The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?

The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?

 

Hypernatremia

Hypocalcemia

Hypokalemia

Hypomagnesemia

 

 

QUESTION 827

 

 

 

The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

 

A. Pedal pulses 11 (weak)

 

B. Twenty-four-hour intake 1000 mL/day for past 2 days

 

C. Serum potassium 3.3

 

D. Pulse rate 150 bpm

 

 

 

QUESTION 828

 

 

 

The 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 829

 

 

 

A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:

 

A. The risks of exposure of the visitor to infectious organisms is great.

 

B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes.

 

C. The client is at extreme risk of acquiring infections.

 

D. Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.

 

 

 

QUESTION 830

 

The nurse enters the room of a client on which a “do not resuscitate” order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, “please save her!” The nurse’s action would be:

 

A. Call the physician and inform him that the client has expired.

 

B. Remind the husband that the physician wrote an order not to resuscitate.

 

C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.

 

D. Call a code and proceed with cardiopulmonary resuscitation.

 

 

 

QUESTION 831

 

Goal setting for a client with Meniere’s disease should include which of the following?

 

A. Frequent ambulation

 

B. Prevention of a fall injury

 

C. Consumption of three meals per day

 

D. Prevention of infection

 

 

 

QUESTION 832

 

A 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 833

 

A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?

 

Cantaloupe

Rice

Chicken

Green beans

 

 

QUESTION 834

 

A 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 835

 

 

 

During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?

 

A. Tinnitus and nausea

 

B. Dermatitis and blurred vision

 

C. Unconsciousness and acetone odor of the breath

 

D. Chills and an elevation of temperature

 

 

 

QUESTION 836

 

A 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 837

 

A 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 838

 

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

 

A. Inspiration is longer than expiration

 

B. Breath sounds are high pitched

 

C. Breath sounds are slightly muffled

 

D. Inspiration and expiration are equal

 

 

 

QUESTION 839

 

Stat 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 840

 

A 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 24–48 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 841

 

 

 

When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

 

A. Open discussion and understanding

 

B. Play-acting out feelings in different roles

 

Storytelling

Drawing pictures

 

 

QUESTION 842

 

 

 

The 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 843

 

A 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 844

 

A 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 10–15 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 845

 

An 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:

 

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 846

 

A woman diagnosed with multiple sclerosis is disturbed with diplopi

 

A. The nurse will teach her to:

 

E. Limit activities which require focusing (close vision)

 

F. Take more frequent naps

 

G. Use artificial tears

 

H. Wear a patch over one eye

 

 

 

QUESTION 847

 

A 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.9AM

 

B.1PM

 

C. 11 AM

 

D.3PM

 

 

 

QUESTION 848

 

A 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 849

 

Morphine 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 850

 

A 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 851

 

A client states to his nurse that “I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells.” Based on this information, which drug might the nurse expect to be discontinued?

 

Prednisone

Timolol maleate (Blocadren)

 C. Garamycin (Gentamicin)

D. Phenytoin (Dilantin)

 

 

 

QUESTION 852

 

The nurse is in the hallway and one of the visitors faints. The nurse should:

 

A. Sit the victim up and lightly slap his face

 

B. Elevate the victim’s legs

 

C. Apply a cool cloth to the victim’s neck and forehead until he recovers

 

D. Sit the victim up and place the head between the knees

 

 

 

QUESTION 853

 

A 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 854

 

Diabetes 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 855

 

Following 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 856

 

A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):

 

A. Allergy to seafood

 

B. History of seizures

 

C. Movable metal implant

 

D. Pin or screw in any bone

 

 

 

QUESTION 857

 

A 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 858

 

Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?

 

A. Nifedipine 10 mg SL for B/P 140/90

 

B. Furosemide 20 mg/PO for decreased urine output

 

C. Magnesium salicylate to decrease inflammation

 

D. Nitroglycerin gr 1/150 for chest pain

 

 

 

QUESTION 859

 

An 18-month-old child has been playing in the garage. His mother brings him to a nurse’s home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:

 

A. Inhaled gasoline fumes

 

B. Ingested a caustic alkali

 

C. Eaten construction chalk

 

D. Lead poisoning

 

 

 

QUESTION 860

 

A 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 anesthesi

 

A. 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 861

 

One 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 862

 

The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:

 

A. Determine child’s activity pattern

 

B. Reduce mother’s sense of guilt

 

C. Instruct parents in use of ipecac

 

D. Teach parents appropriate safety precautions

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