MATERNAL NURSING 1.) Pedro visits the clinic and is told that his sperm count is normal.

A normal sperm count ranges from: A.)20 to 100/ml. B.)100,000 to 200,000/ml C.)100 to 200/ml D.)20 to 100 million/ml Correct ans: D In semen analysis, sperm count varies depending on the male's physical status and sexual activity. The normal value for total sperm count in semen analysis is approximately 20 to 100 million cells/ml. 2.) Female reproductive cells are produced by the: A.)Uterus B.)Fallopian tube C.)Ovaries D.)Pituitary gland Correct ans: C Female reproductive cells, or ova, are produced by the ovaries. Reproductive cells reach the uterus via the fallopian tubes, where conception takes place. The two fallopian tubes are attached to the top of the uterus, one on each side, and extend upward from there, ending near the ovary. The pituitary gland is located in the brain and is a major factor in hormone production and balance 3.) Josie is pregnant for the first time and has type 2 diabetes.She asks the nurse, "What hormone increases throughout pregnancy and may interfere with my insulin dosage?" The nurse answers: A.)Progesterone B.)Estrogen C.)Human Chorionic Gonadotropin (HCG) D.)Human Placental Lactogen (HPL)

Correct ans: D HPL, also called Human Chorionic Somatomammotropin, is produced by the placenta and is antagonistic to insulin. It decreases maternal metabolism of glucose to favor fetal growth and increases the mother's level of free fatty acids. Progesterone and estrogen are ovarian hormones produced by the corpus luteum during early pregnancy. Estrogen is responsible for many of the physiologic changes of pregnancy; progesterone aids in maintenance of the pregnancy and relaxes the smooth muscle. HCG is produced by the placenta and maintains the function of the corpus luteum during early pregnancy. It's the basis for pregnancy tests. 4.) The portion of the uterus whose significant characteristic is to stretch during vaginal birth is the: A.)Corpus B.)Fundus C.)Cervix D.)Dermis Correct ans: C Circular muscle fibers in the cervix stretch to allow for passage of the product of conception. The corpus is the body of the uterus; the fundus is the top portion of the uterus; and the internal os is the portion of the cervix closest to the uterus. 5.)The fetal heart and kidneys are formed from which germ layer? A.)Mesoderm B.)Entoderm C.)Ectoderm D.)Dermis Correct ans: A The mesoderm generates the connective and sclerous tissues, cardiovascular system, musculature, skeleton, spleen, kidneys,

ureters, the wall of the digestive tract, and teeth. The endoderm generates the epithelial layers of the larynx, trachea, bladder, urethra, prostate gland, auditory canal, liver, pancreas, and alimentary canal. The ectoderm generates the epidermis, nervous system, pituitary gland, salivary glands, optic lens, lining of the lower portion of the anal canal, hair, and tooth enamel. The dermis isn't a germ layer. 6.)The structure in the fetus that carries oxygenated blood from the umbilical vein to the inferior vena cava is the: A.)Ductus arteriosus B.)Ductus venosus C.)Foramen Ovale D.)Pulmonary artery Correct ans: B The ductus venosus carries oxygenated blood from the umbilical vein to the inferior vena cava. The ductus arteriosus is the anatomic shunt between the pulmonary artery and the arch of the aorta. The foramen ovale is the opening between atria of the fetal heart. The pulmonary artery arises from the right ventricle of the heart and carries unoxygenated blood to the lungs. 7.) The hormone responsible for the development of the ovum during the menstrual cycle is: A.)Estrogen B.)Progesterone C.)Follicle-stimulating hormone(FSH) D.)Lutenizing hormone (LH) Correct ans: C FSH, which is produced by the pituitary gland, allows the ovarian follicle to grow and develop. Estrogen is responsible for most of the physiologic changes of pregnancy. Progesterone aids in maintenance of the pregnancy and relaxes smooth muscle. LH stimulates ovulation and development of the corpus luteum

8.) WHile discussing the growth and development of the product of conception, a patient asks the nurse, "During what time in my pregnancy is my baby most vulnerable to getting birth defects?" The nurse's response is: A.)"As your baby is forming in the first 2 months because organ development takes place at this time." B.)"Throughout your pregnancy." C.)"Near the end of your pregnancy." D.)"Halfway through your pregnancy:around 20 weeks or 5 months." Correct ans: A Rapid cell division and growth occur during the first 2 months of pregnancy. At the end of the first 8 weeks ( embryonic period), all organ systems and external structures are present. 9.) At prenatal class, Ms. Cruz states that she has just found out that she has a positive pregnancy test. She asks the nurse, "How long does it take before I can feel my baby move?" The correct response is: A.)"You should be feeling movement now." B.)"There is no specific time because every baby is different." C.)"Around 20 weeks, or 5 months' gestation D.)"After the 35th week of pregnancy." Correct ans: C Movement may occur shortly before 20 weeks but usually begins at about this time. 10.) Approximately how many weeks' gestation is a fetus that weighs 1 lb (454g), measures 7 1/2 (19cm) in length, can actively swallow and suck amniotic fluid and has nail on fingers and toes? A.)14 weeks B.)16 weeks C.)20 weeks

D.)24 weeks Correct ans: C 2.) By gestational age 20 weeks, the fetus has developed hands that can form fists and may spend some time sucking on a hand or fist. The fet

MEDICAL-SURGICAL NURSING 50 Items 1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. Hes incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client? a. checking stools for occult blood b. performing range-of-motion exercises to the left side c. keeping skin clean and dry d. elevating the head of the bed to 30 degrees ANS: D Because the clients gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the clients risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority. 2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action: a. destroys the odor-proof seal b. wont affect the colostomy system c. is appropriate for relieving the gas in a colostomy system d. destroys the moisture barrier seal ANS: A

Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas. 3. When assessing the client with celiac disease, the nurse can expect to find which of the following? a. steatorrhea b. jaundiced sclerae c. clay-colored stools d. widened pulse pressure ANS: A Because celiac disease destroys the absorbing surface of the intestine, fat isnt absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesnt cause a widened pulse pressure. 4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because: a. reducing sodium promotes urea nitrogen excretion b. reducing sodium improves her glomerular filtration rate c. reducing sodium increases potassium absorption d. reducing sodium decreases edema ANS: D Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesnt affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isnt affected by sodium intake.

5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the: a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe ANS: D The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbance in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances. 6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect: a. Cushings syndrome b. Diabetes mellitus c. Adrenal crisis d. Diabetes insipidus ANS: D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushings syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension. 7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an

ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: a. limit oral fluid intake for 1 to 2 weeks b. report the presence of fine, sandlike particles through the nephrostomy tube. c. Notify the physician about cloudy or foul-smelling urine d. Report bright pink urine within 24 hours after the procedure ANS: C The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy. 8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. Hes awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6 F (38.1 C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority? a. deficient fluid volume related to osmotic diuresis b. decreased cardiac output related to elevated heart rate c. imbalanced nutrition: Less than body requirements related to insulin deficiency d. ineffective thermoregulation related to dehydration ANS: A A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the clients serum glucose is elevated, food isnt a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of

Imbalanced Nutrition: Less then body requirements isnt appropriate. A temperature of 100.6 F isnt life threatening, eliminating ineffective thermoregulation as the top priority. 9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the doses: a. onset to be at 2 p.m. and its peak at 3 p.m. b. onset to be at 2:15 p.m. and its peak at 3 p.m. c. onset to be at 2:30 p.m. and its peak at 4 p.m. d. onset to be at 4 p.m. and its peak at 6 p.m. ANS: C Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. 10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: a. 52 mm Hg b. 88 mm Hg c. 48 mm Hg d. 68 mm Hg ANS: A CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the following formula: MAP = ((diastolic blood pressure x 2) + systolic blood pressure) /

3 MAP = ((60 x2) + 90) / 3 MAP = 70 mmHg To find the CPP, subtract the clients ICP from the MAP; in this case , 70 mmHg 18 mmHg = 52 mmHg. 11. A 52 yr-old female tells the nurse that she has found a painless lump in her right breast during her monthly selfexamination. Which assessment finding would strongly suggest that this clients lump is cancerous? a. eversion of the right nipple and a mobile mass b. nonmobile mass with irregular edges c. mobile mass that is oft and easily delineated d. nonpalpable right axillary lymph nodes ANS: B Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple retractionnot eversionmay be a sign of cancer. A mobile mass that is soft and easily delineated is most often a fluid-filled benigned cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. 12. A Client is scheduled to have a descending colostomy. Hes very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? a. Social worker b. registered dietician c. occupational therapist d. enterostomal nurse therapist ANS: D An enterostomal nurse therapist is a registered nurse who has received advance education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist

with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. 13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture? a. basilar b. temporal c. occipital d. parietal ANS: A Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done. 14. A male client should be taught about testicular examinations: a. when sexual activity starts b. after age 60 c. after age 40 d. before age 20 ANS: D Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular selfexamination before age 20, preferably when he enters his teens. 15. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review? A. fluid intake for the last 24 hours B. baseline arterial blood gas (ABG) levels C. prior outcomes of weaning D. electrocardiogram (ECG) results ANS: B

Before weaning a client from mechanical ventilation, its most important to have a baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the clients record, and the nurse can refer to them before the weaning process begins. 16. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women: A. perform breast self-examination annually B. have a mammogram annually C. have a hormonal receptor assay annually D. have a physician conduct a clinical evaluation every 2 years ANS: B According to the ACS guidelines, Women older than age 40 should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesteronedependent. 17. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from: A. esophageal perforation B. pulmonary hypertension C. portal hypertension D. peptic ulcers ANS: C Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus.

Bleeding associated with esophageal varices doesnt stem from esophageal perforation, pulmonary hypertension, or peptic ulcers. 18. A 49-yer-old client was admitted for surgical repair of a Colles fracture. An external fixator was placed during surgery. The surgeon explains that this method of repair: A. has very low complication rate B. maintains reduction and overall hand function C. is less bothersome than a cast D. is best for older people ANS: B Complex intra-articular fractures are repaired with external fixators because they have a better long-term outcome than those treated with casting. This is especially true in a young client. The incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must be taught how to do pin care and assess for development of neurovascular complications. 19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction? A. Be sure to eat meat at every meal. B. Monitor your fruit intake and eat plenty of bananas. C. Restrict your salt intake. D. Drink plenty of fluids. ANS: C In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in Protein), bananas (high in potassium), and fluid because the kidneys cant secrete adequate urine.

20. The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. Shes in her 30s and has tow children. Although shes worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping? A. Tell the clients spouse or partner to be supportive while she recovers. B. Encourage the client to proceed with the next phase of treatment. C. Recommend that the client remain cheerful for the sake of her children. D. Refer the client to the American Cancer Societys Reach for Recovery program or another support program. ANS: D The client isnt withdrawn or showing other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the clients spouse or partner to listen to concerns, but the nurse shouldnt tell the clients spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She cant be expected to be cheerful at all times. 21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The nurses explanation to the client should include the fact that: A. The test will evaluate prostatic function. B. The test was ordered to identify the site of a possible infection. C. The test was ordered because clients who have testicular cancer has elevated levels of HCG. D. The test was ordered to evaluate the testosterone level.

ANS: C HCG is one of the tumor markers for testicular cancer. The HCG level wont identify the site of an infection or evaluate prostatic function or testosterone level. 22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals: A. A skin rash. B. Peripheral edema. C. A dry cough. D. Postural hypotension. ANS: B Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but the dont indicate that therapy isnt effective. 23. Which assessment finding indicates dehydration? A. Tenting of chest skin when pinched. B. Rapid filling of hand veins. C. A pulse that isnt easily obliterated. D. Neck vein distention ANS: A Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isnt easily obliterated and neck vein distention indicate fluid overload, not dehydration. 24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: A. Avoid focusing on his weight.

B. Increase his activity level. C. Follow a regular diet. D. Continue leading a high-stress lifestyle. ANS: B The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, lowsodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 25. For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? A. Administer aspirin if the temperature exceeds 38.8 C. B. Inspect the skin for petechiae once every shift. C. Provide for frequent periods of rest. D. Place the client in strict isolation. ANS: B Because thrombocytopenia impairs blood clotting, the nurse should assess the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it can increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact. 26. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has: A. poor peripheral perfusion B. a possible Hematologic problem C. a psychosomatic disorder D. left-sided heart failure

ANS: B SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesnt indicate the clients overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a Hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isnt enough data to assume that the clients problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles. 27. For a client in addisonian crisis, it would be very risky for a nurse to administer: A. potassium chloride B. normal saline solution C. hydrocortisone D. fludrocortisone ANS: A Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones. 28. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature: A. lymphocytes B. thrombocytes C. reticulocytes D. leukocytes ANS: D Leukemia is manifested by an abnormal overpopulation of

immature leukocytes in the bone marrow. 29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis? A. Putting on sterile gloves then opening a container of sterile saline. B. Cleaning the wound with a circular motion, moving from outer circles toward the center. C. Changing the sterile field after sterile water is spilled on it. D. Placing a sterile dressing (1.3 cm) from the edge of the sterile field. ANS: C A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, arent sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated areafor example, from the center outward. The outer inch of a sterile field shouldnt be considered sterile. 30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following? A. high volumes of fluid intake B. aerobic exercise programs C. caffeine-containing products D. foods rich in protein ANS: C Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High- fluid intake helps maintain adequate preload and

cardiac output. Aerobic exercise helps in increase cardiac output and decrease heart rate. Protein-rich foods arent restricted but high-calorie foods are. 31. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the clients hypertension is caused by excessive hormone secretion from which organ? A. adrenal cortex B. pancreas C. adrenal medulla D. parathyroid ANS: A Excessive of aldosterone in the adrenal cortex is responsible for the clients 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 cathecolaminesepinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. 32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus, hypertension, pernicious anemia, and appendectomy. Shes admitted to the hospital and undergoes mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which history finding is a major risk factor for infective endocarditis? A. appendectomy B. pernicious anemia C. diabetes mellitus D. valve replacement ANS: D A heart valve prosthesis, such as a mitral valve replacement, is a major risk factor for infective endocarditis. Other risk factors

include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, IV drug abuse, and immunosuppression. Although diabetes mellitus may predispose a person to cardiovascular disease, it isnt a major risk factor for infective endocarditis, nor is an appendectomy or pernicious anemia. 33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past two years. Shes fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most appropriate for this client? A. Deficient fluid volume related to inability to conserve water B. Imbalanced nutrition: less than body requirements related to hypermetabolic state C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia D. Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency ANS: A The client has signs and symptoms of diabetes insipidus, probably caused by the failure of her renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. The hypernatremia is secondary to her water loss. Imbalanced nutrition related to hypermetabolic state or catabolic effect of insulin deficiency is an inappropriate nursing diagnosis for the client. 34. A 20 yr-old woman has just been diagnosed with Crohns disease. She has lost 10 lb (4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment? A. Let the client eat as desired during the hospitalization. B. Weight the client daily.

C. Ask the client to list what she eats during a typical day. D. Place the client on I & O status and draw blood for electrolyte levels. ANS: C When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldnt be permitted to eat as desired. Weighing the client daily, placing her on I & O status, and drawing blood to determine electrolyte level arent part of a nutritional assessment. 35. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Graves disease? A. Keep an accurate record of intake and output. B. Use nasal desmopressin acetate DDAVP). C. Be sure to get regulate follow-up care. D. Be sure to exercise to improve cardiovascular fitness. Regular follow-up care for the client with Graves disease is critical because most cases eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the clients ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. While exercise to improve cardiovascular fitness is important, for this client the importance of regular follow-up is most critical. 36. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time? A. Deficient knowledge related to interventions used to treat acute

illness B. Impaired physical mobility related to complete bed rest C. Social isolation related to restricted visiting hours in the intensive care unit D. Anxiety related to the threat of death ANS: D Anxiety related to the threat of death is an appropriate nursing diagnosis because the clients anxiety can adversely affect hear rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death is a real and immediate concern. Unless anxiety is dealt with first, the clients emotional state will impede learning. Client teaching should be limited to clear concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the deficient knowledge would continue despite attempts t teaching. Impaired physical mobility and social isolation are necessitated by the clients critical condition; therefore, they arent considered problems warranting nursing diagnoses. 37. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care? A. Putting on a mask when entering the clients room. B. Instructing the client to wear a mask at all times C. Wearing a gown and gloves when providing direct care D. Keeping the door to the clients room open to observe the client ANS: A Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the clients room. Having the client wear a mask at all the times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the clients blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in

a room with laminar air flow, and the door should be closed at all times. 38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should: A. Apply suction to the NG tube every hour. B. Clamp the NG tube if the client complains of nausea. C. Irrigate the NG tube gently with normal saline solution. D. Reposition the NG tube if pulled out. ANS: C The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously, not every hour. The NG tube shouldnt be clamped postoperatively because secretions and gas will accumulate, stressing the suture line. 39. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)? A. administer 2 to 3 L of IV fluid rapidly B. administer 6 L of IV fluid over the first 24 hours C. administer a dextrose solution containing normal saline solution D. administer IV fluid slowly to prevent circulatory overload and collapse ANS: A Regardless of the clients medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in case of hypovolemic shock), isotonic normal saline solution and, when the

client is stabilized, hypotonic half-normal saline solution. 40. Which of the following is an adverse reaction to glipizide (Glucotrol)? A. headache B. constipation C. hypotension D. photosensitivity ANS: D Glipizide may cause adverse skin reactions, such as pruritus, and photosensitivity. It doesnt cause headache, constipation, or hypotension. 41. The nurse is caring for four clients on a step-down intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who: A. has a respiratory infection B. is intubated and on a ventilator C. has pleural chest tubes D. is receiving feedings through a jejunostomy tube ANS: B When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artificial airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. Whit standard procedures the other choices wouldnt be at high risk. 42. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching? A. Make inhalation longer than exhalation. B. Exhale through an open mouth.

C. Use diaphragmatic breathing. D. Use chest breathing. ANS: C In chronic bronchitis, the diaphragmatic is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathingnot chest breathingincreases lung expansion. 43. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isnt answered immediately. The most appropriate response to her would be: A. You seem angry. Would you like to talk about it? B. Calm down. You know that stress will make your symptoms worse. C. Would you like to talk about the problem with the nursing supervisor? D. I can see youre angry. Ill come back when youve calmed down. ANS: A Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesnt acknowledge her feelings. Offering to get the nursing supervisor also doesnt acknowledge the clients feelings. Ignoring the clients feelings suggest that the nurse has no interest in what the client has said.

44. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relive symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure? A. Taking daily walks. B. Engaging in anaerobic exercise. C. Reducing daily fat intake to less than 45% of total calories D. Avoiding foods that increase levels of high-density lipoproteins (HDLs) ANS: A Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels. 45. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the suction to be: A. low pressure and intermittent B. low pressure and continuous C. high pressure and continuous D. high pressure and intermittent ANS: A Gastric decompression is typically low pressure and intermittent. High pressure and continuous gastric suctioning predisposes the gastric mucosa to injury and ulceration.

46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis? A. Risk for injury B. Impaired urinary elimination C. Ineffective breathing pattern D. Imbalanced nutrition: less than body requirements ANS: A In osteoarthritis, stiffness is common in large, weight bearing joints such as the hips. This joint stiffness alters functional ability and range of motion, placing the client at risk for falling and injury. Therefore, client safety is in jeopardy. Osteoporosis doesnt affect urinary elimination, breathing, or nutrition. 47. Parathyroid hormone (PTH) has which effects on the kidney? A. Stimulation of calcium reabsorption and phosphate excretion B. Stimulation of phosphate reabsorption and calcium excretion C. Increased absorption of vit D and excretion of vit E D. Increased absorption of vit E and excretion of Vit D ANS: A PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vit D to its active form: 1 , 25 dihydroxyvitamin D. PTH doesnt have a role in the metabolism of Vit E. 48. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip replacement surgery. Which home assessment finding warrants health promotion teaching from the nurse? A. A bathroom with grab bars for the tub and toilet B. Items stored in the kitchen so that reaching up and bending down arent necessary C. Many small, unsecured area rugs D. Sufficient stairwell lighting, with switches t the top and bottom of the stairs

ANS: C The presence of unsecured area rugs poses a hazard in all homes, particularly in one with a resident at high risk for falls. 49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, I dont need surgerythis will go away on its own. In considering her response to the client, the nurse must depend on the ethical principle of: A. beneficence B. autonomy C. advocacy D. justice ANS: B Autonomy ascribes the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence and justice arent the principles that directly relate to the situation. Advocacy is the nurses role in supporting the principle of autonomy. 50. Which of the following is t he most critical intervention needed for a client with myxedema coma? A. Administering and oral dose of levothyroxine (Synthroid) B. Warming the client with a warming blanket C. Measuring and recording accurate intake and output D. Maintaining a patent airway ANS: D Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Thyroid

replacement will be administered IV. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldnt be used because it may cause vasodilation and shock. Gradual warming blankets would be appropriate. Intake and output are very important but arent critical interventions at this time.