.5 to 2.5 times the
control. Therefore, therapeutic values are 35-85 seconds. This client's APTT is at the low
end of the therapeutic value. Thus, the most likely intervention would be to increase the
heparin infusion rate.Incorrect: The normal control value for the activated partial
thromboplastin time (APTT) is 25-35 seconds. During heparin therapy, the APTT should
be maintained at about 1.5 to 2.5 times the control. Therefore, therapeutic values are 35-
85 seconds. The APTT value indicates the need for increasing the heparin rate to enhance
therapeutic drug levels.Incorrect: Although the APTT is closely monitored throughout
heparin therapy (i.e. approximately every 6 hours), there is no indication in this case for
repeating the APTT before action can be taken. If the APTT value were extremely low or
high a repeat value would be recommended.
Discontinue drug therapy.
Increase the heparin infusion rate.
Maintain current heparin therapy.
Repeat the APTT before any other action.

76

A nurse is observing a client who is being evaluated for possible appendicitis. During the
diagnostic period, which intervention is appropriate?
Incorrect: Enemas or laxatives may increase peristalsis and cause the appendix to
rupture.Correct: To avoid masking critical changes in symptoms, pain medication is
usually withheld until a definite diagnosis of appendicitis has been made.Incorrect: Heat
should be avoided because the increased circulation to the appendix can lead to
rupture.Incorrect: In preparation for possible surgery, the client is given nothing by mouth.
Cleansing the GI tract with saline enemas in preparation for surgery
Withholding analgesics until a diagnosis is established
 Applying heat to the right lower quadrant to promote comfort
Restricting the client to clear liquids to reduce nausea
77

The home health nurse is working with a client who is in the convalescent phase after a
cerebrovascular accident. Which statement by the client indicates to the nurse that further
teaching regarding bowel training is needed?
Correct: If a client indicates s/he frequently uses an enema more teaching is
required. A bowel program of stool softeners, fiber laxatives, and suppositories is
generally implemented to support bowel regularity. Enemas and harsh laxatives are
avoided to prevent diarrhea and fluid and electrolytes imbalances.Incorrect: The client
learned this concept well. Sufficient fluid intake, at least two liters daily, is necessary to
maintain bowel patterns and promote proper stool consistency. Fiber without adequate
fluid can aggravate bowel function.Incorrect: Incorporating the client's circadian rhythms
into the bowel management program may be helpful in promoting defecation at a regular
time.Incorrect: The client is adhering to an important aspect of bowel management. A
well-balanced diet high in fiber stimulates peristalsis.
"I find I need an enema almost every day."
"I am drinking between six and eight glasses of fluid a day."
"My care taker helps me use the toilet at 2 p.m. every day."
"I have increased the fiber in my diet."
78

When planning an influenza immunization clinic, which of the following groups

should be included because they are considered at high risk for flu and respiratory
complications?
Correct: The Advisory Committee for Immunization Practices (ACIP)
recommends immunization against influenza for all persons at increased risk of adverse
consequences from infection of the lower respiratory tract. This would include all persons
older than 65 years of age, infants and children more than 6 months of age who are at
increased risk for complications of influenza because of underlying medical conditions,
and all health care workers.Incorrect: This age group is not considered in a high-risk
category for serious consequences from infection of the lower respiratory tract.Incorrect:
Children in general are not considered at high risk unless they have an underlying medical
condition that places them at risk for adverse consequences from influenza.Incorrect: This
age group is not considered by the ACIP as a high-risk group.
Elderly residents of long term or chronic care facilities
College students in athletic training season
Children that spend 3 days a week or more in day care
High school students who ride the bus to school
79

A client with a known history of alcoholism presents to the emergency department

disoriented to time and place and vomiting dark emesis. The nurse realizes the first
priority should be to:
Correct: Esophageal varices can easily rupture causing excessive bleeding,
hypovolemia, and shock. The client's disorientation and dark emesis suggest bleeding
therefore assessment of vital signs is the first priority to evaluate hemostasis.Incorrect:
Testing stool for blood is an appropriate assessment choice, however it would not be the
first priority in the client exhibiting disorientation and dark emesis.Incorrect: Although
esophageal tamponade may be required, other treatment measures are indicated especially
if severe hemorrhage is not present. Gastric lavage and/or pharmacologic therapy using
vasopressin may be tried initially.Incorrect: Checking prothrombin time would be
important for monitoring the client's bleeding potential, which is often increased due to
poor vitamin K absorption, impaired production of clotting factors, and
thrombocytopenia. However, the priority intervention when bleeding is evident is to
assess the client's hemodynamic status which includes pulse and blood pressure.
assess pulse and blood pressure.
obtain a stool specimen for guaiac.
prepare the client for esophageal tamponade.
perform phlebotomy to check prothrombin time.
80

A 55-year-old male suspected of having prostate cancer is admitted to the hospital.

Which symptoms would be consistent with this diagnosis?
Incorrect: These are clinical manifestations of testicular cancer. Signs/symptoms
of testicular cancer are often subtle until the person notices a feeling of heaviness in the
lower abdomen and groin. A painless lump or swelling may be present. Other nonspecific
symptoms include weight loss, fatigue, and back pain.Correct: When the enlarged
prostate gland impinges on the urethra, obstruction of urinary flow occurs. As a result, the
bladder wall changes in contour creating pockets for urinary retention. Consequently the
bladder has less capacity, muscle tone diminishes, and the bladder cannot empty
completely at each voiding, and urinary stasis creates a fertile medium for bacterial
growth and infection. Symptoms include urinary hesitancy, difficulty starting the stream,
retention, nocturia, dysuria, urgency, and symptoms of UTI.Incorrect: A combination of
hematuria, bilateral flank pain, fever, and pyuria is characteristic of adult polycystic
kidney disease. Cysts are usually bilateral and diffusely scattered throughout the renal
parenchyma causing pain, hematuria, and cyst infections.Incorrect: These are common
clinical manifestations of epididymitis, a common inflammatory process most often
caused by an ascending infection via the ejaculatory duct through the vas deferens into
the epididymis.
Back pain, painless testicular swelling, and weight loss
Dysuria, frequency, urgency, hematuria, nocturia, and retention.
Hematuria, bilateral flank pain, fever, and pyuria
Scrotal pain and swelling, urethral discharge, and low-grade fever

81

Which symptom of Candida albicans, an opportunistic disease, is an early indication of

human immunodeficiency virus (HIV) disease?
Incorrect: Floaters, decreased vision and blindness are symptoms of
Cytomegalovirus (CMV) retinitis. This is the most clinically significant type of infection
in clients with HIV infection.Incorrect: Nodular lesions of the skin are likely to be
Kaposis sarcoma. This common assessment finding is evident on the external skin
surfaces.Incorrect: Fever, night sweats and chronic cough are symptoms of Pneumocystis
carinii pneumonia. This respiratory complication is the most common life-threatening
infection in clients with AIDS.Correct: Whitish-yellow patches in the mouth are
characteristic of candidiasis. This secondary fungal infection, commonly caused by
candida albicans, thrives in a warm, moist environment, such as the mucous membranes
of the mouth, vaginal or intestinal tract. The opportunistic infection occurs frequently in
the immunocompromised host, such as the client with AIDS.
Floaters, decreased vision, and blindness
Nodular lesions on the skin
Fever, night sweats, and chronic cough
Whitish-yellow patches in the mouth
82

Assessing a client with osteoarthritis, the nurse recognizes that the most common clinical
manifestation of the disease is:
Incorrect: Rheumatoid arthritis (RA) is a chronic, systemic, progressive,
inflammatory connective tissue disorder. It affects primarily the small, peripheral joints
with symmetrical distribution. This systemic disease affects all connective tissue,
including the collagen of the heart, muscles, tendons, pleura or blood vessels. As the
disease destroys the joints, the client experiences pain, stiffness, redness, warmth and
swelling to the joints.Correct: Osteoarthritis is a non-inflammatory joint disease
characterized by degeneration and loss of articular cartilage in synovial joints. This
disease is not associated with chemical or metabolic degeneration as there is in
rheumatoid arthritis. Pain upon movement of the involved joints accompanies
osteoarthritis.Incorrect: Rheumatoid arthritis (RA) is a chronic, systemic, progressive,
inflammatory connective tissue disorder. It affects primarily the small, peripheral joints
with symmetrical distribution. This systemic disease affects all connective tissue,
including the collagen of the heart, muscles, tendons, pleura or blood vessels. During the
acute onset of rheumatoid arthritis, the client experiences fever and chills, pain and
swelling of the joints. When RA develops insidiously, morning stiffness may occur as an
early symptom.Incorrect: Rheumatoid arthritis is a chronic, systemic, progressive,
inflammatory connective tissue disorder. It affects primarily the small, peripheral joints
with symmetrical distribution. This systemic disease affects all connective tissue,
including the collagen of the heart, muscles, tendons, pleura or blood vessels. The
erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) are usually elevated
during the acute and chronic states of rheumatoid arthritis.
reddened, swollen joints that are warm to the touch.
pain upon movement of the involved joints.
morning stiffness and fever.
an elevated erythrocyte sedimentation rate (ESR).
83

A nurse has reviewed the cardiac enzyme studies of a client with unstable angina
who was recently admitted to the cardiac care unit. The client's creatine kinase (CK)
is elevated. The nurse can anticipate that further diagnostic studies to help clarify the
client's cardiac injury will be:
Incorrect: Serial blood pressure readings provide important information in the
diagnosis of hypertension. Serial blood pressure readings are not used as a diagnostic tool
to identify degree of myocardial injury and necrosis. Although the blood pressure is
directly affected by myocardial damage if cardiac output is reduced, successively low or
high pressures would not tell the physician any direct information about myocardial cell
injury or death.Incorrect: Central venous pressure monitoring, although helpful in
monitoring fluid status would not provide diagnostic information about the client's
cardiac injury.Incorrect: A stress test is an important diagnostic tool in clients with stable
angina. Client's experiencing unstable angina would be at increased risk for an acute MI if
subjected to exercise stress testing.Correct: CK-MB is the isoenzyme specific to the
myocardium and elevation begins within 4-8 hours after an acute MI. Cardiac troponin
has a high specificity for myocardial injury and rises earlier than CK-MG. Both are
important indicators of myocardial cell damage.
serial blood pressure readings.
central venous pressure monitoring.
a treadmill stress test.
isoenzyme and troponin I levels
84

When assessing a client for fluid and electrolyte imbalances, the nurse knows that a
common cause of iso-osmolar fluid volume deficit (hypovolemia) is:
Correct: Excess blood loss involves fluid and solute loss from the vascular space.
These losses occur in proportion to one another, therefore the loss is isotonic in
nature.Incorrect: A decrease in water intake results in an increase in the number of solutes
in body fluid. The vascular space becomes hyperosmolar.Incorrect: Although vomiting
and diarrhea usually result in fluid losses that are in proportion to electrolyte losses,
severe vomiting and diarrhea cause a loss of body water greater than the loss of solutes
such as electrolytes, resulting in hyperosmolar body fluid.Incorrect: Pure water losses, as
occurs in diabetes insipidus, result in concentration of the solutes in the vascular space
and hyperosmolarity.
hemorrhage.
inadequate fluid intake.
severe vomiting and diarrhea.
water losses with diabetes insipidus.
85

The nurse is caring for a male client who is using home peritoneal dialysis to manage
chronic renal failure. The client informs the nurse that today the fluid returning after the
instillation of the dialysate was cloudy. This is usually a sign of:
Incorrect: Displacement would likely result in little to no return of the
dialysate.Incorrect: Peritoneal dialysis works on the principle of osmosis to cause
movement of extra fluid from the client into the dialysate. This process should not alter
the appearance of the dialysate. A cloudy dialysate return should prompt the nurse to
consult the physician since peritonitis may be present.Incorrect: The purpose of dialysis,
whether peritoneal or hemodialysis is to remove waste and toxic material from the body.
The presence of nitrogenous waste products in the dialysate will not alter the color or
clarity of the solution. Any time the dialysate is cloudy in appearance, peritonitis should
be suspected.Correct: Peritonitis is a major threat during peritoneal dialysis. Peritonitis is
recognized by a fever, chills, abdominal tenderness or pain, vomiting, cloudy outflow of
solution.
displacement of the dialysis tube.
fluid volume deficit.
excess nitrogenous wastes.
peritonitis.

86

When assessing a client with iron deficiency anemia, which of the following set of signs/
symptoms, if present, would coincide with this diagnosis?
Incorrect: These clinical manifestations are characteristic of anemia secondary to
acute blood loss.Correct: These are the classic symptoms of iron deficiency anemia often
associated with chronic blood loss, inadequate iron intake or malabsorption. The hallmark
of iron deficiency anemia is hypochromia, which is small red blood cells that are devoid
of pigment. Clients with iron deficiency anemia often experience a generalized fatigue as
related to diminished oxygen carrying capacity of the hemoglobin.Incorrect: These signs/
symptoms are indicative of hemolytic anemia often caused by drugs or an autoimmune
response against the person's RBCs.Incorrect: These signs/symptoms correlate with
disorders of coagulation such as hemophilia or thrombocytopenia, or may be found in
clients with aplastic anemia along with the usual manifestations of anemia such as
fatigue, exertional dyspnea and pallor.
Hypotension, weakness, tachycardia
Hypochromia, bright red tongue, fatigue
Jaundice, pallor, splenomegaly
Easy bruising, petechiae, infection
87

During a counseling session, the client scheduled for a radical prostatectomy asks the
nurse how the surgery will affect sexual function. The nurse's response should be based
on that fact that:
Incorrect: Although clients are not able to ejaculate, the ability to have an erection
and to experience orgasm will gradually return following radical prostatectomy.Incorrect:
Aside from fertility, most aspects of sexual function will gradually return. However,
clients may be impotent for several months even after a nerve-sparing prostatectomy. It
would be inappropriate to assure the client that sexual function will be completely
normal.Incorrect: The return of erectile capability may be delayed following total
prostatectomy but the ability to have an erection will gradually return for most
clients.Correct: Following any type of radical prostatectomy, the male will no longer be
fertile, because the loss of the prostate gland interrupts the flow of semen and ejaculation
will not occur.
 achieving orgasm will be impossible.
all aspects of intercourse should return to normal.
impotence is a permanent outcome.
infertility will occur.
88

An adult client is admitted with dehydration caused by severe diarrhea. Blood pressure is
98/68, pulse 110/minute, respirations 20/minute. In the initial stages of fluid replacement,
which intravenous solutions would be the best choice?
Incorrect: Dextrose 5% in water is considered an isotonic solution in the
container. However, the glucose is quickly metabolized in the body leaving free water,
which is hypotonic. Hypotonic solutions cause water to move into the cell. Although
considered a hydrating solution would not be the best FIRST choice in this situation
because the client is hypotensive. The best solution to expand the vascular space is an
isotonic solution such as 0.9% NaCl which is considered the isotonic standard
(approximately equal to the sodium chloride concentration of the blood). It should also be
noted that the free water in D5W could dilute the serum sodium level, which has been
lowered by sodium and water losses from the severe diarrhea.Incorrect: A hypotonic
solution such as .45% sodium chloride is useful for daily maintenance of body fluid but
not for replacement therapy. Because it is hypotonic it is not the best choice for initial IV
therapy in the client who is hypotensive.Correct: Because the client is hypotensive, the
first objective is to raise the ECF volume. This is best achieved by using an isotonic
solution such as .9% sodium chloride. Once the client's blood pressure is improved, other
hydrating solutions such as Dextrose 5% in .45% sodium chloride would be given to
hydrate the cell and provide calories and sodium which has been lost.Incorrect: An
extremely hypertonic solution, such as 3% or 5% sodium chloride, is contraindicated in
this situation. A hypertonic solution would draw water out of the cells causing further
dehydration and could cause severe cerebral damage. Hypertonic saline is used when
treating a client with severe hyponatremia.
Dextrose 5% in water
.45% sodium chloride
.9% sodium chloride
3% sodium chloride
89

While setting up total parenteral nutrition (TPN) for a client, the nurse performs which
intervention to prevent fluid and electrolyte imbalance?
Incorrect: When infusing TPN the nurse should maintain a uniform infusion rate
to prevent hypo or hyperglycemia or other fluid/electrolyte imbalances. The nurse closely
monitors blood sugar throughout TPN therapy and the practitioner makes solution
adjustments.Incorrect: The nurse's responsibility is to monitor for signs/symptoms of fluid
and electrolyte imbalances and notify the physician who will make solution adjustments
(i.e. reduce the potassium content if signs of hyperkalemia are present). Discontinuation
of TPN is done gradually to prevent hypoglycemia.Incorrect: As described above, a
uniform infusion rate should be maintained to prevent changes in blood glucose, which
can occur rapidly if the infusion rate were to be increased or decreased.Correct: A
safeguard against too rapid infusion of any IV solution is to use an infusion pump. In
addition, it is equally important to continue to check the flow rate hourly and not assume
that the pump is functioning properly.
Adjust the flow rate based on finger stick glucose levels.
Discontinue the infusion if signs of electrolyte imbalances occur.
Reduce the flow rate if signs of overhydration develop.
Set up an infusion pump and check the flow rate hourly.
90

During a home visit to an elderly client with glaucoma, the nurse evaluates the client's
understanding of the use of eyedrops. Which statement, if made by the client, would
indicate additional teaching is required?
Incorrect: The client has described the proper technique for instilling ophthalmic
drops or ointments.Incorrect: The client's wife understands the importance of safety. The
use of miotic drugs causes pupil constriction and may adversely affect the client's night
vision and adaptation to dark environments.Correct: This statement by the client indicates
more teaching is required. There is no cure for glaucoma but it can be controlled.
Blindness can be prevented by early detection, life-long treatment, close monitoring and
follow-up care. Vision that has been lost to elevated intraocular pressure cannot be
restored, but further loss can be prevented.Incorrect: The client understands the
importance of avoiding increased pressure in the eye. Clients with glaucoma should avoid
activities that increase intraocular such as bending from the waist, sneezing, vomiting,
and straining to have a bowel movement.
"I should pull my lower eyelid down and place the drop/s onto the lower
lid."
"My wife makes sure I do not drive after dark."
"I'm glad I can stop taking this medicine when my vision improves."
"I have been careful to avoid becoming constipated."

91

A client with a tracheostomy tube on mechanical ventilation suddenly becomes restless

and anxious and attempts to cough. The high-pressure alarm sounds on the ventilator.
The first action the nurse should take is:
Incorrect: Although clients who are excessively anxious and fight the ventilator
may be sedated or given a paralyzing agent, sources of the client's anxiety should be
determined and addressed. In this case, behavior suggests the need for airway
clearance.Incorrect: It is important to empty water from the ventilator tubing to prevent
bacterial growth and pneumonia. However, the client's anxiety and attempts to cough in
addition to the high-pressure alarm strongly suggest secretions in the airway. Suctioning
should occur first. It would also be important to check the tubing for kinks or excessive
water that could also sound the high-pressure alarm.Incorrect: An x-ray is not indicated in
this situation. However, it may be appropriate to evaluate the position of an endotracheal
tube; if displaced it could also cause the high-pressure alarm to sound.Correct: The high-
pressure alarm sounds when peak inspiratory pressure reaches the set alarm limit;
indicating secretions in the airway or a mucous plug. Since the client is restless, anxious,
and attempting to cough, the first nursing activity is to suction the tracheostomy tube.
administer an antianxiety agent.
empty water from the ventilator tubing.
obtain a chest x-ray.
suction the tracheostomy tube.
92

A 48-year-old male had a bronchoscopy with tissue biopsy 30 minutes ago. The client
calls the nurse and reports the following symptoms. Which one should prompt the nurse
to immediately notify the practitioner?
Incorrect: Blood-streaked sputum may occur following a tissue biopsy. However,
frank bleeding should be immediately reported.Incorrect: Because of the local anesthetic
sprayed on the tongue and oropharynx, difficulty swallowing is expected until cough and
gag reflexes return.Correct: Following a bronchoscopy it is essential that the nurse
monitor for frank bleeding, laryngeal edema or laryngospasm (stridor) and increasing
shortness of breath. These symptoms may indicate trauma to the larynx or vocal
cords.Incorrect: A moderate amount of throat discomfort is expected following a
bronchoscopy and should be managed with warm saline gargles once the client is able to
effectively swallow.
Blood-streaked sputum
Difficulty swallowing
Progressive dyspnea
Throat discomfort
93

Which classification of medication is primary in the treatment of congestive heart failure

because of its ability to increase the force and strength of the cardiac contraction and
slow the heart rate?
Incorrect: Although beta-adrenergic agonists such as isoproterenol (Isuprel)
enhance myocardial contraction, they cause cardiac stimulation and increase the heart
rate.Incorrect: Morphine sulfate is a narcotic analgesic used to decrease pain. It is also
important in the treatment of pulmonary edema because it eases dyspnea and reduces
preload (vasodilator effect).Incorrect: Diuretics are also primary drugs in the treatment of
congestive heart failure but are given to increase excretion of sodium and water from the
body.Correct: Digitalis preparations such as digoxin (Lanoxin) are classified as positive
inotropic agents that work by increasing the force and strength of myocardial contraction.
In addition, digitalis is a negative chronotropic drug (slows the cardiac rate).
Beta-adrenergic agonists
Narcotic analgesic
Diuretics
Digitalis preparations
94

A 68-year-old male client has a permanent tracheostomy tube following total

laryngectomy. The most appropriate goal for the first postoperative day would be for the
client to:
 Incorrect: Although early ambulation is advocated in most all post-operative
clients to prevent atelectasis and paralytic ileus, it would be unrealistic and perhaps
dangerous to expect the laryngectomy client to ambulate independently the first
postoperative day.Correct: Some degree of airway obstruction is common in clients
following laryngectomy related to edema from surgery or radiation prior to the surgery. A
patent airway is a priority outcome immediately postop and it is reasonable to expect the
client will assist in coughing and mobilizing secretions through the tracheostomy tube or
laryngeal stoma.Incorrect: A nasogastric tube is used for food and fluids to minimize
contamination of the pharyngeal and esophageal suture lines and to prevent fluid from
leaking through the wound into the trachea before healing occurs.Incorrect: The
laryngectomy patient, although very anxious following surgery, will be unable to
verbalize because the larynx (vocal cords) have been removed. Communication can
however be facilitated using other techniques.
ambulate independently.
help maintain a patent airway.
consume oral fluids without aspirating.
verbalize fear and anxiety.
95

Of the following individuals, who is at increased risk for developing acute renal failure
(ARF) from a prerenal cause? The person who:
Incorrect: Postrenal failure is caused by obstruction of urine flow between the
kidney and urethral meatus as in such conditions as renal calculi, neoplasms, and prostatic
hypertrophy.Incorrect: Intrarenal failure is caused by damage to the kidney tissues and
structures and includes tubular necrosis, nephrotoxicity, and alteration in renal blood
flow. Examples of intrarenal causes include glomerulonephritis, coagulopathies,
malignant hypertension, nephrotoxic drugs such as gentamicin (an aminoglycoside),
antiinflammatory agents, tetracyclines, and sulfonamides.Correct: Prerenal causes of ARF
occur secondary to intravascular volume depletion. Examples of conditions leading to
hypovolemia include hemorrhage, dehydration, diabetes insipidus, cirrhosis, excessive
use of diuretics, burns; Conditions that lead to decreased cardiac output such as
congestive heart failure and dysrhythmias are other prerenal causes of ARF.Incorrect:
Nephrotoxic drugs such as the aminoglycosides are classified as intrarenal causes of acute
renal failure.
frequently develops kidney stones.
has a coagulation disorder.
hemorrhages during surgery.
is receiving an aminoglycoside.
The most common complication after a myocardial infarction (MI) is:
Incorrect: Cardiogenic shock is caused by severe myocardial dysfunction and
occurs in 5% to 10% of clients with acute myocardial infarction. Although serious and
potentially fatal, the most common complication after an MI is dysrhythmias.Incorrect:
Although ventricular aneurysms can develop following myocardial infarctions involving
the entire myocardium, they are rare.Incorrect: Free wall rupture of a weakened area of
the myocardium can occur but is very rare.Correct: Dysrhythmias often occur secondary
to the ischemic processes of coronary artery disease and myocardial infarction. In
addition to blocks along the conduction pathway, direct damage to the myocardial cell
can cause electrolyte imbalances that alter the action potential, creating a variety of
dysrhythmias.
shock.
ventricular aneurysms.
rupture of the ventricular wall.
dysrhythmias.
97

The nurse is caring for a client with Type 2 diabetes mellitus. The client's nutritional
history indicates a diet high in carbohydrates and moderately sedentary lifestyle. The
nurse notes the client is 5 feet, 4 inches and weighs 160 pounds. In planning nutritional
management the nurse knows that:
Incorrect: This client's height and weight indicate that she is overweight. A caloric
increase would be inappropriate especially since this client's activity level is
light.Incorrect: A common misconception in diabetes management is that carbohydrates
(CHO) be restricted. Carbohydrates must be distributed on a consistent basis so that blood
nutrients match insulin levels. Distribution of CHOs helps prevent increases in blood
glucose following meals, and allows the blood glucose to return to pre-meal levels before
the next meal. Clients who need to reduce weight are taught to maintain balanced intake
of fat, CHO, and proteins but to reduce total calories.Correct: Weight is a major factor in
monitoring diabetes control. Attaining and maintaining ideal body weight are major
criteria in diabetes management. A large percentage (80-90%) of persons diagnosed with
type 2 diabetes are overweight. The current nutritional management for diabetes is to
maintain reasonable weight and control blood glucose without compromising
health.Incorrect: Although obesity is a significant risk factor for type 2 diabetes, dietary
management and weight loss is usually not sufficient to control blood glucose levels in
the client diagnosed with type 2 diabetes. Many clients with type 2 diabetes require oral
hypoglycemics to help decrease insulin resistance or augment insulin secretion.
an increase in caloric intake is recommended.
carbohydrates should be restricted.
weight reduction is an important goal for care.
diet alone is probably sufficient for glucose control.
98

An elderly client with a diagnosis of congestive heart failure complains of paroxysmal

nocturnal dyspnea. Which nursing actions is most appropriate for the nurse to institute?
Correct: Paroxysmal nocturnal dyspnea occurs 2-5 hours after the client lies down
because chest expansion diminishes in the recumbent position resulting in decreased
ventilation, and venous return to the right heart increases with elevation of the legs. The
client awakes suddenly with severe shortness of breath that subsides only after sitting
upright for 10-30 minutes. Clients experiencing orthopnea must sleep using several
pillows or in a semi-Fowler's position.Incorrect: Increasing oxygen delivery will not
eliminate the problem of orthopnea or nocturnal dyspnea that occurs when the legs are
elevated to the level of the heart and venous return is increased causing increased fluid in
the lungs. The most appropriate nursing measure is to elevate the head of the
bed.Incorrect: Although bedrest decreases the workload of the failing heart, bedrest
without elevation of the head of the bed will not diminish the problem of orthopnea or
nocturnal dyspnea.Incorrect: Restricting fluids may or may not be indicated. If the client
is currently receiving diuretics, a fluid restriction may be contraindicated to avoid fluid
volume deficit. The increase of fluid returning to the lungs when lying in a supine
position with the legs elevated can best be averted by elevating the head of the bed.
Elevate the head of the bed.
Increase O2 to 6 L per nasal cannula.
Institute strict bedrest.
Restrict fluids for the next 24 hours.
99

A client diagnosed with myasthenia gravis is brought to the emergency department with
severe dyspnea, exaggerated muscle weakness, and dysphagia. To determine whether
these symptoms are the result of cholinergic versus myasthenic crisis, the physician
administers the Tensilon test. Of the following drug responses, which would indicate to
the nurse that myasthenic crisis is present?
Incorrect: Myasthenia gravis involves a decrease in the number and effectiveness
of acetylcholine receptors at the neuromuscular junction resulting in progressive muscle
weakness. Myasthenic crisis represents an exacerbation of the symptoms caused by under-
medication with anticholinesterase drugs. In contrast, cholinergic crisis is an exacerbation
of muscle weakness caused by overmedication. Tensilon (a short-acting anticholinsterase)
produces a temporary improvement in myasthenic crisis but no improvement or
worsening of symptoms in cholinergic crisis. Therefore, improved breathing would be
expected if the client were in myasthenic crisis.Incorrect: In cholinergic crisis, muscle
tone does not improve after administration of Tensilon. Instead, weakness increases and
muscle twitching may be observed around the eyes and face.Correct: As explained above,
clients who are experiencing myasthenic crisis respond positively to the Tensilon test
with a temporary improvement in muscle tone.Incorrect: Improvement in the ability to
swallow following Tensilon administration would be expected if the client were in
myasthenic crisis.
Breathing remains unchanged
Facial twitching occurs
Muscle strength briefly improves
Dysphagia worsens
100

When differentiating between wound inflammation and wound infection, the nurse
determines that a 2-day-old surgical incision is likely to be inflamed based on which
physical assessment data?
Correct: Tissue redness (erythema), slight swelling (edema) and increased warmth
are signs of wound inflammation. Fever, purulent drainage, and tachycardia indicate
infection.Incorrect: Pain and drainage may be normal at an incisional site and are not a
sign of inflammation.Incorrect: Adhesions may form after wound healing has occurred.
Purulent drainage is a sign of wound infection.Incorrect: Fever, tachycardia (increased
heart rate) and tachypnea (increased respiratory rate) are signs of infection.
Erythema, slight edema, and increase warmth
Pain at the surgical site and drainage
Adhesions and purulent drainage
Fever, tachycardia, and tachypnea