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1. When assessing a client with chest b. Stop taking the drug when the
pain, the nurse obtains a thorough symptoms subside
history. Which statement of the
patient is most suggestive of anginal c. Avoid aspirin and products that
pectoris? contain aspirin
b. The pain resolved after I ate 5. The nurse is assessing a client with
sandwich Cushing’s disease. Which observation
should be reported to the physician
c. The pain worsened when I took a immediately.
deep breath
a. Pitting edema of the legs
d. The pain occurred while I was
mowing the loan b. Irregular apical pulse
a. Pain that radiates down the posterior 36.A client with increasing difficulty
thigh swallowing , weight loss and fatigue
just received a diagnosis of
b. Back pain when the knees are flexed esophageal cancer. Because this client
c. Atrophy of the lower legs has difficulty swallowing, the nurse
should give the highest priority to
d. Positive Homan’s sign which action.
33.For a client with hepatitis b, the nurse a. Helping the client cope with body
should monitor closely for the onset image disturbance
development of which clinical
manifestation? b. Ensuring adequate nutrition
c. Absence of bacteria on urine 43.A client reports sharp chest pain in the
culture right side of the chest and difficulty of
breathing and has respiratory rate of
d. Normal RBC count 40 bpm. Which goal should the nurse
consider as the top priority?
40.A client has undergone laryngectomy
and tracheostomy formation. Which a. Maintainance of adequate
instruction should the nurse give to circulatory volume
the client and family about the
operation? b. Maintainance of effective
respiration
a. The tracheostomy tube should be
cleaned with alcohol and water. c. Anxiety reduction
41.When caring for a client who has just b. Prepare to administer protamine
had a total laryngectomy,the nurse sulfate
should plan to c. Monitor the paritial thromboplastin
time(PTT)
d. Stop the infusion for 2 hrs and start b. Notify the physician immediately
it at a lower dose as prescribed
c. Assess the irrigation catheter for
45.In a client is chronic bronchitis, which patency and drainage
sign should lead the nurse to suspect
right heart failure (cor pulmonale) d. Asminsiter meperidine 50 mg IM as
prescribe
a. Circumoral cyanosis
49.A client with arterial insuffieciency has
b. Bilateral crackels just undergone below knee
amputation of the right leg. Which
c. Productive cough action should the nurse include in the
d. Leg edema post op[ care plan?
46.When caring for a client with a. Elevate the stump fot the first 24
endotracheal tube, the nurse should hrs
consider which action to be the most b. Maintain the client on complete
important? bed rest
a. Auscultate the lungs for bilateral c. Appy heat to the stump as the
breath sounds client desires
b. Turning the client from side to side d. Remove the pressure dressing
every 2 hrs after the first 8 hrs
c. Monitor serial blood gas every 4 hrs 50.Which of these laboratory test is the
d. Provide frequent oral hygiene most accurate indicator of renal
function
47.The nurse administer albuterol
(Proventil) as prescribed to a client a. BUN
with emphysema. Which findings b. Creatinine clearance
indicate that the drug is producing a
therapeutic effect? c. Serum creatinine
a. RR of 22 bpm d. Urinalysis
66.Two days after repairing a client’s b. Maintain the bed in knee gatch
ruptured cerebral aneurysm, the position
physician orders mannitol (osmitro)
1.5 g/kg, to be infused over 60 c. Keep the client is a semi fowler’s
minutes. If the client weighs 175 lbs, position
how many grams of mannitol should d. Maintain traction in correct body
be administered? allignment
a. 263 g 70.A client who has just received a
b. 119 g diagnosis of early glaucoma is being
prepared for discharge. Which
c. 75g information should the nurse provide
during this client’s discharge teaching
d. 60 g session?
67.A client is receiving a n I.V infusion of a. Instructions for eye patching
mannitol after undergoing intracranial
pressure surgery for removal of a b. Discharge assessment of visual
brain tumor. To determine if this drug acuity
is producing its therapeutic effect, the
nurse should consider which as the c. Demonstration of eye drop
most significant instillation
74.An appropriate plan of care for a client b. Restrict fluids to 1000 ml in 24 hrs
admitted with renal colic would
include which of the following? c. Asminister O2 by nasal canula as
ordered
a. Inserting an indwelling urinary
catheter d. Keep the head of the bed at a 30
degrees angle
b. Straining all urine
78.A client is admitted to the hospital
c. Maintaining T tube patency with a productive cough, night sweats
and fever. Which of these actions is
d. Limiting fluid intake most important in the client’s initial
75.Which statement would not be plan of care?
included in discharge teaching for a a. assess the client’s temperature
client with a history of rheumatoid every 8 hrs
arthritis who was treated with severe
anemia secondary to GI hemorrhage? b. place the client in respiratory
isolation
a. Take your iron supplement with
orange juice
c. monitor the client’f fluidintake and 82.A client with history of atrial fibrillation
output presents to the outpatient clinic with
nausea, vomiting, HR of 55 bpm, and
d. wear gloves during all client visual disturbances. The nurse would
contact further assess the client for which of
79.a client with heart failure has been the following conditions?
receiving an IV infusion at 125 ml/hr. a. Digitalis glycoside toxicity
Now the client is short of breath and
the nurse notes of bilateral crackles, b. Angina
neck vein distention and tachycardia.
What should the nurse do first? c. Heart failure
b. Discontinue the IV access device 83.A client’s ABG values are pH of 7.29,
PaO2 48 mmHg, PaCO2 76 mmHg,
c. Administer the prescribed diuretic HCO3 of 36 mEq/l. the plan of care for
this client with these values would
d. Slow the infusion and notify the include close monitoring for which of
physician the following s/sx?
80.After bronchoscopy, the client must a. Cyanosis and restlessness
receive NPO until the gag reflex
returns. What is the best way to b. Flushed skin and lethargy
assess the gag reflex?
c. Weakness and irritability
a. Instruct the client to cough
d. Anxiety and fever
b. Ask the client to extend the tongue
84.During postural drainage, movement
c. Tickle the uvula with a tongue of secretions from the lower
blade respiratory tract to the upper
respiratory tract occurs due to:
d. Observe while the client swallows
sips of water. a. Friction between the cilia
a. Elevated serum cholesterol level 93.The client has a history of heart failure
and the nurse is preparing the client to
go home. The nurse should instruct c. Reduce fluid volume
the client to:
d. Improve myocardial contractility
a. Monitor urine output daily
97.The most effective measure the nurse
b. Maintain bed rest for at least one can use to prevent the wound
week infection when changing a client’s
dressing after coronary artery bypass
c. Monitor daily potassium intake surgery is to:
d. Weigh daily a. Observe careful handwashing
94.Digoxin is administred IV to clients procedures
with CHF primarily because the drugs b. Cleanse the incisional area with
acts to : antiseptic
a. Dilate coronary artery c. Use prepacked sterile dressing to
b. Increase myocardial contractility cover the wound
60.B. All options except D are signs and 175 lb X 1 kg = 79.55 lbs
symptoms of liver cirrhosis but option 2.2 lbs
B poses the most serious
complication. Advanced liver cirrhosis 79.55 lbs X 1.5 g= 119 g
can lead to hepatic encephalopathy
which is the accumulation of toxins in
thebrain leading to decreased mental
67.C. mannitol is a diuretic that excretes
function and coma.
extra fluid out from the body.
61.C. airway and breathing is always the Increased UO is an indication that
priority. The patient has difficulty of mannitol’s desired effect is achieved
breathing because of the pressure
68.A. bone marrow is also composed of
exerted by the enlarged abdomen to
fat globules that may escapes out
the diaphragm.
during bone fracture and causes fat
62.B. The patient has prolonged clotting embolism. The fat globules can
time which predisposes the patient to impede blood flow making the
bleeding . Coaugulant such as affected leg pale and cool.
phytonadion (Vit. K)should be given to
69.D. traction should be continuous , the
counteract effect .warfarin is an
weight is never removed nor
ancticoagulant which place the patient
interrupted. The patient is in supine
in increased risk of bleeding.
with neck supported by a pillow. The therapy and or to study the stone
leg with a traction should be held composition.
straight and never flexed.
75.B. Vit C such as orange juice enhances
70.C. Glaucoma occurs due to the absorption, tea, coffee and calcium
pressure build up in the eye by reduces iron absorption. Aspirin is
increased amount of aqueous vitrous avoided because it is a blood thinner
humor. Eye drops could either work by and aggravates bleeding
promoting the flow of the aqueous
fluid or decrease the production of it. 76.B. Doctors always prescribed a low
oxygen delivery to patients with COPD
71.D. One priority in acute MI is pain usually at 2 L/min because high
control drugs such as morphine to concentration of oygen can depress
reduce catecholamine induced oxygen the respiratory drive. Besides high
demand to injured heart muscle. oxygen concentration is of no use if
the airway is obstructed with
72.A. cirrhosis may lead to malnutrition. It secretions. It is very important to
is essential to maintain a healthy , encourage the pt to cough out
nutritious diet such as increasing secretions to help clear the airway and
carbohydrate and protein intake. Low encourage deep breathing. All ABG
fat diet should be observed because values are abnoramal.
bile is needed for digestion and bile is
not sufficiently produced in cirrhotic 77.A. Fluid may be increased to liquefy
liver. Salt and Na intake should also be secretions. Oxygen administration and
minimal because patients with putting the pt in semi fowler’s do not
cirrhosis tends to retain extra fluid. help in mobilizing secretions. stroke
When liver cirrhosis is complicated by patients who are on bed rest are prone
hepatic encephalopathy, then this is to respiratory complications because
the time that protein intake should be of retention of secretions. Therefore
limited. assisted ambulation and frequent
positioning may help to mobilize
73.B. kidney produced erythropoietin secretions .
necessary for blood cell formation,
kidney damage leads to anemia. Signs 78.B. the signs and symptoms presented
and symptoms of anemia include easy are indications of PTB. It’s a safe
fatigability and body weakness. precautionary practice to place the pt
Epogen is given SQ or IV to aids in in respiratory isolation to prevent
erythropoeisis and reduces symptoms cross infection while further
of anemia assessment and evaluation is carried
out.
74.B. renal colic is a very excruciating
pain caused by the passage of stone 79.B. the nurse should suspect a
along the ureter. Indwelling catheter circulatory overload because of the
will not ease the pain. It may in fact assessment findings. Initial action is to
add more to the pain experience. T stop the IV to stop further introduction
tube is used to drain bile . Increased of fluid.
fluid intake should be encourage to
help flush the stone. It is appropriate 80.C. contraction of the back of the throat
to collect all urine and strain for stone when the uvula is tickled means that
passage to assess effectiveness of gag reflex has returned.
81.B. Iv rate should be a fast drip to is advised at least for the first couple
immediately restore the fluid volume of days at least 1-2 days. Patients are
strongly advised to participate in
82.A.Digitalis are given to patients with cardiac rehabilitation program to help
cardiac problems to strengthen heart patients to recover quickly and
contraction. Initial s/sx of Digitalis improve their overall physical, mental
toxicity is GI manifestation such as and social functioning.
N/V, loss of appetite, diarrhea. Other
symptoms include visual changes, 91.D. straining against a closed epiglottis
slow pulse , confusion etc. which includes holding breath or
forceful expiration stimulates valsalva
83.B. With the ABG values presented, the maneuver. Pts should be advised to
pt is suffering from respiratory avoid holding breaths while moving .
acidosis.
92.C. rehabilitation begins upon
84.B. In postural drainage, the patient is admission
placed on a trendelenberg position so
gravity aids in the movement of 93.D. weight gain can be a sign that you
mucus to the upper respiratory tract. the pt is retaining fluid and his heart
condition is worsening.
85.B. Immobilization causes calcium lose
from the bones into the bloodstream 94.B. Digitalis is given to increase cardiac
and cause hypercalcemia. The kidney contractility followed by decreased in
in response of hypercalcemia HR
increases its excretion.
95.C. Enalapril is an ACE inhibitor
86.C. increased fluid intake loosen up (Angiotension Converting Enzyme
secretions thus easy to expectorate inhibitor) that decreases BP.
Angiotensin II is a potent
87.C. one classical sign of right side heart vasoconstrictor.
failure is edema due to decreased
venous return. 96.A. beta adrenergic antagonist
antagonizes the action of sympathetic
88.B . Because PVC s may signal an response. It works by reducing the
impending life threatening rhythm , force of contraction of heart muscles
notify the physician if the pt has more thereby reducing peripheral resistance
than six PVCs per minute. and blood pressure .
89.B. creatine phospholinase is an 97.A. Proper handwashing has always
enzyme normally found in muscle been the single most effective
fibers. It is released in the measure to prevent cross
bloodstream when there is muscle contamination and infection.
damage. MI is the interruption of blood
supply causing heart muscle cells to 98.B. Mitral valve stenosis is the
die. narrowing and stiffening of the mitral
valve caused oftenly caused by
90.I’m not sure of the correct answer, but rheumatic fever in adults. Due to the
I guess the best option is B. Pain in MI narrowed valve, blood is not efficiently
doesn’t last until the following day. pumped into the left ventricle, over
Most patients after a heart attack are time, pressure in the atrium increases
hesitant to resume activities, bed rest and blood is backed up to the lungs
and cause pulmonary hypertension
and pulmonary edema which is
manifested by presence of lung
crackles.