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QUESTIONS: for physiological adaptation
1. Nurse Fiona is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize?
a. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses
b. Store the drug in a cool, well-lit place
c. Lie down or sit in a chair for 5 to 10 minutes after taking the drug
d. Restrict alcohol intake to two drinks per day
2. After an amniotomy, nurse Sally is aware that the client goal should take the highest priority?
a. The client will express increased knowledge about amniotomy
b. The client will maintain adequate fetal tissue perfusion
c. The client will display no signs of infection
d. The client will report relief of pain
3. A client is admitted with suspected cirrhosis. During assessment, nurse Lennie is most likely to detect:
a. an increase in chest hair
b. muscle wasting
c. testicular hypertrophy
d. an increased clotting tendency
4. A male client on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?
a. Leg movement
b. Finger movement
c. Lip movement
d. Fighting the ventilator
5. When inspecting a client’s skin, nurse Kate finds a vesicle on the client’s arm. Which description applies to a vesicle?
a. Flat, nonpalpable, and colored
b. Solid, elevated, and circumscribed
c. Circumscribed, elevated, and filled with serous fluid
d. Elevated, pus-filled, and circumscribed
6. Nurse Jinky is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:
a. elevate the client’s head to 90 degrees
b. press the right upper abdomen
c. press the left upper abdomen
d. lie the client flat in bed
7. A male client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonnarcotic antitussive agents. Dr. Rodriguez prescribes codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?
a. It’s a centrally acting antitussive and doesn’t cause dependence
b. It’s a peripherally acting antitussive and doesn’t cause dependence
c. It’s a centrally acting antitussive and can cause dependence
d. It’s a peripherally acting antitussive and can cause dependence
8. A client with human immunodeficiency virus (HIV) infection delivers a neonate. When assessing the neonate, nurse Edwin is most likely to detect:
a. skin vesicles
b. limb dysmorphism
c. conjunctivitis
d. hepatosplenomegaly
9. Nurse Ronald 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
10. Nurse Maureen notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:
a. is responding to the antipsychotic
b. may be experiencing increased energy and is at an increased risk for suicide
c. is ready to be discharged from treatment
d. is experiencing a split personality
11. When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, nurse Yvette should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate?
a. Neonates: 10.6 to 16.5 g/dl
b. 3 months: 10.6 to 16.5 g/dl
c. 3 years: 9.4 to 15.5 g/dl
d. 10 years: 10.7 to 15.5 g/dl
12. A female client is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
a. Calcium and sodium
b. Calcium and phosphorous
c. Phosphorous and potassium
d. Potassium and sodium
13. A client who used heroin during her pregnancy delivers a neonate. When assessing the neonate, nurse Diana expects to find:
a. lethargy 2 days after birth
b. irritability and poor sucking
c. a flattened nose, small eyes, and thin lips
d. congenital defects such as limb anomalies
14. A male adult client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
a. Give the feedings at room temperature
b. Decrease the rate of feedings and the concentration of the formula
c. Place the client in semi-Fowler’s position while feeding
d. Change the feeding container every 12 hours
15. The role of nurse Hans regarding complementary and alternative medicine (CAM) should include:
a. Recommending herbal remedies that the client should use
b. Educating the client about “good” versus “bad” therapies
c. Discouraging the client from using any alternative therapies
d. Educating the client about therapies that he or she is using or is interested in using
16. An antihypertensive medication has been prescribed for a client with hypertension. The client tells nurse Michelle that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action?
a. Tell the client that herbal substances are not safe and should never be used.
b. Advise the client to discuss the use of an herbal substance with the physician
c. Teach the client how to take her blood pressure so that it can be monitored closely.
d. Tell the client that id she takes the herbal substance she will need to have her blood pressure checked frequently.
17. Nurse Jonathan understands that which of the following statements regarding herbal therapies is true?
a. Zinc is used for insomnia
b. Ginger is used to improve memory
c. Echinacea is used for erectile dysfunction
d. Black cohosh produces estrogen-like effects.
18. Nurse Angel has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that the client is not injured. After completing the incident report, the nurse should take which action next?
a. Reassess the client
b. Conduct a staff meeting to describe the fall
c. Document in the nurse’s notes that an incident report was completed
d. Contact the nursing supervisor to update information regarding the fall
19. Nurse Michael is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800mL daily.” The nurse understands that this type of fluid loss can occur through:
a. The skin
b. Urinary output
c. Wound drainage
d. The gastrointestinal tract
20. Nurse Deric is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?
a. A client with a colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client receiving frequent wound irrigations
21. Nurse Dominique caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition?
a. Lung congestion
b. Decreased hematocrit
c. Increased blood pressure
d. Decreased central venous pressure (CVP)
22. Nurse Joy is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?
a. The client taking diuretics
b. The client with renal failure
c. The client with an ileostomy
d. The client who requires gastrointestinal suctioning
23. Nurse Stephanie is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expects to note in this client if excess fluid volume is present?
a. Weight loss
b. Flat neck and hand veins
c. An increase in blood pressure
d. A decreased central venous pressure (CVP)
24. Nurse Rivette is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because the client:
a. Has renal failure
b. Requires nasogastric suction
c. Has a history of Addison’s disease
d. Is taking a potassium-sparing diuretic
25. Nurse Louie reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?
a. U waves
b. Absent P waves
c. Elevated T waves
d. Elevated ST segment
ANSWERS: for physiological adaptation
1. C. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.
2. B. Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus’s life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.
3. B. Cirrhosis causes muscle wasting, a decrease in chest and axillary hair, testicular atrophy, and an increased bleeding tendency.
4. D. Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the client needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, fingers, or lips has no effect on the ventilator and therefore isn’t used to determine the need for another dose.
5. C. A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.
6. B. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux.
7. C. As a centrally acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is a narcotic, it can cause dependence.
8. D. A neonate with HIV infection typically has hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations, and neurologic abnormalities. The other options aren’t typical findings in neonates with HIV infection.
9.C. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be 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 breathing — not chest breathing — increases lung expansion.
10. B. As antidepressants take effect, individuals suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Option A is incorrect because Elavil is an antidepressant, not an antipsychotic. The client shouldn’t be discharged until the risk of suicide has diminished. The elevated mood is a response to the antidepressant, not a split personality.
11. A. To sustain them until active erythropoiesis begins, neonates have Hb concentrations higher than those of older children. The normal value of Hb for neonates is 18 to 27 g/dl. Disease as well as such nonpathologic conditions as age, sex, altitude, and the degree of fluid retention or dehydration can affect Hb values. The values for a 3-month-old, a 3-year-old, and a 10-year-old are correct as stated above.
12. B. In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren’t involved in the development of osteoporosis.
13. B. Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn’t associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn’t been linked to specific congenital anomalies.
14. B. Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client’s discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client’s bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours.
15. D. Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse’s role.
16. B. Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the physician.
17. D. Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting.
18. A. The client’s fall should be treated as private information and shared on a “need to know” basis. Communication regarding the event should involve only those participating in the client’s care. An incident report is a problem-solving document; however, its completion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client’s fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall.
19. A. Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs.
20. A. Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume.
21. D. Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP.
22. B.The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.
23. C. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit.
24. B. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison’s disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.
25. A. A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.
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