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|More NCLEX review questions|
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|Post #1 Dec 8 2009, 10:43 AM||justin.kredible|
NurseReview.Org - Nclex Question Trainer Explanations Test 1
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|Post #4 Dec 8 2009, 08:08 PM||riamolina|
50 item Pharmacology Exam
Source: Saunders Q&A Review 3rd edition
1. A client with myasthenia gravis reports the occurrence of difficulty chewing. The physician prescribes pyridostigmine bromide (Mestinon) to increase muscle strength for this activity. The nurse instructs the client to take the medication at what time, in relation to meals?
a. after dinner daily when most fatigued
b. before breakfast daily
c. as soon as arising in the morning
d. thirty minutes before each meal
Pyridostigmine is a cholinergic medication used to increase muscle strength for the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client’s ability to eat.
2. A client is advised to take senna (Senokot) for the treatment of constipation asks the nurse how this medication works. The nurse responds knowing that it:
a. accumulates water in the stool and increases peristalsis
b. stimulates the vagus nerve
c. coats the bowel wall
d. adds fiber and bulk to the stool
Senna works by changing the transport of water and electrolytes in the large intestine, which causes the accumulation of water in the mass of stool and increased peristalsis.
3. A client is receiving heparin sodium by continuous intravenous infusion. The nurse monitors the client for which adverse effect of this therapy?
a. decreased blood pressure
b. increased pulse rate
Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood.
4. A client is being treated for acute congestive heart failure (CHF) and the client’s vital signs are as follows: BP 85/50 mm Hg; pulse, 96
bpm; respirations, 26 cpm. The physician prescribes digoxin (Lanoxin). To evaluate a therapeutic effectiveness of this medication, the nurse would expect which of the following changes in the client’s vital signs?
a. BP 85/50 mm Hg, pulse 60 bpm, respirations 26 cpm
b. BP 98/60 mm Hg, pulse 80 bpm, respirations 24 cpm
c. BP 130/70 mm Hg, pulse 104 bpm, respirations 20 cpm
d. BP 110/40 mm Hg, 110 bpm, respirations 20 cpm
The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with CHF. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well.
5. Diazepam (Valium) is prescribed for a client with anxiety. The nurse instructs the client to expect which side effect?
Valium, a benzodiazepine, can cause motor incoordination and ataxia and safety precautions should be instituted for clients taking this medication.
6. A client receives oxytocin (Pitocin) to induce labor. During the administration of the oxytocin, it is most important for the nurse to monitor:
a. urinary output
b. fetal heart rate
c. central venous pressure
d. maternal blood glucose
Pitocin produces uterine contractions. Uterine contractions can cause fetal anoxia. The nurse monitors the fetal heart rate and notifies the physician of any significant changes.
7. A clinic nurse is performing assessment on a client who is being seen in the clinic for the first time. When asking about the client’s medication history, the client tells the nurse that he takes nateglinide (Starlix). The nurse then questions the client about the presence of which disorder that is treated with this medication?
c. type 2 diabetes mellitus
d. renal failure
Nateglinide (Starlix) is an antidiabetic medication used to treat type 2 diabetes mellitus in clients whose disease cannot be adequately controlled with diet and exercise. It stimulates the release of insulin from beta cells of the pancreas by depolarizing beta cells, leading to an opening of calcium channels. Resulting calcium influx induces insulin secretion.
8. A client who is taking rifampin (Rifadin) as part of the medication regimen for the treatment of tuberculosis calls the clinic nurse and reports that her urine is a red-orange color. The nurse tells the client to:
a. come to the clinic to provide a urine sample
b. stop the medication until further instructions are given by the physician
c. take the medication dose with an antacid to prevent this adverse effect
d. expect a red-orange color in urine, feces, sweat, sputum, and tears as a harmless side effect
Rifampin (Rifadin) is an antitubercular medication used in conjunction with at least one other antitubercular agent for initial treatment or retreatment of tuberculosis. Urine, feces, sputum, sweat, and tears may become red-orange in color. The client should also be told that soft contact lenses may become permanently stained as a result of this harmless side effect. There is no useful reason for the client to provide a urine sample. The client is not told to stop a medication. Antacids are not usually taken with a medication because of interactive effects.
9. A nurse is caring for a client with a tracheostomy that has been diagnosed with a respiratory infection. The client is receiving vancomycin hydrochloride (Vancocin) 500 mg intravenously every 12 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse effect of the medication?
a. decreased hearing acuity
Vancomycin hydrochloride (Vancocin) is an antibiotic. Adverse and toxic effects include nephrotoxicity characterized by a change in the amount or frequency of urination, anorexia, nausea, vomiting, and increased thirst; ototoxicity characterized by hearing loss due to damage to the auditory branch of the eight cranial nerve; and red-neck syndrome from too rapid injection of the medication characterized by chills, fever, fast heartbeat,
nausea, vomiting, itching, rash and redness on the face, neck, arms, and back. When this medication is administered to a client, nursing responsibilities include monitoring renal function laboratory results, intake and output, and hearing acuity.
10. A nurse is caring for a client with a diagnosis of metastatic breast carcinoma who is receiving tamoxifen citrate (Nolvadex) 10 mg orally twice daily. Which of the following would indicate to the nurse that the client is experiencing a side effect related to the medication?
c. nose bleeds
d. vaginal bleeding
Tamoxifen citrate is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentration of receptors such as the breasts, uterus, and vagina. Frequent side effects include hot flashes, nausea, vomiting, vaginal bleeding or discharge, pruritus, and skin rash. Adverse or toxic effects include retinopathy, corneal opacity, and decreased visual acuity.
11. A client has just been given a prescription for diphenoxylate with atropine (Lomotil). The nurse teaches the client which of the following about the use of this medication?
a. drooling may occur while taking this medication
b. irritability may occur while taking this medication
c. this medication contains a habit-forming ingredient
d. take the medication with a laxative of choice
Diphenoxylate with atropine (Lomotil) is an antidiarrheal. The client should not exceed the recommended dose of this medication because it may be habit-forming. Since this medication is an antidiarrheal, it should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness.
12. A nurse is gathering data from client about the client’s medication history and notes that the client is taking tolterodine tartrate (Detrol LA). The nurse determines that the client is taking the medication to treat which disorder?
b. renal insufficiency
c. pyloric stenosis
d. urinary frequency and urgency
Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.
13. A client has an order to receive psyllium (Metamucil) daily. The nurse administers this medication with:
a. a multivitamin and mineral supplement
b. a dose of an antacid
d. eight ounces of liquid
Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice, and followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect.
14. A nurse is teaching a client taking cyclosporine (Sandimmune) after renal transplant about medication information. The nurse tells the client to be especially alert for:
a. signs of infection
c. weight loss
d. hair loss
Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication, and report them to the physician if experienced. The client is also taught about other side effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints.
15. A nurse reinforces dietary instruction for the client receiving spironolactone (Aldactone). Which food would the nurse instruct the client to avoid while taking this medication?
Aldactone is a potassium-sparing diuretic and the client needs to avoid foods high in potassium, such as whole grain cereals, legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Option c provides the highest source of potassium and should be avoided.
16. Oral lactulose (Chronulac) is prescribed for the client with a hepatic disorder and the nurse provides instructions to the client regarding this medication. Which statement by the client indicates a need for further instructions?
a. “I need to take the medication with water’”
b. “I need to increase fluid intake while taking the medication”
c. “I need to increase fiber in the diet”
d. “I need to notify the physician of nausea occurs”
Lactulose retains ammonia in the colon, promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. It should be taken with water or juice to aid in softening the stool. An increased fluid intake and a high-fiber diet will promote defecation. If nausea occurs, the client should be instructed to drink cola, eat unsalted crackers, or dry toast. It is not necessary to notify the physician.
17. A home care nurse provides instructions to a client taking digoxin (Lanoxin) 0.25 mg daily. Which statement by the client indcates a need for further instructions?
a. “I will take my prescribed antacid if I become nauseated”
b. “It is important to have my blood drawn when prescribed”
c. “I will check my pulse before I take my medication”
d. “I will carry a medication identification card with me”
Digoxin is an antidysrhythmic. The most common early manifestations of toxicity are gastrointestinal (GI) disturbances such as anorexia, nausea, and vomiting. If these manifestations occur, the physician needs to be notified. Digoxin blood levels need to be obtained as prescribed to monitor for therapeutic plasma levels (0.5 to 2.0 ng/mL). The client is instructed to take the pulse, hold the medication if the pulse is below 60 beats per minute, and notify the physician. The client is instructed to wear or carry an ID bracelet or card.
18. A client with anxiety disorder is taking buspirone (BuSpar) and tells the nurse that it is difficult to swallow the tablets. The nurse tells the client to:
a. dissolve the tablet in a cup of coffee
b. crush the tablet before taking it
c. call the physician for a change in medication
d. mix the tablet uncrushed in custard
Buspirone (BuSpar) may be administered without regard to meals and the tablets may be crushed. It is premature to advise the client to call the physician for a change in medication without first trying alternative interventions. Mixing the tablet uncrushed in custard will not ensure ease in
swallowing. Dissolving the tablet in a cup of coffee is not the best instruction to provide to the client because this measure may not ensure that the client will receive the entire dose.
19. A nurse is caring for a child with CHF provides instructions to the parents regarding the administration of digoxin (Lanoxin). Which statement by the mother indicates a need for further instructions?
a. “If my child vomits after I give the medication, I will not repeat the dose”
b. “I will check my child’s pulse before giving the medication”
c. “I will check the dose of the medication with my husband before I give the medication”
d. “I will mix the medication with food”
The medication should not be mixed with food or formula because this method would not ensure that the child receives the entire dose of medication. Options a, b, and c are correct. Additionally, if a dose is missed and is not identified until 4 or more hours later, that dose is not administered. If more than one consecutive dose is missed, the physician needs to be notified.
20. A nurse provides instructions to a client who will begin an oral contraceptives. Which statement by the client indicates the need for further instructions?
a. “I will take one pill daily at the same time every day”
b. “I will not need to use an additional birth control method once I start these pills”
c. “If I miss a pill I need to take it as soon as I remember”
d. “If I miss two pills I will take them both as soon as I remember and I will take two pills the next day also”
The client needs to be instructed to use a second birth control method during the first pill cycle. Options a, b, and c are correct. Additionally, the client needs to be instructed that if she misses three pills, she will need to discontinue use for that cycle and use another birth control method.
21. A nurse provides instructions to a client taking clorazepate (Tranxene) for management of an anxiety disorder. The nurse tells the client that:
a. drowsiness is a side effect that usually disappears with continued therapy
b. if dizziness occurs, call the physician
c. smoking increases the effectiveness of the medication
d. if gastrointestinal disturbances occur, discontinue the medication
Drowsiness occurs as a side effect and usually disappears with continued therapy. The client should be instructed that if dizziness occurs to change positions slowly from lying to sitting, before standing. Smoking reduces medication effectiveness. Gastrointestinal disturbances can occur as an occasional side effect and the medication can be given with food if this occurs.
22. A client with Parkinson’s disease has begun therapy with levodopa (L-dopa). The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for:
a. 24 hours
b. Two to three days
c. One week
d. Two to three weeks
Signs and symptoms of Parkinson’s disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. Clients need to understand this concept to aid in compliance with medication therapy.
23. A nurse in a physician’s office is reviewing the results of a client’s phenytoin (Dilantin) level drawn that morning. The nurse determines that the client has a therapeutic drug level if the client’s result was:
a. 3 mcg/ml
b. 8 mcg/ml
c. 15 mcg/ml
The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication, and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above this range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward.
24. A nurse is caring for a client with a genitourinary tract infection receiving amoxicillin (Augmentin) 500 mg every 8 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse effect related to the medication?
d. watery diarrhea
Amoxicillin is a penicillin. Adverse effects include superinfection, such as potentially fatal antibiotic-associated colitis, that results from altered bacterial balance. Symptoms include abdominal cramps, severe watery diarrhea, and fever. Frequent side effects of the medication include gastrointestinal disturbances (mild diarrhea, nausea, vomiting), headache, and oral or vaginal candidiasis.
25. A nurse is caring for a client with glaucoma who receives a daily dose of acetazolamide (Diamox). Which of the following would indicate to the nurse that the client is experiencing an adverse effect of the medication?
b. difficulty swallowing
c. dark-colored urine and stools
Acetazolamide (Diamox) is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and is manifested by dark-colored urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, and renal colic and calculi. Bone marrow depression may also occur.
26. A nurse is caring for a client with a diagnosis of meningitis who is receiving amphotericin B (Fungizone) intravenously. Which of the following would indicate to the nurse that the client is experiencing an adverse effect related to the medication?
b. decreased urinary output
c. muscle weakness
Amphotericin B is an antifungal medication. Adverse effects include nephrotoxicity evidenced by a decrease in urinary output and the nurse needs to monitor fluid balance and renal function tests for potential signs of this adverse effect. Cardiovascular toxicity, evidenced by hypotension and ventricular fibrillation, can occur but is rare. Anaphylactic reactions are also rare. Vision and hearing alterations, seizures, hepatic failure and coagulation defects may also occur.
27. A nurse has formulated a nursing diagnosis of Disturbed Body Image for a client who is taking spironolactone (Aldactone). The nurse based this diagnosis on assessment of which side effect of the medication?
b. weight gain
d. decreased libido
Spironolactone (Aldactone) is a potassium-sparing diuretic. The nurse should be alert to the fact that the client taking spironolactone may experience body image changes due to threatened sexual identity. These body image changes are related to decreased libido, gynecomastia in males, and hirsutism in females. Since the medication is a diuretic, edema and weight gain should not occur. Excitability is not associated with the use of this medication; rather, drowsiness may occur.
28. A nurse is caring for the client with a history of mild heart failure who is receiving diltiazem hydrochloride (Cardizem) for hypertension. The nurse would assess the client for:
c. peripheral edema and weight gain
d. apical pulse rate lower than baseline
Calcium channel blocking agents, such as diltiazem hydrochloride (Cardizem), are used cautiously in clients with conditions that could be worsened by the medication. These conditions include aortic stenosis, bradycardia, heart failure, acute myocardial infarction, and hypotension. The nurse would assess for signs and symptoms that indicate worsening of these underlying disorders. In this question, the nurse assesses for signs and symptoms indicating heart failure.
29. The wound of a client with an extensive burn injury is being treated with the application of silver sulfadiazine (Silvadene). Which symptom would indicate to the nurse that the client is experiencing a side effect related to systemic absorption?
a. pain at the wound site
b. burning and itching at the wound site
c. a localized rash
Silver sulfadiazine (Silvadene) is a cream used for extensive burn wounds. Significant systemic absorption may occur if applied to extensive burns. Side effects of the medication include pain, burning, itching and a localized rash. Systemic side effects include anorexia, nausea, vomiting, headache, diarrhea, dizziness, photosensitivity, and joint pain.
30. A nurse is caring for a client with a diagnosis of rheumatoid arthritis who is receiving sulindac (Clinoril) 150 mg po twice daily. Which
finding would indicate to the nurse that the client is experiencing a side effect related to the medication?
d. tingling in the extremities
Sulindac (Clinoril) is a nonsteroidal antiinflammatory medication (NSAID). Frequent side effects include gastrointestinal (GI) disturbances including constipation or diarrhea, indigestion, and nausea. Dermatitis, a rash, dizziness, and a headache are also frequent side effects.
31. The nurse notes that the client is receiving filgrastim (Neupogen). The nurse checks which of the following to determine medication effectiveness?
a. neutrophil count
b. platelet count
c. blood urea nitrogen
d. creatinine level
Filgrastim is a biologic modifier that stimulates production, maturation, and activation of neutrophils. Therefore the nurse would monitor the client’s neutrophil count. The platelet count measures the amount of platelets; a decreased level places the client at risk for bleeding. The blood urea nitrogen and creatinine level measures renal function.
32. A nurse is monitoring a client who is taking fluphenazine decanoate (Prolixin) for signs of leucopenia. Which finding indicates a sign of this blood dyscrasia?
a. blurred vision
c. sore throat
d. dry mouth
Blood dyscrasias can occur as an adverse effect of fluphenazine decanoate. Leukopenia is indicative of a low white blood cell count and places the client at risk for infection. The nurse would monitor the client for signs of infection such as a sore mouth, gums, or throat. Blurred vision, dry mouth, and constipation are occasional side effects of the medication but are not indicative of leukopenia.
33. A nurse is administering amphotericin B (Fungizone) to a client intravenously to treat a fungal infection. The nurse monitors the result of which electrolyte study during therapy with this medication?
Life-threatening hypokalemia can occur with the administration of amphotericin B. Therefore, the nurse monitors the results of serum potassium levels, which should be prescribed at least biweekly during therapy. Magnesium levels should also be monitored.
34. A clinic nurse asks a client with diabetes mellitus being seen in the clinic for the first time to list the medications that she is taking. Which combination of medications taken by the client should the nurse report to the physician?
a. Acetohexamide (Dymelor) and trimethoprim-sulfamethoxazole (Bactrim)
b. Chlorpropamide (Diabenase) and amitriptyline (Elavil)
c. Glyburide (DiaBeta) and Lanoxin (Digoxin)
d. Tolbutamide (Orinase) and amoxicillin (Amoxil)
Sulfonylureas are hypoglycemic agents that lower the blood glucose. Acetohexamide (Dymelor), chlorpropamide (Diabinese), glyburide (DiaBeta), and tolbutamide (Orinase) are sulfonylureas. If a sulfonylureas is administered with a sulfonamide (option a), increased glycemic effects can occur.
35. A nurse is caring for a client receiving streptogramin (Synercid) by intravenous intermittent infusion for the treatment of a bone infection develops diarrhea. Which nursing action would the nurse implement?
a. administer an antidiarrheal agent
b. notify the physician
c. discontinue the medication
d. monitor the client’s temperature
Synercid is an antimicrobial agent. One adverse effect of the medication is superinfection, including antibiotic-associated colitis, which may result from bacterial imbalance. If the client develops diarrhea, the medication should be withheld, and the physician is notified. The nurse would not discontinue the medication. The nurse would not administer an antidiarrheal unless specifically prescribed by the physician.
36. A client has been taking fosinopril (Monopril) for 2 months. The nurse determines that the client is having the intended effects of therapy if the nurse notes which of the following?
a. lowered BP
b. lowered pulse rate
c. increased WBC
d. increased monocyte count
Monopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure. It can cause tachycardia as a side effect of therapy, making option b incorrect. Other side effects of the medication are neutropenia and agranulocytopenia, making options c and d incorrect.
37. A client is taking labetalol (Normodyne). The nurse monitors the client for which frequent side effect of the medication?
c. increased energy level
d. night blindness
Impotence is a common side effect of labetalol and may be distressing to the client. Other side effects of this medication are bradycardia, weakness, and fatigue. Night blindness is unrelated to this medication, although this medication can cause blurred vision and dry eyes.
38. An older client has been using cascara sagrada on a long-term basis. The nurse determines that which laboratory result is a result of the side effects of this medication?
a. sodium 135 mEq/L
b. sodium 145 mEq/L
c. potassium 3.1 mEq/L
d. potassium 5.0 mEq/L
Hypokalemia can result from long-term use of casanthrol (cascara sagrada), which is a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The normal range for potassium is 3.5 to 5.1 mEq/L. The normal range for sodium is 135 to 145 mEq/L.
39. A client has an order to begin short-term therapy with enoxaparin (Lovenox). The nurse explains to the client that this medication is being ordered to:
a. dissolve urinary calculi
b. reduce the risk of deep vein thrombosis
c. relieve migraine headaches
d. stop progression of multiple sclerosis
Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in selected clients at risk. It is not used to treat urinary calculi, migraine headaches, or multiple sclerosis.
40. Quinidine gluconate (Dura Quin) is prescribed for a client. The nurse reviews the client’s medical record, knowing that which of the following is a contraindication in the use of this medication?
a. complete atrioventricular (AV) block
b. muscle weakness
Quinidine gluconate is an antidysrhythmic medication used as prophylactic therapy to maintain normal sinus rhythm after conversion of atrial fibrillation and/or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, abnormal impulses and rhythms caused by escape mechanisms, and in myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency.
41. A client has been taking benzonatate (Tessalon) as ordered. The nurse tells the client that this medication should do which of the following?
a. take away nausea and vomiting
b. calm the persistent cough
c. decrease anxiety level
d. increase comfort level
Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex.
42. Auranofin (Ridaura) is prescribed for a client with rheumatoid arthritis, and the nurse monitors the client for signs of an adverse effect related to the medication. Which of the following indicates an adverse effect?
Auranofin (Ridaura) is a gold preparation that is used as an antirheumatic. Gold toxicity is an adverse effect and is evidenced by decreased hemoglobin, leukopenia, reduced granulocyte counts, proteinuria, hematuria, stomatitis,
glomerulonephritis, nephrotic syndrome, or cholestatic jaundice. Anorexia, nausea, and diarrhea are frequent side effects of the medication.
43. A nurse is providing instructions to a client regarding quinapril hydrochloride (Accupril). The nurse tells the client:
a. to take the medication with food only
b. to rise slowly from a lying to a sitting position
c. to discontinue the medication if nausea occurs
d. that a therapeutic effect will be noted immediately
Accupril is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast. A full therapeutic effect may be noted in 1 to 2 weeks.
44. A female client tells the clinic nurse that her skin is very dry and irritated. Which product would the nurse suggest that the client apply to the dry skin?
a. glycerin emollient
d. acetic acid solution
Glycerin is an emollient that is used for dry, cracked, and irritated skin. Aspercreame and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected by Pseudomonas aeruginosa.
45. A client with advanced cirrhosis of the liver is not tolerating protein well, as eveidenced by abnormal laboratory values. The nurse anticipates that which of the following medications will be prescribed for the client?
a. lactulose (Chronulac)
b. ethacrynic acid (Edecrin)
c. folic acid (Folvite)
d. thiamine (Vitamin B1)
The client with cirrhosis has impaired ability to metabolize protein because of liver dysfunction. Administration of lactulose aids in the clearance of ammonia via the gastrointestinal (GI) tract. Ethacrynic acid is a diuretic. Folic acid and thiamine are vitamins, which may be used in clients with liver disease as supplemental therapy.
46. A nurse is planning dietary counseling for the client taking triamterene (Dyrenium). The nurse plans to include which of the following in a list of foods that are acceptable?
a. baked potato
d. pears canned in water
Triamterene is a potassium-sparing diuretic, and clients taking this medication should be cautioned against eating foods that are high in potassium, including many vegetables, fruits, and fresh meats. Because potassium is very water-soluble, foods that are prepared in water are often lower in potassium.
47. A client is taking famotidine (Pepcid) asks the home care nurse what would be the best medication to take for a headache. The nurse tells the client that it would be best to take:
a. aspirin (acetylsalicylic acid, ASA)
b. ibuprofen (Motrin)
c. acetaminophen (Tylenol)
d. naproxen (Naprosyn)
The client is taking famotidine, a histamine receptor antagonist. This implies that the client has a disorder characterized by gastrointestinal (GI) irritation. The only medication of the ones listed in the options that is not irritating to the GI tract is acetaminophen. The other medications could aggravate an already existing GI problem.
48. A nurse has taught a client taking a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which of the following beverages from the dietary menu?
a. chocolate milk
b. cranberry juice
Cola, coffee, and chocolate contain xanthine and should be avoided by the client taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.
49. A client with histoplasmosis has an order for ketoconazole (Nizoral). The nurse teaches the client to do which of the following while taking this medication?
a. take the medication on an empty stomach
b. take the medication with an antacid
c. avoid exposure to sunlight
d. limit alcohol to 2 ounces per day
The client should be taught that ketoconazole is an antifungal medication. It should be taken with food or milk. Antacids should be avoided for 2 hours after it is taken because gastric acid is needed to activate the medication. The client should avoid concurrent use of alcohol, because the medication is hepatotoxic. The client should also avoid exposure to sunlight, because the medication increases photosensitivity.
50. A nurse is preparing the client’s morning NPH insulin dose and notices a clumpy precipitate inside the insulin vial. The nurse should:
a. draw up and administer the dose
b. shake the vial in an attempt to disperse the clumps
c. draw the dose from a new vial
d. warm the bottle under running water to dissolve the clump
The nurse should always inspect the vial of insulin before use for solution changes that may signify loss of potency. NPH insulin is normally uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, because potency is questionable, it is safer to discard the vial and draw up the dose from a new vial.
|Post #5 Dec 8 2009, 09:08 PM||riamolina|
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. In addition to the headache and hypertension, which of the following symptoms would you expect Mr. Jones to exhibit?
Dysphagia and hemiplegia.
*All of the above.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. The team leader instructs you to remove Mr. Jones dentures. You do so because
the team leader will report you if you do not follow directions.
The dentures need to be cleaned.
*the dentures might obstruct the respiratory passages.
Mr. Jones usually removes them for sleep anyway.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. Unresponsive patients like Mr. Jones may develop a drying of the cornea, which is usually caused by
paralysis of the eyelid.
*absence of the blinking reflex and reduction in tear formation.
lack of humidity in the room.
bulging of the eyeballs.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. The MAIN objective in the nursing care of the stroke patient is to
*prevent complications that will delay rehabilitation.
provide good nutrition.
provide relief of pain.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. In the nursing assessment you note that Mr. Jones has left-sided paralysis. When Mr. Jones is turned on his side, it is important to
elevate the head and knee gatch.
elevate the foot of the bed.
*support the affected arm and leg with pillows.
support the unaffected arm and leg with pillows.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. Mr. Jones regains consciousness, but is unable to speak. This disorder is known as
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. Mr. Jones' program of rehabilitation should begin
when he is ready to go home.
when he is able to understand directions.
when he regains consciousness.
*on the day he is admitted to the hospital.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. Mr. Jones develops cyanosis. This may occur because
he has hypertension.
*secretions have accumulated in his respiratory passages and he is unable to breathe well.
he has developed emphysema.
he is anemic.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. Mr. Jones physician has ordered that intravenous fluids be administered slowly in order to
*prevent overloading the circulatory system.
prevent respiratory secretions from accumulating.
Mr. Jones, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician and Mr. Jones is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Jones complained of a headache before retiring the night before. Proper positioning of Mr. Jones is very important in order to : 1. prevent dependent edema 2. prevent contractures 3. improve circulation 4. prevent aspiration
1, 2, and 3.
2, 3, and 4.
*All of the above.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. A woman who, like Mrs. Arps, is pregnant for the first time is called a
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Before the end of the 3rd month of pregnancy, the products of conception are known as the
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Mrs. Arps' amenorrhea is classified as which type of sign of pregnancy?
A positive sign.
A probable sign.
*A presumptive sign.
A negative sign.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Mrs. Arps' prenatal examination includes all of the following EXCEPT
a routine physical,including past medical history.
urinalysis for sugar and albumin.
*a gallbladder series.
temperature, pulse,respiration, and blood pressure.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Mrs. Arps confides to you that she has to urinate at frequent intervals. You explain that this frequency of urination usually subsides when the
placenta is fully developed.
fetal kidneys begin to function.
*uterus rises into the abdominal cavity.
mother's kidneys enlarge to accommodate the extra waste.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. During the first half of her pregnancy, the physician will most probably wish to see Mrs. Arps every
1 to 2 weeks.
2 to 3 weeks.
*3 to 4 weeks.
6 to 8 weeks.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Mrs.Arps complains of nausea and vomiting as well as heartburn. You recommend that she alter her diet by reducing the intake of
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. You also advise Mrs. Arps that her nausea and vomiting can be relieved if, one-half hour before rising in the morning, she
drinks a glass of milk.
drinks a cup of hot tea.
eats a piece of fruit.
*eats a piece of dry toast or a plain cracker.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. The most probable cause of Mrs. Arps' heartburn is
an increase in the production of bile.
an increase in the production of stomach acid.
*a rising of the uterine fundus.
a decrease in digestive enzymes.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. To prevent or control constipation, you encourage Mrs. Arps to increase all of the following EXCEPT her
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. The physician prescribes mineral oil to relieve occasional constipation. You instruct Mrs. Arps not to take it at or near mealtimes because mineral oil interferes with the absorption of vitamin
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. As Mrs. Arps' pregnancy progresses, the physician uses a fetoscope to check for the fetal heart sounds. The nurse first expects to hear fetal heart sounds when the woman has been pregnant
8 to 10 weeks.
10 to 12 weeks.
13 to 15 weeks.
*18 to 20 weeks.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Mrs. Arps has chloasma, which is best described as
stretch marks on the abdomen.
*brown spots on the face.
a dark vertical line on the abdomen.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. Mrs. Arps should eat which of the following foods to increase her iron intake?
*Lean meat or dried beans.
Green or yellow vegetables.
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. For which of the following discomforts of pregnancy that Mrs. Arps may experience is the pelvic rock most often recommended?
You are employed as a practical nurse in an obstetrician's office. You have just greeted Mrs. Arps and escorted her to the examining room. Mrs. Arps is 26 years old and has missed two menstrual periods. She is eagerly anticipating confirmation of a hoped-for first pregnancy. To help ensure an adequate calcium intake, you encourage Mrs. Arps to increase her daily milk intake to
Mr. VanBeever is an 80-year-old resident in a health-related facility. He suffers from arteriosclerotic heart disease but is ambulatory. His medications are Digoxin 0.25 mg OD daily and Lasix 40 mg BID and he is on a salt-poor diet. He has been known to sneak and wander around the neighborhood. He is unfriendly to the other residents and considers himself superior to them. The nurse discovers that Mr. VanBeever, who complains constantly about the "tasteless" food, has gone out and bought salt and hot, pickled peppers to put on his food. Which of the following actions should the nurse take?
Call Mr. VanBeever's doctor and report this action.
*Chart the action and report it to the supervisor.
Take the condiments away from Mr. VanBeever.
Scold Mr. VanBeever and tell him that he is undoing all the staff's good work
Mr. VanBeever is an 80-year-old resident in a health-related facility. He suffers from arteriosclerotic heart disease but is ambulatory. His medications are Digoxin 0.25 mg OD daily and Lasix 40 mg BID and he is on a salt-poor diet. He has been known to sneak and wander around the neighborhood. He is unfriendly to the other residents and considers himself superior to them. When planning nursing care for Mr. VanBeever, which of the following behaviours is it MOST important that the staff be alerted?
His constant complaints.
*His wandering around the neighborhood.
His refusal of meals.
His hiding of condiments in his room.
Mrs. Henry has an ulcer on her lower leg. Continuous warm, moist compresses have been ordered. When administering these compresses, it is important to
explain the procedure to Mrs. Henry carefully so that she can learn to prepare the compresses herself.
warm at least one quart of solution each time because these are continuous compresses.
put Mrs. Henry in a wheelchair so that the compresses can be applied more easily.
*check the moisture of the compresses often so that they are never dry.
Mrs. Henry has an ulcer on her lower leg. Continuous warm, moist compresses have been ordered. After Mrs. Henry's ulcer has healed, her physician recommends elastic stockings. The purpose of these stockings is to
increase circulation in the legs.
protect the legs from injury.
provide warmth for the lower legs.
*support the blood vessels in the leg.
Mrs. Henry has an ulcer on her lower leg. Continuous warm, moist compresses have been ordered. When instructing Mrs. Henry in the proper use of these stockings, the nurse should tell her that the stockings should be
worn 20 hours a day.
*applied early in the morning before arising from bed.
held up with circular garters.
worn only when she anticipates standing for long periods of time.
Mrs. Witchey has been confined to bed for several weeks but refuses to change position or perform the exercises ordered by her doctor to maintain adequate circulation in her legs. One day she tells the doctor her legs hurt, and he diagnoses her condition as thrombophlebitis. Thrombophlebitis is
*inflammation of the vein caused by a blood clot in the blood vessel.
a traumatic inflammation of a blood vessel.
a bulging of the wall of an artery.
an ulceration within the blood vessels.
Mrs. Witchey has been confined to bed for several weeks but refuses to change position or perform the exercises ordered by her doctor to maintain adequate circulation in her legs. One day she tells the doctor her legs hurt, and he diagnoses her condition as thrombophlebitis. The most common symptom of thrombophlebitis is
cyanosis of the affected leg.
*pain in the calf of the leg.
severe swelling of the ankles.
bulging of the affected blood vessels.
Mrs. Witchey has been confined to bed for several weeks but refuses to change position or perform the exercises ordered by her doctor to maintain adequate circulation in her legs. One day she tells the doctor her legs hurt, and he diagnoses her condition as thrombophlebitis. A nursing procedure that is CONTRAINDICATED in thrombophlebitis is
turning the patient form side to side.
elevating the head of the bed.
*massaging the legs.
rubbing the back.
Mrs. Witchey has been confined to bed for several weeks but refuses to change position or perform the exercises ordered by her doctor to maintain adequate circulation in her legs. One day she tells the doctor her legs hurt, and he diagnoses her condition as thrombophlebitis. Thrombophlebitis is a complication of a variety of illnesses and can be best be avoided by
*early ambulation and exercises to increase circulation.
the administration of antibiotics.
giving the patient daily doses of vitamin K.
restricting physical activity of any kind after surgery.
Mrs. Witchey has been confined to bed for several weeks but refuses to change position or perform the exercises ordered by her doctor to maintain adequate circulation in her legs. One day she tells the doctor her legs hurt, and he diagnoses her condition as thrombophlebitis. The doctor tells Mrs. Witchey to stop smoking. She cannot understand why and says, "It's my legs that are bothering me, not my lungs." As a practical nurse, your best reply to her would be
"Your doctor is afraid your condition will spread to your lungs."
*Nicotine narrows the blood vessels in your body and makes your condition worse.
"Smoking dulls your appetite, and poor nutrition makes your condition worse."
There is no connection between smoking and your condition, but you would feel better if you stopped smoking.
Mrs. Witchey has been confined to bed for several weeks but refuses to change position or perform the exercises ordered by her doctor to maintain adequate circulation in her legs. One day she tells the doctor her legs hurt, and he diagnoses her condition as thrombophlebitis. The aim of nursing care for patients with thrombophlebitis is to
prevent breakdown of tissues.
provide proper nutrition.
provide proper rest.
*prevent an embolism.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Congestive heart failure is best described as a cardiac condition in which there is
an abnormality in the structure of the heart.
*a decreased flow of blood through the heart and great vessels, resulting from failure of the heart to function as a pump.
a blood clot within one of the heart chambers.
a sudden spasm of the heart muscle due to a decreased blood supply.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Mr. Dehaven's doctor orders complete bed rest for him. This means that Mr. Dehaven
is encouraged to rest as much as possible.
*is confined to bed but can assume responsibility for much of his personal care.
is confined to bed but is allowed to get up to go to the bathroom as necessary.
must remain as quiet as possible and everything involving the slightest physical effort must be done for him.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Mr. Dehaven is suffering from severe dypsnea. The position in which he will be most comfortable is
Sims' left lateral position.
the Trendelenburg position.
the supine position.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Back care for Mr. Dehaven is
not indicated because a cardiac patient must have absolute rest.
less important than for most patients because the edema pads the bony prominences of the body.
*more important than for most patients because a cardiac patient often has edematous tissue, which readily breaks down.
important when thepatient's skin shows signs of developing ulcerations.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Cardiac patients like Mr. Dehaven are sometimes not permitted to have cold drinks or iced foods because
they act as a stimulant to the heart.
*extreme cold has a constricting effect on blood vessels and may increase the workload of the heart.
cold decreases circulation and overburdens the heart.
cold drinks cause the formation of gas and lead to stomach cramps.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Mr. Dehaven is given a low sodium diet. When edema is present, the intake of sodium is restricted because it
slows the heartbeat.
causes hardening of the arteries.
decreases the urinary output.
*holds fluid in the tissues.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. One food substance that contains sodium and is commonly part of the average person's diet is
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Which of the following foods is LOWEST in sodium content?
Canned meats and fish.
Milk and milk products.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Because there may be "hidden" sources of sodium, which of the following should be carefully checked by reading the label to see if sodium is present? 1. Canned or processed foods. 2. Toothpastes and mouthwashes. 3. Packaged bakery products. 4. Patent medicines.
1, 2, 3, and 4.
2 and 4.
1 and 3.
*1, 3, and 4
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. To prevent depletion of potassium by the diuretics Mr. Dehaven is taking, the nurse advised him to eat
chocolate chip cookies.
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Mr. Dehaven's doctor places him on digitalis. This drug is classified as a
The chief action of digitalis is to
lower the blood pressure.
prevent the formation of clots.
increase the pulse rate.
*slow and strengthen the heartbeat
Mr. Dehaven, aged 62, is assigned to you for morning care. His diagnosis is congestive heart failure. Before each dose of digitalis is administered to Mr. Dehaven, you must remember to
*check his pulse.
check his respiration.
take his blood pressure.
check with the lab to see whether a test of bleeding time has been done.
|Post #6 Dec 9 2009, 02:01 AM||Karsie|
1. The following clients present to a walk-in clinic at the same time. Which should the nurse schedule to be seen first?
a) 25 year old with high fever, vomiting and diarrhea
b) 38 year old with sore throat, fever, and swollen lymph glands
c) 40 year old with severe headache, vomiting and stiff neck
d) 44 year old limping on a very swollen bruised ankle
2. Of the four clients listed below, which responsibility should the nurse direct the technician to carry out first?
a) 89 year old with COPD resting quietly on 2 liters of o2 needs morning vitals with 02 sat
b) 77 year old with gastrointestinal bleeding needs bedside commode emptied
c) 55 year old diabetic with fasting blood sugar of 75, at 80% of breakfast and needs morning snack
d) 49 year old with rheumatoid arthritis needs splints reapplied to both hands
3. The LPN is assigned to care for a client who had a total right hip two days ago. Which observation should the LPN report immediately to the nurse?
a) incisional pain rated on 6 on a scale of 0-10
b) reddened incision line with a temperature of 99.6 F
c) pain and redness in the left lower leg
d) the client is not tolerating 20lbs of weight bearing on the right leg
4. The nurse just received report on the following clients. Who should the nurse see first?
a) 35 year old with suspected acute tubular necrosis, urine output totaled 25cc's for the last two hours.
b) 49 year old with cancer of the breast, 2 days post mastectomy, reported to be having difficulty coping with the diagnosis.
c) 54 year old with TB in respiratory isolation, requesting pain medication.
d) 36 year old with chest tube insertion after a spontaneous pneumothorax, respirations 16.
5. After receiving report on the following clients, who should the nurse assess first?
a) 25 year old with the hemoglobin level of 15.9
b) 36 year old on Coumadin with a prothrombin time of 35. 6 seconds
c) 38 year old with a total calcium level of 9.4
d) 45 year old with a BUN of 30 and creatinine of 1.1
6. After completing assessment rounds, which finding would the nurse report to the physician immediately?
a) client who has not had a bowel movement in 4 days abdomen is firm
b) client who had a pulse of 89 and regular now has pulse of 100 and irregular
c) client who is very depressed and has eaten 10% of meals for the last 2 days
d) client who has developed a rash around the neck and face who has been on iv penicillin for 2 days
7. After receiving report on four clients at 7am, what should the nurse complete first?
a) call physician to report antiemetic for client who has been vomiting
b) notify family of a clients transfer to ICU for chest pain
c) call a potassium level of 5.9 to the attention of the physician
d) begin routine assessment rounds, starting with the sickest client
8. A 62 year old client has a history of coronary heart disease and is brought into the ER complaining of chest pain. What initial action should be taken by the nurse?
a) give the client ntg gr 1/150 sl now
b) call the cardiologist about the admission
c) place the client in a high Fowlers position after loosening the shirt
d) check blood pressure and note the location and degree of chest pain
9. As a nurse working the ER, which patient needs the most immediate attention?
a) a 3 yr old with a barking cough, oxygen sat of 93 in room air, and occasional inspiratory stridor
b) a 10 month old with a tympanic temperature of 102, green nasal drainage, and pulling at the ears
c) an 8 month old with a harsh paroxysmal cough, audible expiratory wheeze and mild retractions
d) a 3 year old with complaints of a sore throat, tongue slightly protruding out his mouth, and drooling
10. As the office nurse, you are reviewing client messages for a return call. Which client should the nurse call back first.
a) client 36 weeks gestation complaining of facial edema
b) a client 24 weeks gestation complaining of urinary frequency
c) a client 12 weeks gestation whose had five episodes of vomiting in 36 hours
d) a client 20 weeks gestation complaining of white, thick vaginal discharge
|Post #7 Dec 9 2009, 02:21 AM||Karsie|
NCLEX Practice Questions 1-10
1. A nurse is reviewing a patient’s medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.
2. A nurse is reviewing a patient’s PMH. The history indicates photosensitive reactions to medications.
Which of the following drugs has not been associated with photosensitive reactions? Note: More than one answer may be correct.
3. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?
4. You are responsible for reviewing the nursing unit’s refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator’s contents?
B: Humulin (injection)
D: Epogen (injection)
5. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
6. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?
A: Immediately see a social worker
B: Start prophylactic AZT treatment
C: Start prophylactic Pentamide treatment
D: Seek counseling
7. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
B: Diabetic nephropathy
C: Autonomic neuropathy
D: Somatic neuropathy
8. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
A: Multiple sclerosis
B: Anorexia nervosa
D: Systemic sclerosis
9. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?
D: Irritable bowel syndrome
10. Rho gam is most often used to treat____ mothers that have a ____ infant.
A: RH positive, RH positive
B: RH positive, RH negative
C: RH negative, RH positive
D: RH negative, RH negative
Answers Key 1 - 10
1.(A) and (B) are both contraindicated with pregnancy.
2. (F) All of the others have can cause photosensitivity reactions.
3. (D) All of the others can cause urine discoloration.
4. (A) Corgard could be removed from the refigerator.
5. (D) IgG is the only immunoglobulin that can cross the placental barrier.
6. (B) AZT treatment is the most critical innervention.
7. (C) Autonomic neuropathy can cause inability to urinate.
8. (B) All of the clinical signs and systems point to a condition of anorexia nervosa.
9. (B) Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion.
10. (C) Rho gam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.
**These questions were reproduced from http://www.nclexinfo.com and placed here as a public service.
This body of work is not the property of this site. For any questions, please direct your attention to www.nclexinfo.com
NCLEX Practice Questions 11-20
11. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?
A: A Guthrie test can check the necessary lab values.
B: The urine has a high concentration of phenylpyruvic acid
C: Mental deficits are often present with PKU.
D: The effects of PKU are reversible.
12. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?
A: Onset of pulmonary edema
B: Metabolic alkalosis
C: Respiratory alkalosis
D: Parkinson’s disease type symptoms
13. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is?
A: Let others know about the patient’s deficits.
B: Communicate with your supervisor your patient safety concerns.
C: Continuously update the patient on the social environment.
D: Provide a secure environment for the patient.
14. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?
A: Deep breathing techniques to increase O2 levels.
B: Cough regularly and deeply to clear airway passages.
C: Cough following bronchodilator utilization
D: Decrease CO2 levels by increase oxygen take output during meals.
15. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
A: Slow pulse rate
B: Weight gain
C: Decreased systolic pressure
D: Irregular WBC lab values
16. A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome?
A: Simian crease
C: Oily skin
17. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?
18. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”
A: Green vegetables and liver
B: Yellow vegetables and red meat
19. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans?A: S. pneumonia
B: H. influenza
C: N. meningitis
D: Cl. difficile
20. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is.
A: The life span of RBC is 45 days.
B: The life span of RBC is 60 days.
C: The life span of RBC is 90 days.
D: The life span of RBC is 120 days.
Answer Key 11-20.
11. (D) The effects of PKU stay with the infant throughout their life.
12. (D) Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.
13. (D) This patient’s safety is your primary concern.
14. (C) The bronchodilator will allow a more productive cough.
15. (B) Weight gain is associated with CHF and congenital heart deficits.
16. (C) The skin would be dry and not oily.
17. (A) Streptokinase is a clot busting drug and the best choice in this situation.
18. (A) Green vegetables and liver are a great source of folic acid.
19. (D) Cl. difficile has not been linked to meningitis.
20. (D) RBC’s last for 120 days in the body.
**These questions were reproduced from http://www.nclexinfo.com and placed here as a public service.
This body of work is not the property of this site. For any questions, please direct your attention to www.nclexinfo.com
NCLEX Practice Questions 21-30
21. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?
A: Following surgery
B: Upon admit
C: Within 48 hours of discharge
D: Preoperative discussion
22. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in?
A: Trust vs. mistrust
B: Initiative vs. guilt
C: Autonomy vs. shame
D: Intimacy vs. isolation
23. A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in?
A: Trust vs. mistrust
B: Initiative vs. guilt
C: Autonomy vs. shame
D: Intimacy vs. isolation
24. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in?
A: Trust vs. mistrust
B: Initiative vs. guiltC: Autonomy vs. shame
D: Intimacy vs. isolation
25. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?
A: 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg
B: 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
C: 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
D: 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg
26. When you are taking a patient’s history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?
27. Which of the following conditions would a nurse not administer erythromycin?
A: Campylobacterial infection
B: Legionnaire’s disease
D: Multiple Sclerosis
28. A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?
A: Decreased HR
C: Muscle weakness of the extremities
29. A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?
B: Extreme Thirst
C: Weight gain
D: Acetone breath smell
30. A patient’s chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute?
A: Increased appetite
D: Poor tolerance of light
Answer Key 21-30.
21. (B) Discharge education begins upon admit.
22. (B) Initiative vs. guilt- 3-6 years old
23. (A) Trust vs. Mistrust- 12-18 months old
24. (D) Intimacy vs. isolation- 18-35 years old
25. (B) HR and Respirations are slightly increased. BP is down.
26. (A) Elavil is a tricyclic antidepressant.
27. (D) Erythromycin is used to treat conditions A-C.
28. (D) Answer choices A-C were symptoms of acute hyperkalemia.
29. (C) Weight loss would be expected.
30. (A) Loss of appetite would be expected.
**These questions were reproduced from http://www.nclexinfo.com and placed here as a public service.
This body of work is not the property of this site. For any questions, please direct your attention to
NCLEX Practice Questions 31-40
31. A nurse if reviewing a patient’s chart and notices that the patient suffers from conjunctivitis. Which of
the following microorganisms is related to this condition?
A: Yersinia pestis
B: Helicobacter pyroli
C: Vibrio cholera
D: Hemophilus aegyptius
32. A nurse if reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of
the following microorganisms is related to this condition?
A: Borrelia burgdorferi
B: Streptococcus pyrogens
C: Bacilus anthracis
D: Enterococcus faecalis
33. A fragile 87 year-old female has recently been admitted to the hospital with increased confusion and
falls over last 2 weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is
most likely to be performed?
A: FBC (full blood count)
B: ECG (electrocardiogram)
C: Thyroid function tests
D: CT scan
34. A 84 year-old male has been loosing mobility and gaining weight over the last 2 months. The patient
also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests
is most likely to be performed?
A: FBC (full blood count)
B: ECG (electrocardiogram)
C: Thyroid function tests
D: CT scan
35. A 20 year-old female attending college is found unconscious in her dorm room. She has a fever and a
noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to
be performed first?
A: Blood sugar check
B: CT scan
C: Blood cultures
D: Arterial blood gases
36. A 28 year old male has been found wandering around in a confused pattern. The male is sweaty and
pale. Which of the following tests is most likely to be performed first?
A: Blood sugar check
B: CT scan
C: Blood cultures
D: Arterial blood gases
37. A mother is inquiring about her child’s ability to potty train. Which of the following factors is the
most important aspect of toilet training?
A: The age of the child
B: The child ability to understand instruction.
C: The overall mental and physical abilities of the child.
D: Frequent attempts with positive reinforcement.
38. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
A: This too shall pass.
B: Take the child immediately to the ER
C: Contact the Poison Control Center quickly
D: Give the child syrup of ipecac
39. A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target
areas is the most appropriate?
A: Gluteus maximus
B: Gluteus minimus
C: Vastus lateralis
D: Vastus medialis
40. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4 year-old
boy who is non-verbal. This child does not have on any identification. What should the nurse do?
A: Contact the provider
B: Ask the child to write their name on paper.
C: Ask a co-worker about the identification of the child.
D: Ask the father who is in the room the child’s name.
Answer Key 31-40.
31. (D) Choice A is linked to Plague, Choice B is linked to peptic ulcers, Choice C is linked to Cholera.
32. (A) Choice B is linked to Rheumatic fever, Choice C is linked to Anthrax, Choice D is linked to
33. (D) A CT scan would be performed for further investigation of the hemiparesis.
34. (C) Weight gain and poor temperature tolerance indicate something may be wrong with the thyroid
35. (C) Blood cultures would be performed to investigate the fever and rash symptoms.
36. (A) With a history of diabetes, the first response should be to check blood sugar levels.
37. (C) Age is not the greatest factor in potty training. The overall mental and physical abilities of the
child is the most important factor.
38. (C) The poison control center will have an exact plan of action for this child.
39. (C) Vastus lateralis is the most appropriate location.
40. (D) In this case you are able to determine the name of the child by the father’s statement. You should
not withhold the medication from the child following identification.
**These questions were reproduced from http://www.nclexinfo.com and placed here as a public service.
This body of work is not the property of this site. For any questions, please direct your attention to
|Post #8 Sep 2 2010, 02:39 AM||Karsie|
Here is a great review site:
NCLEX Test Review
The site includes 40 practice test questions (links on the left violet panel).
Here are some more review sites:
NCLEX-PN Practice Exam Part 1 – Answers and Rationales
NCLEX-PN Practice Exam Part 2 – Answers and Rationales
NCLEX-PN Practice Exam Part 3 – Answers and Rationales
NCLEX-PN Practice Exam Part 4 – Answers and Rationales
NCLEX-PN Practice Exam Part 5 – Answers and Rationales
NCLEX-PN Practice Exam Part 6 – Answers and Rationales
NCLEX-PN Practice Exam Part 7 – Answers and Rationales
NCLEX-PN Practice Exam Part 8 - Answers and Rationales
NCLEX-RN Questions and Answers Made Incredibly Easy!
by Lippincott Williams & Wilkins
Lippincott's Q & A Review for NCLEX-RN
by Diane McGovern Billings
Lippincott's Review for NCLEX-RN
by Diane McGovern Billings
Kaplan NCLEX-RN Exam 2010 with CD-ROM: Strategies for the Registered Nursing
Edited by Karsie, Sep 2 2010, 03:27 AM.
|Post #9 Sep 2 2010, 03:34 AM||NightinGail|
|Post #10 Jun 23 2011, 06:33 AM||Grizwald|
NCLEX Oncology Questions:
1. A male client has an abnormal result on a Papanicolaou test. After admitting, he read his chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
a. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin
b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
c. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found
d. Alteration in the size, shape, and organization of differentiated cells
2. For a female client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
a. “Client verbalizes feelings of anxiety.”
b. “Client doesn’t guess at prognosis.”
c. “Client uses any effective method to reduce tension.”
d. “Client stops seeking information.”
3. A male client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
a. Related to visual field deficits
b. Related to difficulty swallowing
c. Related to impaired balance
d. Related to psychomotor seizures
4. A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:
a. hair loss.
5. Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
a. breast self-examination.
c. fine needle aspiration.
d. chest X-ray.
6. A male client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
a. “Keep the stoma uncovered.”
b. “Keep the stoma dry.”
c. “Have a family member perform stoma care initially until you get used to the procedure.”
d. “Keep the stoma moist.”
7. A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
a. Urine output of 400 ml in 8 hours
b. Serum potassium level of 3.6 mEq/L
c. Blood pressure of 120/64 to 130/72 mm Hg
d. Dry oral mucous membranes and cracked lips
8. Nurse April is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
a. cancerous lumps.
b. areas of thickness or fullness.
c. changes from previous self-examinations.
d. fibrocystic masses.
9. A client, age 41, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
a. Onset of sporadic sexual activity at age 17
b. Spontaneous abortion at age 19
c. Pregnancy complicated with eclampsia at age 27
d. Human papillomavirus infection at age 32
10. A female client is receiving methotrexate (Mexate), 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
a. probenecid (Benemid)
b. cytarabine (ara-C, cytosine arabinoside [Cytosar-U])
c. thioguanine (6-thioguanine, 6-TG)
d. leucovorin (citrovorum factor or folinic acid [Wellcovorin])
11. The nurse is interviewing a male client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
a. Duodenal ulcers
c. Weight gain
12. Nurse Amy is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:
a. perform breast self-examination annually.
b. have a mammogram annually.
c. have a hormonal receptor assay annually.
d. have a physician conduct a clinical examination every 2 years.
13. A male client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?
a. Persistent nausea
d. Chronic ache or pain
14. For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
a. Administering aspirin if the temperature exceeds 102° F (38.8° C)
b. Inspecting the skin for petechiae once every shift
c. Providing for frequent rest periods
d. Placing the client in strict isolation
15. Nurse Lucia is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms:
a. yearly after age 40.
b. after the birth of the first child and every 2 years thereafter.
c. after the first menstrual period and annually thereafter.
d. every 3 years between ages 20 and 40 and annually thereafter.
16. Which intervention is appropriate for the nurse caring for a male client in severe pain receiving a continuous I.V. infusion of morphine?
a. Assisting with a naloxone challenge test before therapy begins
b. Discontinuing the drug immediately if signs of dependence appear
c. Changing the administration route to P.O. if the client can tolerate fluids
d. Obtaining baseline vital signs before administering the first dose
17. A 35 years old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:
a. cell division or mitosis during the M phase of the cell cycle.
b. normal cellular processes during the S phase of the cell cycle.
c. the chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle–nonspecific).
d. one or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle–nonspecific).
18. The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
19. When caring for a male client diagnosed with a brain tumor of the parietal lobe, the nurse expects to assess:
a. short-term memory impairment.
b. tactile agnosia.
d. contralateral homonymous hemianopia.
20. A female client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:
a. a decreased serum creatinine level.
c. Bence Jones protein in the urine.
d. a low serum protein level.
21. A 35 years old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
a. White, cottage cheese–like patches on the tongue
b. Yellow tooth discoloration
c. Red, open sores on the oral mucosa
d. Rust-colored sputum
22. During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
a. Recommending that the client discontinue chemotherapy
b. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
c. Monitoring the client’s platelet and leukocyte counts
d. Checking regularly for signs and symptoms of stomatitis
23. What should a male client over age 52 do to help ensure early identification of prostate cancer?
a. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
b. Have a transrectal ultrasound every 5 years.
c. Perform monthly testicular self-examinations, especially after age 50.
d. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly.
24. A male client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
a. Anticipatory grieving
b. Impaired swallowing
c. Disturbed body image
d. Chronic low self-esteem
25. A male client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
a. Stand as far away from the implant as possible and call for help.
b. Pick up the implant with long-handled forceps and place it in a lead-lined container.
c. Leave the room and notify the radiation therapy department immediately.
d. Put the implant back in place, using forceps and a shield for self-protection, and call for help.
26. Jeovina, with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
a. Vision changes
b. Hearing loss
27. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?
c. Reproductive tract
d. White blood cells (WBCs)
28. A 34-year-old female client is requesting information about mammograms and breast cancer. She isn’t considered at high risk for breast cancer. What should the nurse tell this client?
a. She should have had a baseline mammogram before age 30.
b. She should eat a low-fat diet to further decrease her risk of breast cancer.
c. She should perform breast self-examination during the first 5 days of each menstrual cycle.
d. When she begins having yearly mammograms, breast self-examinations will no longer be necessary.
29. Nurse Brian is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
a. 24 hours
b. 2 to 4 days
c. 7 to 14 days
d. 21 to 28 days
30. The nurse is preparing for a female client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
a. The client lies still.
b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band
NCLEX Review: Oncology Questions Part 1 Answers and Rationale
1.Answer D. Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found is called metaplasia.
2.Answer A. Verbalizing feelings is the client’s first step in coping with the situational crisis. It also helps the health care team gain insight into the client’s feelings, helping guide psychosocial care. Option B is inappropriate because suppressing speculation may prevent the client from coming to terms with the crisis and planning accordingly. Option C is undesirable because some methods of reducing tension, such as illicit drug or alcohol use, may prevent the client from coming to terms with the threat of death as well as cause physiologic harm. Option D isn’t appropriate because seeking information can help a client with cancer gain a sense of control over the crisis.
3.Answer C. A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.
4.Answer C. Radiation therapy may cause fatigue, skin toxicities, and anorexia regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific, not generalized, adverse effects of radiation therapy.
5.Answer C. Fine needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the most reliable method for detecting breast lumps early. Mammography is used to detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib metastasis.
6.Answer D. The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.
7.Answer D. Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include dry oral mucous membranes, cracked lips, decreased urine output (less than 40 ml/hour), abnormally low blood pressure, and a serum potassium level below 3.5 mEq/L.
8.Answer C. Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.
9.Answer D. Like other viral and bacterial venereal infections, human papillomavirus is a risk factor for cervical cancer. Other risk factors for this disease include frequent sexual intercourse before age 16, multiple sex partners, and multiple pregnancies. A spontaneous abortion and pregnancy complicated by eclampsia aren’t risk factors for cervical cancer.
10.Answer D. Leucovorin is administered with methotrexate to protect normal cells, which methotrexate could destroy if given alone. Probenecid should be avoided in clients receiving methotrexate because it reduces renal elimination of methotrexate, increasing the risk of methotrexate toxicity. Cytarabine and thioguanine aren’t used to treat osteogenic carcinoma.
11.Answer D. Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren’t preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.
12.Answer B. The American Cancer Society guidelines state, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually [not every 2 years]; all women should perform breast self-examination monthly [not annually]." The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.
13.Answer C. Indigestion, or difficulty swallowing, is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn’t one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer.
14.Answer B. Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
15.Answer A. The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are incorrect. It’s recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years.
16.Answer D. The nurse should obtain the client’s baseline blood pressure and pulse and respiratory rates before administering the initial dose and then continue to monitor vital signs throughout therapy. A naloxone challenge test may be administered before using a narcotic antagonist, not a narcotic agonist. The nurse shouldn’t discontinue a narcotic agonist abruptly because withdrawal symptoms may occur. Morphine commonly is used as a continuous infusion in clients with severe pain regardless of the ability to tolerate fluids.
17.Answer B. Antimetabolites act during the S phase of the cell cycle, contributing to cell destruction or preventing cell replication. They’re most effective against rapidly proliferating cancers. Miotic inhibitors interfere with cell division or mitosis during the M phase of the cell cycle. Alkylating agents affect all rapidly proliferating cells by interfering with DNA; they may kill dividing cells in all phases of the cell cycle and may also kill nondividing cells. Antineoplastic antibiotic agents interfere with one or more stages of the synthesis of RNA, DNA, or both, preventing normal cell growth and reproduction.
18.Answer B. When following the ABCD method for assessing skin lesions, the A stands for "asymmetry," the B for "border irregularity," the C for "color variation," and the D for "diameter."
19.Answer B. Tactile agnosia (inability to identify objects by touch) is a sign of a parietal lobe tumor. Short-term memory impairment occurs with a frontal lobe tumor. Seizures may result from a tumor of the frontal, temporal, or occipital lobe. Contralateral homonymous hemianopia suggests an occipital lobe tumor.
20.Answer C. Presence of Bence Jones protein in the urine almost always confirms the disease, but absence doesn’t rule it out. Serum calcium levels are elevated because calcium is lost from the bone and reabsorbed in the serum. Serum protein electrophoresis shows elevated globulin spike. The serum creatinine level may also be increased.
21.Answer C. The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese–like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia.
22.Answer B. To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen peroxide and water for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer viscous lidocaine or systemic analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn’t be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn’t decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn’t decrease the pain.
23.Answer A. The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won’t identify changes in the prostate gland due to its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastases
24.Answer A. Anticipatory grieving is an appropriate nursing diagnosis for this client because few clients with gallbladder cancer live more than 1 year after diagnosis. Impaired swallowing isn’t associated with gallbladder cancer. Although surgery typically is done to remove the gallbladder and, possibly, a section of the liver, it isn’t disfiguring and doesn’t cause Disturbed body image. Chronic low self-esteem isn’t an appropriate nursing diagnosis at this time because the diagnosis has just been made.
25.Answer B. If a radioactive implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in a lead-lined container, then notify the radiation therapy department immediately. The highest priority is to minimize radiation exposure for the client and the nurse; therefore, the nurse must not take any action that delays implant removal. Standing as far from the implant as possible, leaving the room with the implant still exposed, or attempting to put it back in place can greatly increase the risk of harm to the client and the nurse from excessive radiation exposure.
26.Answer A. The client must report changes in visual acuity immediately because this adverse effect may be irreversible. Tamoxifen isn’t associated with hearing loss. Although the drug may cause anorexia, headache, and hot flashes, the client need not report these adverse effects immediately because they don’t warrant a change in therapy.
27.Answer A. The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.
28.Answer B. A low-fat diet (one that maintains weight within 20% of recommended body weight) has been found to decrease a woman’s risk of breast cancer. A baseline mammogram should be done between ages 30 and 40. Monthly breast self-examinations should be done between days 7 and 10 of the menstrual cycle. The client should continue to perform monthly breast self-examinations even when receiving yearly mammograms.
29.Answer C. Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
30.Answer D. During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.
|Post #11 Jun 23 2011, 06:44 AM||Grizwald|
Psychosocial Integrity NCLEX Review Questions Part 2
1. After a car accident, Jessy, age 10, is treated in the emergency department for a fractured clavicle and evaluated for a possible head injury. Alert and oriented, she keeps asking what will happen to her. Which nursing diagnosis is most appropriate?
a. Anxiety related to separation from parents and an unfamiliar environment
b. Hypothermia related to head injury
c. Interrupted family processes related to maturational crisis
d. Risk for infection related to sepsis
2. A male client, age 68, admitted for treatment of a colon tumor, asks the nurse, “Do I have cancer?” Which response by nurse Gemma would be best?
a. Most people your age develop some type of colon problem
b. Your physician can discuss this in more detail
c. You sound concerned about what is happening
d. You’ll have to have some tests before cancer can be ruled out
3. Myrna, age 17, rarely expresses feelings and usually remains passive. However, when angry, her face becomes flushed and her blood pressure rises to 170/100 mm Hg. Her parents are passive and easygoing. The adolescent may be using which defense mechanism to handle anger?
4. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective individual coping?
a. Inability to make choices and decisions without advice
b. Showing interest only in solitary activities
c. Avoiding developing relationships
d. Recurrent self-destructive behavior with history of depression
5. Cess is concerned because her breast-feeding infant wants to “nurse all the time.” Which of the following responses best indicates the normal newborn’s breast-feeding behavior?
a. Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings
b. Let me call the lactation consultant to make sure that your baby is feeding properly
c. Don’t worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction
d. It seems as if your baby is hungry. Why don’t you provide your baby with formula after the feeding to make sure he’s getting enough nourishment
6. To establish a good interview relationship with an adolescent, which of the following strategies is most appropriate?
a. Asking personal questions unrelated to the situation
b. Writing down everything the teen says
c. Asking open-ended questions
d. Discussing the nurse’s own thoughts and feelings about the situation
7. Which of the following factors would have the most influence on the outcome of a crisis situation?
b. Previous coping skills
d. Perception of the problem
8. A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which of the following interventions should nurse Kate implement?
a. Discuss the client’s concern with the husband
b. Refer the client to a psychiatrist
c. Invite a client with a similar experience to speak with the client
d. Refer the client to a sex therapist
9. A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells nurse Dennia, “I can’t keep up with my housework any more because I spend so much time caring for the baby.” The nurse should:
a. help the client break down large tasks into smaller ones
b. encourage the client to work faster
c. reassure the client that her feelings will soon pass
d. help the client accept her new role
10. During labor, a client greatly relies on her husband for support. They previously attended childbirth education classes, and now he’s working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple?
a. Ineffective family coping: Compromised related to labor
b. Readiness for enhanced family coping related to participation in pregnancy and delivery
c. Powerlessness related to pain
d. Ineffective role performance related to involvement with the pregnancy
11. Nurse Levy is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
a. Avoiding the use of recreational drugs and alcohol
b. Refraining from telling anyone about the diagnosis
c. Following safer-sex practices
d. Telling potential sex partners about the diagnosis, as required by law
12. During the initial admission process, a geriatric client seems confused. What is the most probable cause of this client’s confusion?
b. Altered long-term memory
c. Decreased level of consciousness (LOC)
d. Stress of an unfamiliar situation
13. Which is the most appropriate nursing diagnosis for a grieving family?
a. Interrupted family processes
c. Spiritual distress
d. Ineffective coping
14. During the mental status examination, a client may be asked to explain such proverbs as “Don’t cry over spilled milk.” The purpose is to evaluate the client’s ability to think:
15. During rounds, a client admitted with gross hematuria asks nurse Alma about the physician’s diagnosis. To facilitate effective communication, what should the nurse do?
a. Ask why the client is concerned about the diagnosis
b. Change the subject to something more pleasant
c. Provide privacy for the conversation
d. Give the client some good advice
16. Nurse Yvette refers a client with terminal cancer to a local hospice. What is the goal of this referral?
a. To provide support for the client and family in coping with terminal illness
b. To ensure that the client gets counseling regarding health care costs
c. To teach the client and family about cancer and its treatment
d. To help the client find appropriate treatment options
17. Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person’s conscious awareness?
18. A 15-year-old female with a urinary tract infection is admitted to the facility. She tells nurse Lauren she hopes that she’s pregnant. Which of the following would be the best response by the nurse?
a. Does your mother know about this?
b. Tell me what pregnancy would mean to you
c. Congratulations. Does the baby’s father know?
d. I hope you aren’t pregnant; you’re too young
19. A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
a. I’ll play card games with my friends
b. I’ll take a long trip to visit my aunt
c. I’ll bowl with my team after discharge
d. I’ll eat lunch in a restaurant every day
20. While in the facility, a client with obsessive-compulsive disorder saves all used medicine cups and paper cups and arranges them in elaborate sculptures in the room. At home, the client saves mail and magazines and makes elaborate paper sculptures from them. Which outcome would indicate successful treatment for this client?
a. The client throws away all disposable cups
b. The client is discharged and takes the cups home
c. The client keeps the cups in a bag in his room
d. The client goes home on pass and arranges magazines
21. The parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate?
a. Children of that age view death as temporary and reversible, which makes it hard to explain
b. Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth
c. At this developmental stage, children are afraid of death, so it’s best not to discuss it with them
d. At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it
22. A chronically ill school-age child is most vulnerable to which stressor?
a. Mutilation anxiety
b. Anticipatory grief
c. Anxiety over school absences
d. Fear of hospital procedures
23. A geriatric client with Alzheimer’s disease has been living with his grown child’s family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement?
a. It’s difficult dealing with Dad. It’s a thankless job
b. We had no idea this would be so difficult. It’s our cross to bear
c. Dad really seems to be making progress. We’re hoping he’ll be able to move back into his house soon
d. Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break
24. When developing a plan of care for a hospitalized child, nurse Pauleen knows that children in which age-group are most likely to view illness as a punishment for misdeeds?
b. Preschool age
c. School age
25. An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?
a. Encouraging the infant to hold a bottle
b. Keeping the infant on bed rest to conserve energy
c. Rotating caregivers to provide more stimulation
d. Maintaining a consistent, structured environment
Psychosocial Integrity NCLEX Review Questions Part 2 Answers and Rationale
1. Answer A. The nature of the accident, the child’s pain, and the unfamiliar facility environment support a nursing diagnosis of Anxiety. A diagnosis of Hypothermia related to head injury isn’t appropriate because the child is alert and oriented, indicating that a head injury, if present, isn’t severe and is unlikely to cause hypothermia. Unlike the homecoming of a new baby or riding a bicycle for the first time, a car accident isn’t a maturational crisis.
2. Answer C. This response conveys empathy and invites further discussion of the client’s concerns. The other options block communication by failing to address the client’s concerns and feelings.
3. Answer B. The adolescent may be introjecting (assuming as her own) her parents’ belief that anger shouldn’t be outwardly expressed. She may also be holding and somatizing in her angry feelings, as evidenced by her increased blood pressure. (A blood pressure rise is a common physiological reaction to the fight-or-flight response that may be brought on by strong emotions. Habitual failure to express anger may contribute to hypertension
4. Answer A. Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don’t show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren’t met, this isn’t a typical response.
5. Answer A. Breast milk is the ideal food for a newborn. As a result, the infant will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother’s breast-feeding attempts are unsatisfactory. Nurses shouldn’t suggest giving formula to a breast-feeding infant.
6. Answer C. Open-ended questions allow the teen to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he’s being probed with unnecessary questions. Writing everything down during the interview can be a distraction and won’t allow the nurse to observe how the adolescent behaves. Discussing the nurse’s thoughts and feelings may bias the assessment and is inappropriate when interviewing any client.
7. Answer B. Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Option A is the best answer.
8. Answer C. Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn’t need professional help. Discussing the concerns with the client’s husband doesn’t address the client’s needs. In fact, the client may feel that the nurse violated confidentiality.
9. Answer A. If a client feels overwhelmed by the additional tasks brought on by her new role as a mother, the nurse should help her break down large tasks into smaller, more manageable ones. Encouraging her to work faster or reassuring her that her feelings will soon pass wouldn’t address her needs. The nurse can’t help the client accept her new role if the client feels overwhelmed.
10. Answer B. The client and her husband are working together for a common goal. He’s offering support, and they’re sharing the experience of childbirth, making Readiness for enhanced family coping related to participation in pregnancy and delivery an appropriate nursing diagnosis. The other options suggest that the couple have a problem that isn’t indicated in the question.
11. Answer C. It’s essential that clients with AIDS follow safer-sex practices to prevent transmission of the human immunodeficiency virus (HIV). Although it’s helpful if clients with AIDS avoid using recreational drugs and alcohol, it’s more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.
12. Answer D. The stress of being in an unfamiliar situation, such as admission to a hospital, can cause confusion in geriatric clients. Depression doesn’t produce confusion, but it can cause mood changes, weight loss, anorexia, constipation, and early morning awakening. In geriatric clients, long-term memory usually remains intact, although short-term memory may be altered. Decreased LOC doesn’t normally result from aging; therefore, it’s a less likely cause of confusion in this client.
13. Answer C. Spiritual distress related to experienced loss most accurately describes the problem; therefore, nursing care should be based on this diagnosis. Families may not have altered family process or suffer from ineffective coping. Although the family may feel powerless, this isn’t the most accurate diagnosis.
14. Answer C. Abstract thinking is the ability to conceptualize and interpret meaning. It’s a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can’t conceptualize and comprehend abstract meaning. They interpret such statements as "Don’t cry over spilled milk" in a literal sense such as "Even if you spill your milk, you shouldn’t cry about it."
15. Answer C. Providing privacy for the conversation is a form of active listening, which focuses solely on the client’s needs. Asking why the client is concerned, changing the subject, or giving advice tends to block therapeutic communication.
16. Answer A. Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn’t focus on counseling regarding health care costs. Most clients referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.
17. Answer C. Repression, the unconscious exclusion of painful or conflicting thoughts, impulses, or memories from awareness, is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense identification in which one incorporates another person’s or group’s values or qualities into one’s own ego structure. Regression is a retreat to an earlier level of developmental behavioral during a time of stress. Denial is the avoidance of unpleasant realities by ignoring them.
18. Answer B. When talking with adolescents, it’s best to get their viewpoints and thoughts first. Doing so promotes therapeutic communication. Asking whether the mother knows or about the baby’s father focuses the attention away from the adolescent. Making a statement about her being too young to be pregnant is a value judgment and inappropriate.
19. Answer A. During chemotherapy, playing cards is an appropriate diversional activity because it doesn’t require a great deal of energy. To conserve energy, the client should avoid such activities as taking long trips, bowling, and eating in restaurants every day. However, the client may take occasional short trips and can dine out on special occasions.
20. Answer A. With an obsessive-compulsive client, a goal of treatment is to throw away hoarded items. Moving the hoarded items or rearranging them wouldn’t indicate progress because these actions allow the inappropriate behavior to continue.
21. Answer D. By age 9 or 10, most children have an adult concept of death. Caregivers should discuss death with them in terms consistent with their developmental stage. School-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. School-age children may fantasize about the unknown aspects of death; these fantasies may increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.
22. Answer C. The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who’s chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.
23. Answer D. This statement demonstrates a realistic understanding of the client’s disorder and effective family coping with the challenges it presents. Options A and B indicate that the family is having difficulty adjusting. Option C suggests that the family is in denial or has an unrealistic view of the prognosis for a client with Alzheimer’s disease.
24. Answer B. Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.
25. Answer D. The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
|Post #12 Jun 23 2011, 06:56 AM||Tina Reyes|
Medical Surgical Nursing Practice Test
Here is 50-item practice test on Medical Surgical Nursing. Answers will be posted soon. Go here for the questions:
Here are the answers and rationale:
|Post #13 Jun 23 2011, 09:42 AM||Bonnie Delfin|
Practice Test III- Medical Surgical Nursing
Q.1) Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
A. Total volume of circulating whole blood
B. Total volume of intravascular plasma
C. Permeability of capillary walls (your answer)
D. Permeability of kidney tubules
In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
Q.2) Which of the following complications associated with tracheostomy tube?
A. Increased cardiac output
B. Acute respiratory distress syndrome (ARDS)
C. Increased blood pressure
D. Damage to laryngeal nerves (your answer)
Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
Q.3) An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
A. increased capillary fragility and permeability (correct answer)
B. increased blood supply to the skin
C. self inflicted injury
D. elder abuse
Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in
loosely structured dermis.
Q.4) Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
A. Liver disease
B. Myocardial damage (your answer)
Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
Q.5) A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
A. 1 to 3 weeks
B. 6 to 12 months (your answer)
C. 3 to 5 months
D. 3 years and more
Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
Q.6) A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
B. Atonic (correct answer)
In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
Q.7) Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
A. high blood pressure
B. stomach cramps
C. headache (your answer)
D. shortness of breath
Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
Q.8) Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
A. Raw carrots
B. Apple juice
C. Whole wheat bread
D. Cottage cheese (your answer)
One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
Q.9) Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
A. Promotes the removal of antibodies that impair the transmission of impulses
B. Stimulates the production of acetylcholine at the neuromuscular junction.
C. Decreases the production of autoantibodies that attack the acetylcholine receptors. (correct answer)
D. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
Q.10) Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
B. Airway obstruction
C. Hoarseness (your answer)
Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
Q.11) Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
A. Bowel function
B. Peripheral sensation
C. Bleeding tendencies (correct answer)
D. Intake and out put
Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
Q.12) What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
A. 4 to 12 years. (correct answer)
B. 20 to 30 years
C. 40 to 50 years
D. 60 to 70 years
The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
Q.13) Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
A. Active joint flexion and extension (correct answer)
B. Continued immobility until pain subsides
C. Range of motion exercises twice daily
D. Flexion exercises three times daily
Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
Q.14) A client has undergone laryngectomy. The immediate nursing priority would be:
A. Keep trachea free of secretions (your answer)
B. Monitor for signs of infection
C. Provide emotional support
D. Promote means of communication
Patent airway is the most priority; therefore removal of secretions is necessary.
Q.15) While performing a physical assessment of a male client with gout of the great toe, NurseVivian should assess for additional tophi (urate deposits) on the:
B. Ears (your answer)
Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
Q.16) A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
A. Flank pain radiating in the groin
B. Distention of the lower abdomen (your answer)
C. Perineal edema
D. Urethral discharge
This indicates that the bladder is distended with urine, therefore palpable.
Q.17) A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure?
Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
A. Electrolyte imbalance
B. Head trauma (correct answer)
C. Epilepsy (your answer)
D. Congenital defect
Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
Q.18) Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
A. A client with high blood
B. A client with bowel obstruction
C. A client with glaucoma (your answer)
D. A client with U.T.I
Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
Q.19) Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
A. Potential wound infection
B. Potential ineffective coping
C. Potential electrolyte balance
D. Potential alteration in renal perfusion (your answer)
There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
Q.20) Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
A. dairy products (your answer)
Good source of vitamin B12 are dairy products and meats.
Q.21) A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
A. Administering Heparin
B. Administering Coumadin (correct answer)
C. Treating the underlying cause
D. Replacing depleted blood products
Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
Q.22) Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes:
A. Accurate dose delivery (correct answer)
B. Shorter injection time
C. Lower cost with reusable insulin cartridges
D. Use of smaller gauge needle.
These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
Q.23) Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
A. Urine output greater than 30ml/hr (correct answer)
B. Respiratory rate of 21 breaths/minute
C. Diastolic blood pressure greater than 90 mmhg
D. Systolic blood pressure greater than 110 mmhg
Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
Q.24) What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
A. Pupil size and papillary response (correct answer)
B. cholesterol level
D. Bowel sounds
It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
Q.25) After a long leg cast is removed, the male client should:
A. Cleanse the leg by scrubbing with a brisk motion
B. Put leg through full range of motion twice daily
C. Report any discomfort or stiffness to the physician
D. Elevate the leg when sitting for long periods of time. (correct answer)
Elevation will help control the edema that usually occurs.
Q.26) Among the following components thorough pain assessment, which is the most significant?
C. Causing factors
D. Intensity (your answer)
Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
Q.27) Nurse Anna is aware that early adaptation of client with renal carcinoma is:
A. Nausea and vomiting
B. flank pain
C. weight gain
D. intermittent hematuria (your answer)
Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
Q.28) Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
A. “Practice using the mechanical aids that you will need when future disabilities arise”.
B. “Follow good health habits to change the course of the disease”.
C. “Keep active, use stress reduction strategies, and avoid fatigue. (your answer)
D. “You will need to accept the necessity for a quiet and inactive lifestyle”.
The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
Q.29) The nurse is aware the early indicator of hypoxia in the unconscious client is:
B. Increased respirations
D. Restlessness (your answer)
Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
Q.30) The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
A. High levels of low density lipid (LDL) cholesterol (correct answer)
B. High levels of high density lipid (HDL) cholesterol
C. Low concentration triglycerides
D. Low levels of LDL cholesterol.
An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
Q.31) Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
A. Palms of the hands and axillary regions
B. Palms of the hand (correct answer)
C. Axillary regions
D. Feet, which are set apart
The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
Q.32) A male client has undergone spinal surgery, the nurse should:
A. Observe the client’s bowel movement and voiding patterns
B. Log-roll the client to prone position
C. Assess the client’s feet for sensation and circulation (your answer)
D. Encourage client to drink plenty of fluids
Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
Q.33) Among the following clients, which among them is high risk for potential hazards from the surgical experience?
A. 67-year-old client (correct answer)
B. 49-year-old client
C. 33-year-old client
D. 15-year-old client
A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
Q.34) A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
A. Assist the client with sitz bath
B. Apply war soaks in the scrotum
C. Elevate the scrotum using a soft support (your answer)
D. Prepare for a possible incision and drainage.
Elevation increases lymphatic drainage, reducing edema and pain.
Q.35) Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
C. Steroids (correct answer)
Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
Q.36) Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except
A. effects of radiation
B. chemotherapy side effects
C. meningeal irritation
D. gastric distension (correct answer)
Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
Q.37) A male client’s left tibia is fractures in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
A. Swelling of the left thigh
B. Increased skin temperature of the foot
C. Prolonged reperfusion of the toes after blanching (correct answer)
D. Increased blood pressure
Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
Q.38) Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
A. signed consent
B. vital signs (correct answer)
C. name band
D. empty bladder
An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and
assessment is provided for.
Q.39) A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
A. Ineffective health maintenance (correct answer)
B. Impaired skin integrity
C. Deficient fluid volume
Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
Q.40) Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
A. Right atrium
B. Superior vena cava
D. Pulmonary (correct answer)
When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
Q.41) Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
A. Increase the flow of normal saline (correct answer)
B. Assess the pain further
C. Notify the blood bank
D. Obtain vital signs.
The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
Q.42) Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
A. A history of high risk sexual behaviors.
B. Positive ELISA and western blot tests (correct answer)
C. Identification of an associated opportunistic infection
D. Evidence of extreme weight loss and high fever
These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
Q.43) Which of the following stage the carcinogen is irreversible?
A. Progression stage (correct answer)
B. Initiation stage
C. Regression stage
D. Promotion stage
Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
Q.44) A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
A. Vital signs q4h
B. Weighing daily
C. Urine output hourly (correct answer)
D. Level of consciousness q4h
The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
Q.45) Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing:
A. Hypovolemia (correct answer)
B. renal failure
C. metabolic acidosis
In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
Q.46) Nurse Jon assesses vital signs on a client undergone epidural anesthesia.
Which of the following would the nurse assess next?
B. Bladder distension (correct answer)
D. Ability to move legs
The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
Q.47) Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
A. Flapping hand tremors (correct answer)
B. An elevated hematocrit level
Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
Q.48) Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
B. Specific gravity
C. Glucose (correct answer)
The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
Q.49) A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
A. Sleeping in cool and humidified environment
B. Daily baths with fragrant soap (correct answer)
C. Using clothes made from 100% cotton
D. Increasing fluid intake
The use of fragrant soap is very drying to skin hence causing the pruritus.
Q.50) Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere's disease except:
D. Glucocorticoids (correct answer)
Glucocorticoids play no significant role in disease treatment.
|Post #14 Jun 23 2011, 10:06 AM||Karmela|
1. Which of the following interventions will be most effective in improving Transcultural communications with oncology clients and their families?
a. Use touch to show concern and caring for the client
b. Focus attention on verbal communication skills only
c. Establish a rapport and listen to their concerns
d. Maintain eye contact at all times
Establishing a rapport and listening to their concerns builds a universal trusting relationship necessary for the nursing care. Use of touch, verbal communication skills and eye contact varies from culture to culture and norms.
2. The nurse is assisting the physician with a thoracentesis for a client with suspected lung cancer. If the client has malignant effusion, the nurse would expect the fluid to be
a. Milky white
b. Straw colored
An exudative pleural effusion which is bloody suggests malignant effusion. Parapneumonic effusion have the following characteristic from turbid to milky white. Straw colored is seen mostly at the first hours of post-thoracentesis.
3. Which of the following has been associated with fatigue from cancer chemotherapy?
a. Decreased quality of life
b. Increase risk of infection
c. Improved disease prognosis
d. Pericardial effusion
Cancer fatigue is manifested by weakness and verbalizations of decreased energy in performing the daily activities of living. Increased risk for infection, improved disease prognosis and pericardial effusion has no direct relationship with fatigue.
4. Which of the following would be considered an iatrogenic cause of cancer?
a. Ionizing radiation from radon
b. Ionizing radiation from uranium one
c. X-rays used to treat a tumor
d. Ultraviolet radiation from sun
X-rays used to treat a tumor is considered iatrogenic cause of cancer since iatrogenic means doctor or hospital related cause of cancer. The other options pertains to environmental cause of cancer.
5. In addition to acetaminophen, which drugs are recommended from Step 1 of the World Health Organiztion (WHO) analgesic ladder for the treatment of mild to moderate cancer-related pain?
NSAIDs (non-steriodal anti-inflammatory drugs) is included in the Step 1 of the World Health organization analgesic ladder. Oxycodone belongs to the step 3, codeine is an example of opoids on step 2. Propoxyphene is in a group of drugs called narcotic pain relievers. It is used to relieve mild to moderate pain.
6. A terminally ill 82 year old client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. Conservative management of the nausea and vomiting may be achieved with the use of.
a. A nasogastric suction tube
b. Intravenous antiemetics
c. Osmotic laxatives
d. A clear liquid diet
A clear liquid diet for this patient is appropriate in order to lessen the episodes of nausea and vomiting. The three other options denotes invasive approaches.
7. Any biologic response modifiers (BRMs) have expected side effects of fever and chills or a flu like syndrome. These side effects typically:
a. Are controlled with antipyretics
b. Increased in intensity with continued therapy
c. Last 24 to 72 hours
d. Have a biphasic pattern
It is actually self-limiting. Patients should be instructed on conserving energy and planning rest periods throughout the day. Emphasis should be placed on proper nutrition and hydration. Antipyretics are not used for management according to the recent research (source: http://www.msdlatinamerica.com/ebooks/LippincottsCancerChemotherapyHandbook/sid102736.html) It does not increased in intensity as well as it does not have a biphasic pattern.
8. Which of the following represents the most appropriate nursing intervention for a client with pruritus caused by cancer or the treatments?
a. Administration of antihistamines
c. Medicated cool baths
d. Silk sheets
Medicated cool baths denotes an independent nursing interventions which targets comfort of the patient. Administering antihistamines and steroids needs the order of physicians which means it is a dependent role of the nurse. Silk sheets does not provide relief from the pruritus.
9. The nurse caring for a client who is receiving external radiation therapy for treatment of lung cancer should anticipate that the client will have which of the following?
b. Improved energy level
d. Normal white blood cell count
External radiation therapy is a treatment which uses radiation (x-ray energy) to kill cancer cells. It can be used to treat or prevent the spread of one or more cancer tumors. Side effects when external radiation therapy are applied includes problems in breathing, or have swelling and infections if a tumor is inside the lungs and difficulty in swallowing. Diarrhea, improved energy level and normal white blood cell count are not part of the side effects of it.
10. Carcinogenesis is irreversible in which of the following stages?
a. Progression stage
b. Promotion stage
c. Initiation stage
d. Regression stage
Progression stage involves additional mutations happen and where carcinogenesis is irreversible. Promotion stage includes altered gene expression, suppressed immune response and enhanced cell division. Initiation stage involves detoxification of reactive molecules. There is no regression stage for carcinogenesis.
11. Cancer prevalence is defined as:
a. The number of new cancers in a year
b. All cancer cases more than 5 years
c. The like hood cancer will occur in a lifetime
d. The number of persons with cancer at a given point in time
Cancer prevalence is the number of person with cancer at a given point in time. Crude rate is the number of new cancers in a year. Lifetime risk is the like hood cancer will occur at a given point in time. Cancer incidence is the number of persons with cancer at a given point in time.
12. A nurse us providing education in community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate?
a. Apply sunscreen only after going to the water
b. Avoid peek exposure from 9am to 1pm
c. Wear a loosely woven clothing for added ventilation
d. Apply sunscreen with a sun protection factor of 15 or more before sun exposure
This is the best recommendation that a nurse could say. Applying sunscreen only after going to the water makes the sunscreen ineffective. Wearing loosely woven clothing for added ventilation is not appropriate. Applying sunscreen with a sun protection factor of 15 or more before sun exposure is correct however it does not answer the question on how to avoid it.
13. Which of the following reasons explains why Meperidine (Demerol) is not recommended for chronic cancer-related pain?
a. It has a high potential for abuse
b. It has agonist-antagonist properties
c. It must be given intravascular to be effective
d. It contains a metabolite that causes seizures
Meperidine (Demerol) contains a metabolite that causes seizures, it also results to sudden withdrawals. The rest of the choices does not describe meperidine.
14. Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient?
a. Teaching the client diaphragmatic breathing techniques
b. Administering cough suppressants as ordered
c. Teaching an encouraging pursed-lip breathing
d. Placing the client in a low semi-fowlers position
Pursed-lip breathing is one of the simplest ways to control shortness of breath. Diaphragmatic breathing is only effective for pain management. Administering cough suppressants is not therapeutic at this stage. While placing the client in a low semi-fowler’s position makes it harder for the patient to breathe due to the incorrect angle.
15. A 58-year old client is receiving chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following?
a. " Chemotherapy affects all rapidly dividing cells"
b. " the molecular structure of the DNA is altered"
c. " Cancer cell are susceptible to drug toxins"
d. " Chemotherapy encourages cancer cells to divide"
Chemotherapy affects all rapidly dividing cells is the appropriate answer. It does not only destroy the molecular structure of the DNA, not susceptible to toxins and it does not encourage cells to divide.
16. A 56-year old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
a. Decrease in appetite
c. Spasms of the diaphragm
d. Cough and shortness of breath
Spasms of the diaphragm indicates pulmonary toxicity in chemotherapy causing difficulty in breathing. While decrease in appetite, drowsiness and cough and shortness of breath are generalized form of symptoms that needs further investigation.
17. A 62-year old woman has had a left modified radical mastectomy with axillary node dissection. The nurse is aware that lymphedema is a common complication that can occur
a. With right-sided radical mastectomies
b. In older women
c. From 6 to 20 years after surgery
d. At any time after the procedure 7 to 10 days after surgery or not all
Some cases may become evident later in life when a triggering event or worsening of the condition causes the lymphatic transport capacity to exceed the volume of interstitial fluid formation, causing the patient to be unable to maintain normal lymphatic flow. The rest of the choices does not describe the etiology of lypmhedema.
18. The nurse is assessing a 42- year old client with cancer. He has lost 1 pound in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 38.3. the fever is indicative of
a. Inadequate nutrition
b. New resistance to current antiemetic therapy
c. Expected response to chemotherapy treatment
Ondansetron hydrochloride (Zofran®) is approved to prevent nausea and vomiting caused by chemotherapy, radiation, or surgery. This prescription medication is available in several forms, such as tablets, orally disintegrating tablets, a liquid, and an intravenous form. Although most people tolerate ondansetron well, this medication is not suitable for everyone. A few of the conditions that should let healthcare providesr know about before taking the medication include liver problems, an irregular heart rhythm, and any allergies. Potential side effects include constipation, fatigue, and headaches. Fever is not included as an indication of side effect of the drug.
19. Which of the following variables is most important to asses when determining the impact of the cancer diagnosis and treatment modalities on a long term survivor’s quality of life
a. Occupation and employability
b. Functional status
c. Evidence of disease
d. Individual values and beliefs
The patient’s will to survive matters a lot. Hope during the darkest part of cancer may have the key to successful treatment since the patient has the energy to cooperate and compliant with the regimen. Occupation and employability and functional status are similar in idea could be classified as factors that maybe affected by the diagnosis but not with the treatment of cancer. Evidence of the disease has varied impact to the patient.
20. A 57-year old woman has difficulty with mobility after her cancer treatment therapies and states, “Why should I bother trying to get better? It doesn’t seem to make any difference that I do” the nurse response by helping the client establish reasonable activity goals, choose her own foods from the menu, and make choices about her daily activities. These interventions represent the nurse’s attempt to address which of the following nursing diagnoses?
a. Ineffective coping
c. Impaired adjustment
d. Dysfunctional grieving
Powerlessness according to NANDA is perception that one’s own actions will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening. Ineffective coping is Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. Impaired adjustment is inability to modify lifestyle or behavior in a manner consistent with a change in health status. Dysfunctional grieving is intellectual and emotional responses and behaviors by which individuals, families, communities work through the process of modifying self-concept based on the perception of potential loss.
21. Which of the following activities indicates that the client with cancer is adapting well to body image changes?
a. The client names his brother as the person to call if he is experiencing suicidal intention
b. The client discusses changes in body structure and function
c. The client discusses the date he has to return work
d. The client serves as a volunteer in a client-to-client visitation program
Client to client visitation program allows each patient with similar cancer to interact and publicly denounce stigma due to alterations in the body. Suicidal intention denotes depression and desperation. If the client discusses changes in body structure and function, he is trying to rationalize which is a defense mechanism.
22. When a 62-year old client and his family receive the initial diagnosis of colon cancer, the nurse can act as an advocate:
a. Helping them maintain a sense of optimism and hopefulness
b. Determining their understanding of the results of the diagnostic testing
c. Listening carefully to their perceptions of what their needs are
d. Providing them with written materials about the cancer site and its treatment
Listening carefully to their perception of what their needs are is acting in behalf of the patient and looking on the interest of the patient. Helping them maintain a sense of optimism and hopefulness means that the nurse functions as a counselor. Determining their understanding of the results of the diagnostic testing and giving them with written materials about the cancer site and its treatment are ways when a nurse functions as a teacher.
23. In an attempt to call public attention to the cancer survivor’s needs, a bill of rights was put forth by the:
a. American cancer society
b. National coalition of Cancer Survivors
c. National Cancer Institute
d. National Hospice Organization
National Coalition for Cancer Survivorship: A survivor-led advocacy group that works on behalf of the millions of cancer survivors and the millions more touched by this disease. Founded in the US in 1986, NCCS issued the following 12 principles as Imperatives for Quality Cancer Care: Access, Advocacy, Action and Accountability. ACS (American Cancer Society) is a nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives and diminishing suffering from cancer through research, education, advocacy, and service. National Cancer Institute gives accurate, up-to-date, comprehensive cancer information from the US government's principal agency for cancer research.
24. A 72-year old woman with cancer needs assistance with her financial concerns. The nurse would suggest which of the following persons see the client?
a. Bank representative
b. Social worker
c. Oncology nurse
d. Representative of the hospital billing department
A social worker could help the client in terms of financial matter, they are the once responsible in helping the patients access treatments provided by the government. A bank representative could not help her at this moment. An oncology nurse provides quality care in caring manifestations of cancer in her. A representative of the hospital billing department can’t help her also since this person is just responsible in collecting payments.
25. The nurse is caring for a client with cancer who has intractable dyspnea. The nurse is aware that the physician may order which of the following types of drugs to relieve the dyspnea
a. Mucolytic agents
Opioids are very effective in relieving dyspnea, although the exact mechanism is not understood. Contrary to common belief, this effect does not result through inhibition of respiratory drive. Relief from the "work of breathing" is a function of steady-state opioid levels, much like steady-state opioid levels relieve pain. A mucolytic agent or expectorant is any agent which dissolves thick mucus and is usually used to help relieve respiratory difficulties. Antidepressants are medications prescribed for treating depression. A diuretic is any drug that elevates the rate of urination and thus provides a means of forced dieresis.
|Post #15 Jun 23 2011, 10:20 AM||Karmela|
Nursing Bullets: Medical-Surgical Nursing Part I
The ultimate review for Medical-Surgical Nursing! It contains 350 bits of information regarding the (dreaded but fun to learn) medical–surgical nursing. This will review you to different concepts behind diagnostic examinations, nursing procedures, and many more!
Relax your mind…ready yourself for an influx of information.
Take a long deep breath.
Are you ready?
Bone scan is done by injecting radioisotope per IV & X-rays are taken.
To prevent edema edema on the site of sprain, apply cold compress on the area for the 1st 24 hrs
To turn the client after lumbar Laminectomy, use logrolling technique
Carpal tunnel syndrome occurs due to the injury of median nerve.
Massaging the back of the head is specifically important for the client w/ Crutchfield tong.
A 1 yr old child has a fracture of the L femur. He is placed in Bryant’s traction. The reason for elevation of his both legs at 90 deg. angle is his weight isn’t adequate to provide sufficient countertraction, so his entire body must be used.
Swing-through crutch gait is done by advancing both crutches together & the client moves both legs past the level of the crutches.
The appropriate nursing measure to prevent displacement of the prosthesis after a right total hip replacement for arthritis is to place the patient in the position of right leg abducted.
Pain on non-use of joints, subcutaneous nodules & elevated ESR are characteristic manifestations of rheumatoid arthritis.
Teaching program of a patient w/ SLE should include emphasis on walking in shaded area.
Otosclerosis is characterized by replacement of normal bones by spongy & highly vascularized bones.
Use of high pitched voice is inappropriate for the client w/ hearing impairment.
Rinne’s test compares air conduction w/ bone conduction.
Vertigo is the most characteristic manifestation of Meniere’s disease.
Low sodium is the diet for a client w/ Meniere’s disease.
A client who had cataract surgery should be told to call his MD if he has eye pain.
Risk for Injury takes priority for a client w/ Meniere’s disease.
Irrigate the eye w/ sterile saline is the priority nursing intervention when the client has a foreign body protruding from the eye.
Snellen’s Test assesses visual acuity.
Presbyopia is an eye disorder characterized by lessening of the effective powers of accommodation.
The primary problem in cataract is blurring of vision.
The primary reason for performing iridectomy after cataract extraction is to prevent secondary glaucoma.
In acute glaucoma, the obstruction of the flow of aqueous humor is caused by displacement of the iris.
Glaucoma is characterized by irreversible blindness.
Hyperopia is corrected by convex lens.
Pterygium is caused primarily by exposure to dust.
A sterile chronic granulomatous inflammation of the meibomian gland is chalazion.
The surgical procedure w/c involves removal of the eyeball is enucleation.
Snellen’s Test assesses visual acuity.
Presbyopia is an eye disorder characterized by lessening of the effective powers of accommodation.
The primary problem in cataract is blurring of vision.
The primary reason for performing iridectomy after cataract extraction is to prevent secondary glaucoma.
In acute glaucoma, the obstruction of the flow of aqueous humor is caused by displacement of the iris.
Glaucoma is characterized by irreversible blindness.
Hyperopia is corrected by convex lens.
Pterygium is caused primarily by exposure to dust.
A sterile chronic granulomatous inflammation of the meibomian gland is chalazion.
The surgical procedure w/c involves removal of the eyeball is enucleation.
The client is for EEG this morning. Prepare him for the procedure by rendering hair shampoo, excluding caffeine from his meal & instructing the client to remain still during the procedure.
If the client w/ increased ICP demonstrates decorticate posturing, observe for flexion of elbows, extension of the knees, plantar flexion of the feet,
The nursing diagnosis that would have the highest priority in the care of the client who has become comatose following cerebral hemorrhage is Ineffective Airway Clearance.
The initial nursing action—for a client who is in the clonic phase of a tonic-clonic seizure—is to obtain equipment for orotracheal suctioning.
The first nursing intervention in a quadriplegic client who is experiencing autonomic dysreflexia is to elevate his head as high as possible.
Following surgery for a brain tumor near the hypothalamus, the nursing assessment should include observing for inability to regulate body temp.
Post-myelogram (using metrizamide (Amipaque) care includes keeping head elevated for at least 8 hrs.
Homonymous hemianopsia is described by a client had CVA & can only see the nasal visual field on one side & the temporal portion on the opposite side.
Ticlopidine may be prescribed to prevent thromboembolic CVA.
To maintain airway patency during a stroke in evolution, have orotracheal suction available at all times.
For a client w/ CVA, the gag reflux must return before the client is fed.
Clear fluids draining from the nose of a client who had a head trauma 3 hrs ago may indicate basilar skull fracture.
An adverse effect of gingival hyperplasia may occur during Phenytoin (DIlantin) therapy.
Urine output increased: best shows that the mannitol is effective in a client w/ increased ICP.
A client w/ C6 spinal injury would most likely have the symptom of quadriplegia.
Falls are the leading cause of injury in elderly people.
Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.
Secondary prevention is early detection. Examples include purifiedv protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.
Tertiary prevention is treatment to prevent long-term complications.
A patient indicates that he’s coming to terms with having a chronic disease when he says, “I’m never going to get any better.”
On noticing religious artifacts and literature on a patient’s nightv stand, a culturally aware nurse would ask the patient the meaning of the items.
A Mexican patient may request the intervention of a curandero, orv faith healer, who involves the family in healing the patient.
In an infant, the normal hemoglobin value is 12 g/dl.
The nitrogen balance estimates the difference between the intake and use of protein.
Most of the absorption of water occurs in the large intestine.
Most nutrients are absorbed in the small intestine.
When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”
A vegan diet should include an abundant supply of fiber.
A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis.
First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.
To induce sleep, the first step is to minimize environmental stimuli.
Before moving a patient, the nurse should assess the patient’sv physical abilities and ability to understand instructions as well as the amount of strength required to move the patient.
To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weeklyv intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).
To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.
To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow.
Vitamin C is needed for collagen production.
Only the patient can describe his pain accurately.
Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.
Patient-controlled analgesia is a safe method to relieve acute painv caused by surgical incision, traumatic injury, labor and delivery, or cancer.
An Asian American or European American typically places distance between himself and others when communicating.
Active euthanasia is actively helping a person to die.
Brain death is irreversible cessation of all brain function.
Passive euthanasia is stopping the therapy that’s sustaining life.
A third-party payer is an insurance company.
Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective.
A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.
Voluntary euthanasia is actively helping a patient to die at the patient’s request.
Bananas, citrus fruits, and potatoes are good sources of potassium.
Good sources of magnesium include fish, nuts, and grains.
Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
Intrathecal injection is administering a drug through the spine.
When a patient asks a question or makes a statement that’sv emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.
The steps of the trajectory-nursing model are as follows:
– Step 1: Identifying the trajectory phase
– Step 2: Identifying the problems and establishing goals
– Step 3: Establishing a plan to meet the goals
– Step 4: Identifying factors that facilitate or hinder attainment of the goals
– Step 5: Implementing interventions
– Step 6: Evaluating the effectiveness of the interventions
A Hindu patient is likely to request a vegetarian diet.
Pain threshold, or pain sensation, is the initial point at which a patient feels pain.
The difference between acute pain and chronic pain is its duration.
Referred pain is pain that’s felt at a site other than its origin.
Alleviating pain by performing a back massage is consistent with the gate control theory.
Romberg’s test is a test for balance or gait.
Pain seems more intense at night because the patient isn’t distracted by daily activities.
Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency.
No pork or pork products are allowed in a Muslim diet.
Two goals of Healthy People 2010 are:
– Help individuals of all ages to increase the quality of life and the number of years of optimal health
– Eliminate health disparities among different segments of the population.
A community nurse is serving as a patient’s advocate if she tells av malnourished patient to go to a meal program at a local park.
If a patient isn’t following his treatment plan, the nurse should first ask why.
When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.
Ethnocentrism is the universal belief that one’s way of life is superior to others’.
When a nurse is communicating with a patient through an interpreter,v the nurse should speak to the patient and the interpreter.
In accordance with the “hot-cold” system used by some Mexicans,v Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”
Prejudice is a hostile attitude toward individuals of a particular group.
Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.
Increased gastric motility interferes with the absorption of oral drugs.
The three phases of the therapeutic relationship are orientation, working, and termination.
Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.
Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion.
When measuring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more than two-thirds the length of the extremity that’s used.
When administering a drug by Z-track, the nurse shouldn’t use thev same needle that was used to draw the drug into the syringe because doing so could stain the skin.
Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.
When evaluating whether an answer on an examination is correct, thev nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.
Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient.
Beneficence is the duty to do no harm and the duty to do good.v There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.
Nonmaleficence is the duty to do no harm.
Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.
A = Airway. This category includes everything that affects a patentv airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.
B = Breathing. This category includes everything that affects thev breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
C = Circulation. This category includes everything that affects thev circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.
D = Disease processes. If the patient has no problem with the airway,v breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.
E = Everything else. This category includes such issues as writing anv incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.
Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.
Egalitarian theory emphasizes that equal access to goods and servicesv must be provided to the less fortunate by an affluent society.
Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.
Process recording is a method of evaluating one’s communication effectiveness.
When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.
When feeding an elderly patient, essential foods should be given first.
Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.
Isometric exercises are performed on an extremity that’s in a cast.
A back rub is an example of the gate-control theory of pain.
Anything that’s located below the waist is considered unsterile; av sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is considered unsterile.
A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.
A “shift to the right” is evident when the number of mature cells inv the blood increases, as seen in advanced liver disease and pernicious anemia.
Before administering preoperative medication, the nurse should ensurev that an informed consent form has been signed and attached to the patient’s record.
A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.
Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.
Usually, patients who have the same infection and are in strict isolation can share a room.
Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.
For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.
Whether the patient can perform a procedure (psychomotor domain ofv learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning).
According to Erik Erikson, developmental stages are trust versusv mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60).
When communicating with a hearing impaired patient, the nurse should face him.
An appropriate nursing intervention for the spouse of a patient whov has a serious incapacitating disease is to help him to mobilize a support system.
Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C).
Milk is high in sodium and low in iron.
When a patient expresses concern about a health-related issue, beforev addressing the concern, the nurse should assess the patient’s level of knowledge.
The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.
Unlike false labor, true labor produces regular rhythmic contractions, abdominal discomfort, progressive descent of the fetus, bloody show, and progressive effacement and dilation of the cervix.
To help a mother break the suction of her breast-feeding infant, the nurse should teach her to insert a finger at the corner of the infant’s mouth.
Administering high levels of oxygen to a premature neonate can cause blindness as a result of retrolental fibroplasia.
Amniotomy is artificial rupture of the amniotic membranes.
During pregnancy, weight gain averages 25 to 30 lb (11 to 13.5 kg).
Rubella has a teratogenic effect on the fetus during the first trimester. It produces abnormalities in up to 40% of cases without interrupting the pregnancy.
Immunity to rubella can be measured by a hemagglutination inhibition test (rubella titer). This test identifies exposure to rubella infection and determines susceptibility in pregnant women. In a woman, a titer greater than 1:8 indicates immunity.
When used to describe the degree of fetal descent during labor, floating means the presenting part isn’t engaged in the pelvic inlet, but is freely movable (ballotable) above the pelvic inlet.
When used to describe the degree of fetal descent, engagement means when the largest diameter of the presenting part has passed through the pelvic inlet.
Fetal station indicates the location of the presenting part in relation to the ischial spine. It’s described as –1, –2, –3, –4, or –5 to indicate the number of centimeters above the level of the ischial spine; station –5 is at the pelvic inlet.
Fetal station also is described as +1, +2, +3, +4, or +5 to indicate the number of centimeters it is below the level of the ischial spine; station 0 is at the level of the ischial spine.
During the first stage of labor, the side-lying position usually provides the greatest degree of comfort, although the patient may assume any comfortable position.
During delivery, if the umbilical cord can’t be loosened and slipped from around the neonate’s neck, it should be clamped with two clamps and cut between the clamps.
An Apgar score of 7 to 10 indicates no immediate distress, 4 to 6 indicates moderate distress, and 0 to 3 indicates severe distress.
To elicit Moro’s reflex, the nurse holds the neonate in both hands and suddenly, but gently, drops the neonate’s head backward. Normally, the neonate abducts and extends all extremities bilaterally and symmetrically, forms a C shape with the thumb and forefinger, and first adducts and then flexes the extremities.
Pregnancy-induced hypertension (preeclampsia) is an increase in blood pressure of 30/15 mm Hg over baseline or blood pressure of 140/95 mm Hg on two occasions at least 6 hours apart accompanied by edema and albuminuria after 20 weeks’ gestation.
Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and fetal movement felt by the examiner (not usually present until 4 months’ gestation)
Goodell’s sign is softening of the cervix.
Quickening, a presumptive sign of pregnancy, occurs between 16 and 19 weeks’ gestation.
Ovulation ceases during pregnancy.
Any vaginal bleeding during pregnancy should be considered a complication until proven otherwise.
To estimate the date of delivery using Nägele’s rule, the nurse counts backward 3 months from the first day of the last menstrual period and then adds 7 days to this date.
At 12 weeks’ gestation, the fundus should be at the top of the symphysis pubis.
Cow’s milk shouldn’t be given to infants younger than age 1 because it has a low linoleic acid content and its protein is difficult for infants to digest.
If jaundice is suspected in a neonate, the nurse should examine the infant under natural window light. If natural light is unavailable, the nurse should examine the infant under a white light.
The three phases of a uterine contraction are increment, acme, and decrement.
The intensity of a labor contraction can be assessed by the indentability of the uterine wall at the contraction’s peak. Intensity is graded as mild (uterine muscle is somewhat tense), moderate (uterine muscle is moderately tense), or strong (uterine muscle is boardlike).
Chloasma, the mask of pregnancy, is pigmentation of a circumscribed area of skin (usually over the bridge of the nose and cheeks) that occurs in some pregnant women.
The gynecoid pelvis is most ideal for delivery. Other types include platypelloid (flat), anthropoid (apelike), and android (malelike).
Pregnant women should be advised that there is no safe level of alcohol intake.
The frequency of uterine contractions, which is measured in minutes, is the time from the beginning of one contraction to the beginning of the next.
Vitamin K is administered to neonates to prevent hemorrhagic disorders because a neonate’s intestine can’t synthesize vitamin K.
Before internal fetal monitoring can be performed, a pregnant patient’s cervix must be dilated at least 2 cm, the amniotic membranes must be ruptured, and the fetus’s presenting part (scalp or buttocks) must be at station –1 or lower, so that a small electrode can be attached.
Fetal alcohol syndrome presents in the first 24 hours after birth and produces lethargy, seizures, poor sucking reflex, abdominal distention, and respiratory difficulty.
Variability is any change in the fetal heart rate (FHR) from its normal rate of 120 to 160 beats/minute. Acceleration is increased FHR; deceleration is decreased FHR.
In a neonate, the symptoms of heroin withdrawal may begin several hours to 4 days after birth.
In a neonate, the symptoms of methadone withdrawal may begin 7 days to several weeks after birth.
In a neonate, the cardinal signs of narcotic withdrawal include coarse, flapping tremors; sleepiness; restlessness; prolonged, persistent, high-pitched cry; and irritability.
The nurse should count a neonate’s respirations for 1 full minute.
Chlorpromazine (Thorazine) is used to treat neonates who are addicted to narcotics.
The nurse should provide a dark, quiet environment for a neonate who is experiencing narcotic withdrawal.
In a premature neonate, signs of respiratory distress include nostril flaring, substernal retractions, and inspiratory grunting.
Respiratory distress syndrome (hyaline membrane disease) develops in premature infants because their pulmonary alveoli lack surfactant.
Whenever an infant is being put down to sleep, the parent or caregiver should position the infant on the back. (Remember back to sleep.)
The male sperm contributes an X or a Y chromosome; the female ovum contributes an X chromosome.
Fertilization produces a total of 46 chromosomes, including an XY combination (male) or an XX combination (female).
The percentage of water in a neonate’s body is about 78% to 80%.
To perform nasotracheal suctioning in an infant, the nurse positions the infant with his neck slightly hyperextended in a “sniffing” position, with his chin up and his head tilted back slightly.
Organogenesis occurs during the first trimester of pregnancy, specifically, days 14 to 56 of gestation.
After birth, the neonate’s umbilical cord is tied 1″ (2.5 cm) from the abdominal wall with a cotton cord, plastic clamp, or rubber band.
Gravida is the number of pregnancies a woman has had, regardless of outcome.
Para is the number of pregnancies that reached viability, regardless of whether the fetus was delivered alive or stillborn. A fetus is considered viable at 20 weeks’ gestation.
An ectopic pregnancy is one that implants abnormally, outside the uterus.
The first stage of labor begins with the onset of labor and ends with full cervical dilation at 10 cm.
The second stage of labor begins with full cervical dilation and ends with the neonate’s birth.
The third stage of labor begins after the neonate’s birth and ends with expulsion of the placenta.
In a full-term neonate, skin creases appear over two-thirds of the neonate’s feet. Preterm neonates have heel creases that cover less than two-thirds of the feet.
The fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is delivered. This time is needed to stabilize the mother’s physical and emotional state after the stress of childbirth.
At 20 weeks’ gestation, the fundus is at the level of the umbilicus.
At 36 weeks’ gestation, the fundus is at the lower border of the rib cage.
A premature neonate is one born before the end of the 37th week of gestation.
Pregnancy-induced hypertension is a leading cause of maternal death in the United States.
A habitual aborter is a woman who has had three or more consecutive spontaneous abortions.
Threatened abortion occurs when bleeding is present without cervical dilation.
A complete abortion occurs when all products of conception are expelled.
Hydramnios (polyhydramnios) is excessive amniotic fluid (more than 2,000 ml in the third trimester).
Stress, dehydration, and fatigue may reduce a breast-feeding mother’s milk supply.
During the transition phase of the first stage of labor, the cervix is dilated 8 to 10 cm and contractions usually occur 2 to 3 minutes apart and last for 60 seconds.
A nonstress test is considered nonreactive (positive) if fewer than two fetal heart rate accelerations of at least 15 beats/minute occur in 20 minutes.
A nonstress test is considered reactive (negative) if two or more fetal heart rate accelerations of 15 beats/minute above baseline occur in 20 minutes.
A nonstress test is usually performed to assess fetal well-being in a pregnant patient with a prolonged pregnancy (42 weeks or more), diabetes, a history of poor pregnancy outcomes, or pregnancy-induced hypertension.
A pregnant woman should drink at least eight 8-oz glasses (about 2,000 ml) of water daily.
When both breasts are used for breast-feeding, the infant usually doesn’t empty the second breast. Therefore, the second breast should be used first at the next feeding.
A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or less at birth.
A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz) or less at birth.
When teaching parents to provide umbilical cord care, the nurse should teach them to clean the umbilical area with a cotton ball saturated with alcohol after every diaper change to prevent infection and promote drying.
Teenage mothers are more likely to have low-birth-weight neonates because they seek prenatal care late in pregnancy (as a result of denial) and are more likely than older mothers to have nutritional deficiencies.
Linea nigra, a dark line that extends from the umbilicus to the mons pubis, commonly appears during pregnancy and disappears after pregnancy.
Implantation in the uterus occurs 6 to 10 days after ovum fertilization.
Placenta previa is abnormally low implantation of the placenta so that it encroaches on or covers the cervical os.
In complete (total) placenta previa, the placenta completely covers the cervical os.
In partial (incomplete or marginal) placenta previa, the placenta covers only a portion of the cervical os.
Abruptio placentae is premature separation of a normally implanted placenta. It may be partial or complete, and usually causes abdominal pain, vaginal bleeding, and a boardlike abdomen.
Cutis marmorata is mottling or purple discoloration of the skin. It’s a transient vasomotor response that occurs primarily in the arms and legs of infants who are exposed to cold.
The classic triad of symptoms of preeclampsia are hypertension, edema, and proteinuria. Additional symptoms of severe preeclampsia include hyperreflexia, cerebral and vision disturbances, and epigastric pain.
Ortolani’s sign (an audible click or palpable jerk that occurs with thigh abduction) confirms congenital hip dislocation in a neonate.
The first immunization for a neonate is the hepatitis B vaccine, which is administered in the nursery shortly after birth.
If a patient misses a menstrual period while taking an oral contraceptive exactly as prescribed, she should continue taking the contraceptive.
If a patient misses two consecutive menstrual periods while taking an oral contraceptive, she should discontinue the contraceptive and take a pregnancy test.
If a patient who is taking an oral contraceptive misses a dose, she should take the pill as soon as she remembers or take two at the next scheduled interval and continue with the normal schedule.
If a patient who is taking an oral contraceptive misses two consecutive doses, she should double the dose for 2 days and then resume her normal schedule. She also should use an additional birth control method for 1 week.
Eclampsia is the occurrence of seizures that aren’t caused by a cerebral disorder in a patient who has pregnancy-induced hypertension.
In placenta previa, bleeding is painless and seldom fatal on the first occasion, but it becomes heavier with each subsequent episode.
Treatment for abruptio placentae is usually immediate cesarean delivery.
Drugs used to treat withdrawal symptoms in neonates include phenobarbital (Luminal), camphorated opium tincture (paregoric), and diazepam (Valium).
Infants with Down syndrome typically have marked hypotonia, floppiness, slanted eyes, excess skin on the back of the neck, flattened bridge of the nose, flat facial features, spadelike hands, short and broad feet, small male genitalia, absence of Moro’s reflex, and a simian crease on the hands.
The failure rate of a contraceptive is determined by the experience of 100 women for 1 year. It’s expressed as pregnancies per 100 woman-years.
The narrowest diameter of the pelvic inlet is the anteroposterior (diagonal conjugate).
The chorion is the outermost extraembryonic membrane that gives rise to the placenta.
The corpus luteum secretes large quantities of progesterone.
From the 8th week of gestation through delivery, the developing cells are known as a fetus.
In an incomplete abortion, the fetus is expelled, but parts of the placenta and membrane remain in the uterus.
The circumference of a neonate’s head is normally 2 to 3 cm greater than the circumference of the chest.
After administering magnesium sulfate to a pregnant patient for hypertension or preterm labor, the nurse should monitor the respiratory rate and deep tendon reflexes.
During the first hour after birth (the period of reactivity), the neonate is alert and awake.
When a pregnant patient has undiagnosed vaginal bleeding, vaginal examination should be avoided until ultrasonography rules out placenta previa.
After delivery, the first nursing action is to establish the neonate’s airway.
Nursing interventions for a patient with placenta previa include positioning the patient on her left side for maximum fetal perfusion, monitoring fetal heart tones, and administering I.V. fluids and oxygen, as ordered.
The specific gravity of a neonate’s urine is 1.003 to 1.030. A lower specific gravity suggests overhydration; a higher one suggests dehydration.
The neonatal period extends from birth to day 28. It’s also called the first 4 weeks or first month of life.
A woman who is breast-feeding should rub a mild emollient cream or a few drops of breast milk (or colostrum) on the nipples after each feeding. She should let the breasts air-dry to prevent them from cracking.
Breast-feeding mothers should increase their fluid intake to 2½ to 3 qt (2,500 to 3,000 ml) daily.
After feeding an infant with a cleft lip or palate, the nurse should rinse the infant’s mouth with sterile water.
The nurse instills erythromycin in a neonate’s eyes primarily to prevent blindness caused by gonorrhea or chlamydia.
Human immunodeficiency virus (HIV) has been cultured in breast milk and can be transmitted by an HIV-positive mother who breast-feeds her infant.
A fever in the first 24 hours postpartum is most likely caused by dehydration rather than infection.
Preterm neonates or neonates who can’t maintain a skin temperature of at least 97.6° F (36.4° C) should receive care in an incubator (Isolette) or a radiant warmer. In a radiant warmer, a heat-sensitive probe taped to the neonate’s skin activates the heater unit automatically to maintain the desired temperature.
During labor, the resting phase between contractions is at least 30 seconds.
Lochia rubra is the vaginal discharge of almost pure blood that occurs during the first few days after childbirth.
Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after childbirth.
Lochia alba is the vaginal discharge of decreased blood and increased leukocytes that’s the final stage of lochia. It occurs 7 to 10 days after childbirth.
Colostrum, the precursor of milk, is the first secretion from the breasts after delivery.
The length of the uterus increases from 2½” (6.3 cm) before pregnancy to 12½” (32 cm) at term.
To estimate the true conjugate (the smallest inlet measurement of the pelvis), deduct 1.5 cm from the diagonal conjugate (usually 12 cm). A true conjugate of 10.5 cm enables the fetal head (usually 10 cm) to pass.
The smallest outlet measurement of the pelvis is the intertuberous diameter, which is the transverse diameter between the ischial tuberosities.
Electronic fetal monitoring is used to assess fetal well-being during labor. If compromised fetal status is suspected, fetal blood pH may be evaluated by obtaining a scalp sample.
In an emergency delivery, enough pressure should be applied to the emerging fetus’s head to guide the descent and prevent a rapid change in pressure within the molded fetal skull.
After delivery, a multiparous woman is more susceptible to bleeding than a primiparous woman because her uterine muscles may be overstretched and may not contract efficiently.
Neonates who are delivered by cesarean birth have a higher incidence of respiratory distress syndrome.
The nurse should suggest ambulation to a postpartum patient who has gas pain and flatulence.
Massaging the uterus helps to stimulate contractions after the placenta is delivered.
When providing phototherapy to a neonate, the nurse should cover the neonate’s eyes and genital area.
The narcotic antagonist naloxone (Narcan) may be given to a neonate to correct respiratory depression caused by narcotic administration to the mother during labor.
In a neonate, symptoms of respiratory distress syndrome include expiratory grunting or whining, sandpaper breath sounds, and seesaw retractions.
Cerebral palsy presents as asymmetrical movement, irritability, and excessive, feeble crying in a long, thin infant.
The nurse should assess a breech-birth neonate for hydrocephalus, hematomas, fractures, and other anomalies caused by birth trauma.
When a patient is admitted to the unit in active labor, the nurse’s first action is to listen for fetal heart tones.
In a neonate, long, brittle fingernails are a sign of postmaturity.
Desquamation (skin peeling) is common in postmature neonates.
A mother should allow her infant to breast-feed until the infant is satisfied. The time may vary from 5 to 20 minutes.
Nitrazine paper is used to test the pH of vaginal discharge to determine the presence of amniotic fluid.
A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) during the first trimester and slightly less than 1 lb (0.5 kg) per week during the last two trimesters.
Neonatal jaundice in the first 24 hours after birth is known as pathological jaundice and is a sign of erythroblastosis fetalis.
A classic difference between abruptio placentae and placenta previa is the degree of pain. Abruptio placentae causes pain, whereas placenta previa causes painless bleeding.
Because a major role of the placenta is to function as a fetal lung, any condition that interrupts normal blood flow to or from the placenta increases fetal partial pressure of arterial carbon dioxide and decreases fetal pH.
Precipitate labor lasts for approximately 3 hours and ends with delivery of the neonate
Methylergonovine (Methergine) is an oxytocic agent used to prevent and treat postpartum hemorrhage caused by uterine atony or subinvolution.
As emergency treatment for excessive uterine bleeding, 0.2 mg of methylergonovine (Methergine) is injected I.V. over 1 minute while the patient’s blood pressure and uterine contractions are monitored.
Braxton Hicks contractions are usually felt in the abdomen and don’t cause cervical change. True labor contractions are felt in the front of the abdomen and back and lead to progressive cervical dilation and effacement.
The average birth weight of neonates born to mothers who smoke is 6 oz (170 g) less than that of neonates born to nonsmoking mothers.
Culdoscopy is visualization of the pelvic organs through the posterior vaginal fornix.
The nurse should teach a pregnant vegetarian to obtain protein from alternative sources, such as nuts, soybeans, and legumes.
The nurse should instruct a pregnant patient to take only prescribed prenatal vitamins because over-the-counter high-potency vitamins may harm the fetus.
High-sodium foods can cause fluid retention, especially in pregnant patients.
A pregnant patient can avoid constipation and hemorrhoids by adding fiber to her diet.
If a fetus has late decelerations (a sign of fetal hypoxia), the nurse should instruct the mother to lie on her left side and then administer 8 to 10 L of oxygen per minute by mask or cannula. The nurse should notify the physician. The side-lying position removes pressure on the inferior vena cava.
Oxytocin (Pitocin) promotes lactation and uterine contractions.
Lanugo covers the fetus’s body until about 20 weeks’ gestation. Then it begins to disappear from the face, trunk, arms, and legs, in that order.
In a neonate, hypoglycemia causes temperature instability, hypotonia, jitteriness, and seizures. Premature, postmature, small-for-gestational-age, and large-for-gestational-age neonates are susceptible to this disorder.
Neonates typically need to consume 50 to 55 cal per pound of body weight daily.
Because oxytocin (Pitocin) stimulates powerful uterine contractions during labor, it must be administered under close observation to help prevent maternal and fetal distress.
During fetal heart rate monitoring, variable decelerations indicate compression or prolapse of the umbilical cord.
Cytomegalovirus is the leading cause of congenital viral infection.
Tocolytic therapy is indicated in premature labor, but contraindicated in fetal death, fetal distress, or severe hemorrhage.
Through ultrasonography, the biophysical profile assesses fetal well-being by measuring fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate (nonstress test), and qualitative amniotic fluid volume.
A neonate whose mother has diabetes should be assessed for hyperinsulinism.
In a patient with preeclampsia, epigastric pain is a late symptom and requires immediate medical intervention.
After a stillbirth, the mother should be allowed to hold the neonate to help her come to terms with the death.
Molding is the process by which the fetal head changes shape to facilitate movement through the birth canal.
If a woman receives a spinal block before delivery, the nurse should monitor the patient’s blood pressure closely.
If a woman suddenly becomes hypotensive during labor, the nurse should increase the infusion rate of I.V. fluids as prescribed.
The best technique for assessing jaundice in a neonate is to blanch the tip of the nose or the area just above the umbilicus.
During fetal heart monitoring, early deceleration is caused by compression of the head during labor.
After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the patient’s I.V. solution, as prescribed, to promote postpartum involution of the uterus and stimulate lactation.
Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue, starch, or hair. It may occur during pregnancy and can endanger the fetus.
A pregnant patient should take folic acid because this nutrient is required for rapid cell division.
A woman who is taking clomiphene (Clomid) to induce ovulation should be informed of the possibility of multiple births with this drug.
If needed, cervical suturing is usually done between 14 and 18 weeks’ gestation to reinforce an incompetent cervix and maintain pregnancy. The suturing is typically removed by 35 weeks’ gestation.
During the first trimester, a pregnant woman should avoid all drugs unless doing so would adversely affect her health.
Most drugs that a breast-feeding mother takes appear in breast milk.
The Food and Drug Administration has established the following five categories of drugs based on their potential for causing birth defects: A, no evidence of risk; B, no risk found in animals, but no studies have been done in women; C, animal studies have shown an adverse effect, but the drug may be beneficial to women despite the potential risk; D, evidence of risk, but its benefits may outweigh its risks; and X, fetal anomalies noted, and the risks clearly outweigh the potential benefits.
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations; tachycardia; and shock.
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations; tachycardia; and shock.
The mechanics of delivery are engagement, descent and flexion, internal rotation, extension, external rotation, restitution, and expulsion.
A probable sign of pregnancy, McDonald’s sign is characterized by an ease in flexing the body of the uterus against the cervix.
Amenorrhea is a probable sign of pregnancy.
A pregnant woman’s partner should avoid introducing air into the vagina during oral sex because of the possibility of air embolism.
The presence of human chorionic gonadotropin in the blood or urine is a probable sign of pregnancy.
Radiography isn’t usually used in a pregnant woman because it may harm the developing fetus. If radiography is essential, it should be performed only after 36 weeks’ gestation.
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