Post by Nursing Board 101 on Aug 18, 2010 12:44:40 GMT -5
Analysis
Health Promotion and Maintenance
Nursing Process/Analysis
Adult Health/Cardiovascular
1. A nurse is assessing the extent of pitting edema in a client with congestive heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pit. The nurse interprets this finding as which measurement of pitting edema?
a. 1+
b. 2+
c. 3+
d. 4+
A. The level of pitting edema is rated on a scale of 1+ to 4+. A barely perceptible pit is rated as 1+. A deeper pit that rebounds in a few seconds is rated as 2+. A deep pit that rebounds in 10 to 20 seconds is rated as 3+. A deeper pit that rebounds in greater than 30 seconds is rated as 4+.
2. The nurse notes documentation that a client's peripheral pulses are +3. The nurse determines that the pulses are
a. Full and brisk
b. Absent
c. Normal or average
d. Palpable, but diminished
A. Pulses are rated on a scale of 0 to +4 as follows: 0 = absent; +1 = palpable, but diminished; +2 = normal or average; +3 = full and brisk; and +4 = full and bounding, often visible.
3. A nurse is reviewing a client’s record and notes that the results of the client’s vision test using a Snellen chart is 20/50. The nurse interprets this to mean that the client
a. Has normal vision
b. Has minimal visual
c. Can read at a distance of 20 feet what a client with normal vision can read at 50 feet
d. Can read at a distance of 50 feet what a client with normal vision can read at 20 feet
C. When recording the results of visual acuity using the Snellen chart, the nurse would record the result using the numeric fraction noted at the end of the last successful line read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, whereas the bottom number (denominator) gives the distance at which a person with normal vision could have read that particular line. Thus, 20/50 means that the client can read at a distance of 20 feet what a client with normal vision can read at 50 feet. Normal visual acuity is 20/20. Minimal vision is a vague description of a client’s visual acuity.
4. A prenatal client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse formulates which nursing diagnosis for this client?
a. Ineffective Coping
b. Dysfunctional Grieving
c. Situational Low Self-esteem
d. Deficient Knowledge
D. Deficient Knowledge indicates a lack of information or psychomotor skills concerning a skill, condition, or treatment. This nursing diagnosis best describes the situation presented in the question. Situational Low Self-esteem represents temporary negative feelings about self in response to an event. Ineffective Coping implies that the person is unable to manage stressors adequately. Dysfunctional Grieving implies prolonged unresolved grief leading to detrimental activities.
5. The nurse notes documentation that a client has the presence of cherry angiomas located on the abdomen. On assessment of the client, the nurse would expect to note which characteristic of this skin lesion?
a. Ruby red papules
b. Thickened skin areas
c. Pinpoint-sized red or purple spots
d. Areas of redness warm to touch
A. Cherry angiomas are noted as ruby red papules. Areas of skin thickening are noted as senile keratosis. Pinpoint-sized red or purple spots are known as petechiae. Areas of redness that are warm to touch are noted as erythema.
6. A nurse is assessing the risk factors for acquiring pneumonia during hospitalization for a group of clients. The nurse determines that which of the following clients is at lowest risk?
a. An older client with diabetes mellitus
b. A client with human immunodeficiency virus (HIV)
c. A client with a spinal cord injury who is immobile
d. A postoperative client who is ambulating
D. The postoperative client who is ambulating is at lowest risk. This client has had no direct insult to the respiratory tract. Clients with HIV, an upper respiratory infection, or a chronic disease (e.g., heart, lung, or kidney disease; diabetes mellitus; or cancer) are at greater risk for development of pneumonia. Clients who are on bed rest and are immobilized also are at risk for development of pneumonia.
7. A nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client at greatest risk for abruptio placenta is the one who
a. Is 26 years old and is a primipara
b. Rides an exercise bike for 30 minutes 3 times weekly
c. Has maternal hypertension
d. Takes folic acid supplements daily
C. Risk factors for abruptio placenta include maternal hypertension, smoking, and alcohol and/or cocaine use during pregnancy. Other risk factors include blunt external abdominal trauma, poor nutrition, and history of placental abruption.
8. The nurse teaches a client with gastroesophageal reflux disease (GERD) about the measures to prevent reflux while sleeping. The nurse determines that the client needs additional instructions if the client states
a. "I shouldn't eat anything at bedtime."
b. "I should take an antacid at bedtime."
c. "I should sleep flat on my right side."
d. "Losing weight will decrease some of the stomach pressure."
C. Elevation of the head of the bed 6 to 8 inches will prevent nocturnal reflux. The client is instructed to avoid eating within 3 hours to bedtime to prevent nocturnal reflux. Antacids and histamine receptor antagonists may be prescribed for the client. Losing weight (if overweight) will decrease the gastroesophageal pressure gradient.
9. A nurse provides instructions to a client about the measures to treat gout. The nurse determines that the client needs additional instructions if the client states that
a. The intake of red meats needs to be limited.
b. Weight loss can help prevent an attack.
c. Medication can help keep the uric acid level down.
d. Fluid intake needs to be limited.
D. Medication therapy is a component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or will reduce its production for clients with chronic gout. Fluid intake is important to promote uric acid excretion. Weight loss can reduce the incidence of attacks and reduce uric acid levels. A decrease in the intake of red meats and organ meats will assist in controlling uric acid levels.
10. A nurse provides instructions to a client who is being discharged 24 hours after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions?
a. "I need to avoid any strenuous lifting for about two weeks."
b. "I shouldn't work out at the gym for about two weeks."
c. "I will call the physician if my urine becomes bloody."
d. "A fever is normal after this procedure."
D. After percutaneous renal biopsy, the client is instructed to report immediately fever, increasing pain levels (back, flank, or shoulder), bleeding from the puncture site, weakness, dizziness, grossly bloody urine, or dysuria. Activity should be restricted if blood is seen in the urine. The client also is instructed to avoid strenuous lifting, physical exertion, or trauma to the biopsy site for up to 2 weeks after discharge.
11. A clinic nurse has provided instructions to the mother of a child with a urinary tract infection. Which statement by the mother indicates a need for further instructions?
a. "I should wipe my child from front to back after urination or a bowel movement."
b. "I should increase my child's fluid intake."
c. "I should encourage my child to hold the urine and to urinate at least four times a day."
d. "I should avoid the use of bubble baths with my child."
C. The parents should be taught to wipe the child from front to back after urination or a bowel movement to avoid moving bacteria from the anus to the urethra. Fluid intake including water should be encouraged. The child should be encouraged to avoid holding urine and to urinate at least four times a day; also, the bladder should be emptied with each void to prevent residual urine. Bubble baths are avoided secondary to possible urethral irritation.
12. A nurse provides dietary instructions to a client with hypertension. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which of the following food items?
a. Hot dogs
b. Turkey
c. Salad with blue cheese dressing
d. Corned beef hash
B. A client with hypertension needs to avoid foods that are high in sodium, such as bacon, hot dogs, luncheon meat, chipped or corned beef, kosher meat, smoked or salted meat or fish, peanut butter, and a variety of shellfish. Processed foods, canned foods, cheese, and many salad dressings also are high in sodium.
13. The nurse is providing dietary instructions to a client with ascites who will be discharged to home from the hospital. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which food item?
a. Canned green beans
b. Fresh plums
c. Cooked ham
d. Bologna
B. The client with ascites is generally encouraged to avoid foods that are high in sodium, which could aggravate fluid retention. The diet should be high in protein (unless specifically advised otherwise) and high in calories. Canned foods, ham, and cold cuts are high in sodium.
14. A nurse has provided instructions to a client with chronic obstructive pulmonary disease about the procedure for performing pursed lip breathing. The nurse observes the client perform the procedure and determines that he or she is performing it correctly if the client
a. Takes a deep breath and exhales quickly
b. Monitors inspiration time and ensures that expiration time is less than inspiration time
c. Lies on the side in a supine position to perform the procedure
d. Sits in an upright position, takes a deep breath, and exhales slowly
D. Pursed lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, the client is instructed to take a deep breath and to exhale slowly through pursed lips. Therefore, options 1, 2, and 3 are incorrect.
15. A nurse has completed discharge teaching with the family of a client who requires dressing changes at home. Which method of evaluation would the nurse use to best determine the family’s competence in performing the dressing changes?
a. Asking a family member to perform the dressing change and observing the procedure
b. Asking a family member to identify the supplies needed to perform the dressing change
c. Asking a family member to list the steps of the procedure for performing the dressing change
d. Asking a family member to verbalize the procedure for performing the dressing change
A. Return demonstration is the most reliable evaluation of procedure performance. Selection of equipment is included in a return demonstration. Asking a family member to list the steps for the procedure or to verbalize the procedure does not allow the nurse to observe the psychomotor skill needed to perform the procedure.
16. A nurse is teaching a client diagnosed with iron deficiency anemia about the foods that are high in iron. The nurse tells the client to consume which high-iron food?
a. Refined white bread
b. Egg whites
c. Mushrooms
d. Spinach
D. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat; liver and other organ meats; blackstrap molasses; and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, beets, carrots, raisins, and apricots.
17. A clinic nurse provides instructions to a woman in the second trimester of pregnancy regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures?
a. "I will sleep on a soft mattress."
b. "I will avoid doing those pelvic tilt exercises."
c. "I will avoid getting tired, and I should work at maintaining a good posture."
d. "I will wear shoes with a heel of at least 2 inches."
C. Backache can occur because of the exaggerated lumbar and cervicothoracic curves caused by the change in the center of gravity from the enlarging abdomen. The client should be instructed to sleep on a firm mattress, to avoid fatigue, and to maintain good posture and body mechanics. Pelvic tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity.
18. A prenatal client reports heartburn, and the nurse provides instructions to the client regarding measures to alleviate the discomfort. Which statement by the client indicates a need for further instructions?
a. "I need to eat small, frequent meals."
b. "I need to avoid fatty or spicy foods."
c. "I need to lie down after eating."
d. "I need to drink approximately 2000 mL fluid per day."
C. Heartburn is associated with regurgitation of gastric acid contents into the esophagus. Self-care measures for heartburn include eating small, frequent meals; avoiding fatty or spicy foods; remaining upright for 30 minutes after eating; and drinking approximately 2000 mL fluid per day.
19. During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the client’s lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion?
a. Transfusion reaction
b. Allergic reaction
c. Sepsis
d. Circulatory overload
D. Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in central venous pressure are clinical indications of circulatory overload caused from excessive infusion amounts or too rapid of an infusion rate. Clinical manifestations of sepsis include fever, abdominal cramps, nausea, vomiting, and diarrhea. A transfusion reaction and an allergic reaction are similar and can include manifestations such as flushing, itching, urticaria, tachycardia, and low back pain.
20. A client with type 1 diabetes mellitus has a blood glucose level of 554 mg/dL. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
C. Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level increases. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis.
21. A client is scheduled for a liver biopsy, and the nurse reviews the results of the laboratory tests prescribed for the client. The nurse would contact the physician if which laboratory result is noted?
a. Platelets: 210,000/mm<sup>3</sup>
b. Thrombin time: 20 seconds
c. Hematocrit: 40%
d. Hemoglobin: 14 g/dL
B. The normal thrombin time is 10 to 15 seconds. A prolonged time indicates that the client is at risk for bleeding. Coagulation profile tests are performed before a liver biopsy to ensure that the client is not at risk for bleeding as a result of the procedure. The laboratory results in options A,C, and D are within reference range.
22. A client who sustained an inhalation burn injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is confused and combative. The nurse determines that the client is experiencing
a. Anxiety
b. Fear
c. Hypoxia
d. Pain
C. After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. Options A, B, and D are not associated with the data in the question.
23. A nurse is reviewing the assessment data in the record of a client assigned to her care and notes documentation that the client has pallor. The nurse determines that this skin color variation is most likely caused by
a. An increased amount of bilirubin deposits in the tissues
b. An increased amount of deoxygenated hemoglobin associated with hypoxia
c. A reduced amount of oxyhemoglobin from decreased blood flow
d. An increased amount of melanin in the tissues
C. Pallor, a decrease in skin color, is caused by a decreased amount of oxyhemoglobin resulting from decreased blood flow. Some causes of pallor include anemia or shock. Pallor can best be assessed in the face, conjunctivae, nail beds, palms of the hands, or lips. A bluish discoloration (cyanosis) is caused by an increased amount of deoxygenated hemoglobin associated with hypoxia. A yellow-orange skin discoloration (jaundice) is caused by an increased amount of bilirubin deposits in the tissues. A tan-brown skin color is caused by an increased amount of melanin in the tissues.
24. A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets that this is an expected finding in the client with which problem?
a. Diarrhea
b. Diabetes insipidus
c. Burn injury
d. Pulmonary edema being treated with loop diuretics
C.A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the result to the physician. Burn injuries are a cause of hyperkalemia. Other common causes of hyperkalemia include adrenal insufficiency (Addison disease), renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or diabetes insipidus or the client being treated with loop diuretics is at risk for hypokalemia.
25. The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg and notes the presence of edema in the foot below the cast. The nurse would interpret that this finding indicates
a. Impaired arterial circulation
b. The presence of an infection
c. Impaired venous return
d. Arterial insufficiency
C. Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast, or the presence of hot spots, which are areas of the cast that are warmer than other areas.
26. A nurse reviews the assessment data on a client with a head injury and notes that the client's intracranial pressure reading is 10 mm Hg. On the basis of this finding, the nurse determines that the client's intracranial pressure reading
a. Is increased
b. Is normal
c. Needs to be reduced with aggressive treatment measures
d. Requires physician notification
B. The normal intracranial pressure readings are between 0 and 15 mm Hg, and pressures greater than 20 mm Hg are considered to be increased. Therefore, options A, C, and D are incorrect.
27. A nurse is reviewing the laboratory results of a client with cancer and notes that the calcium level is 14 mg/dL. The nurse determines that this calcium level is consistent with which oncological emergency?
a. Syndrome of inappropriate antidiuretic hormone (SIADH)
b. Spinal cord compression
c. Superior vena cava syndrome
d. Hypercalcemia
D. One potentially life-threatening complication of cancer is hypercalcemia, which is characterized by calcium levels greater than 11 mg/dL. Although spinal cord compression and superior vena cava syndrome also are oncological emergencies, they are not characterized by high calcium levels. SIADH also is an oncological emergency, but it is characterized by hyponatremia.
28. A nurse reviews a client's urinalysis report. The nurse determines that which finding is abnormal?
a. Opacity is clear.
b. Specific gravity is 1.018.
c. Ketones are negative.
d. Protein is positive.
D. The urine has a normal pH range of 4.5 to 8, and a specific gravity ranging from 1.002 to 1.035. Urine typically is screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative.
29. A client with chronic renal failure returns to the nursing unit after receiving his second hemodialysis treatment, and the nurse monitors the client closely for signs of disequilibrium syndrome. The nurse monitors for which sign of this syndrome?
a. Irritability
b. Mental confusion
c. Tachycardia
d. Hypothermia
B. Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a greater residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates. The signs in options 1, 3, and 4 are not associated with disequilibrium syndrome.
30. A home care nurse is assessing a client who has begun using peritoneal dialysis 1 week ago. The nurse would suspect the onset of peritonitis if which of the following is noted on assessment?
a. Oral temperature of 99.0° F
b. Anorexia
c. Cloudy dialysate output
d. Mild abdominal discomfort
C. Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The slight temperature increase in option 1 is not the clearest indicator of infection. The complaint of anorexia is too vague to indicate peritonitis. Some mild abdominal discomfort may occur initially with peritoneal dialysis.
Health Promotion and Maintenance
Nursing Process/Analysis
Adult Health/Cardiovascular
1. A nurse is assessing the extent of pitting edema in a client with congestive heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pit. The nurse interprets this finding as which measurement of pitting edema?
a. 1+
b. 2+
c. 3+
d. 4+
A. The level of pitting edema is rated on a scale of 1+ to 4+. A barely perceptible pit is rated as 1+. A deeper pit that rebounds in a few seconds is rated as 2+. A deep pit that rebounds in 10 to 20 seconds is rated as 3+. A deeper pit that rebounds in greater than 30 seconds is rated as 4+.
2. The nurse notes documentation that a client's peripheral pulses are +3. The nurse determines that the pulses are
a. Full and brisk
b. Absent
c. Normal or average
d. Palpable, but diminished
A. Pulses are rated on a scale of 0 to +4 as follows: 0 = absent; +1 = palpable, but diminished; +2 = normal or average; +3 = full and brisk; and +4 = full and bounding, often visible.
3. A nurse is reviewing a client’s record and notes that the results of the client’s vision test using a Snellen chart is 20/50. The nurse interprets this to mean that the client
a. Has normal vision
b. Has minimal visual
c. Can read at a distance of 20 feet what a client with normal vision can read at 50 feet
d. Can read at a distance of 50 feet what a client with normal vision can read at 20 feet
C. When recording the results of visual acuity using the Snellen chart, the nurse would record the result using the numeric fraction noted at the end of the last successful line read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, whereas the bottom number (denominator) gives the distance at which a person with normal vision could have read that particular line. Thus, 20/50 means that the client can read at a distance of 20 feet what a client with normal vision can read at 50 feet. Normal visual acuity is 20/20. Minimal vision is a vague description of a client’s visual acuity.
4. A prenatal client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse formulates which nursing diagnosis for this client?
a. Ineffective Coping
b. Dysfunctional Grieving
c. Situational Low Self-esteem
d. Deficient Knowledge
D. Deficient Knowledge indicates a lack of information or psychomotor skills concerning a skill, condition, or treatment. This nursing diagnosis best describes the situation presented in the question. Situational Low Self-esteem represents temporary negative feelings about self in response to an event. Ineffective Coping implies that the person is unable to manage stressors adequately. Dysfunctional Grieving implies prolonged unresolved grief leading to detrimental activities.
5. The nurse notes documentation that a client has the presence of cherry angiomas located on the abdomen. On assessment of the client, the nurse would expect to note which characteristic of this skin lesion?
a. Ruby red papules
b. Thickened skin areas
c. Pinpoint-sized red or purple spots
d. Areas of redness warm to touch
A. Cherry angiomas are noted as ruby red papules. Areas of skin thickening are noted as senile keratosis. Pinpoint-sized red or purple spots are known as petechiae. Areas of redness that are warm to touch are noted as erythema.
6. A nurse is assessing the risk factors for acquiring pneumonia during hospitalization for a group of clients. The nurse determines that which of the following clients is at lowest risk?
a. An older client with diabetes mellitus
b. A client with human immunodeficiency virus (HIV)
c. A client with a spinal cord injury who is immobile
d. A postoperative client who is ambulating
D. The postoperative client who is ambulating is at lowest risk. This client has had no direct insult to the respiratory tract. Clients with HIV, an upper respiratory infection, or a chronic disease (e.g., heart, lung, or kidney disease; diabetes mellitus; or cancer) are at greater risk for development of pneumonia. Clients who are on bed rest and are immobilized also are at risk for development of pneumonia.
7. A nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client at greatest risk for abruptio placenta is the one who
a. Is 26 years old and is a primipara
b. Rides an exercise bike for 30 minutes 3 times weekly
c. Has maternal hypertension
d. Takes folic acid supplements daily
C. Risk factors for abruptio placenta include maternal hypertension, smoking, and alcohol and/or cocaine use during pregnancy. Other risk factors include blunt external abdominal trauma, poor nutrition, and history of placental abruption.
8. The nurse teaches a client with gastroesophageal reflux disease (GERD) about the measures to prevent reflux while sleeping. The nurse determines that the client needs additional instructions if the client states
a. "I shouldn't eat anything at bedtime."
b. "I should take an antacid at bedtime."
c. "I should sleep flat on my right side."
d. "Losing weight will decrease some of the stomach pressure."
C. Elevation of the head of the bed 6 to 8 inches will prevent nocturnal reflux. The client is instructed to avoid eating within 3 hours to bedtime to prevent nocturnal reflux. Antacids and histamine receptor antagonists may be prescribed for the client. Losing weight (if overweight) will decrease the gastroesophageal pressure gradient.
9. A nurse provides instructions to a client about the measures to treat gout. The nurse determines that the client needs additional instructions if the client states that
a. The intake of red meats needs to be limited.
b. Weight loss can help prevent an attack.
c. Medication can help keep the uric acid level down.
d. Fluid intake needs to be limited.
D. Medication therapy is a component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or will reduce its production for clients with chronic gout. Fluid intake is important to promote uric acid excretion. Weight loss can reduce the incidence of attacks and reduce uric acid levels. A decrease in the intake of red meats and organ meats will assist in controlling uric acid levels.
10. A nurse provides instructions to a client who is being discharged 24 hours after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions?
a. "I need to avoid any strenuous lifting for about two weeks."
b. "I shouldn't work out at the gym for about two weeks."
c. "I will call the physician if my urine becomes bloody."
d. "A fever is normal after this procedure."
D. After percutaneous renal biopsy, the client is instructed to report immediately fever, increasing pain levels (back, flank, or shoulder), bleeding from the puncture site, weakness, dizziness, grossly bloody urine, or dysuria. Activity should be restricted if blood is seen in the urine. The client also is instructed to avoid strenuous lifting, physical exertion, or trauma to the biopsy site for up to 2 weeks after discharge.
11. A clinic nurse has provided instructions to the mother of a child with a urinary tract infection. Which statement by the mother indicates a need for further instructions?
a. "I should wipe my child from front to back after urination or a bowel movement."
b. "I should increase my child's fluid intake."
c. "I should encourage my child to hold the urine and to urinate at least four times a day."
d. "I should avoid the use of bubble baths with my child."
C. The parents should be taught to wipe the child from front to back after urination or a bowel movement to avoid moving bacteria from the anus to the urethra. Fluid intake including water should be encouraged. The child should be encouraged to avoid holding urine and to urinate at least four times a day; also, the bladder should be emptied with each void to prevent residual urine. Bubble baths are avoided secondary to possible urethral irritation.
12. A nurse provides dietary instructions to a client with hypertension. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which of the following food items?
a. Hot dogs
b. Turkey
c. Salad with blue cheese dressing
d. Corned beef hash
B. A client with hypertension needs to avoid foods that are high in sodium, such as bacon, hot dogs, luncheon meat, chipped or corned beef, kosher meat, smoked or salted meat or fish, peanut butter, and a variety of shellfish. Processed foods, canned foods, cheese, and many salad dressings also are high in sodium.
13. The nurse is providing dietary instructions to a client with ascites who will be discharged to home from the hospital. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which food item?
a. Canned green beans
b. Fresh plums
c. Cooked ham
d. Bologna
B. The client with ascites is generally encouraged to avoid foods that are high in sodium, which could aggravate fluid retention. The diet should be high in protein (unless specifically advised otherwise) and high in calories. Canned foods, ham, and cold cuts are high in sodium.
14. A nurse has provided instructions to a client with chronic obstructive pulmonary disease about the procedure for performing pursed lip breathing. The nurse observes the client perform the procedure and determines that he or she is performing it correctly if the client
a. Takes a deep breath and exhales quickly
b. Monitors inspiration time and ensures that expiration time is less than inspiration time
c. Lies on the side in a supine position to perform the procedure
d. Sits in an upright position, takes a deep breath, and exhales slowly
D. Pursed lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, the client is instructed to take a deep breath and to exhale slowly through pursed lips. Therefore, options 1, 2, and 3 are incorrect.
15. A nurse has completed discharge teaching with the family of a client who requires dressing changes at home. Which method of evaluation would the nurse use to best determine the family’s competence in performing the dressing changes?
a. Asking a family member to perform the dressing change and observing the procedure
b. Asking a family member to identify the supplies needed to perform the dressing change
c. Asking a family member to list the steps of the procedure for performing the dressing change
d. Asking a family member to verbalize the procedure for performing the dressing change
A. Return demonstration is the most reliable evaluation of procedure performance. Selection of equipment is included in a return demonstration. Asking a family member to list the steps for the procedure or to verbalize the procedure does not allow the nurse to observe the psychomotor skill needed to perform the procedure.
16. A nurse is teaching a client diagnosed with iron deficiency anemia about the foods that are high in iron. The nurse tells the client to consume which high-iron food?
a. Refined white bread
b. Egg whites
c. Mushrooms
d. Spinach
D. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat; liver and other organ meats; blackstrap molasses; and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, beets, carrots, raisins, and apricots.
17. A clinic nurse provides instructions to a woman in the second trimester of pregnancy regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures?
a. "I will sleep on a soft mattress."
b. "I will avoid doing those pelvic tilt exercises."
c. "I will avoid getting tired, and I should work at maintaining a good posture."
d. "I will wear shoes with a heel of at least 2 inches."
C. Backache can occur because of the exaggerated lumbar and cervicothoracic curves caused by the change in the center of gravity from the enlarging abdomen. The client should be instructed to sleep on a firm mattress, to avoid fatigue, and to maintain good posture and body mechanics. Pelvic tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity.
18. A prenatal client reports heartburn, and the nurse provides instructions to the client regarding measures to alleviate the discomfort. Which statement by the client indicates a need for further instructions?
a. "I need to eat small, frequent meals."
b. "I need to avoid fatty or spicy foods."
c. "I need to lie down after eating."
d. "I need to drink approximately 2000 mL fluid per day."
C. Heartburn is associated with regurgitation of gastric acid contents into the esophagus. Self-care measures for heartburn include eating small, frequent meals; avoiding fatty or spicy foods; remaining upright for 30 minutes after eating; and drinking approximately 2000 mL fluid per day.
19. During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the client’s lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion?
a. Transfusion reaction
b. Allergic reaction
c. Sepsis
d. Circulatory overload
D. Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in central venous pressure are clinical indications of circulatory overload caused from excessive infusion amounts or too rapid of an infusion rate. Clinical manifestations of sepsis include fever, abdominal cramps, nausea, vomiting, and diarrhea. A transfusion reaction and an allergic reaction are similar and can include manifestations such as flushing, itching, urticaria, tachycardia, and low back pain.
20. A client with type 1 diabetes mellitus has a blood glucose level of 554 mg/dL. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
C. Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level increases. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis.
21. A client is scheduled for a liver biopsy, and the nurse reviews the results of the laboratory tests prescribed for the client. The nurse would contact the physician if which laboratory result is noted?
a. Platelets: 210,000/mm<sup>3</sup>
b. Thrombin time: 20 seconds
c. Hematocrit: 40%
d. Hemoglobin: 14 g/dL
B. The normal thrombin time is 10 to 15 seconds. A prolonged time indicates that the client is at risk for bleeding. Coagulation profile tests are performed before a liver biopsy to ensure that the client is not at risk for bleeding as a result of the procedure. The laboratory results in options A,C, and D are within reference range.
22. A client who sustained an inhalation burn injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is confused and combative. The nurse determines that the client is experiencing
a. Anxiety
b. Fear
c. Hypoxia
d. Pain
C. After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. Options A, B, and D are not associated with the data in the question.
23. A nurse is reviewing the assessment data in the record of a client assigned to her care and notes documentation that the client has pallor. The nurse determines that this skin color variation is most likely caused by
a. An increased amount of bilirubin deposits in the tissues
b. An increased amount of deoxygenated hemoglobin associated with hypoxia
c. A reduced amount of oxyhemoglobin from decreased blood flow
d. An increased amount of melanin in the tissues
C. Pallor, a decrease in skin color, is caused by a decreased amount of oxyhemoglobin resulting from decreased blood flow. Some causes of pallor include anemia or shock. Pallor can best be assessed in the face, conjunctivae, nail beds, palms of the hands, or lips. A bluish discoloration (cyanosis) is caused by an increased amount of deoxygenated hemoglobin associated with hypoxia. A yellow-orange skin discoloration (jaundice) is caused by an increased amount of bilirubin deposits in the tissues. A tan-brown skin color is caused by an increased amount of melanin in the tissues.
24. A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets that this is an expected finding in the client with which problem?
a. Diarrhea
b. Diabetes insipidus
c. Burn injury
d. Pulmonary edema being treated with loop diuretics
C.A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the result to the physician. Burn injuries are a cause of hyperkalemia. Other common causes of hyperkalemia include adrenal insufficiency (Addison disease), renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or diabetes insipidus or the client being treated with loop diuretics is at risk for hypokalemia.
25. The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg and notes the presence of edema in the foot below the cast. The nurse would interpret that this finding indicates
a. Impaired arterial circulation
b. The presence of an infection
c. Impaired venous return
d. Arterial insufficiency
C. Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast, or the presence of hot spots, which are areas of the cast that are warmer than other areas.
26. A nurse reviews the assessment data on a client with a head injury and notes that the client's intracranial pressure reading is 10 mm Hg. On the basis of this finding, the nurse determines that the client's intracranial pressure reading
a. Is increased
b. Is normal
c. Needs to be reduced with aggressive treatment measures
d. Requires physician notification
B. The normal intracranial pressure readings are between 0 and 15 mm Hg, and pressures greater than 20 mm Hg are considered to be increased. Therefore, options A, C, and D are incorrect.
27. A nurse is reviewing the laboratory results of a client with cancer and notes that the calcium level is 14 mg/dL. The nurse determines that this calcium level is consistent with which oncological emergency?
a. Syndrome of inappropriate antidiuretic hormone (SIADH)
b. Spinal cord compression
c. Superior vena cava syndrome
d. Hypercalcemia
D. One potentially life-threatening complication of cancer is hypercalcemia, which is characterized by calcium levels greater than 11 mg/dL. Although spinal cord compression and superior vena cava syndrome also are oncological emergencies, they are not characterized by high calcium levels. SIADH also is an oncological emergency, but it is characterized by hyponatremia.
28. A nurse reviews a client's urinalysis report. The nurse determines that which finding is abnormal?
a. Opacity is clear.
b. Specific gravity is 1.018.
c. Ketones are negative.
d. Protein is positive.
D. The urine has a normal pH range of 4.5 to 8, and a specific gravity ranging from 1.002 to 1.035. Urine typically is screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative.
29. A client with chronic renal failure returns to the nursing unit after receiving his second hemodialysis treatment, and the nurse monitors the client closely for signs of disequilibrium syndrome. The nurse monitors for which sign of this syndrome?
a. Irritability
b. Mental confusion
c. Tachycardia
d. Hypothermia
B. Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a greater residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates. The signs in options 1, 3, and 4 are not associated with disequilibrium syndrome.
30. A home care nurse is assessing a client who has begun using peritoneal dialysis 1 week ago. The nurse would suspect the onset of peritonitis if which of the following is noted on assessment?
a. Oral temperature of 99.0° F
b. Anorexia
c. Cloudy dialysate output
d. Mild abdominal discomfort
C. Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The slight temperature increase in option 1 is not the clearest indicator of infection. The complaint of anorexia is too vague to indicate peritonitis. Some mild abdominal discomfort may occur initially with peritoneal dialysis.