A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner

QUESTION 751A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner

 

describes the limp as a “Trendelenburg gait.” This gait is characteristic of:

 

A. Scoliosis

 

B. Dislocated hip

 

C. Fractured femur

 

D. Fractured pelvis

 

QUESTION 752A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most

 

accurate measure to include in his care?

 

A. Weigh the child twice daily on the same scale.

 

B. Monitor intake and output.

 

C. Check urine specific gravity of each voiding.

 

D. Observe for edema.

 

QUESTION 753The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:

 

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A. Discussing their needs with the nursing staff

 

B. Discussing their needs with other family members

 

C. Seeking support from their minister

 

D. Refusing to participate in the child’s care

 

QUESTION 754A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip.

 

Which of the following nursing interventions would be appropriate during the first 24 hours?

 

A. Position on side or abdomen.

 

B. Maintain elbow restraints in place unless she is being directly supervised.

 

C. Clean suture line every shift.

 

D. Offer pacifier when she cries.

 

QUESTION 755A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother

 

stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are

 

appropriate. Which nursing diagnosis should have priority?

 

A. Altered nutrition: less than body requirements related to inability to take in adequate calories

 

B. Altered growth and development related to decreased intake of food

 

C. Activity intolerance related to imbalance between oxygen supply and demand

 

D. Decreased cardiac output related to ineffective pumping action of the heart

 

QUESTION 756A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the

 

child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care

 

plan. Which of these nursing diagnoses should have top priority during the first 2448 hours postburn?

 

A. Pain related to tissue damage from burns

 

B. Potential for infection related to contamination of wounds

 

C. Fluid volume deficit related to increased capillary permeability

 

D. Potential for impaired gas exchange related to edema of respiratory tract

 

QUESTION 757A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby’s condition.

 

The nurse knows that the pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been consulted but has not yet seen the

 

baby. What should the nurse do first?

 

A. Call the orthopedist and request that he come to see the baby now.

 

B. Question the mother and find out what the pediatrician has told her about the baby’s condition.

 

C. Tell the mother that this is not a serious condition.

 

D. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces.

 

QUESTION 758Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:

 

A. Mothers carry the gene and pass it to their sons

 

B. Fathers carry the gene and pass it to their daughters

 

C. Both parents must have the disease for a child to have the disease

 

D. Both parents must be carriers for a child to have the disease

 

QUESTION 759Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in,

 

circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:

 

A. Transport of glucose into body cells and storage of glycogen in the liver

 

B. Glycogenolysis and facilitation of glucose use for energy

 

C. Glycogenolysis and catabolism

 

D. Catabolism and hyperglycemia

 

QUESTION 760A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and

 

lunch at noon. What time should he expect the greatest risk for hypoglycemia?

 

A. 9 AM

 

B. 1 PM

 

C. 11 AM

 

D. 3 PM

 

QUESTION 761A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to

 

attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:

 

A. “You should ask your doctor about this.”

 

B. “Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin.”

 

C. “No, do not increase your insulin. Exercise will not affect your insulin needs.”

 

D. “No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells.”

 

QUESTION 762The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a

 

short-acting insulin is:

 

A. Novolin Regular

 

B. Humulin NPH

 

C. Lente Beef

 

D. Protamine zinc insulin

 

QUESTION 763When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?

 

A. NPH

 

B. Human or pork

 

C. Regular

 

D. Long acting

 

QUESTION 764A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium.

 

Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

 

A. Hematocrit, hemoglobin, and white blood cell (WBC) count

 

B. Blood urea nitrogen, electrolytes, and creatinine

 

C. Glucose, glucose tolerance test, and random blood sugar

 

D. X-rays, electroencephalogram, and electrocardiogram(ECG)

 

QUESTION 765A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:

 

A. Notify the physician immediately

 

B. Hold the morning lithium dose and continue to observe the client

 

C. Administer the morning lithium dose as scheduled

 

D. Obtain an order for benztropine (Cogentin)

 

QUESTION 766A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days

 

ago, and that now he is starting to “feel kind of shaky.” Based on the information given above, nursing care goals for this client will initially focus on:

 

A. Self-concept problems

 

B. Interpersonal issues

 

C. Ineffective coping skills

 

D. Physiological stabilization

 

QUESTION 767One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, “It’s really not all my fault that I have a drinking problem. Alcoholism runs in

 

my family. Both my grandfather and father were heavy drinkers.” The nurse’s best response would be:

 

A. “That might be a problem. Tell me more about them.”

 

B. “Risk factors can often be controlled by self-responsibility.”

 

C. “It sounds like you’re intellectualizing your drinking problem.”

 

D. “Your grandfather and father were both alcoholics?”

 

QUESTION 768A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program.

 

Nursing interventions for the teenager will most likely include:

 

A. Establishing routine tasks and activities around mealtimes

 

B. Administering medications such as lithium

 

C. Requiring the client to eat more during meals

 

D. Checking the client’s room frequently

 

QUESTION 769A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

 

A. Accepting her present body image

 

B. Verbalizing realistic feelings about her body

 

C. Having an improved perception of her body image

 

D. Exhibiting increased self-esteem

 

QUESTION 770A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood

 

swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse,

 

“Nobody in here seems to really care about the clients. I thought nurses cared about people!” The client is exhibiting the ego defense mechanism:

 

A. Reaction formation

 

B. Rationalization

 

C. Splitting

 

D. Sublimation

 

QUESTION 771A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most

 

effective response would be:

 

A. “How can you say that I don’t care? We just met.”

 

B. “What makes you think the nurses don’t care?”

 

C. “You will feel differently about us in a few days.”

 

D. “You seem angry. Tell me more about how you feel.”

 

QUESTION 772A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are

 

routinely administered either before or during ECT?

 

A. Thioridazine (Mellaril), lithium, and benztropine

 

B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)

 

C. Sodium, potassium, and magnesium

 

D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)

 

QUESTION 773A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO)

 

inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

 

A. Potassium-rich foods

 

B. Tryptophan

 

C. Tyramine

 

D. Saturated fats

 

QUESTION 774The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:

 

A. Oculogyric crisis

 

B. Hypertensive crisis

 

C. Orthostatic hypotension

 

D. Tardive dyskinesia

 

QUESTION 775A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic.

 

The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day.

 

During a recent clinic visit, she says to the nurse, “I can’t stay still at night. I toss and turn and can’t fall asleep.” The nurse suspects that she may be experiencing:

 

A. Akathisia

 

B. Akinesia

 

C. Dystonia

 

D. Opisthotonos

 

QUESTION 776On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking “the blue pill” (haloperidol) in the morning and evening, and “the white

 

pill” (benztropine) right before bedtime. The nurse might suggest to the client that she try:

 

A. Doubling the daily dose of benztropine

 

B. Decreasing the haloperidol dosage for a few days

 

C. Taking the benztropine in the morning

 

D. Taking her medication with food or milk

 

QUESTION 777A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she

 

wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client’s:

 

A. Level of insight

 

B. Thought processes

 

C. Mood and affect

 

D. Abstracting abilities

 

QUESTION 778The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared

 

to an adult, include:

 

A. Fewer alveoli, slower respiratory rate

 

B. Diaphragmatic breathing, larger volume of air

 

C. Larger number of alveoli, diaphragmatic breathing

 

D. Rounded shape of chest, smaller volume of air

 

QUESTION 779A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

 

A. A productive cough

 

B. Expiratory stridor

 

C. Drooling

 

D. Crackles in the lower lobes

 

QUESTION 780Which of the following nursing care goals has the highest priority for a child with epiglottitis?

 

A. Sleep or lie quietly 10 hr/day.

 

B. Consume foods from all four food groups.

 

C. Be afebrile throughout her hospital stay.

 

D. Participate in play activities 4 hr/day.

 

QUESTION 781Which of the following nursing orders has the highest priority for a child with epiglottitis?

 

A. Vital signs every shift

 

B. Tracheostomy set at bedside

 

C. Intake and output

 

D. Specific gravity every shift

 

QUESTION 782Often children are monitored with pulse oximeter. The pulse oximeter measures the:

 

A. O2 content of the blood

 

B. Oxygen saturation of arterial blood

 

C. PO2

 

D. Affinity of hemoglobin for O2

 

QUESTION 783A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse

 

suspects that he may have been physically abused. In accordance with the law, the nurse must:

 

A. Tell the physician her concerns

 

B. Report her suspicions to the authorities

 

C. Talk to the child’s father

 

D. Confront the child’s mother

 

QUESTION 784The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse

 

knows that his:

 

A. Behavior is not normal, and a child psychiatrist should be consulted.

 

B. Mother is lying to protect herself.

 

C. Lying is normal behavior for a preschool child who is learning to separate fantasy from reality.

 

D. Behavior indicates a developmental delay, because preschoolers should be able to tell right from wrong.

 

QUESTION 785A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child’s case manager knows that treatment has been

 

effective when:

 

A. The child is removed from the home and placed in foster care

 

B. The child’s parents identify the ways in which he is different from the rest of the family

 

C. The child’s father is arrested for child abuse

 

D. The child’s parents can identify appropriate behaviors for children in his age group

 

QUESTION 786Nursing assessment of early evidence of septic shock in children at risk includes:

 

A. Fever, tachycardia, and tachypnea

 

B. Respiratory distress, cold skin, and pale extremities

 

C. Elevated blood pressure, hyperventilation, and thready pulses

 

D. Normal pulses, hypotension, and oliguria

 

QUESTION 787A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

 

A. Disorientation

 

B. Low-grade fever

 

C. Diarrhea

 

D. Hypertension

 

QUESTION 788One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children

 

is:

 

A. Blood pressure

 

B. Level of consciousness

 

C. Skin turgor

 

D. Fluid intake

 

QUESTION 789A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the

 

foods which are included in a:

 

A. Lactose-restricted diet

 

B. Gluten-restricted diet

 

C. Phenylalanine-restricted diet

 

D. Fat-restricted diet

 

QUESTION 790An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing

 

the admission assessment, the nurse would expect to observe which of the following:

 

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A. Both lower extremities warm to touch with 2_pedal pulses

 

B. Both lower extremities cyanotic when placed in a dependent position

 

C. Decreased or absent pedal pulse in the left leg

 

D. The left leg warmer to touch than the right leg

 

QUESTION 791A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

 

A. Validate that he is not allergic to iodine or shellfish.

 

B. Instruct him to start active range of motion of his left leg immediately following the procedure.

 

C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.

 

D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.

 

QUESTION 792A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this

 

medication:

 

A. Dissolves any clots already formed in the arteries

 

B. Prevents the conversion of prothrombin to thrombin

 

C. Interferes with the synthesis of vitamin K-dependent clotting factors

 

D. Stimulates the manufacturing of platelets

 

QUESTION 793A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching

 

concerning the warfarin therapy?

 

A. “If you forget to take your morning dose, double the night time dose.”

 

B. “You should take aspirin instead of acetaminophen (Tylenol) for headaches.”

 

C. “Carry a medications alert card with you at all times.”

 

D. “You should use a straight-edge razor when shaving your arms and legs.”

 

QUESTION 794A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the

 

following priority nursing diagnosis–Alteration in comfort, pain related to:

 

A. Increased excretion of lactic acid due to myocardial hypoxia

 

B. Increased blood flow through the coronary arteries

 

C. Decreased stimulation of the sympathetic nervous system

 

D. Decreased secretion of catecholamines secondary to anxiety

 

QUESTION 795Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the

 

morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?

 

A. Increased level of consciousness

 

B. Increased rate and depth of respirations

 

C. Increased peripheral vasodilation

 

D. Increased perception of pain

 

QUESTION 796A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions

 

immediately after he returns to his room?

 

A. Place him on NPO restriction for 4 hours.

 

B. Monitor the catheterization site every 15 minutes.

 

C. Place him in a high Fowler position.

 

D. Ambulate him to the bathroom to void.

 

QUESTION 797The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80

 

mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?

 

A. Serum electrolytes

 

B. Arterial blood gases

 

C. Complete blood count

 

D. 12-Lead ECG

 

QUESTION 798Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following

 

statements by the client would validate an understanding of his medication?

 

A. “I would notify my physician immediately if I experience nausea, vomiting, and double vision.”

 

B. “I could stop taking this medication when I begin to feel better.”

 

C. “I should only take the medication if my heart rate is greater than 100 bpm.”

 

D. “I should always take this medication with an antacid.”

 

QUESTION 799When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this

 

rash?

 

A. Small round or oval reddish brown macules scattered over the entire body

 

B. Scattered clusters of macules, papules, and vesicles over the body

 

C. Bright red appearance of the palmar surface of the hands

 

D. Reddened butterfly shaped rash over the cheeks and nose

 

QUESTION 800The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, “I get them whenever I bump into anything.” The

 

nurse would expect to note a decrease in which of the following laboratory tests?

 

A. Number of platelets

 

B. WBC count

 

C. Hemoglobin level

 

D. Number of lymphocytes

 

QUESTION 801A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?

 

A. Increase your oral intake of fluids to at least 4000 mL every day.

 

B. Avoid contact with people who have contagious illnesses.

 

C. Brush your teeth at least 4 times a day with a firm toothbrush.

 

D. Immediately stop taking the prednisone if you feel depressed.

 

QUESTION 802During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec’s cirrhosis of the liver. The nurse knows the

 

pruritus is directly related to:

 

A. A loss of phagocytic activity

 

B. Faulty processing of bilirubin

 

C. Enhanced detoxification of drugs

 

D. The formation of collateral circulation

 

QUESTION 803Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his

 

speech pattern. Which of the following foods would be appropriate for his bedtime snack?

 

A. Fresh fruit

 

B. A milkshake

 

C. Saltine crackers and peanut butter

 

D. A ham and cheese sandwich

 

QUESTION 804Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his

 

speech pattern. Which of the following foods would be appropriate for his bedtime snack?

 

A. Fresh fruit

 

B. A milkshake

 

C. Saltine crackers and peanut butter

 

D. A ham and cheese sandwich

 

QUESTION 805A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:

 

A. Prevent systemic infection

 

B. Promote diuresis

 

C. Decrease ammonia formation

 

D. Acidify the small bowel

 

QUESTION 806The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly–High risk for injury: Increased susceptibility

 

to bleeding related to:

 

A. Increased absorption of vitamin K

 

B. Thrombocytopenia due to hypersplenism

 

C. Diminished function of the Kupffer cells

 

D. Increased synthesis of the clotting factors

 

QUESTION 807A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn

 

on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as:

 

A. Compensated metabolic alkalosis

 

B. Respiratory acidosis

 

C. Partially compensated metabolic alkalosis

 

D. Combined respiratory and metabolic acidosis

 

QUESTION 808Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of

 

dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:

 

A. Remove the potassium from the body by renin exchange

 

B. Protect the myocardium from the effects of hypokalemia

 

C. Promote rapid protein catabolism

 

D. Drive potassium from the serum back into the cells

 

QUESTION 809The nurse writes the following nursing diagnosis for a client in acute renal failure–Impaired gas exchange related to:

 

A. Decreased red blood cell production

 

B. Increased levels of vitamin D

 

C. Increased red blood cell production

 

D. Decreased production of renin

 

QUESTION 810A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming

 

more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:

 

A. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position

 

B. Administering analgesics as ordered

 

C. Having the child turn, cough, and deep breathe every 12 hours

 

D. Remaining with the child and keeping as calm and quiet as possible

 

QUESTION 811A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to “Irrigate NG tube with sterile

 

saline q1h and prn.” The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

 

A. Water will deplete electrolytes resulting in metabolic acidosis.

 

B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.

 

C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.

 

D. Saline will increase peristalsis in the bowel.

 

QUESTION 812A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is

 

receiving morphine sulfate 1015 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and

 

promoting return of urinary function after surgery, the nurse would:

 

A. Provide food and fluids at the client’s request

 

B. Maintain IV, increasing the rate hourly until the client voids

 

C. Report to the surgeon if the client is unable to void within 8 hours of surgery

 

D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention

 

QUESTION 813A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for

 

giving antibiotics prior to surgery is to:

 

A. Provide cathartic action within the colon

 

B. Reduce the risk of wound infection from anaerobic bacteria

 

C. Relieve the client’s concern regarding possible infection

 

D. Reduce the risk of intraoperative fever

 

QUESTION 814A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the

 

medication, the nurse should:

 

A. Not give the digoxin if the pulse is_60

 

B. Not give the digoxin if the pulse is_100

 

C. Take the apical pulse for a full minute

 

D. Monitor for visual disturbances, a side effect of digoxin

 

QUESTION 815The family member of a child scheduled for heart surgery states, “I just don’t understand this open-heart or closed-heart business. I’m so confused! Can you help

 

me understand it?” The nurse explains that patent ductus arteriosus repair is:

 

A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.

 

B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.

 

C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.

 

D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.

 

QUESTION 816A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much

 

atropine should be given?

 

A. 0.06 mL

 

B. 0.38 mL

 

C. 2.7 mL

 

D. Information given insufficient to determine the amount of atropine to be administered

 

QUESTION 817Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the

 

postanesthesia care unit, the nurse should:

 

A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations

 

B. Obtain pulse and blood pressure readings noting rate and quality of pulse

 

C. Reassure the client that his surgery is over and that he is in the recovery room

 

D. Review physician’s orders, administering medications as ordered

 

QUESTION 818A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature

 

elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take

 

dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:

 

A. Infection postoperatively

 

B. Malignant hyperthermia

 

C. Neuroleptic malignant syndrome

 

D. Fever postoperatively

 

QUESTION 819A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals

 

abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client

 

has developed:

 

A. Gastritis

 

B. Evisceration

 

C. Peritonitis

 

D. Pulmonary embolism

 

QUESTION 820A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, “The anesthesiologist said

 

she was going to give me balanced anesthesia. What exactly is that?” The best explanation for the nurse to give the client would be that balanced anesthesia:

 

A. Is a type of regional anesthesia

 

B. Uses equal amounts of inhalation agents and liquid agents

 

C. Does not depress the central nervous system

 

D. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications

 

QUESTION 821A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is

 

afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of

 

suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is:

 

A. Having a heart attack

 

B. Wanting attention from the nurses

 

C. Suffering from complete upper airway obstruction

 

D. Hyperventilating

 

QUESTION 822A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an

 

appropriate antibiotic to treat P.

 

aeruginosa such as:

 

A. Cefoperazone (Cefobid)

 

B. Clindamycin (Cleocin)

 

C. Dicloxacillin (Dycill)

 

D. Erythromycin (Erythrocin)

 

QUESTION 823A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

 

A. Orally in the morning and at bedtime

 

B. Only one time during the day as long as it is always at the same time of day

 

C. Rectally at bedtime

 

D. As soon as she awakens, prior to any activity

 

QUESTION 824A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating

 

include:

 

A. Administering diazepam (Valium) 1015 mg po q4h and q1h prn for hyperventilating episode

 

B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation

 

C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur

 

D. Using distraction to help control the client’s hyperventilation episodes

 

QUESTION 825A client delivered a stillborn male at term. An appropriate action of the nurse would be to:

 

A. State, “You have an angel in heaven.”

 

B. Discourage the parents from seeing the baby.

 

C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.

 

D. Reassure the parents that they can have other children.

 

QUESTION 826A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse

 

explains that:

 

A. The test is inconclusive and should be repeated

 

B. Further testing is needed

 

C. The test is normal and the fetus is reacting appropriately

 

D. The fetus is distressed

 

QUESTION 827Which stage of labor lasts from delivery of the baby to delivery of the placenta?

 

A. Second

 

B. Third

 

C. Fourth

 

D. Fifth

 

QUESTION 828On the third postpartum day, the nurse would expect the lochia to be:

 

A. Rubra

 

B. Serosa

 

C. Alba

 

D. Scant

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