Question 1
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
A) Additional potassium will be given IV
B) Blood for coagulation studies will be drawn
C) Total parenteral nutrition (TPN) will be started
D) Serum lipase levels will be evaluated
Review Information: The correct answer is C: Total parenteral nutrition (TPN) will be started. The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
Question 2
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
A) Decreased breath sounds in right lower lobe
B) Aspiration of a residual of 100cc of formula
C) Decrease in bowel sounds
D) Urine output of 250 cc in past 8 hours
Review Information: The correct answer is A: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
Question 3
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
A) Explain that the procedure will help him to get well
B) Show a cartoon character with a blood pressure cuff
C) Explain that the blood pressure checks the heart pump
D) Permit handling the equipment before putting the cuff in place
Review Information: The correct answer is D: Permit handling the equipment before putting the cuff in place The best way to gain the toddler''s cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
Question 4
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, “I refuse both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to
A) document the situation in the notes
B) report the situation to the health care provider
C) talk with the client's family about the situation
D) ask the client to talk about concerns regarding "hot" treatments
Review Information: The correct answer is D: ask the client to talk about concerns regarding "hot" treatments The "hot-cold" system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages, herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this framework.
Question 5
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
A) Benzodiazepines
B) Chlorpromazine (Thorazine)
C) Succinylcholine (Anectine)
D) Thiopental sodium (Pentothal Sodium)
Review Information: The correct answer is C: Succinylcholine (Anectine) Succinylcholine is given intravenously to promote skeletal muscle relaxation.
Question 6
Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct?
A) It is to observe reactive service and product problem solving
B) Improvement of the processes in a proactive, preventive mode is paramount
C) A chart audits to finds common errors in practice and outcomes associated with goals
D) A flow chart to organize daily tasks is critical to the initial stages
Review Information: The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount Total quality management and continuous quality improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem-solving.
Question 7
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
A) "He has been taking long naps for a week."
B) "He has had an ear infection for the past 2 days."
C) "He has been eating more red meat lately."
D) "He seems to be going to the bathroom more frequently."
Review Information: The correct answer is B: "He has had an ear infection for the past 2 days." Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.
Question 8
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
A) high fever
B) nausea
C) face and neck edema
D) night sweats
Review Information: The correct answer is B: nausea Because the client with Hodgkin''s disease is usually healthy when therapy begins, the nausea is especially troubling.
Question 9
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
A) Short-term relief can be expected
B) The medication acts as a stimulant
C) Dosage will be increased as tolerated
D) Initial side effects often continue
Review Information: The correct answer is A: Short-term relief can be expected Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
Question 10
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
A) 1 year of age
B) 2 years of age
C) 3 years of age
D) 4 years of age
Review Information: The correct answer is B: 2 years of age A child should be at least 2 years of age to use the radial pulse to assess heart rate.
