Answers and Ration Ali Ties

Endocrine and Metabolic Disorders Test
Question 1 of 5
A nurse is about to administer a client's morning dosage of insulin. The client's order is for 5 U of regular and 10 U of NPH given as a basal dose. He also is to receive an
amount prescribed from his medium-dose sliding scale (shown below), based on his morning blood glucose level. The nurse performs a bedside blood glucose
measurement and the result is 264 mg/dl. How many total units of insulin should the nurse administer to the client?
Plasma Low dose Medium dose High dose Very high dose
glucose (Regular (Regular (Regular (Regular
(mg/dl) insulin) insulin) insulin) insulin)
< 70 Call Call physician Call Call physician
physician physician
71-140 0U 0U 0U 0U
141-180 1U 2U 4U 10 U
181-240 2U 4U 8U 15 U
241-300 4U 6U 12 U 20 U
301-400 6U 9U 16 U 25 U
> 400 8 U and call 12 U and call 20 U and call 30 U and call
physician physician physician physician
Answer:
4u
Correct Answer: 21 Your Answer: 4u

RATIONALES: The basal dosage for this client is 5 U of regular insulin and 10 U of NPH insulin. Using the medium-dose sliding scale and the client's blood glucose reading
of 264 mg/dl, the nurse should determine that an additional 6 U of regular insulin are required, totalling 21 U (5 U + 10 U + 6 U = 21 U).
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application
The nurse is feeding an average-size client when the client suddenly begins choking on his food. According to the American Heart Association, the
nurse should intervene using the actions listed below. List the actions in the sequence in which the nurse should perform them.
1. Administer abdominal thrusts until effective or until client becomes unresponsive.

2. Activate the emergency response team.
3. Ask the client if he can speak.
4. Perform a tongue-jaw lift.
5. Open the airway and attempt to ventilate the client.
6. Give up to five abdominal thrusts.
RATIONALES: According to the American Heart Association, the nurse should ask the client if he's choking and if he can speak. Next, the nurse should
administer abdominal thrusts or chest thrusts (if the client is obese or pregnant). The nurse should continue thrusts until they are effective or until the
client becomes unresponsive. When the latter occurs, the nurse should activate the emergency response team and then perform a tongue-jaw left.
Next, the nurse should open the airway and try to ventilate the client. If the airway is still obstructed, the nurse should reposition the head and try to
ventilate again. Then, the nurse should give up to five abdominal thrusts.
020168 4 2 0.39 1
false test 5 true
Cardiovascular Disorders Test
Question 4 of 5
The nurse is interpreting a client's telemetry strip. If the QT interval is 0.52 second and the R-R interval is 1.72 seconds, how many seconds is the QTc interval (the QT
interval corrected for the heart rate)?
Answer:
50
Correct Answer: 0.39 Your Answer: 50

RATIONALES: To correct the QT interval for variations in heart rate, divide the measured QT interval by the square root of the measured R-R interval.
Square root of 1.72 = 1.31

0.52 ÷ 1.31 = 0.39 second
The QTc should be less than 0.44 seconds in men, and less than 0.46 seconds in women.
NURSING PROCESS STEP: Analysis
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
028149 1 3 180,36;190,45 0
false test 5 false 191,30

010051 4 1 2,3,4,5 3
true test 5 false 2,3,4,5
025049 12 0 4 11
true pretest 75 false 4
Endocrine and Metabolic Disorders Pretest
Question 12 of 75
When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:
1. a blood pressure of 130/70 mm Hg.
2. a blood glucose level of 130 mg/dl.
3. bradycardia.
4. a blood pressure of 176/88 mm Hg.
Correct Answer: 4 Your Answer: 4

RATIONALES: Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia,
hypermetabolism, and weight loss. It isn't associated with the other options.
NURSING PROCESS STEP: Assessment
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis
029004 14 0 4 13

Genitourinary Disorders Pretest
Question 14 of 75
During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by:
1. slowing the glomerular filtration rate.
2. increasing sodium resorption.
3. decreasing potassium excretion.
4. stimulating or hindering micturition.

RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to
generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate,
increase sodium resorption, or decrease potassium excretion.
COGNITIVE LEVEL: Knowledge
RATIONALES: Vesicles are elevated, sharply defined lesions that are usually less than 1 cm in diameter and contain serous fluid. Common examples
of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 1 cm in
diameter; an example is a second-degree burn wound. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid
matter. Pustules are elevated lesions less than 1 cm in diameter, and containing purulent material; examples include impetigo and acne lesions.
NURSING PROCESS STEP: Evaluation
CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None

021074 16 0 3 15

Oncologic Disorders Pretest
Question 16 of 75
The nurse is developing a care plan for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone
marrow suppression become noticeable?
1. 24 hours
2. 2 to 4 days
3. 7 to 14 days
4. 21 to 28 days

RATIONALES: Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
022134 21 3 206,257;216,271 20
true pretest 75 false 133,196

Gastrointestinal Disorders Pretest
Question 21 of 75
Indicate the location of an ostomy for which the client could eventually not need to wear an ostomy bag?
The green rectangle shows the correct answer.

RATIONALES: With a sigmoid colostomy, the feces are solid; therefore, the client may eventually gain enough control that he would not need to wear a colostomy bag. With
a descending colostomy, the feces are semi-mushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid. In these three
latter cases, it is unlikely that the client could gain control of elimination; consequently, wearing an ostomy bag would be necessary.
NURSING PROCESS STEP: Planning
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
004032 22 0 2 21

Basic Physical Assessment Pretest
Question 22 of 75
A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
1. Place a tongue blade on the front of the tongue and ask the client to say "ah."
2. Place a tongue blade lightly on the posterior aspect of the tongue.
3. Place a tongue blade on the middle of the tongue and ask the client to cough.
4. Place a tongue blade on the uvula.

RATIONALES: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the tongue with a tongue blade, which should elicit gagging. Having the
client say "ah" evaluates cranial nerves IX and X. However, a tongue blade isn't necessary to hold down the tongue; the client need only stick out the tongue. Placing a
tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.
003105 24 0 4 23

Medication and I.V. Administration Pretest
Question 24 of 75
A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should
recognize this as:
1. psychotic symptoms.
2. parkinsonism.
3. akathisia.
4. dystonia.

RATIONALES: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic
symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of
akathisia are restlessness, pacing, and inability to sit still.
001171 25 0 2 24

Basic Physical Care Pretest
Question 25 of 75
The nurse-manager of a home health facility includes which item in the capital budget?
1. Salaries and benefits for her staff
2. A $1,200 computer upgrade
3. Office supplies
4. Client education materials costing $300

RATIONALES: Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client
education materials are part of the operating budget.
CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
025150 26 0 1 25

Question 26 of 75
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone
secretion from which gland?
1. Adrenal cortex
2. Pancreas
3. Adrenal medulla
4. Parathyroid

RATIONALES: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it
promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla
secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.
014056 27 0 4 26

Psychotic Disorders Pretest
Question 27 of 75
Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction?
1. Hypertension
2. Respiratory arrest
3. Tourette syndrome
4. Retinal pigmentation

RATIONALES: Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other options don't occur as a result of exceeding this dose.
028005 29 0 4 28

Respiratory Disorders Pretest
Question 29 of 75
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
1. Nausea or vomiting
2. Abdominal pain or diarrhea
3. Hallucinations or tinnitus
4. Light-headedness or paresthesia

RATIONALES: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting,
abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base
imbalance.
003143 30 2 8 29
true pretest 75 false

Medication and I.V. Administration Pretest
Question 30 of 75
The physician prescribes heparin 25,000 U in 250 ml of normal saline solution to infuse at 600 U/hour for a client who suffered an acute myocardial infarction. After 6 hours
of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The physician orders an increase in the infusion to 800 U/hour. The nurse should set the infusion
pump to deliver how many milliliters per hour?
Answer:

RATIONALES: The following formula is used to calculate drug dosages:
Dose on hand/Quantity on hand = Dose desired/X
The nurse should use the following equations:
25,000 U/250 ml = 800 U/hour/X.
Cross-multiply to solve for X and divide each side of the equation by 25,000 U
X = 8 ml/hour.
001065 31 0 4 30

Question 31 of 75
What is an appropriate nursing intervention for a client with an arm restraint?
1. Applying the restraint loosely to prevent pressure on the skin
2. Tying the restraint to the side rail
3. Positioning the restrained arm in full extension
4. Monitoring circulatory status every 2 hours

RATIONALES: The nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure
without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an
immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow slight joint
movement without reducing the effectiveness of the restraint.
CLIENT NEEDS SUBCATEGORY: Safety and infection control
020107 32 0 3 31

Cardiovascular Disorders Pretest
Question 32 of 75
After coronary artery bypass graft surgery, a client is admitted to the surgical intensive care unit and connected to a cardiac monitor. The nurse can't detect a pulse or blood
pressure and observes the following pattern on the electrocardiogram (ECG) monitor. What does this pattern show?
1. Artifact
2. Ventricular tachycardia
3. Ventricular fibrillation
4. Electromechanical dissociation

RATIONALES: This ECG shows ventricular fibrillation as indicated by undetectable P waves; no discernible heart rate; a chaotic, completely irregular rhythm; and a wavy
baseline. Artifact is distortion on the ECG caused by interference or loose connections. In ventricular tachycardia, P waves seldom are discernible; the ventricular rate is
above 100 beats/minute; and QRS complexes are wide, bizarre, and regular. In electromechanical dissociation, the ECG shows electrical activity with no mechanical
contraction; the client lacks a pulse.
COGNITIVE LEVEL: Comprehension
001015 33 0 3 32

Question 33 of 75
To follow standard precautions, the nurse should carry out which measure?
1. Recapping needles after use
2. Wearing a gown when bathing a client
3. Wearing gloves when administering I.M. medication
4. Wearing gloves for all client contact

RATIONALES: To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating
contact with the blood, body fluid, mucous membranes, or nonintact skin of any client (such as when administering an I.M. injection); and wear a gown during procedures
that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this
activity isn't likely to cause contact with blood or body fluids.
004012 39 0 2 38

Basic Physical Assessment Pretest
Question 39 of 75
A client reports abdominal pain. Which action would aid the nurse's investigation of this complaint?
1. Using deep palpation
2. Assessing the painful area last
3. Assessing the painful area first
4. Checking for warmth in the painful area

RATIONALES: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. To prepare the client, the nurse
should always let the client know when the painful area will be assessed. Pressure resulting from deep palpation may cause rupture of an underlying mass. Checking for
warmth in the painful area offers no real information about the client's pain.
COGNITIVE LEVEL: Comprehension
024082 40 1 4,5 39
true pretest 75 false 3,4,5

Immune and Hematologic Disorders Pretest
Question 40 of 75
The nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse
(LPN). Which statements by the LPN indicate her understanding of HIV transmission?
1. "I'll wear a gown, mask, and gloves for all client contact."
2. "I don't need to wear any personal protective equipment because nurses have a low risk of occupational exposure."
3. "I'll wear a mask if the client has a cough caused by an upper respiratory infection."
4. "I'll wear a mask, gown, and gloves when splashing of body fluids is likely."
5. "I'll wash my hands after client care."
Correct Answer: 4,5 Your Answer: 3,4,5

RATIONALES: Standard precautions include wearing gloves for any known or anticipated contact with blood or other body fluids,
tissue, mucous membranes, or nonintact skin. If the task may result in splashing or splattering of blood or body fluids to the face, a
mask and goggles or face shield should be worn. If the task may result in splashing or splattering of blood or body fluids to the body, a
fluid-resistant gown or apron should be worn. Hands should be washed before and after client care and after removing gloves. A
gown, mask, and gloves aren't necessary for client care unless contact with body fluids, tissue, mucous membranes, or nonintact skin
is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV isn't transmitted
in sputum unless blood is present.
020136 41 0 3 40

Cardiovascular Disorders Pretest
Question 41 of 75
The nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?
1. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.
2. Store the drug in a cool, well-lit place.
3. Lie down or sit in a chair for 5 to 10 minutes after taking the drug.
4. Restrict alcohol intake to two drinks per day.

RATIONALES: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak.
Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the
pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its
effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.
022051 48 0 4 47

Question 48 of 75
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
1. Jaundice
2. Pruritus of the arms and legs
3. Fatigue during ambulation
4. Irritability and drowsiness

RATIONALES: Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and
symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results
of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.
018106 49 1 1,3,5 48

Postpartum Period Pretest
Question 49 of 75
A mother with a past history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below
would lead to this nursing judgment?
1. Sudden dyspnea
2. Chills, fever
3. Diaphoresis
4. Hypertension
5. Confusion
Correct Answer: 1,3,5 Your Answer: 5

RATIONALES: Sudden dyspnea with diaphoresis and confusion are classic signs and symptoms of dislodgment of a thrombus (stationary blood clot) from a varicose vein
becoming an embolus (moving clot) that lodges itself into the pulmonary circulation. Chills and fever would indicate an infection. A client with an embolus could be
hypotensive, not hypertensive.
016023 50 0 1 49

Antepartum Period Pretest
Question 50 of 75
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?
1. "8 days after conception"
2. "When the woman misses a menstrual period"
3. "2 to 3 weeks after fertilization"
4. "As soon as hormone levels decline"

RATIONALES: Based on human chorionic gonadotropin (hCG) levels in the blood and urine, pregnancy can be diagnosed as early as 8 days after conception, when the
syncytiotrophoblast produces hCG. Sensitive and specific pregnancy tests can detect hCG in the blood and urine even before the first missed menstrual period. A missed
period may also be related to other factors, such as poor nutrition, strenuous athletic activity, and certain drugs. Levels of hCG rise rapidly until about the 20th week of
gestation. By the 20th week, they decline gradually and stay low for the remainder of gestation. Other hormones, such as human placental lactogen, estrogen, and
progesterone, increase during pregnancy.
025146 56 0 1 55

Question 56 of 75
Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for which condition?
1. Hypocortisolis
m
2. Hypoglycemia
3. Hyperglycemi
a
4. Hypercalcemi
a

RATIONALES: The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given
during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the
corticotropin-secreting tumor is removed, the client shouldn't be at risk for hyperglycemia. Calcium imbalance shouldn't occur in this situation.
001178 57 0 1 56

Question 57 of 75
A client's attorney must prove which elements for a professional negligence action?
1. Duty, breach of duty, damages, and causation
2. Duty, damages, and causation
3. Duty, breach of duty, and damages
4. Breach of duty, damages, and causation

RATIONALES: Any professional negligence action must meet four demands — commonly known as the four D's — to be considered negligence and result in legal action: a
duty for the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, the breach of duty resulted in damages and the
damages were caused by a direct result of the negligence, (causation).
017006 58 0 1 57

Intrapartum Period Pretest
Question 58 of 75
A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal
perfusion?
1. Fetal heart rate variability within 5 to 10 beats/minute
2. Persistent fetal bradycardia
3. Late decelerations
4. Variable decelerations and sinusoidal pattern

RATIONALES: Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered
acceptable. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the
intervillous spaces during uterine contractions — a nonreassuring pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe
fetal anemia or asphyxiation.
015092 60 1 1,2,3,4 59
true pretest 75 false 2,3,4

Substance Abuse, Eating Disorders, Impulse Control Disorders Pretest
Question 60 of 75
The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan?
1. Strongly encourage participation in Alcoholics Anonymous (AA).
2. Provide nutritional information and counseling.
3. Establish an exercise program.
4. Discuss relapse prevention.
5. Have the client introduce himself slowly to people from his former lifestyle.
Correct Answer: 1,2,3,4 Your Answer: 2,3,4

RATIONALES: AA is an outpatient support group for recovering alcoholics. It allows clients to share their problems and gain support from members of the group to avoid
further alcohol abuse. Strongly encourage participation in this support group. Provide the client with nutritional information and counseling, particularly if the client is
underweight or malnourished. Establish an exercise program appropriate for the client's physical health. Discourage the client from reestablishing relationships with former
"drinking friends," because this could lead to relapse.
022053 64 0 3 63

Question 64 of 75
When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to
be:
1. reporting pain
relief.
2. maintaining body weight.
3. maintaining fluid
balance.
4. reestablishing a normal bowel

pattern.

RATIONALES: Because a client with a small-bowel obstruction can't tolerate oral intake, fluid volume deficit may occur and can be
life-threatening. Therefore, maintaining fluid balance is the primary goal. The other options are secondary; pain relief and maintaining
body weight don't reflect life-threatening conditions, and the client's normal bowel pattern can be reestablished after fluid volume is
stabilized.
024014 68 0 1 67

Immune and Hematologic Disorders Pretest
Question 68 of 75
A client with a myocardial infarction is admitted to an acute care facility. During the admission history, the nurse learns that the client also has hypertension and progressive
systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
1. Risk for impaired skin

integrity
2. Constipatio
n
3. Ineffective
thermoregulation
4. Risk for imbalanced nutrition: More than body

requirements

RATIONALES: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and
digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea
from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause ineffective
thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for
inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.
028150 70 3 208,130;220,150 69
true pretest 75 false 218,187

Respiratory Disorders Pretest
Question 70 of 75
The nurse is performing a respiratory assessment on a client with left lower lobe atelectasis. Identify the area where the nurse may hear fine crackles associated with this
condition.
The green rectangle shows the correct answer.

RATIONALES: To auscultate the left lower lobe from the anterior chest, use the landmarks of the left anterior axillary line, between the fifth and sixth intercostal spaces.
026100 71 0 4 70

Musculoskeletal Disorders Pretest
Question 71 of 75
A home care nurse visits a client with muscular dystrophy. Which comment by the client indicates the he needs more information about an advance directive?
1. "I'm going to the doctor to get a new brace next week."
2. "I've got a sore on my heel where my wheelchair rubs."
3. "My dog is my best friend. I really don't have anyone who can make decisions for me when I no longer can."
4. "I love apple pie. I don't ever want a feeding tube when the time comes that I can't eat."

RATIONALES: Option 4 indicates that the client needs information about advance directives. In this statement, the client is voicing his wish not to have a feeding tube when
his condition deteriorates. However, he doesn't explain that he's outlined these wishes in an advance directive. Options 1 and 2 are statements about the client's condition
and his care plan. They don't indicate that the client requires more information about advance directives. Option 3 indicates that the client needs information about obtaining
a health care power of attorney.
025169 73 0 1 72

Question 73 of 75
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic
test results to prevent arrhythmias.
1. Serum potassium level
2. Serum calcium
level
3. Serum sodium level
4. Serum chloride level

RATIONALES: During periods of acidosis, potassium leaves the cell causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell
causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect
on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.

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Endocrine and Metabolic Disorders Test

Correct Answer: 21 Your Answer: 4u

NURSING PROCESS STEP: Implementation

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies

COGNITIVE LEVEL: Application

1. Administer abdominal thrusts until effective or until client becomes unresponsive.

false test 5 true

Cardiovascular Disorders Test

Correct Answer: 0.39 Your Answer: 50

Square root of 1.72 = 1.31

NURSING PROCESS STEP: Analysis

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Reduction of risk potential

COGNITIVE LEVEL: Application

false test 5 false 191,30

true test 5 false 2,3,4,5

true pretest 75 false 4

Endocrine and Metabolic Disorders Pretest

1. a blood pressure of 130/70 mm Hg.

2. a blood glucose level of 130 mg/dl.

4. a blood pressure of 176/88 mm Hg.

Correct Answer: 4 Your Answer: 4

NURSING PROCESS STEP: Assessment

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Physiological adaptation

COGNITIVE LEVEL: Analysis

true pretest 75 false 4

1. slowing the glomerular filtration rate.

2. increasing sodium resorption.

3. decreasing potassium excretion.

4. stimulating or hindering micturition.

Correct Answer: 4 Your Answer: 4

NURSING PROCESS STEP: Assessment

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Physiological adaptation

COGNITIVE LEVEL: Knowledge

NURSING PROCESS STEP: Evaluation

CLIENT NEEDS CATEGORY: Health promotion and maintenance

CLIENT NEEDS SUBCATEGORY: None

COGNITIVE LEVEL: Knowledge

true pretest 75 false 3

Correct Answer: 3 Your Answer: 3

NURSING PROCESS STEP: Implementation

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies

COGNITIVE LEVEL: Knowledge

true pretest 75 false 133,196

The green rectangle shows the correct answer.

NURSING PROCESS STEP: Planning

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Basic care and comfort

COGNITIVE LEVEL: Application

true pretest 75 false 2

2. Place a tongue blade lightly on the posterior aspect of the tongue.

4. Place a tongue blade on the uvula.

Correct Answer: 2 Your Answer: 2

NURSING PROCESS STEP: Assessment

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Basic care and comfort

COGNITIVE LEVEL: Knowledge

true pretest 75 false 3

Correct Answer: 4 Your Answer: 3