Post by Nursing Board 101 on Aug 18, 2010 12:46:16 GMT -5
1. A nurse is reviewing the diagnostic tests prescribed for a client. The nurse notes that a lupus cell preparation (LE cell prep) has been ordered. The nurse determines that this test is used to screen primarily for which of following disorders?
a. Histoplasmosis
b. Systemic lupus erythematosus (SLE)
c. Human immunodeficiency virus (HIV)
d. Progressive systemic sclerosis
B. The LE cell prep may be performed on a client suspected of having SLE, or to screen for progressive systemic sclerosis. However, it is primarily used to screen for SLE. The other options are not associated with this diagnostic test.
2. The nurse is caring for a hospitalized client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse contacts the physician if which laboratory result is noted that may be an indication of potential pancreatitis?
a. Increased potassium
b. Increased serum triglycerides
c. Increased blood urea nitrogen
d. Increased creatinine
B. An increased triglyceride or amylase level may indicate pancreatitis from the medication, which can be potentially fatal. If this occurs, the medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure. Options 3 and 4 relate to renal function and are not associated with this medication. This medication may decrease potassium.
3. A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that the client has a
a. Greenstick fracture
b. Comminuted fracture
c. Open fracture
d. Simple fracture
C. An open fracture (compound fracture) is one in which the skin has been broken and the wound extends to the depth of the fractured bone. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone; one side of the bone is fractured, and the other side is bent. A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft, with some possible displacement but without breaking the skin.
4. The client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle accident. The nurse monitors for complications and assesses the client most closely for which of the following complications in the early post-trauma period?
a. Bradycardia
b. Pain
c. Hematuria
d. Fever
C. One complication of a pelvic fracture is damage to the kidneys and lower urinary tract. Therefore, the nurse would monitor for signs of this complication, which would include bloody urine. This client is also at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh area. Signs of hypovolemic shock include tachycardia and hypotension. Although infection is also a complication (indicated by a fever), it is not generally noted in the early post-trauma period.
5. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. Which finding indicates an early sign of increased intracranial pressure?
a. Increase in systolic blood pressure
b. Decreasing level of consciousness
c. Shallow, slow respirations
d. Decrease in pulse rate
B. Decreasing level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Other early signs include headache that increases in intensity with coughing or straining; pupillary changes such as dilation with slowed constriction, visual disturbances such as diplopia, and ptosis; and contralateral motor or sensory losses. Options 1, 3, and 4 indicate late signs of increasing intracranial pressure.
6. The nurse is performing an assessment on a client with a diagnosis of Bell’s palsy. The nurse would expect to observe which of the following symptoms in the client?
a. Twitching on the affected side of the face
b. Ptosis of the eyelid and closure of the eye
c. Facial drooping
d. Periorbital edema
C. Bell’s palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. Options 1, 2, and 4 are not associated findings in Bell’s palsy.
7. A client with a diagnosis of multiple myeloma is admitted to the hospital. On assessment, the nurse asks the client which question that specifically relates to a clinical manifestation of this disorder?
a. "Are you having any bone pain?"
b. "Do you have diarrhea?"
c. "Have you noticed an increase in appetite?"
d. "Do you have feelings of anxiety and nervousness, together with difficulty sleeping?"
A. Multiple myeloma is characterized by an abnormal proliferation of plasma B cells. These cells infiltrate the bone marrow and produce abnormal and excessive amounts of immunoglobulin. The most common presenting symptom is bone pain. Hypercalcemia occurs as a result of release of calcium from the deteriorating bone tissue; subsequently, the client experiences confusion, somnolence, constipation, nausea, and thirst.
8. The nurse is preparing to care for a client with a diagnosis of metastatic cancer and notes documentation in the client’s chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client?
a. Sunken eyes and a hollow cheek appearance
b. Periorbital edema and swelling around the ears
c. Generalized edema and the presence of weight gain
d. Increased blood pressure and ascites
A. A cachexia condition indicates a chronic wasting of the body. Cachexia accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes, hollow cheeks, and an exhausted, defeated expression. Options B, C, and D are not characteristics of a cachexia appearance.
9. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula. The nurse expects to note which finding if the fistula is patent?
a. White fibrin specks noted in the fistula
b. Palpation of a thrill over the site of the fistula
c. Lack of a bruit at the site of the fistula
d. Warmth and redness at the site of the fistula
B. An internal arteriovenous fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. The fistula is internal. To determine patency, the nurse palpates over the fistula for a thrill and auscultates for a bruit. The nurse would not note white fibrin specks in the fistula, because the fistula is internal. Warmth and redness may indicate a potential inflammatory process.
10. A physician's office nurse is assessing a client who recently had a renal transplant. The nurse monitors for which signs of acute graft rejection?
a. Hypotension, graft tenderness, and anemia
b. Hypertension, oliguria, thirst, and hypothermia
c. Fever, vomiting, hypotension, and copious amounts of dilute urine
d. Fever, hypertension, graft tenderness, and malaise
D. Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Options A, B, and C do not completely identify signs of acute rejection.
11. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when
a. Suctioning is required frequently
b. Excessive secretions are suctioned from a tracheostomy
c. The client’s skin and mucous membranes are light pink
d. Aspiration of gastric contents occurs during suctioning
D. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distension. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication.
12. A nurse is performing a cardiovascular assessment on a client with heart failure. Which of the following items would the nurse assess to gain the best information about the client’s left-sided heart function?
a. Breath sounds
b. Peripheral edema
c. Jugular vein distention
d. Hepatojugular reflux
A. The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function.
13. A nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which of the following indicates a complication?
a. A blood pressure of 138/88 mm Hg
b. An irregular heart rate
c. A reddish coloration in the client's face
d. A pulse oximetry level of 95%
B. The client should be monitored closely for complications related to suctioning, including hypoxemia, cardiac irregularities resulting from vagal stimulation, mucosal trauma, and paroxysmal coughing. If complications occur during the procedure, especially cardiac irregularities, the procedure is stopped, and the client is reoxygenated.
14. An emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition?
a. Slow deep respirations
b. Asymmetric chest movement
c. Loss of consciousness
d. Anxiety
B. Flail chest is a thoracic injury resulting in paradoxical (asymmetric) motion of the chest wall segments. The client also exhibits severe chest pain; oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; decreased breath sounds on auscultation; and cyanosis. Although the client may exhibit anxiety related to difficulty breathing, anxiety can occur in any respiratory disorder in which dyspnea is a problem. Loss of consciousness can occur with a head injury, or if the respiratory condition deteriorated significantly.
15. A nurse is caring for a client with a tracheostomy tube and is monitoring the client for subcutaneous emphysema. The nurse identifies this complication by noting which of the following?
a. Crackling sounds heard in the upper lobes bilaterally
b. A puffy and crackling sensation on palpation of the tissues surrounding the tracheostomy site
c. Signs of respiratory distress
d. Dyspnea
B. Subcutaneous emphysema occurs when air escapes from the tracheostomy incision into the tissues, dissects fascial planes under the skin, and accumulates around the face, neck, and upper chest. These areas appear puffy, and slight finger pressure produces a crackling sound and sensation. Generally, this is not a serious condition, because the air eventually will be absorbed. Options 1, 3, and 4 are not signs of subcutaneous emphysema, but they could be signs of other complications.
16. A nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which of the following is noted?
a. Abdominal distention
b. Excess mucus production
c. Abnormal skin and mucous membrane color
d. Use of accessory muscles to assist with breathing
A. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 2, 3, and 4 are not findings associated with this complication.
17. A nurse is assessing a client who was treated for an asthma attack. The nurse determines that the client's respiratory status has worsened if which of the following is noted?
a. Loud wheezing
b. Wheezing during inspiration and expiration
c. Wheezing on expiration only
d. Diminished breath sounds
D. Diminished breath sounds are an indication of obstruction and possible impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. The client with a severe asthma attack may have no audible wheezing because of the decrease of airflow. Clients may experience loud wheezes with minor attacks, whereas others may not wheeze with severe attacks. Wheezing usually occurs first on expiration. The client may wheeze during both inspiration and expiration as the asthma attack progresses.
18. A nurse is reviewing the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which of the following findings would the nurse most likely expect to note?
a. Increased creatinine levels
b. Hypotension
c. Low serum potassium
d. Tea-colored urine
D. Gross hematuria resulting in dark brown or smoky, tea-colored urine is a classic symptom of glomerulonephritis. Hypertension also is a common finding in glomerulonephritis. Blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration.
19. A nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the physician has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which of the following?
a. Undescended or hidden testes
b. The opening of the urethral meatus below the normal placement on the glans penis
c. The opening of the urethral meatus on the ventral side of the glans penis
d. The urinary bladder on the outside of the body
D. Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. Option 1 describes cryptorchidism. Option 2 describes hypospadias. Option 3 describes epispadias.
20. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse does which of the following to assess for the major symptom associated with subdural hematoma?
a. Checks for contractures of the extremities
b. Tests for equality of extremities when stimulating reflexes
c. Monitors the urinary output pattern
d. Monitors the urine for blood
B. A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can, especially if the infant is actively bleeding, cause changes in the stimuli responses in the extremities on the opposite side of the body. Option A is incorrect because contractures would not occur this soon after delivery. Options C and D are incorrect. An infant, after delivery, would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma.
21. A nurse notes documentation in a client's medical record that the client is experiencing anuria. On the basis of this notation, the nurse determines that the client
a. Is unable to produce urine
b. Has a diminished capacity to form urine
c. Has difficulty having a bowel movement
d. Has episodes of alternating constipation and diarrhea
A. Anuria is the term used to describe an inability to produce urine. Oliguria is a diminished capacity to form urine and is most likely the result of a decrease in renal perfusion. Options C and D do not relate to urinary tract dysfunction.
22. A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's intake and output and expects that
a. The client's output will be decreased.
b. The client's urine will be dilute.
c. The client's urine production will be increased.
d. The majority of the client's fluid will be excreted through the skin.
A. Febrile conditions affect urine production. The client who is diaphoretic loses fluids through insensible water loss, which decreases urine production. However, the increased body temperature associated with fever increases accumulation of body wastes. Although urine volume may be reduced, it is highly concentrated. Options B, C, and D are incorrect.
23. A nurse is monitoring a client for signs and symptoms of hypocalcemia. Which of the following symptoms is an indication of this electrolyte imbalance?
a. Lethargy
b. Depressed sensorium
c. Confusion
d. Irritability
B. Most of the clinical manifestations of hypocalcemia are related to neuromuscular hyperexcitability. These can include numbness and tingling of the hands, toes, and lips and emotional lability such as irritability and anxiety. Positive Trousseau’s or Chvostek’s sign also are present. Options A, B, and C are signs of hypercalcemia.
24. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection?
a. “Do you have any blood in your urine?”
b. “Have you noticed any swelling in your feet?”
c. “Have you had any flank pain or headaches?”
d. “Have you had any vaginal discharge?”
D. Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick, white vaginal discharge. Hematuria, flank pain, and headache are clinical manifestations associated with urinary tract infections. Edema is not associated with a vaginal infection.
25. A client with sickle cell disease is admitted to the hospital with vaso-occlusive crisis. The nurse assesses the client for which most frequent manifestation of the disorder?
a. Low-grade fever
b. Pain
c. Leukopenia
d. Blurred vision
B. A vaso-occlusive crisis has a sudden onset and results in severe pain in the long bones, joints, chest, back, and abdomen. The face may also be involved. Fever and leukocytosis are also manifestations. Blurred vision is not specifically associated with this condition.
26. The nurse monitors for which acid-base disorder that can most likely occur in a client with an ileostomy?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
A. Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for development of the acid-base disorders identified in options B, C, and D.
27. A hospitalized client with a peripheral intravenous (IV) line calls the nurse and reports that the IV site is painful. The nurse assesses the IV site and notes that it is cool and pale, and that the IV has stopped flowing. The nurse determines that which of the following effects has probably occurred?
a. Infiltration
b. Phlebitis
c. Thrombosis
d. Infection
A. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and insert a new IV line. The other three options are likely to be accompanied by warmth, not coolness, at the site.
28. A client in the second trimester of pregnancy is admitted to the maternity unit with a diagnosis of abruptio placentae. The nurse expects to note which clinical manifestation associated with this disorder?
a. Painless vaginal bleeding
b. Soft, relaxed uterus with normal tone
c. Uterine hypertonicity
d. Nontender uterus
C. In abruptio placentae, abdominal pain, uterine tenderness, and uterine hypertonicity are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Observation of the fetal monitoring often reveals loss of variability and late decelerations, uterine hyperstimulation, and increased resting tone. Painless, bright red vaginal bleeding; a soft, relaxed uterus with normal tone; and a nontender uterus are signs of placenta previa.
29. An antepartum client is diagnosed with bacterial vaginosis. The nurse expects to note which of the following on assessment of the client?
a. Hematuria and hypertension
b. Itching and vaginal discharge
c. Proteinuria and hematuria
d. Costovertebral angle pain
B. Clinical manifestations of bacterial vaginosis include pain, itching, and a thick, white vaginal discharge. Proteinuria, hematuria, hypertension, and costovertebral angle pain are clinical manifestations associated with urinary tract infections.
30. A nurse receives a report at the beginning of the shift about a client with an intrauterine fetal demise. On assessment of the client, the nurse expects to note which of the following?
a. Increased blood pressure, proteinuria, and edema
b. Regression of pregnancy symptoms and absence of fetal heart tones
c. Uterine size greater than expected for gestational age
d. Intractable vomiting and dehydration
B. Symptoms of a fetal demise include a decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. In addition, many symptoms of the pregnancy may diminish, such as breast size and tenderness. Option A is associated with preeclampsia. Option D is associated with hyperemesis gravidarum.
a. Histoplasmosis
b. Systemic lupus erythematosus (SLE)
c. Human immunodeficiency virus (HIV)
d. Progressive systemic sclerosis
B. The LE cell prep may be performed on a client suspected of having SLE, or to screen for progressive systemic sclerosis. However, it is primarily used to screen for SLE. The other options are not associated with this diagnostic test.
2. The nurse is caring for a hospitalized client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse contacts the physician if which laboratory result is noted that may be an indication of potential pancreatitis?
a. Increased potassium
b. Increased serum triglycerides
c. Increased blood urea nitrogen
d. Increased creatinine
B. An increased triglyceride or amylase level may indicate pancreatitis from the medication, which can be potentially fatal. If this occurs, the medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure. Options 3 and 4 relate to renal function and are not associated with this medication. This medication may decrease potassium.
3. A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that the client has a
a. Greenstick fracture
b. Comminuted fracture
c. Open fracture
d. Simple fracture
C. An open fracture (compound fracture) is one in which the skin has been broken and the wound extends to the depth of the fractured bone. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone; one side of the bone is fractured, and the other side is bent. A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft, with some possible displacement but without breaking the skin.
4. The client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle accident. The nurse monitors for complications and assesses the client most closely for which of the following complications in the early post-trauma period?
a. Bradycardia
b. Pain
c. Hematuria
d. Fever
C. One complication of a pelvic fracture is damage to the kidneys and lower urinary tract. Therefore, the nurse would monitor for signs of this complication, which would include bloody urine. This client is also at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh area. Signs of hypovolemic shock include tachycardia and hypotension. Although infection is also a complication (indicated by a fever), it is not generally noted in the early post-trauma period.
5. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. Which finding indicates an early sign of increased intracranial pressure?
a. Increase in systolic blood pressure
b. Decreasing level of consciousness
c. Shallow, slow respirations
d. Decrease in pulse rate
B. Decreasing level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Other early signs include headache that increases in intensity with coughing or straining; pupillary changes such as dilation with slowed constriction, visual disturbances such as diplopia, and ptosis; and contralateral motor or sensory losses. Options 1, 3, and 4 indicate late signs of increasing intracranial pressure.
6. The nurse is performing an assessment on a client with a diagnosis of Bell’s palsy. The nurse would expect to observe which of the following symptoms in the client?
a. Twitching on the affected side of the face
b. Ptosis of the eyelid and closure of the eye
c. Facial drooping
d. Periorbital edema
C. Bell’s palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. Options 1, 2, and 4 are not associated findings in Bell’s palsy.
7. A client with a diagnosis of multiple myeloma is admitted to the hospital. On assessment, the nurse asks the client which question that specifically relates to a clinical manifestation of this disorder?
a. "Are you having any bone pain?"
b. "Do you have diarrhea?"
c. "Have you noticed an increase in appetite?"
d. "Do you have feelings of anxiety and nervousness, together with difficulty sleeping?"
A. Multiple myeloma is characterized by an abnormal proliferation of plasma B cells. These cells infiltrate the bone marrow and produce abnormal and excessive amounts of immunoglobulin. The most common presenting symptom is bone pain. Hypercalcemia occurs as a result of release of calcium from the deteriorating bone tissue; subsequently, the client experiences confusion, somnolence, constipation, nausea, and thirst.
8. The nurse is preparing to care for a client with a diagnosis of metastatic cancer and notes documentation in the client’s chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client?
a. Sunken eyes and a hollow cheek appearance
b. Periorbital edema and swelling around the ears
c. Generalized edema and the presence of weight gain
d. Increased blood pressure and ascites
A. A cachexia condition indicates a chronic wasting of the body. Cachexia accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes, hollow cheeks, and an exhausted, defeated expression. Options B, C, and D are not characteristics of a cachexia appearance.
9. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula. The nurse expects to note which finding if the fistula is patent?
a. White fibrin specks noted in the fistula
b. Palpation of a thrill over the site of the fistula
c. Lack of a bruit at the site of the fistula
d. Warmth and redness at the site of the fistula
B. An internal arteriovenous fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. The fistula is internal. To determine patency, the nurse palpates over the fistula for a thrill and auscultates for a bruit. The nurse would not note white fibrin specks in the fistula, because the fistula is internal. Warmth and redness may indicate a potential inflammatory process.
10. A physician's office nurse is assessing a client who recently had a renal transplant. The nurse monitors for which signs of acute graft rejection?
a. Hypotension, graft tenderness, and anemia
b. Hypertension, oliguria, thirst, and hypothermia
c. Fever, vomiting, hypotension, and copious amounts of dilute urine
d. Fever, hypertension, graft tenderness, and malaise
D. Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Options A, B, and C do not completely identify signs of acute rejection.
11. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when
a. Suctioning is required frequently
b. Excessive secretions are suctioned from a tracheostomy
c. The client’s skin and mucous membranes are light pink
d. Aspiration of gastric contents occurs during suctioning
D. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distension. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication.
12. A nurse is performing a cardiovascular assessment on a client with heart failure. Which of the following items would the nurse assess to gain the best information about the client’s left-sided heart function?
a. Breath sounds
b. Peripheral edema
c. Jugular vein distention
d. Hepatojugular reflux
A. The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function.
13. A nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which of the following indicates a complication?
a. A blood pressure of 138/88 mm Hg
b. An irregular heart rate
c. A reddish coloration in the client's face
d. A pulse oximetry level of 95%
B. The client should be monitored closely for complications related to suctioning, including hypoxemia, cardiac irregularities resulting from vagal stimulation, mucosal trauma, and paroxysmal coughing. If complications occur during the procedure, especially cardiac irregularities, the procedure is stopped, and the client is reoxygenated.
14. An emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition?
a. Slow deep respirations
b. Asymmetric chest movement
c. Loss of consciousness
d. Anxiety
B. Flail chest is a thoracic injury resulting in paradoxical (asymmetric) motion of the chest wall segments. The client also exhibits severe chest pain; oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; decreased breath sounds on auscultation; and cyanosis. Although the client may exhibit anxiety related to difficulty breathing, anxiety can occur in any respiratory disorder in which dyspnea is a problem. Loss of consciousness can occur with a head injury, or if the respiratory condition deteriorated significantly.
15. A nurse is caring for a client with a tracheostomy tube and is monitoring the client for subcutaneous emphysema. The nurse identifies this complication by noting which of the following?
a. Crackling sounds heard in the upper lobes bilaterally
b. A puffy and crackling sensation on palpation of the tissues surrounding the tracheostomy site
c. Signs of respiratory distress
d. Dyspnea
B. Subcutaneous emphysema occurs when air escapes from the tracheostomy incision into the tissues, dissects fascial planes under the skin, and accumulates around the face, neck, and upper chest. These areas appear puffy, and slight finger pressure produces a crackling sound and sensation. Generally, this is not a serious condition, because the air eventually will be absorbed. Options 1, 3, and 4 are not signs of subcutaneous emphysema, but they could be signs of other complications.
16. A nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which of the following is noted?
a. Abdominal distention
b. Excess mucus production
c. Abnormal skin and mucous membrane color
d. Use of accessory muscles to assist with breathing
A. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 2, 3, and 4 are not findings associated with this complication.
17. A nurse is assessing a client who was treated for an asthma attack. The nurse determines that the client's respiratory status has worsened if which of the following is noted?
a. Loud wheezing
b. Wheezing during inspiration and expiration
c. Wheezing on expiration only
d. Diminished breath sounds
D. Diminished breath sounds are an indication of obstruction and possible impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. The client with a severe asthma attack may have no audible wheezing because of the decrease of airflow. Clients may experience loud wheezes with minor attacks, whereas others may not wheeze with severe attacks. Wheezing usually occurs first on expiration. The client may wheeze during both inspiration and expiration as the asthma attack progresses.
18. A nurse is reviewing the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which of the following findings would the nurse most likely expect to note?
a. Increased creatinine levels
b. Hypotension
c. Low serum potassium
d. Tea-colored urine
D. Gross hematuria resulting in dark brown or smoky, tea-colored urine is a classic symptom of glomerulonephritis. Hypertension also is a common finding in glomerulonephritis. Blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration.
19. A nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the physician has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which of the following?
a. Undescended or hidden testes
b. The opening of the urethral meatus below the normal placement on the glans penis
c. The opening of the urethral meatus on the ventral side of the glans penis
d. The urinary bladder on the outside of the body
D. Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. Option 1 describes cryptorchidism. Option 2 describes hypospadias. Option 3 describes epispadias.
20. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse does which of the following to assess for the major symptom associated with subdural hematoma?
a. Checks for contractures of the extremities
b. Tests for equality of extremities when stimulating reflexes
c. Monitors the urinary output pattern
d. Monitors the urine for blood
B. A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can, especially if the infant is actively bleeding, cause changes in the stimuli responses in the extremities on the opposite side of the body. Option A is incorrect because contractures would not occur this soon after delivery. Options C and D are incorrect. An infant, after delivery, would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma.
21. A nurse notes documentation in a client's medical record that the client is experiencing anuria. On the basis of this notation, the nurse determines that the client
a. Is unable to produce urine
b. Has a diminished capacity to form urine
c. Has difficulty having a bowel movement
d. Has episodes of alternating constipation and diarrhea
A. Anuria is the term used to describe an inability to produce urine. Oliguria is a diminished capacity to form urine and is most likely the result of a decrease in renal perfusion. Options C and D do not relate to urinary tract dysfunction.
22. A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's intake and output and expects that
a. The client's output will be decreased.
b. The client's urine will be dilute.
c. The client's urine production will be increased.
d. The majority of the client's fluid will be excreted through the skin.
A. Febrile conditions affect urine production. The client who is diaphoretic loses fluids through insensible water loss, which decreases urine production. However, the increased body temperature associated with fever increases accumulation of body wastes. Although urine volume may be reduced, it is highly concentrated. Options B, C, and D are incorrect.
23. A nurse is monitoring a client for signs and symptoms of hypocalcemia. Which of the following symptoms is an indication of this electrolyte imbalance?
a. Lethargy
b. Depressed sensorium
c. Confusion
d. Irritability
B. Most of the clinical manifestations of hypocalcemia are related to neuromuscular hyperexcitability. These can include numbness and tingling of the hands, toes, and lips and emotional lability such as irritability and anxiety. Positive Trousseau’s or Chvostek’s sign also are present. Options A, B, and C are signs of hypercalcemia.
24. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection?
a. “Do you have any blood in your urine?”
b. “Have you noticed any swelling in your feet?”
c. “Have you had any flank pain or headaches?”
d. “Have you had any vaginal discharge?”
D. Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick, white vaginal discharge. Hematuria, flank pain, and headache are clinical manifestations associated with urinary tract infections. Edema is not associated with a vaginal infection.
25. A client with sickle cell disease is admitted to the hospital with vaso-occlusive crisis. The nurse assesses the client for which most frequent manifestation of the disorder?
a. Low-grade fever
b. Pain
c. Leukopenia
d. Blurred vision
B. A vaso-occlusive crisis has a sudden onset and results in severe pain in the long bones, joints, chest, back, and abdomen. The face may also be involved. Fever and leukocytosis are also manifestations. Blurred vision is not specifically associated with this condition.
26. The nurse monitors for which acid-base disorder that can most likely occur in a client with an ileostomy?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
A. Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for development of the acid-base disorders identified in options B, C, and D.
27. A hospitalized client with a peripheral intravenous (IV) line calls the nurse and reports that the IV site is painful. The nurse assesses the IV site and notes that it is cool and pale, and that the IV has stopped flowing. The nurse determines that which of the following effects has probably occurred?
a. Infiltration
b. Phlebitis
c. Thrombosis
d. Infection
A. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and insert a new IV line. The other three options are likely to be accompanied by warmth, not coolness, at the site.
28. A client in the second trimester of pregnancy is admitted to the maternity unit with a diagnosis of abruptio placentae. The nurse expects to note which clinical manifestation associated with this disorder?
a. Painless vaginal bleeding
b. Soft, relaxed uterus with normal tone
c. Uterine hypertonicity
d. Nontender uterus
C. In abruptio placentae, abdominal pain, uterine tenderness, and uterine hypertonicity are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Observation of the fetal monitoring often reveals loss of variability and late decelerations, uterine hyperstimulation, and increased resting tone. Painless, bright red vaginal bleeding; a soft, relaxed uterus with normal tone; and a nontender uterus are signs of placenta previa.
29. An antepartum client is diagnosed with bacterial vaginosis. The nurse expects to note which of the following on assessment of the client?
a. Hematuria and hypertension
b. Itching and vaginal discharge
c. Proteinuria and hematuria
d. Costovertebral angle pain
B. Clinical manifestations of bacterial vaginosis include pain, itching, and a thick, white vaginal discharge. Proteinuria, hematuria, hypertension, and costovertebral angle pain are clinical manifestations associated with urinary tract infections.
30. A nurse receives a report at the beginning of the shift about a client with an intrauterine fetal demise. On assessment of the client, the nurse expects to note which of the following?
a. Increased blood pressure, proteinuria, and edema
b. Regression of pregnancy symptoms and absence of fetal heart tones
c. Uterine size greater than expected for gestational age
d. Intractable vomiting and dehydration
B. Symptoms of a fetal demise include a decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. In addition, many symptoms of the pregnancy may diminish, such as breast size and tenderness. Option A is associated with preeclampsia. Option D is associated with hyperemesis gravidarum.