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Student Exam Results
Student Exam Results

Student Information

Last Name:

madriaga

Reference:

First Name:

abigail

 

Exam:

RN Lesson 8 Posttest

Total Attempts:

2

Total Submitted Attempts : 1

Mark: 43 %

 
   

Incorrect

(Ref: 1437)A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission?

 
 

Learner Response:

B) Side-lying on the left with the head elevated 35 degrees

 

Correct Response:

A) Side-lying on the left with the head elevated 10 degrees

Feedback:

Gravity will draw the most blood flow to the dependent portion of the lung. For unilateral chest disease, it is best to place the healthiest part of the lung in the dependent position to enhance blood flow to the area where gas exchange will be best. Ventilation would be minimally affected in the right dependent lung. This position also enhances the drainage of the infected part of the lung. A head elevation of 35 degrees is counterproductive to therapeutic blood flow and the drainage of secretions. At this elevation stasis of secretions is enhanced at the lung bases. Delaune, S. & Lander, P. (2006). Fundamentals in nursing: standards and practice. (3rd ed). Clinton Park, New York: Delmar Cengage Learning. Black, J., Hawks, J. & Keene, A. (2009). Medical Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.). St. Louis: Elsevier.

 
 

Incorrect

(Ref: 1442)During an assessment on a client in heart failure a nurse should expect on auscultation of the heart which sound?

 
 

Learner Response:

C) Systolic murmur

Correct Response:

A) Ventricular gallop of S<sub>3</sub>

Feedback:

A ventricular gallop, S3, is caused by blood flowing rapidly into a distended non-compliant ventricle. This is the most common sound with left-sided heart failure. Estes, M.E.Z. (2006). Health assessment and physical examination. (3rd ed). Albany, NY: Delmar Cengage Learning. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

 
 

Incorrect

(Ref: 1533)A client is admitted with a tentative diagnosis of heart failure. Which assessment should a nurse expect to be consistent with this problem?

 

Learner Response:

D) Heart murmur

Correct Response:

C) Inspiratory crackles

Feedback:

In heart failure, fluid backs up into the lungs as a result of inefficient cardiac pumping. The fluid is manifested in breath sounds as crackles which may be on inspiration or expiration. The other findings are more consistent with the condition of a myocardial infarction. Estes, M.E.Z. (2006). Health assessment and physical examination. (3rd ed). Albany, NY: Delmar Cengage Learning. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G. & Bucher, L. (2007). Medical-Surgical Nursing:

Assessment & Management of Clinical Problems. St. Louis: Elsevier.

Correct

(Ref: 1545)Which of these findings by a nurse should be a priority for clients with a history of being in a motorized vehicle accident?

Learner Response:

B) Pupils fixed and dilated

Correct Response:

B) Pupils fixed and dilated

Feedback:

Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to the upper brain stem. It is a poor prognostic sign. The other findings indicate more of a partial dysfunction of the brain or spinal cord. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Price, S.A. & Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th ed.). St. Louis: Elsevier.

Correct

(Ref: 1592)A nurse is caring for a client in hypertensive crisis. The priority assessment in the first hour of care after admission to the critical care unit should focus on which factor?

Learner Response:

D) Cognitive function

Correct Response:

D) Cognitive function

Feedback:

The organ most susceptible to damage in hypertensive crisis is the brain due to rupture of the cerebral blood vessels. Neurologic findings must be closely monitored. Ignatavicius, D. & Workman, M. (2009). Medical-Surgical Nursing: Critical Thinking for Collaborative Care. (6th ed.). St. Louis: Elsevier. Black, J., Hawks, J. & Keene, A. (2009). Medical Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.). St. Louis: Elsevier.

Student Exam Results
Student Exam Results

Incorrect

(Ref: 1601)While caring for a client who was admitted with myocardial infarction (MI) two days ago, a nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

Learner Response:

C) send blood, urine and sputum for cultures

Correct Response:

B) administer PRN acetaminophen as ordered

Feedback:

Leukocytosis and fever are common outcomes on day two after MIs because of the inflammatory process associated with an acute MI. Nursing interventions should focus on the promotion of comfort. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G. & Bucher, L. (2007). Medical-Surgical Nursing:

 

Assessment & Management of Clinical Problems. St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Correct

(Ref: 1611)A nurse is caring for a client diagnosed with a new atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which finding is a cause for the most concern?

Learner Response:

C) A cold, pale lower leg

Correct Response:

C) A cold, pale lower leg

Feedback:

This assessment suggests the presence of an embolus from the left atrial associated with the atrial fibrillation. Peripheral pulses should be checked immediately for differences. Evaluation of cognitive function for stroke like findings should also be done. Embolus is a concern especially within the initial 24 to 72 hours after a conversion back to sinus rhythm occurs. This is the reason for the anticoagulant therapy with this cardiac dysrhythmia. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G. & Bucher, L. (2007). Medical-Surgical Nursing:

 

Assessment & Management of Clinical Problems. St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Correct

(Ref: 1612)Which finding suggests that antibiotic therapy as not been effective for a client with infective endocarditis and must be reported by a nurse immediately to the health care provider?

Learner Response:

B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)

Correct Response:

B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)

Feedback:

Persistent, prolonged fever over 72 hours after the initiation of antibiotic therapy may be an indication that the antibiotics are not effective and may need to be changed. This means the organism is not sensitive to this type of medication. Ignatavicius, D. & Workman, M. (2009). Medical-Surgical Nursing: Critical Thinking for Collaborative Care. (6th ed.). St. Louis: Elsevier. Black, J., Hawks, J. & Keene, A. (2009). Medical Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.). St. Louis: Elsevier.

Correct

(Ref: 1630)During the admission of a 72 year-old client with a diagnosis of right-sided heart failure, which finding should a nurse anticipate?

Learner Response:

B) Jugular vein distention

Correct Response:

B) Jugular vein distention

Feedback:

Signs of right-sided heart failure include jugular vein distention at 35-45 degrees or higher elevation of the head of the bed, fatigue, nausea, vomiting, sacral edema and bilateral feet with ankle edema. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Estes, M.E.Z. (2006). Health assessment and physical examination. (3rd ed). Albany, NY: Delmar Cengage Learning.

Incorrect

(Ref: 1634)A nurse is about to assess a six month-old child with non-organic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be have which assessment?

Learner Response:

A) Irritable and "colicky", making no attempts to pull to standing

Correct Response:

D) Pale, have thin arms and legs, and uninterested in surroundings

Feedback:

Diagnosis of NOFTT is made on anthropomorphic findings with documentation of growth retardation which would lead a nurse to expect muscle-wasting and paleness. In cases of NOFTT, the cause may be a variety of psychosocial factors and these children may be below normal in intellectual development, language, and social interactions. James, S. & Ashwill, J. (2007). Nursing Care of Children: Principles and Practice. (3rd ed.). Philadelphia:

 

Elsevier. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

Elsevier.

Incorrect

(Ref: 1655)Which of these findings should a nurse more closely associate with iron deficiency anemia in a 10 month-old infant?

Learner Response:

C) Hypoactivity

Correct Response:

B) Pale mucosa of the eyelids and lips

14 September 2009 7:29:17AM

Page 2 of 9

Student Exam Results Incorrect (Ref: 1601)While caring for a client who was admitted with myocardial infarction
Student Exam Results
Student Exam Results

Feedback:

In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia. The normal heart rate of infants is the range of 120 to 180. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

Elsevier. James, S. & Ashwill, J. (2007). Nursing Care of Children: Principles and Practice. (3rd ed.). Philadelphia:

Elsevier.

Correct

(Ref: 1657)A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be the most indicative of the etiology for this crisis?

Learner Response:

D) "I used cold medicine last week, and I have gotten worse."

Correct Response:

D) "I used cold medicine last week, and I have gotten worse."

Feedback:

Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis also called a vaso-occlusive crisis. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

 

Elsevier. Ball, J., & Bindler, R. (2005). Child Health Nursing: Partnering with Children of Families. Upper Saddle River, N.J.: Pearson Education.

Correct

(Ref: 1661)A two year-old child is brought to the emergency department at 2:00 in the afternoon. The mother states: “My child

has not had a wet diaper all day.” A nurse finds the child is of a pallor color with a heart rate of 132. What assessment data should the nurse obtain next?

Learner Response:

A) Status of the eyes and the tongue

Correct Response:

A) Status of the eyes and the tongue

Feedback:

Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110. The other information would be collected afterwards. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

 

Elsevier. James, S. & Ashwill, J. (2007). Nursing Care of Children: Principles and Practice. (3rd ed.). Philadelphia:

Elsevier.

Correct

(Ref: 1664)A nurse is assessing an eight month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?

Learner Response:

D) "When I put the baby in a back lying position that's how I find it hours later."

Correct Response:

D) "When I put the baby in a back lying position that's how I find it hours later."

Feedback:

Cerebral palsy is known as a condition whereby motor dysfunction occurs secondary to damage in the motor centers of the brain. Inability to roll over by eight months of age would illustrate one delay in the infant's attainment of developmental milestones. This dysfunction is most commonly associated with cerebral hyopoxia during the birth process. Ball, J., & Bindler, R. (2005). Child Health Nursing: Partnering with Children of Families. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

Elsevier.

Incorrect

(Ref: 1840)A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. What should be a nurse's priority action?

Learner Response:

C) Initiate intravenous therapy

Correct Response:

B) Assess for dyspnea or stridor

Feedback:

Due to the location of the burns, the client is at risk for the development of upper airway edema and subsequent respiratory distress. James, S. & Ashwill, J. (2007). Nursing Care of Children: Principles and Practice. (3rd ed.). Philadelphia:

 

Elsevier. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

Elsevier.

Incorrect

(Ref: 1998)A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During a nurse’s initial evening

rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which one would alert the nurse to a complication of the therapy?

Learner Response:

A) "I have a sharp pain in my chest when I take a breath."

Correct Response:

B) "I have been coughing up foul-tasting, brown, thick sputum."

14 September 2009 7:29:17AM

Page 3 of 9

Student Exam Results Feedback: In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with
Student Exam Results
Student Exam Results

Feedback:

Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for any type of infection. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Black, J., Hawks, J. & Keene, A. (2009). Medical Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.). St. Louis: Elsevier.

Correct

(Ref: 2355)A client has altered renal function and is being treated at home. During weekly visits a nurse should plan to use which of these parameters to evaluate fluid balance?

Learner Response:

D) Weekly trends in daily weights

Correct Response:

D) Weekly trends in daily weights

Feedback:

The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 mL of retained fluid. Other options are considered as part of data collection for fluid balance, but they are not the most accurate indicators of fluid balance. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Incorrect

(Ref: 2356)A nurse should teach that sufficient potassium should be included in the diet of a client who takes digoxin because hypokalemia in combination with this medication has which outcome?

Learner Response:

D) Alters level of consciousness

Correct Response:

A) Can predispose to dysrhythmias

Feedback:

A nurse should monitor for a decrease in the client’s potassium levels below normal. Low potassium enhances the effects of digoxin and predisposes the client to digoxin toxicity and dysrhythmias. The other option findings are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Incorrect

(Ref: 2357)Which findings of a client diagnosed with uncontrolled hypertension requires an immediate action by a nurse?

Learner Response:

B) Rales at lung bases

Correct Response:

D) Weakness in left arm

Feedback:

In a client who has uncontrolled hypertension, weakness in the extremities is a sign of cerebral involvement with the risk for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not medical emergencies. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Correct

(Ref: 2393)Which intervention is most important for a nurse to implement prior to the initial administration of digoxin to a client diagnosed with heart failure and atrial fibrillation?

Learner Response:

A) Assess the apical pulse with a full 60 second count

Correct Response:

A) Assess the apical pulse with a full 60 second count

Feedback:

A nurse’s responsibility is to take the client’s pulse before the adminsitration of digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 or greater than 120 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the initial assessment before administration of an initial or later doses of digoxin. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar.

Incorrect

(Ref: 2399)A nurse is performing CPR on an adult who had a cardiopulmonary arrest. Another nurse enters the room in response to the call for help. After checking the client’s pulse and respirations, what should be the function of the second nurse?

Learner Response:

B) Go get the code cart

Correct Response:

C) Participate with the compressions or breathing

14 September 2009 7:29:17AM

Page 4 of 9

Student Exam Results Feedback: Foul smelling and tasting sputum signals a risk of a lung abscess.
Student Exam Results
Student Exam Results

Feedback:

Once CPR is started, it is to be continued using the approved technique until such time as a health care provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the two person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to leave the room for equipment. The client’s advanced directives should have been filed on admission and the choices known prior to the initiation of CPR. Potter P., & Perry, A. (2008). Fundamentals of Nursing. (7th ed.). St. Louis: Elsevier. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

Delmar.

Incorrect

(Ref: 2400)Which action can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis (ALS)?

Learner Response:

B) Use incentive spirometer every four hours

Correct Response:

C) Chest physiotherapy twice a day

Feedback:

These clients have potential inability to have voluntary and involuntary muscle movement or activity. Thus, active exercises and incentive spirometer may not be feasible for the immobilized client. Repositioning is targeted to circulation issues and is not specific for prevention of complications associated with the lung. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar.

Incorrect

(Ref: 2407)A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of

the prostate (TURP) 12 hours ago. Which finding at this time should a nurse report to the health care provider?

Learner Response:

B) Occasional suprapubic cramping about every hour

Correct Response:

C) Minimal drainage into the urinary collection bag

Feedback:

All of the options except the lack of drainage into the collection bag are expected complaints after this procedure. A lack of drainage needs to be reported immediately since minimal urinary drainage puts the client at risk for bladder rupture. The flow rate of the continuous irrigation would need to be slowed until the health care provider is notified. If an order to irrigate the urinary drainage system is written, sterile technique would be used. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar.

Incorrect

(Ref: 2415)An older adult client admitted after a fall at home begins to seize and loses consciousness. What action by a nurse is appropriate to do next?

Learner Response:

B) Collect pillows and pad the side rails of the bed

Correct Response:

A) Stay with client and observe the movements of the client

Feedback:

For the client’s safety, remain at the bedside and observe respirations, the movements of the extremities, and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client’s mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar.

Correct

(Ref: 2419)A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. Labor is to be induced. At the time of the ROM, the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 188 beats/min. Which assessment findings may be an early indication that the client is developing a complication of the laboring process?

Learner Response:

A) FHT 188 beats/min

Correct Response:

A) FHT 188 beats/min

Feedback:

An increase in FHT may indicate maternal infection. The other assessment findings are normal expectations at this time. Wong, D., Perry, S., & Hockenberry, M. (2006). Maternal Child Nursing Care. (3rd ed.). St. Louis: Elsevier. Condon, M.C. (2004). Women's health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

Correct

(Ref: 2426)A nurse is providing care to a 17 year-old client in the postoperative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client may have diniminshed oxygenation?

Learner Response:

C) Increasing pulse rate

Correct Response:

C) Increasing pulse rate

14 September 2009 7:29:17AM

Page 5 of 9

Student Exam Results Feedback: Once CPR is started, it is to be continued using the approved
Student Exam Results
Student Exam Results

Feedback:

The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body’s compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal and less than 90% would be of a concern. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Condon, M.C. (2004). Women's health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

Incorrect

(Ref: 2429)A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg one hour ago reports that the pain is getting worse. A nurse should recognize that the client may be developing which complication?

Learner Response:

C) Fatty embolism

Correct Response:

A) Acute compartment syndrome

Feedback:

Increasing pain that is not relieved by narcotic analgesics is an indication of compartment syndrome after a bone fracture. It requires immediate action by the nurse. Thromboembolic complications include deep vein thrombosis and pulmonary embolism which are not characterized by increasing pain at the site of injury. Both pulmonary embolism and fat embolism are associated with respiratory findings. Osteomyelitis is a bone infection which could occur some time after the initial injury, usually at least 48 to 72 hours. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar.

Correct

(Ref: 2430)A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. A nurse determines that the client’s blood pressure has a trend of increased readings. Which action should the nurse take first?

Learner Response:

B) Have the client turn to the left side

Correct Response:

B) Have the client turn to the left side

Feedback:

A priority action is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored every four hours or more often if indicated, but no data in the stem supports a check of temperature. The deep tendon reflexes are checked as needed especially when magnesium drips are being infused. Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

 

Elsevier. Wong, D., Perry, S., & Hockenberry, M. (2006). Maternal Child Nursing Care. (3rd ed.). St. Louis: Elsevier.

Incorrect

(Ref: 2454)Which of these clients who are diagnosed as being in the terminal stage of cancer is least appropriate to suggest the use of patient-controlled analgesia (PCA) with an electronic pump?

Learner Response:

C) An older adult client with numerous arthritic nodules on the hands

Correct Response:

D) A preschooler with intermittent episodes of alertness

Feedback:

A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump. Children in the school-aged group of six to 12 years of age and up are better candidates for PCA electronic pumps. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G. & Bucher, L. (2007). Medical-Surgical Nursing:

 

Assessment & Management of Clinical Problems. St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Incorrect

(Ref: 2457)A client who is to have antineoplastic chemotherapy tells a nurse “I have a fear of being sick all the time. I would like to try acupuncture.” Which of these beliefs if stated by the client would be incorrect about acupuncture and need clarification by the nurse?

Learner Response:

D) "By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations

Correct Response:

it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over." C) "The flow of life is believed to flow through major pathways called nerve clusters in your body."

Feedback:

The major pathways are called meridians, not nerve clusters. The other options are correct information about acupuncture. Delaune, S. & Lander, P. (2006). Fundamentals in nursing: standards and practice. (3rd ed). Clinton Park, New York: Delmar Cengage Learning. Altman, G. B. (2009). Delmar Learning's Fundamental and Advanced Nursing Skills. (3rd ed.). Canada:

 

Delmar.

Correct

(Ref: 2458)As a nurse is speaking with a group of teens about antineoplastic therapy, which of these side effects would the nurse expect this group to be more interested in during the discussion?

Learner Response:

D) Hair loss

Correct Response:

D) Hair loss

14 September 2009 7:29:17AM

Page 6 of 9

Student Exam Results Feedback: The earliest sign of poor oxygenation is an increasing pulse rate as
Student Exam Results
Student Exam Results

Feedback:

The major concern for adolescents is body image. Thus, hair loss would be the most disturbing to this group of clients. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G. & Bucher, L. (2007). Medical-Surgical Nursing:

Assessment & Management of Clinical Problems. St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Correct

(Ref: 2459)A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by a nurse?

Learner Response:

  • A) "Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use

another form of contraception."

Correct Response:

  • A) "Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use

Feedback:

another form of contraception." All of these options are correct information. The most important point to reinforce is the continued need to take additional action for birth control until it is determined that no risk is present for a possibility of a pregnancy outcome.

Monahan, F., Sands, J., Neighbors, N., Marek, J. F. & Green-Nigro, C. (2006). Phipp's Medical-Surgical Nursing: Health and Illness Perspectives. (8th ed.). St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Incorrect

(Ref: 2460)A man diagnosed with epididymitis two days ago calls a nurse at a health clinic to discuss the situation. What information is most important for the nurse to ask about at this time?

Learner Response:

C) "Do you have any questions about your care?"

Correct Response:

B) "Did your provider recommend that you be tested for Chlamydia?"

Feedback:

Epididymitis can result from Chlamydia infection, in which case the client’s sexual partners should be tested as well. All of the questions should be asked; however, the determination of the reason for the client’s referral is the most important to start with. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Incorrect

(Ref: 2461)A female client talks to a nurse in the provider’s office about uterine fibroids which are also called leiomyomas or myomas. What statement by the woman is incorrect and indicates that more teaching is needed?

Learner Response:

B) "My fibroids are noncancerous tumors that grow slowly."

Correct Response:

D) "Fibroids that cause no problems still need to be taken out."

Feedback:

Fibroids that cause no findings may require only “watchful waiting” with no treatment. Only when the client’s findings become disturbing to them would surgical interventions be considered. Condon, M.C. (2004). Women's health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Incorrect

(Ref: 2464)Which of these statements by a client would indicate to a nurse that the client understands the issues with end stage renal disease?

Learner Response:

C) "I expect to have periods of little water with voiding and then sometimes to have a lot of water."

Correct Response:

A) "I have to go at intervals for epoetin (Procrit) injections at the health department."

Feedback:

Anemia is caused by reduced endogenous erythropoietin production in the kidney. Primary end-stage renal disease is treated with subcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells. These clients have low serum calcium levels. Monahan, F., Sands, J., Neighbors, N., Marek, J. F. & Green-Nigro, C. (2006). Phipp's Medical-Surgical Nursing: Health and Illness Perspectives. (8th ed.). St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Incorrect

(Ref: 2465)Which of these statements from clients who telephone into a community health clinic to talk to a nurse would suggest that the nurse needs to refer to them for an immediate appointment with a health care provider?

Learner Response:

B) "I am a diabetic and today I have been going to the bathroom every hour"

Correct Response:

D) "I went to the bathroom and my urine looked very red and it didn't hurt when I went"

Feedback:

With this description of findings this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G. & Bucher, L. (2007). Medical-Surgical Nursing:

Assessment & Management of Clinical Problems. St. Louis: Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Student Exam Results
Student Exam Results

Correct

(Ref: 2466)A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?

Learner Response:

B) Within one minute after the dye is injected the client's entire body turns a bright red color.

Correct Response:

B) Within one minute after the dye is injected the client's entire body turns a bright red color.

Feedback:

This observation suggest anaphylaxis from the dye injection which results in massive vasodilation. Other findings of anaphylaxis are immediate wheezing and/or respiratory arrest. The salty taste in the mouth, the feeling of warmth and the complaint of nausea are expected side effects of the injection of the dye. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Incorrect

(Ref: 2467)Which information is a priority for a nurse to reinforce to an older client after an intravenous pyelography?

Learner Response:

C) During waking hours drink at least one eight ounce glass of fluid every hour for the next two days

Correct Response:

  • D) Measure the urine output for the next day and immediately notify the health care provider if it is less than

Feedback:

your usual This information would alert to the complication of acute renal failure which may occur as a complication from the dye used during the procedure. Renal failure occurs most often in older adult clients who are often dehydrated before the dye injection. They should force fluids if no contraindications for 24 hours after the test.

 

Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Correct

(Ref: 2472)A nurse is discussing Kawasaki disease with a group of student nurses. What statement made by a student about Kawasaki disease is incorrect and needs to be clarified?

Learner Response:

  • C) "Kawasaki disease occurs most often in boys, children younger than age five and children of Hispanic

 

descent."

 

Correct Response:

  • C) "Kawasaki disease occurs most often in boys, children younger than age five and children of Hispanic

Feedback:

descent." Kawasaki disease occurs most often in boys, children younger than age five and children of Asian descent, particularly Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis); a rash on the main part of the body (trunk) and in the genital area; red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; and swollen lymph nodes in the neck. Fever reduction signals the second phase, when the findings slowly go away. In the third phase findings, except for abnormal lab values, are gone unless complications associated with the heart develop. The disease lasts from two to 12 weeks without treatment. With treatment, the child usually improves within 24 hours. The cause of Kawasaki disease is not known.

 

Hockenberry, M.J. & Wilson, D. (2007). Wong's nursing care of infants and children. (8th ed.). St. Louis:

Elsevier. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

Incorrect

(Ref: 2473)A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for a nurse to reinforce?

Learner Response:

  • C) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to

Correct Response:

remove any tumors B) It is critical to report promptly to your health care provider any findings of peptic ulcers

Feedback:

Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite. Abdominal pain, rigidity and tenderness can signal perforation of the ulcer and should be reported to the provider immediately. Zollinger-Ellison syndrome can occur in both children and adults. All of the other options are correct information about this syndrome. Smeltzer, S.C., Bare, B.G., Hinkle, J. & Cheever, K.H. (2008). Brunner-Suddarth's Textbook of Medical Surgical Nursing. (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier.

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Student Exam Results Correct (Ref: 2466)A nurse is observing a client during an excretory urogram. Which
Student Exam Results
Student Exam Results

14 September 2009 7:29:17AM

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Student Exam Results 14 September 2009 7:29:17AM Page 9 of 9