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1. How to be a nurse in ON? Answer: CNO register 2.

What is RPNAOs mission Answer: Offers insurance for malpractice and misconduct 3. What affected RPN history? World War two 4. Third birth stage: 6-8 hours 5. Post operative attention: 8 hours without voiding 6. MI effect factors: hyper cholesterol 7. MI- how long can have sex: 4-6 weeks 8. Why this pt refused to be discharged (MI): face long time to recover 9. AIDS pt: no body talks to him: diagnosis: social isolation 10. SOB: assess what: head, chest and abdomen 11. 4years childs characteristics: one time thinks one thing 12. A pregnant womans membranes rupture, what should she do? Go to hospital 13. A pregnant womans first stage of labor, what should nurse do: company the pt 14. The highest risk group of breast cancer: over 40 years old women 15. what do cancer cells look like: large, irregular 16. The side effects of chemotherapy: decrease the RBC and WBC 17. Pt died, what should nurse do: cleans the pt and align the pt to straight position 18. What must the family experience to recover from the death pt: accept the lost 19. MI pt said: I dont have MI and I think it is digestive problems. What is the pts defensive mechanism? Deny 20. Dying pt with his family: how to care the pt: 1-2 hours step in to give care 21. How to describe the skin traction: no invasive to keep right alignment 22. what kind of reduction is skin traction? Closed reduction 23. AIDS precaution: universal precaution: bath with gloves on 24. Catheterization pt- how to prevent UTI: aseptic clean 25. 4 years old obesity: How to loss weight: adjust the food menus 26. how do nurses do for a confused pt: simple orientation 27. Diabetic pt has lower blood sugar: give 6 Life Saver 28. Diabetic pt has 8820 Kcal menu: answer: yogurt, butter, sandwich, and peach 29. Diabetic pt has hemiopia( half vision): how do nurse to approach the pt: from front, square to approach pt 30. Gonaria (sexual transmitted disease) pts antibiotic treatment: first choice: erythromycin 31. When dose pt with first pregnancy feel the infant moving: 18 weeks 32. what is the higher risk for the drug abusing moms baby: SIDS 33. What is the neglect: put on the artificial limb for pt without knowing how to do that 34. what is the different from libel and slander: libel is writing form to insult someone. Slander is the verbally insult someone.

35. What is meaning of nursing note: Labile: unstable 36. Pt with AIDS has skin tumor, how to describe: red purple lesion on skin. 37. What cant eat for pt with gallbladder disease: pork chop? 38. What nurse should do for a pt has jaundice with pruritus (itching): cold compress 39. Asking pt what is the meaning of A stitch in time save nine is to assess pts? Abstract reasoning. 40. A catholic female wanted to do birth control surgery, but according to her religion, she cant do this surgery. She asked the nurse what she can do. Answer: go to catholic hospital to ask them. 41. This female gave some birth for girls, but no boys. Her father-in-law said bad words to her. What should nurse say: Keep quiet because this is hospital. 42. A Mom said she has abused the child. What should nurse do: report to the leader. 43. A nurse saw another nurse stole something. What should this nurse do: offer the nurse to see the leader together. 44. Pt has some condition and cant eat? What should nurse do: offer finger food and fluid 45. Pt was crying. What should nurse do: sit with pt. 46. Which indicates pt has diabetes: decrease weight, increase urine, and? 47. Diabetes teaching: exercise 48. Diabetes teaching: eat: high protein, low carbohydrate? 49. Teaching engorgement pt: before feeding: warm compress. No feeding: cold compress 50. Nursing cares umbilical cord: alcohol + cotton swab 51. UC pathological change: within colon, mucous membrane, and continued lesion. 52. final stage of pregnancy: tailor sitting to release pain 53. what factors affect nutrition: ( answer is including: culture) 54. How to assess reproductive organs: use gentle touch 55. dressing change for a pt with amputation: use recurrent wrap 56. Cirrhosis: low sodium intake

Practical nursing jeopardy game Part 1 1. You are reviewing the meds for a client. You note the physician has prescribed a medication dose that is twice the amount that the client reports taking at home. What is your next most appropriate action? a. Question the client about the accuracy of the reported dosage. b. Consult with the Registered Nurse (RN). c. Administer the medication as prescribed. d. Administer half of the prescribed dose and then notify the RN. Answer: b. Consult with the registered Nurse Rationale; if you determine a physicians order is unclear or if you have a question about

the order, you should consult with the RN, who will then contact the physician prior to implementing the order. Under no circumstance should carry out the order unless it is clarified. Questioning the client may make them upset. You would not administer the medication or administer an altered dose. 2. You have an order to give the first dose of hydrochlorothiazide (HCTZ) to a client. You would question the order if the client had a history of allergy to : a. iodine b. Shellfish c. Penicillin d. Sulfa drugs Answer: d. sulfa drugs Rationale: Thiazide diuretics such as HCTZ are sulfa- based medications, and a client with a sulfa allergy is at risk for an allergy reaction. A sulfa allergy must be communicated to the pharmacies, physician, nurse, and other health care providers. 3. You note that your client is taking Atorvastatin (Lipitor). You determine that the client is taking this medication to treat: a. Heart failure b. Renal calculi c. Hypercholesterolemia d. Diabetes mellitus type 2 Answer: Hypercholesterolemia Rationale: Lipitor is a HMG-CoA reductase inhibitor used to treat hypercholesterolemia. It is not used to treat the other disorders.
4. Your client with osteoarthritis (OA) is ordered diclofenac sodium. If you were reviewing the clients medication sheet. You would plan to verify the order for diclofenac sodium with the RN if which of the following other medications was listed? a. Primidone (Mysoline) b. Calcium c. Warfarin sodium (Coumadin) d. Vitamin C supplement Answer: c. Warfarin sodium (Coumadin) Rationale: diclofenac sodium is a NSAID medication. Interactions may occur with anticoagulants such as Coumadin, resulting in increased risk of bleeding. You should consult with RN regarding a potencial medication interaction. The other medications do not interact with dicfenac sodium. Mysoline is an anticonvulsiant, TUMS are an antacid, and vitamin C is a nutritional supplement. 5. A client has been diagnosed with gout and prescribed allopurinol. You would question the physician if the dosage for which of the following medications already prescribed has not

changed? a. Adenosine (Adenocard) b. Digoxin (Lanoxin) c. Ergonovine maleate (Ergotrate) d. Warfarin sodium (Coumadin) Answer: D. Warfarin sofium (Coumadin) Rationale: (Allopurinol) is an antigout medication that may increase the effect of oral anticoagulants, such as Warfarin sodium. Thus, the dosage of warfarin sodium may have to be decreased. Adenosine is an antidysrhythmic. Digoxin is a cardiac glycoside. Ergotrate is an antimigraine medication. 6. Your client has a cerebellar lesion. You should plan to obtain which of the following for use by this client? a. A raised toilet seat b. A slider board c. Adaptive eating utensils d. A walker Answer: d. A walker Rationale: the cerebellium is responsible for balance and coordination. A walker provides stability for the client during ambulation. A raised toilet seat is useful if ability to flex the hips id impaired. A slider board is useful for a client with weak legs, and adaptive utensils are useful if the client has partial paralysis of the hand. 7. You are caring for a client who experienced a thrombotic cerebrovascular accident (CVA) and has residual hemiparesis of the right arm and leg. Where would you place objects for client? a. Just out of the clients reach, on the right side b. Just out of the clients reach, on the left side c. Within the clients reach, on the right side d. Within the client reach, on the left side Answer: d. within the clients reach, on the left side Ratinale: Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects on the unaffected side and within reach. This reduces client frustration and aids in client safety because s/he does not have to strain and reach for needed items. 8. Your client has an impairment of cranial nerve (CN) II. What do you tell the clients spouse to do maintain client safety in the home? a. Speak to the client in a loud voice b. Serve food that is not too hot or too cold c. Keep traveled paths in the home free of clutter d. Lower the temperature setting of the water heater Answer:c. keep traveled paths in the home free of clutter Rationale: CN II is the optic nerve which governs vision. You can enhance safety by encouraging

family to keep pathway free of clutter to prevent falls. Lowering the temperature of the water heater would be useful if the client had peripheral nerve damage. Speaking to the client in a loud voice may help compersate for a deficit of CN vIII (vestibulocochlear). CN VII (facia) and CN1X(glossopharyngeal) control taste. 9. You work in a LTC facility with residents diagnosed with Alzheimers disease (AD). You understand that this means your clients have pathology of which of the following elements of nervous system? a. Neuronal dendrites b. Neurotransmitters c. Peripheral nerves d. Monoamine oxidase Answer: a. Neuronal dendrites Rationale: AD is characterized by changes in the dendrites of neurons. The decrease in the number and composition of dendrites is responsible for the symptoms of the disease. The other options are not related to the pathology of Alzheimers disease. 10. Your client with spinal cord injury suddenly complains of a severe, throbbing headache and autonomic dysreflexia is suspected which of following actions should you take first? a. Lower the HOB and remove the noxious stimulus b. Raise the HOB and remove the noxious stimulus c. Lower the HOB and administer an antihypertensive agent d. Remove the noxious stimulus and administer an antihypertensive agent Answer: b. raise the HOB and remove the noxious stimulus Rationale: Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation that can be dangerous d/t vasoconstriction and elevation of blood pressure. Key nursing actions would be to sit the client up in bed, remove the stimulus, and bring the BP under control with antihypertensives. 11. You are reinforcing instructions to a mother regarding how to provide a bath to newborn. Which statement by the mother indicates a need for further instructions? a. I should bathe my baby after feeding b. I should fill a clean basin or sink with 2 or 3 inches of water and then check the temperature using my wrist c. I should never leave the baby in the tub of the water alone d. I should gather all supplies before I begin the bath Answer: a. I should bathe my newborn after a feeding Rationale: it is not advisable to bathe a newborn or infant after a feeding because handling may cause regurgitation. Since bathing is thought to be relaxing to the newborn, before feeding may be the best time. The other options are appropriate interventions for bathing a newborn.

12. You are reinforcing instructions to the mother of a male newborn who is not circumcised about measures to clean the penis. Which of the following statements made by the mother indicates an understanding of how to clean the newborns penis? a. I need to retract the foreskin and clean the penis every time I give my newborn a bath b. I should gently retract the foreskin as far as it will go on the penis and pull the skin back over the penis after cleaning c. I should retract the foreskin and clean the penis every time I change the diaper d. I need to avoid pulling the foreskin to clean the penis because this may cause adhesions Answer: d. I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions Rationale: in the newborn males, prepuce is continuous with the epidermis of the gland and is not retractable. If retraction is forced, adhesions can develop. Current recommendations are to allow separation to occur naturally which usually occurs between 3 years and puberty. 13. You are caring for a child following a tonsillectomy. You note that the child is drowsy. As you prepare to take vital signs, the child begins to vomit. Your initial nursing action would be to a. Administer the prescribed antiemetic b. b. Turn the child to the side c. Notify the RN d. Sit the child upright Answer: b. Turn the child to the side Rationale: Following tonsillectomy, if vomiting occurs, the child who is still drowsy is turned to the side. The nurse may notify the RN, but this would not be the initial action. An NPO status would be maintained and an antiemetic may be prescribed; however, the first priority is airway patency. 14. You are providing instructions to a mother of a toddler regarding the safe use of car seat. You determine the mother understands the safe use of the car seat if she states which of following? e. The car seat can be placed in a face-forward position when my toddler is 27 high f. The car seat should never be placed in a face-forward position g. The seat can be placed in a face-forward position anytime h. The seat is only suitable until my toddler is 40 lbs Answer: d. The seat is only suitable until my toddler is 40 lbs Rationale: Once a toddler is able to sit up alone, car safety seats can be adjusted to face forward in an upright position. The car seat is suitable for the growing toddler until the toddler reaches the weight of 40 lbs. The other options are incorrect. 15. You are assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the following do you avoid in the plan of care? a. Pad the side rails of the bed with blankets

b. Maintain the bed in a low position c. Restrain the child ids a seizure occurs d. Place the child in a side-lying lateral position if a seizure occurs Answer: c. restrain the child id a seizure occurs Rationale: restrains are not to be applied to a child with a seizure because they could cause injury to the child. The side rails of the bed are padded with blankets, and the bed is maintained in a low position to provide safety if the child has a seizure. Positioning the child on his or her side will prevent aspiration as the saliva drains out of the childs mouth during the seizure. 16. You are collecting health info from a 49 years old Caucasian male. His BP is 126/80 mm Hg at rest, total cholesterol is 285 md/dl, and random CBG level is 117 mg/dl. You determine he has which modifiable risk factors for cardiovascular disease? a. Age b. Hyperlipidemia c. Hypertension d. Glucose intolerance Answer: Hyperlipidemia Rationale: While hypertension is a major risk factor for CAD, it is directly influenced by hyperlipidemia. Glucose intolerance is a contributing factor. Age greater than 40 is a nonmodifiable risk factor. 17. You are monitoring the status of a client who had a myocardial infarction (MI) 3 days ago, and you note newly developed bilateral 1+ edema in the lower extremities. Which of the following client-related items should you review next? a. Fluid balance over the last 3 days b. Number of meals eaten since admission c. History of salt intake prior to admission d. History of recent weight gain or loss prior to admission. Answer: a. Fluid balance over the last 3 days Rationale: Edema results from accumulation of excess fluid in the interstitial spaces and can be assessed by noting if the clients intake had been greater than output over the 3 days. This client is at risk for heart failure d/t MI and this measurement will help determine if there is increased fluid volume on board that the heart has to pump. History of weight change or salt intake prior to admission is not relevant, and neither is the number of meals eaten. 18.You are assisting in the care of a client with known heart disease who suddenly develops dyspnea at rest. You should plan to take which of the following actions first to assist the client? a. Elevate the HOB to at least 45 degrees b. Assist the client out of bed to chair c. Obtain an oxygen cannula (nasal prongs) d. Perform continuous monitoring of oxygen saturation

Answer:a. a. Elevate the HOB to at least 45 degrees Rationale: Dyspnea generally is managed by treating the cause. Symptom relief may be achieved or assisted by keeping the HOB elevated. In severe cases, supplemental oxygen is prescribed. The client would remain on bedrest at this time. Oxygen saturation would be monitored, and the first action is to elevate the head of the bed. 19.Your client who is experiencing an MI. has had a drop in heart rate into the 50 to 56 beats per minute range. He is also complaining of nausea. You interpret these symptoms are due to stimulation of which of the following cranial nerves (CN)? e. Glossopharyngeal (CN 1X) f. Vagus (CN X) g. Spinal accessory (CN XI) h. Hypoglossal (CN XI) Answer: b. Vagus (CN X) Rationale:The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also responsible for the decrease in heart rate because approx. 75% of all parasympathetic stimulation is carried by the vagus nerve. CN IX is responsible for taste in the post 2/3 of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder movement. CN XII is responsible for tongue movement. 20.Your client is admitted to your LTC facility directly from home with a diagnosis if leg ulcer. You conclude the client has impaired arterial circulation based on which of the following characteristics of the leg ulcer? a. Pale with little granulation tissue b. Brown pigmentation of surrounding skin c. Deep reddish coloured bas d. Superficial with uneven edges. Answer: a. Pale with little granulation tissue Rationale: Arterial leg ulcers tend to be deep and pale with uneven edge and little granulation tissue. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has pale discoloration consistent with peripheral arterial disease. The other options are typical assessment findings with venous stasis ulcer due to venous insufficiency. 21. You have made an error in documenting an assessment finding on a client and obtain the clients chart to correct the error. You would correct the error by: a. Trying to erase the error for space to write in the correct data. b. Using white correction fluid to delete the error and writing the correct data. c. Drawing one line through the error, initialing, and dating the line, then providing the correct information. d. Documenting a late entry into the clients chart Answer: c. Drawing one line through the error, initialing, and dating the line, and then providing the

correct information. Rationale: If you make an error in documenting in the clients record, you should follow agency policy to correct the error. This included drawing one line through the error, initialing and dating the line, and then providing the correct information. Erasing data or using correction fluid are prohibited. A late entry is used to document additional information not initially remembered at the time of documentation. 22. You hear a client calling out for help. You hurry down the hall to the clients room and find her lying on the floor. You perform a complete assessment, inform the physician, and complete an incident report. Which of the following do you document on the incident report? a. The client was found lying on the floor b. The client climbed over the side rails c. The client fell out of bed d. The client became restless and tried to get out of bed. Answer: a. The client was found lying on the floor Rationale: The incident report should contain the clients name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option A is the only option that describes the facts as observed by the nurse. The other options are interpretations of the situation and are not factual data observed by nurse. 23. You give an inaccurate dose of a medication to a client. Following assessment of client, you complete and incident report, and notify the nurse manager and physician. You (the nurse who administered the inaccurate dose) understand that the a. Error will result in suspension b. Incident report is a method of promoting quality care and risk management c. Incident will be report to the College of Nurses d. Incident will be documented in your personnel file. Answer: b. Incident report is a method of promoting quality care and risk management. Rationale: Proper documentation of unusual occurrences incidents, and accidents, and the nursing actions taken as a result is internal to the agency and allows the review of quality of care and determine any potential risks, Based in this case, the error would not result in suspension, nor be documented in the personnel file. There is no reason in this scenario to report the incident to the CNO. 24. You witnessed a client experience a seizure. As part of following-up documentation, it is unnecessary for you to include which of the following pieces of information: a. Seizure progression and type of movements b. Changes in pupil size or eye deviation c. Duration of seizure d. Food and fluid intake for 1 hour prior to the seizure Answer: d. Food and fluid intake for 1 hour prior to the seizure Rationale: Typically, seizure assessment includes the time the seizure began, part(s) of the body

affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition, and postictal status. The amount of food or fluid taken in the hour before may have some relevance to the likelihood of aspiration, but is not part of standard assessment protocols. 25. Your client has sustained a bruise to the skin following a fail. On inspection, you note that the bruise in purplish. You would document this finding most accurately using which of the following terms? a. Purpura b. Petechiae c. Ecchymosis d. Erythema Answer: c. Ecchymosis Rationale: Purpura is an umbrella term that incorporates ecchymosis and petechiae . Ecchymosis is a type of purpuric legion and is also known as a bruise. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin. 26. You measure the BP of a client you are seeing for the first time, and find it to be 156/94 mm Hg. What is you r next priority to collect data about relating to the following factors for hypertension/ a. Family history b. Ethic group c. Excess weight d. Protein intake Answer: c. Excess weight Rationale: Obesity stress and sodium intake are modifiable risk factors of hypertension. These are of utmost importance because they can be changes by the individual. Studies have shown that weight loss in obese people lowers BP. Family history and ethnicity are nonmodifiable risk factors and as such, are less important. Protein intake has no relationship to hypertension. 27. You are admitting a patient who was in a MVA after drinking heavily. You would monitor this client regularly for which of the following early signs of alcohol withdrawal? a. Delusions, fever, vomiting, agitation b. Clouding of consciousness, tachycardia c. Anxiety, tremor, insomnia, tachycardia d. Disorientation, diaphoresis, insomnia Answer: a. Anxiety, tremor, insomnia, tachycardia Rationale: early signs of ETOH withdrawal develop with a few hours after cessation or reduction of alcohol and peak at 24 -48 hours. Early signs include anxiety, tremor, anorexia, insomnia, irritability, elevation in pulse and BP, nausea, vomiting, and poorly formed hallucinations or illusions. The signs identified in the other options are not early signs of ETOH withdrawal.

28. You are assigned to assist in caring for a client with multiple sclerosis whi is receiving an intravenous (IV) dose of methocarbamal (Robaxin). While caring for the client, you carefully monitor for: a. Hypertension b. Bradycardia c. Tachycardia d. Palpitations Answer: b. Bradycardia Rationale: Intravenous administration of methocarbamol (Robaxin) can cause hypotension and bradycardia. You need to monitor carefully for theses side effects by taking vital signs every 15 minutes during the infusion. The medication should also be placed on a controlled infusion device (IV pump). 29. You are caring for a 79-year-old woman with a history of urinary tract infection (UTI). You would monitor this client for which of the following unusual symptoms of UTI that are noted in the older client? a. Fever b. Urgency c. Frequency d. Confusion Answer: d. Confusion Rationale: In an older client, a UTI may present with a vague symptom such as increasing mental confusion or frequent unexplained falls. Frequency and urgency commonly occur with UTI in younger clients. Fever can be associated with a variety of conditions. 30. You are collecting data from a client who is suspected of having bladder cancer. You would first question the client about which of the following most common symptoms of this type of cancer? a. Hematuria b. Dysuria c. Urinary frequency d. Urinary urgency Answer: a. Hematuria Rationale: The most common symptom with clients with bladder cancer is hematuria. The client may also experience other urinary symptoms such as frequency, urgency and dysuria. These symptoms are often associated with cancer situ.

Part 2 1. Your client is scheduled to receive digoxin (Lanoxin) 0.125 mg by mouth. You read the med

label and note that each tablet contains 0.25 mg. You should do which of the following? a. 1 tablet b. 2 tablets c. A quarter tablet d. Half Answer: d. Administer half a tablet of digoxin 2. The physician prescribes phenytoin (Dilantin) 0.1 g po tid. You determine that the prescribed dosage is within normal range because the client will be receiving a total of how many milligrams (mg) in a 24 hrs period? a. 100 mg b. 200mg c. 300mg d. 400mg Answer: c. 300 mg 3. The physician prescribed meperidine hydrochloride (Demerol) 40 mg IM stat. for a postoperative client in pain. The med tablet states meperidine hydrochlorides (Demerol) 50 mg per ml. How many ml will you prepare to administer to the client? a. 0.5 ml b. 0.6 c. 0.8 d. 1.0 Answer: c. 0.8 ml 4. The physician orders zidovudine (AZT) 0.3g po q12h. The med label states zidovudine (AZT) 100 mg capsules. How many tablets do you prepare to administer for one dose? a. 0.5 tab b. 1 tab c. 2 tab d. 3 tab Answer: d. 3 tabs 5. The physician orders atropine sulfate 0.4 mg IM stat. The med label states atropine sulfate 0.3 mg per ml. How much medication do you prepare to administer the dose? a. 1.0 ml b. 1.3 c. 1.8 d. 2.0 Answer: 1.3 ml

6. Your client has incisional pain and complaining to you about performing respiratory exercises. She is willing to do the deep breathing, but states it hurts to cough. You provide gentle encouragement and appropriate pain management to the client, and knowing that coughing is needed to : a. expel mucus from the airways b. dilate the terminal bronchioles c. Provided for increased oxygen tension in the alveoli d. Exercise the muscles of respiration Answer: a. Expel mucus from the airways Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address this purpose. 7. You are monitoring the status of a client experiencing dyspnea. You are aware that which of the following factors will decrease the work of breathing for this client? a. Increased mucus production b. Interstitial pulmonary edema c. Increased airway resistance d. Bronchodilation Answer: d. Bronchodilation Rationale: Bronchodilation decreased the airway resistance and decreased the work of breathing for the client. Clients with increased mucous production, edema, or bronchospasm have increased airway resistance, which increases the work of breathing. 8. A client who is experiencing respiratory difficulty asks you Why is it so much easier to breathe out than in? In providing a response, you include that breathing is easier on exhalation because the: a. Respiratory muscles contract b. Respiratory muscles relax c. Air flows by gravity d. Air is flowing against a pressure gradient Answer: b. Respiratory muscles relax Rationale: Exhalation is less taking for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It dose not flow against a pressure gradient. 9. Your client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. You understand that which of the following is an expected finding with this client?

a. Hyperinflation of the lungs documented by CXR b. A widened diaphragm documented by CXR c. Increased oxygen saturation with ambulation d. A shortened expiratory phase of the respiratory cycle Answer: a. Hyperinflation of lungs documented by CXR Rationale: The clinical manifestations of COPD are several including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. CXR results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced. 10. You work on a general surgery floor. A client is admitted to your unit after being thrown from a motor vehicle during an accident. You suspect the client has sustained a closed pneumothorax if which of the following noted in the client on data collection: a. Respiratory rate of 12 breaths per minute b. The presence of a barrel chest c. A sucking sound at the site of injury d. Shortness of breath and chest pain Answer: d. Shortness of breath and chest pain Rationale: Classic symptoms of closed pneumothorax are shortness of breath and chest pain. With a larger pneumothorax, the client may experience diminished breath sounds, tachypnea, cyanosis, and subcutaneous emphysema. There may also be hyperresonance on the affected side. A sucking sound at the site of injury indicates an open pneumothorax. A barrel chest is consistent with emphysema. A low respiratory rate could be due to a number of causes. 11. You are working a night shift. As you enter the medication room you find a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. The most appropriate initial action for you is which of the following? a. Call the police b. Call security c. Lock the co-worker in the med room until help is obtained d. Call the nursing supervisor Answer: d. Call the nursing supervisor Rationale: The CNO required reporting impaired nurses. They have jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor who will then report to the CNO and other authorities as required. Option c is inappropriate and unsafe action. Security may be called if a disturbance occurs. Calling the police may occur, but not as an initial action. 12. You are collecting data on a child and note the presence of old and new bruises on the childs back and legs. You suspect physical abuse and report the finding to the RN. Knowing that

which of the following is necessary? a. Filling charges against the childs mother and father b. Reporting the case to legal authorities c. Asking the mother to identify the person who is physically abusing the child d. Telling the child that he or she will go to a foster home Answer: b. Reporting the case to legal authorities Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. It is not appropriate for the nurse to file charges against the mother or father. It is also inappropriate to ask the mother to identify the abuser because the abuser may be the mother. Option d id clearly inappropriate and would produce fear in the child. 13. You witness an accident on the highway and stop to help. You note the client has sustained head injury and a compound # to the left leg. You provide the appropriate care prior to ambulance arrival. The client develops a severe bone infection at the # site and requires an amputation. He sues you since you provided care at the accident scene. Which of the following is accurate? a. The Good Samaritan Law will protect the nurse b. The Good Samaritan Law will not protect the nurse c. The Good Samaritan Law will protect the nurse, even if you accepted payment for the care you gave d. The Good Samaritan Law only applies to lay persons, not health care professionals Answer: a. The Good Samaritan Law will protect the nurse Rational: A Good Samaritan Law encourages nurse and other health care providers to provide care to a person when an accident, emergency, or injury occurs without fear to being sued for the care provided. Its protection lies in preventing nurses from being sued for negligence, even further injury occurred because of the care provided. It applies as long as payment for care is not received, and care given is not willfully or wantonly negligent. 14. A hospitalized client tells you that a living will is being prepared and that his lawyer will bring it to the hospital today for witness signatures. He asks you for obtaining a witness to the will. The most appropriate response to the client is which of the following? a. I will sign as a witness to your signature b. You will need to find a witness on your own c. I will call the nursing supervisor to seek assistance regarding your request d. What is a living will Answer: c. I will call the nursing supervisor to seek assistance regarding your request Rationale: Living wills are required to be in writing and signed by the client. The clients signature must be either witnessed by specified individuals or notarized. Some facilities do not allow nurses to witness living wills. You should seek assistance in this case. The other options are not therapeutic or appropriate.

15. You are employed at a LTC facility. You are waiting to receive a report from the lab via fax. The fax machine activates and you expect the report, but instead you receive a sexually oriented photograph. The most appropriate nursing action is to: a. Cut up the photograph and throw it away b. Call the lab and ask for the name of the person who sent the photograph c. Call the police d. Call the nursing supervisor and report the incident Answer: d. Call the nursing supervisor and report the incident Rationale: Sexual harassment in the workplace in prohibited by law. Making sexually suggestive jokes, inappropriately touching someone, pressuring a coworker for a date, and openly displaying sexually oriented photos are examples of conduct that could be considered sexual harassment. If you believe that you are being subjected to unwanted sexual conduct, your concerns must be reported immediately. 16. You report to work for the evening shift and receive your assignment from the charge nurse. After making initial rounds and checking all of your assigned clients. Which client will you plan to care for first? a. A client who is ambulatory b. A client with a fever who is diaphoretic and restless c. A client scheduled for physical therapy at 1600 d. A postoperative client who has just received pain medication Answer: a. A client with a fever who is diaphoretic and restless Rationale: You would plan to care for this client first because this clients needs are the priority. It is best to wait for the pain medication to take effect before providing care to the postoperative client. The client who is ambulatory and the client scheduled for physical therapy do not have priority needs related to care. 17. You are giving a bed bath to a client. You plan to discard the water in the bath basin a. after washing the clients eyes, face, neck and ears b. After washing the clients chest c. After washing the clients legs d. After washing the clients arms Answer. C. After washing the clients legs Rationale: When giving a bed bath, the nurse should change the bath water when the water becomes cool. The bath water is discarded after washing the clients legs. A clean basin is then obtained to provide perineal care to prevent cross-contamination. 18. You are reviewing information related to inflammation. You understand that the primary purpose is to neutrophile in the inflammatory response is to: a. Dilate the blood vessels b. Increase fluids at the site of injury

c. Phagocytize and potentially harmful agents d. Produce permeability of the blood vessels Answer: c. Phagocytize any potentially harmful agents Rationale: In the inflammatory response, neutrophiles appear in the area of injury in 30 to 60 minutes. Their primary purpose is to ingest and destroy (phagocytize) any potentially agnets, such as microorganisms. Options A and D are a result of vasodilation. Option B occurs with exudates formation. 19. You note that your client eyes are reddened, and she states that an eye infection has been diagnosed. You interpret that the client is most likely referring to infection of which of the following structures that provides a protective covering for the eye? a. Iris b. Lens c. Cornea d. Conjuctiva Answer: d. Conjuctiva Rationale: The conjuctiva is a thin, transparent layer of mucous membrane that covers the eyeballs and lines the eyelids. Infection of the conjuctiva is called conjunctivitis, which is a contagious condition. The other options relate to specific eye structure. 20. Your nurse manager employs a leadership style in which decisions regarding the management of the nursing unit are made without input from the staff. You understand that the type of leadership style that is implemented by the nurse manager is: a. Autocratic b. Situational c. Democratic d. Laissez faire Answer: a. Autocratic Rationale: The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organization goals. Decisions are made without input from staff. Democratic styles best empower staff toward excellence because it allows professional growth. Situational leadership style uses a style depending on the situation and event. Laissez faire allows staff to work without assistance, direction, or supervision. 21. The physician orders a bolus of 500 ml of 0.9% NS to run over 4 hours. The drop factor is 10 drops per 1 ml. You plan to adjust the flow rate at how many drops per minute? a. 15 drops per minute b. 17 drops c. 19 drops d. 21 drops

Answer: d. 21 drops per minute 22. You are asked to prepare an IV infusion of 1000 ml 5 % dextrose in lactated Ringers at 80 ml/hr for a client. You time tape the bag with a start time of 0900. After making hourly marks on the time tape, you note that the completion time for the bag is: a. 1530 b. 1730 c. 1930 d. 2130 Answer: d. 2130 23. The physician orders 3000 ml of D5W to run over a 24 hours period. The droop factor is 15 drops per ml. You adjust the flow rate to run at how many drops per minute? a. 15 drops per minute b. 17 c. 25 d. 31 Answer: 31 drops per minute 24. The physician orders 500 ml of 0.9 NS to run over 5 hours. The drop factor is 10 drops per ml. You adjust the flow rate to deliver how many drops per minute? a. 14 drops per minute b. 17 c. 20 d. 22 Answer: a. 14 drops per minute 25. The client is to receive 1000 ml of D5W over a period at 100 ml per hour. The drop factor is 10 drops per ml. You adjust the flow rate to deliver how many drops per minute? a. 10 drops per minute b. 13 drops per minute c. 17 d. 20 Answer: c. 17 drops per minute 26. You are caring for a recent postoperative client has just regained bowel sounds. The physician has allowed a clear liquid diet. You check to see that which of the following is available in the clients room before allowing the client to drink? a. Straw b. Napkin c. Suction equipment

d. Oxygen saturation monitor Answer: c. Suction equipment Rationale: Aspiration is a concern when offering fluid to a postoperative client. It is possible that the client could still have some impairment to the swallowing reflex as an effect from anesthesia. You should check the gag and swallowing reflexes before offering fluid to the client. An oxygen saturation monitor is unnecessary. A napkin and straw are help, but not necessary. In fact, the straw could contribute to formation of flatus and post-op GI tract discomfort 27. You will be assisting in admitting a client for observation and post-procedure care who has undergone esophagogastroduodenoscopy (EGD). You would plan to do which of the following first once the client arrives? a. measure the clients temperature b. Monitor for complains for heartburn c. Monitor for return of the gag reflex d. Give warm gargles for a sore throat Answer: c. Monitor for return of the gag reflex Rationale: You should place highest priority on monitoring for return of the gag reflex which is part of managing the clients airway. The clients vital signs should be monitored next a sudden sharp increase in temperature could indicate perforation of the GI tract. Monitoring for sore throat and heartburn are also important, but are of lesser priority than the clients airway. 28. The client who underwent left total knee replacement (TKR) asks you how long the affected leg should remain in the continuous passive motion (CPM) machine. You respond that the physician generally prescribes the time but that the CPM machine is generally used: a. For 2 hours at a time followed by 2 hours of rest b. Twenty four hours a day c. For 15 minutes out of every hours d. For 8-12 hours each day Answer: d. For 8 -12 hours each day Rationale: A CPM machine is often put in place while the client who underwent TKR is still in the PACU. The CPM machine is generally uses for 8 -12 hours each day, and the range of motion is increased gradually. The current trend is intermittent use each day for several hours at a time 29. You are assisting in the care of a client who overdosed on aspirin 24 hours ago. You would report to the RN which of the following finding associated with an anticipated acid-base disturbance? a. Drowsiness, headache, and tachypnea b. Decreased respiratory rate and depth, and cardiac irregularities c. Disorientation and dyspnea d. Tachypnea, dizziness, and paresthesias Answer: a. Drowsiness, headache, and tachypnea

Rationale: The client who ingests a large amount of aspirin (acelyisalicylic acid) is at risk for developing metabolic acidosis 24 hours later. If this occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism (Option B), but by 24 hours, this mechanism falls and the client is in metabolic acidosis. Option C is associated with respiratory acidosis. Option D is associated with respiratory alkalosis. 30. You work in a LTC facility. One of the residents tells you I had heartburn, and took 20 of those heartburn pills You send her to the hospital for assessment. Upon her return to the facility, you would expect a diagnosis of which acid-base imbalance, and expect a note of which of the following signs and symptoms? a. Respiratory acidosis: disorientation and dyspnea b. Respiratory alkalosis: dizziness and tachypnea c. Metabolic acidosis: drowsiness and headache d. Metabolic alkalosis: decreased respiratory rate and depth Answer: d. Metabolic alkalosis: decreased respiratory rate and depth Rationale: Excessive antacid use is associated with metabolic alkalosis. The client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism

Part 3 1. You are getting ready to five doses of furosemide (lasix) 40 mg and digoxin (Lanoxin) 0.125 mg to a client with heart failure. Just before giving the doses. You should check which of the following most recent lab values? a. Magnesium level b. Creatinine level c. Sodium level d. Potassium level Answer: d. Potassiium level Rationale: The serum potassium level should be monitored carefully in client receiving both digoxin and lasix. Hypokalemia can cause heightened digitalis effect. Hypokalemia also predisposes the cardiac client to ventricular dysrhythmias. There is no indication the client has renal insufficiency, making option B incorrect. Although option A and C identify lab values that should be monitored, potassium level is the priority lab value. 2. A 31- year-old adult has a seum total cholesterol level draw as part of a routine health screening. You know that the target goal for this measurement is for it to be under: a. 200 mg/dl b. 150mg/dl

c. 300mg/dl d. 250mg/dl Answer: a. 200 mg /dl 3. You are caring for a client diagnosed with pancreatitis. You monitor the clients lab result, knowing that which enzyme is not produced in the pancreas a. Lipase b. Lactas c. Amylase d. Trypsin Answer: b. Lactase Rationale: Lactase is produced in the small intestine and aid in spitting neutral fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins respectively. 4. You are assisting in admitting a client to the unit after a basal skull fracture and note clear fluid draining from the ear. You conclude that the fluid is cerebrospinal fluid (CSF) if the fluid: a. Is grossly bloody with a PH of 6 b. Is clear and tests negative for glucose c. Clumps together on the dressing and has a PH of 7 d. Separates into concentric rings and tests positive for glucose Answer: d. Separates into concentric rings and tests positive for glucose Rationale: Leakage of CSF from the ears or nose may accompany basilar skull fracture. The nurse can determine if the drainage is CSF by noting if it separates into bloody and yellow concentric rings on dressing material (called Halos sign) CSF will also test positive for glucose whereas nasal or other mucous will not 5. You are caring client who is retaining carbon dioxide (CO2) due to respiratory disease. You plan care knowing that as the client s CO2 level rises, the PH should: a. Rise b. Fall c. Remain unchanged d. Double Answer: Fall Rationale: CO2 acts as an acid in the body. Therefore, with a rise in CO2, there is a corresponding fall in PH 6. You are assisting in a Code Blue. The physician is about to defibrillate the client and you hear the physician say in a loud voice Clear. Which of the following immediate actions should you take:

a. Step away from the bed and ensure others have done the same b. Prepare to place the client in a mortuary bag c. Call the family into the room witness the CPR d. Move toward the bed to assist the physician Answer: a. Step away from the bed and ensure that all others have done the same Rationale: It is essential for the safety of all personnel to be clear of the client or clients bed when the defibrillator paddles are being discharged. Otherwise, you may be defibrillated along with the client 7. You are assisting in developing the plan of care for and older adult client to prevent fall. Which of the following actions would be lease likely to prevent a fall from occurring? a. Placing the bed in lowest position b. Placing the call light within the clients reach c. Keeping the bathroom light off at nighttime d. Keeping the side rails up while the client is bed Answer: c. Keeping the bathroom light off at nighttime Rationale: To prevent falls, a brightlight or bathroom or hall light should be kept on to prevent sundowning and increase in disorientation with approaching darkness. Options A B and D are appropriate actions to prevent falls from occurring. 8. The physician writes an order to apply a heating pad to a client back. You implement the prescribed order and avoid which of the following: a. Setting the heating pad on a low setting b. Placing the heating pad under the client c. Assessing the heating pad periodically for proper electrical functioning d. Assessing the skin integrity frequently for signs of burns Answer: Placing the heating pad under the client Rationale: The heating pad should never be placed under the client, but it should be placed tightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. Options A ,C and C are appropriate measures for the use of a heating pad 9. You are employed in a LTC facility. You hear a resident yell help, fire! You rush to the residents room and find the waste basket on fire. You immediately: a. Remove the resident from the room b. Active the fire alarm c. Run away from the fire d. Extinguish the fire with a blanket Answer: a. Remove the resident from the room Rationale: The order of the priority in the event of a fire is to rescue the client in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors, and last, the fire is extinguished. Running away from the fire dose not promote client safety. Trying to extinguish the fire with a blanket may cause the fire to grow bigger as the blanket burns

10. Your client is receiving bolus feedings via a nasogastric (NG) tube. You plan to place the client in which of the following most optimal positions once the feeding is completed? a. HOB elevated 45-60 degrees with client supine for 15 minutes b. HOB in Semi-Folwers with client in left lateral position for 60 minutes c. HOB flat with client supine for at least 60 minutes d. HOB elevate 30 to 45 degrees with client in the right lateral position for 60 minutes Answer: d. HOB elevated 30-45 degrees with client in the right lateral position for 60 minutes Rationale: Aspiration is a possible complication associated with NG tube feeding. The HOB should be elevated 30- 45 degrees for 30 to 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat supine positions should be avoided for the first 30 minutes after tube feed. 11. You are having a conversation with a male client who is actively hallucination. The client is fearful that the voice will direct him to kill himself or will hurt him directly. Which of the following nursing statements would be most therapeutic at this time? a. I don't hear them, but it must be frightening to hear voices that others cant hear b. I know you believe they are going to cause you harm, but it is not true c. I know whose voices you are hearing, and I told them not to hurt you d. I can hear the voices too, but they are telling you to go to bed now Answer: a. I don't hear them, but it must be frightening to hear voices that others cant hear Rationale: It is important for the nurse to let the client know that what the client is saying is not heard by the nurse and to avoid reinforcing the clients altered reality. The nurse avoids confronting the client, but rather says supportive things such as this must be very frightening for you 12. A client has been admitted to the psychiatric unit you work on because the client has displayed violet behaviour and is at risk for potentially harming others. You would avoid doing which of the following when caring for this client? a. Closing the door to the client room when giving care b. Admitting the client to a room near the nurses station c. Facing the client while speaking and providing care d. Arranging for a security officer to be available in the general area Answer: a. Closing the door to the clients room when giving care Rationale: The nurse should not isolate self with a potentially violent client. The door to the clients room should remain open when giving care. The client should be placed in a room near the nurses station and not at the distant end of the corridor. The nurse should never turn away from the client. A security officer should be readily available if there is imminent violence. 13. You are assigned to a client who is psychotic. The client is pacing, agitated, and using

aggressive gestures, and rapid speech. You determine that which of the following is the immediate priority of care? a. Provide other clients on the unit with a sense of comfort and safety by isolating the psychotic client. b. Assist in caring for the client in a controlled environment, such as a quiet room c. Provide safety for both the client and other clients on the unit d. Offer the client a less stimulated area in which to calm down and gain control Answer: c. Provide safety for both the client and other clients on the unit Rationale: Safety for both the client and other client s is the priority. Option B and D address only the clients needs. Option A addresses only the needs of the other clients on the unit 14. You are working with a client who id delusional. The client says to you. The leader of a religious cult is being sent to assassinate me Which of the following is the best nursing response? a. I dont know about religious cult. Are you afraid that people are trying to hurt you? b. What makes you think that cult members are being sent to hurt you? c. There are no religious cults in this area that are going to kill you? d. I dont believe that you are telling me is true. Answer: a. I dont know about a religious cult. Are you afraid that people are trying to hurt you? Rationale: The nurse who disagrees with a clients delusions may make the client feel more defensive and cling to the delusions even more firmly. It is most therapeutic for the nurse to empathize with the clients experience. The nurse can also use the opportunity to try to explore further meaning of the experience of client. Option B. C and D are non-therapeutic. 15. A client with a potential for violence is exhibiting agitated behaviour. The client is using aggressive gestures and making belligerent comments to the other clients and is continuously pacing in the hallway. Which of the following nursing statements would be most therapeutic at this time? a. You are going to be restrained if you do not change your behaviour? b. Please stop so I dont have to put you in seclusion c. What is causing you to become agitated? d. Why are you intent on upsetting the other clients? Answer: c. What is causing you to become agitated? Rationale: The most appropriate response is to ask the client what is causing the anger. This helps make the client aware of the behaviour and may assist the nurse in planning appropriate interventions. Options A and B constitute threats to the client which are inappropriate. Option D is confrontational and could further escalate the clients behaviour. 16. A new diagnosed client with diabetes mellitus (DM) is learning about insulin administration and management. You should be certain to include which of the following pieces of information when discussing self-management with the client?

a. Extra insulin is needed prior to heavy exercise b. When acetone is present in the urine, less insulin should be taken c. Insulin vials should be stored in the refrigerator d. A systematic plan for site rotation should be followed Answer: d. A systematic plan for site rotation should be followed Rationale: Injection sites should be rotated. The client should be instructed to give injections in one area about an inch apart until the whole area has been used, then change to another site. This prevents dramatic changes in daily insulin absorption. The other statements are incorrect. Insulin dosage should not be increased prior to heavy exercise. If acetone is found in the urine, it could indicate the need for additional insulin. To minimize discomfort associated with insulin injections, insulin should be given at room temperature 17. You have just supervised a newly diagnosed diabetic client self-inject NPH insulin at 0730. You review the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between: a. 0930 and 1130 b. 1330 and 1930 c. 0730 and 2330 d. 0130 and 0730 Answer: 1330 and 1930 Rationale: NPH is an intermediate-acting insulin. It begins to work in 1-2 hours (onset), peaks in 6 to 12 hours, and last for 13 to 24 hours (duration). Hypoglycemic reactions most likely occur during peak times. Thus option b is correct. 18. A client is diagnosed with diabetic retinopathy. You are interviewing the client, and ask about which of the following factors which correlates strongly with the development of this complication of diabetes mellitus? a. Presence of conjunctivitis and other infections b. Extent of blood glucose control and number of years since diagnosis of diabetes mellitus c. Coexistence of other precipitating diseases such as cataracts or glaucoma d. Concurrent history of myopia or hyperopia Answer: b. Extent of blood glucose control and umber of years since diagnosis of diabetes mellitus Rationale: Several studies show a strong correlation between the development of diabetic retinopathy and blood glucose control and length of time with diabetes. There is no other condition listed in option A. C. or D. 19. You are assigned to care for a client with type 1 diabetes mellitus. You would monitor for which of the following signs of hypoglycemia when assessing this clients status periodically during your shift? a. Anorexia

b. Tremors c. Hot, dry skin d. Muscle cramps Answer: b. Tremor Rationale: Decreases blood glucose levels trigger autonomic nervous system symptoms such as nervousness, irritability, and tremors. Hot, dry skin accompanies hyperglycemia. Anorexia and muscle cramps are unrelated to hypoglycemia. 20. You work at a community walk-in client. A client enters the clinic after suffering a bee sting. The client is afraid of a severe reaction because a friend had one a few years earlier. You would a. Soak the area in povidine-iodine b. Tell the client not to worry unless if becomes hard to breathe c. Ask the client if he or she ever received a bee sting in the past d. Refer the client to the emergency room Answer: c. Ask the client if he or she ever received a bee sting in the past Rationale: In most allergies, a reaction occurs on second and subsequent contacts with the allergen. The most appropriate action, therefore, would be to ask the client if he or she ever received a bee sting in the past. Option A and D are unnecessary. Option B is inappropriate advise the client should not be told not to worry 21. You are reading the operative record for a client who had cardiac surgery and note that the clients cardiac output after surgery was 3.6 L/min. You interpret that a. Above the normal range b. In the high normal range c. In the low normal range d. Below the normal range Answer: Below the normal range Rationale: The normal cardiac output for the adult can range from 4-8 L/min. The heart normally pumps 5L of blood every minute 22. A client reports to you a history of using large doses of antacids to combat chronic stomach upset. You collect further data from the client to detect signs of which of the following acidbase disturbances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis Answer: d. Metabolic alkalosis Rationale: Oral antacids commonly contain compounds that bind onto the hydrochlorid acid in the stomach to neutralize it. Excessive use or oral antacids containing sodium or calcium bicarbonate can cause a metabolic alkalosis over time

23. You are assisting in the care of a client who is at risk for hyponatremia. You would monitor this client for which of the following manifestations of this electrolyte imbalance? a. Slow pulse rate b. High blood pressure c. Flaccid muscle d. Abdominal cramping Answer: d. Abdominal cramping Rationale: Signs of hyponatremia include rapid thread pulse, postural blood pressure changes, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizures, mental confusion and apprehension. 24. You overhear that a client is having occasional ventricular dysrhthmias. You review the clients lab results, recalling that which of the following electrolyte development? a. Hypernatremia b. Hypochloremia c. Hypercalcemia d. Hypokalemia Answer: d. Hypokalemia Rationale: The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte (potassium) imbalance increases the electrical instability of the heart. 25. Your client is experiencing an episode of hypoglycemia. You understand that the physiological mechanism that should take place to combat this decline in blood glucose level is: a. Decreased epinephrine release b. Decreased cortisol release c. Increased insulin secretion d. Increases glucagons secretion Answer: d. Increased glucagon secretion Rationale: Glucagon is secreted from the alpha cells in the pancreas in response to declining blood glucose levels. At the same time, hypoglycemia triggers increased cortisol release, increased epinephrine release, and decreased secretion of insulin. 26. One of your LTC residents has been placed on warfarin sodium (Coumadin). You are teaching the client and the family about nutritional considerations while on this medication. Which of the following foods should the resident avoid while taking warfarin sodium (Coumading)? a. Cherries b. Broccoli c. Spaghetti d. Potatoes

Answer: Broccoli Rationale: Anticoagulation medications work by antagonizing the action of vitamin K which is needs for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as broccoli, cabbage, turnip greens, and lettuce. The other options list foods that are lower in vitamin K. 27 You are assisting in developing the plan of care for an elderly client admitted to a LTC facility. You document in the plan of care to place the client in which of the following positions to be best reduce the risk of aspiration during meals? a. On the left side in bed b Upright in a chair c. In low folwers position with legs elevated d. On the right side in bed Answer: Upright in a chair Rationale: Sitting a client upright in a chair will facilitate chewing and swallowing and prevent the reflux of stomach contents. The client should not be placed in low folwers position because this increased the risk of aspiration. Options A and D are also not appropriate positions to prevent aspiration. 28 You are preparing to conduct a presentation about anorexia nervosa and are preparing a handout that lists the characteristics of this disorder. Which of the following characteristics will you list on the handout? a. The individual has a realistic body image but feels that the eating behaviours are out of control b. Body weight is markedly decreased below normal c. The individual may experience feelings of guilt and worthlessness d. The individual may experience a decreased self-esteem Answer: b. Body weight is markedly decreased below normal Rationale: In anorexia nervosa, body weigh is markedly decreased below normal. Option A, C, and D are characteristics of bulimia nervosa. 29. You have been assigned to the care of a client diagnosed with bulimia nervosa. You understand which of the following is unnecessary in the care of the client? a. Observing for excessive exercise b. Checking the clients belongings for laxatives and diuretics c. Monitoring intake and output d. Monitoring electrolyte levels. Answer: a. Observing for excessive exercise Rationale: The client with bulimia nervosa is likely to induce frequent vomiting and use diuretics and laxatives excessively. This puts client at risk for both fluid and electrolyte imbalances. The nurse should monitor for both of these in this client. Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa.

30. You are caring a recently admitted client diagnosed with anorexia nervosa. Upon entering the clients room, you find the client in the middle of a series of set of rapid sit-ups. Which of the following actions would be most appropriate for you to take initially? a. Interrupt the client and offer to take her for a walk b. Interrupt the client and weight her immediately c. Allow the client to complete her exercise program d. Tell the client that she is not allowed to exercise rigorously. Answer: a. Interrupt the client and offer to take her for a walk Rationale: When working with a client with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amount of exercise. Client with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake.