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Which of the following is the drug of choice for Anthrax? 1.Furosemide Lasix…a diuretic 2.Aminophyllin respiratory medication 3.Cipro or doxycycline or.

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Presentation on theme: "Which of the following is the drug of choice for Anthrax? 1.Furosemide Lasix…a diuretic 2.Aminophyllin respiratory medication 3.Cipro or doxycycline or."— Presentation transcript:

1 Which of the following is the drug of choice for Anthrax? 1.Furosemide Lasix…a diuretic 2.Aminophyllin respiratory medication 3.Cipro or doxycycline or penicillin 4.Tamoxifen used for estrogen receptor- positive breast tumors

2 Which of the following is the most appropriate type of isolation precaution for a patient diagnosed with Botulism? 1.Contact 2.Universal Precautions 3.Respiratory 4.Reverse

3 Which of the following is the most appropriate type of isolation precaution for a patient diagnosed with Botulism? 1.Contact 2.Universal Precautions not spread from person to person…use standard precautions. 3.Respiratory 4.Reverse

4 Practice Question 41 A nurse is preparing to assist the physician in performing a liver biopsy. The nurse would assist the client to which position for this test? 1. Right lateral side-lying 2. Left lateral side-lying 3. Prone with the hands crossed under the head 4. Supine with the right hand under the head.

5 Practice Question 41 A nurse is preparing to assist the physician in performing a liver biopsy. The nurse would assist the client to which position for this test? 1. Right lateral side-lying anatomical location of the liver makes this choice incorrect 2. Left lateral side-lying anatomical location of the liver makes this choice incorrect 3. Prone with the hands crossed under the head anatomical location of the liver makes this choice incorrect 4. Supine with the right hand under the head. Client is also instructed to remain as still as possible during the procedure.

6 Practice Question 42 The nurse is providing instructions to the client with a gastric ulcer regarding the administration of sucralfate (Carafate).The nurse instructs the client to 1. take the medication after meals & at bedtime with a snack. 2. take the medication with meals & at bedtime with a glass of milk. 3. to space the medication around the clock, taking it very 6 hours. 4. to take the medication 1 hour before meals and at bedtime.

7 The nurse is providing instructions to the client with a gastric ulcer regarding the administration of sucralfate (Carafate).The nurse instructs the client to 1. take the medication after meals & at bedtime with a snack. 2. take the medication with meals & at bedtime with a glass of milk. 3. to space the medication around the clock, taking it very 6 hours. 4. to take the medication 1 hour before meals and at bedtime. sucralfate forms a protective coating over the gastric ulcer – food intake will stimulate gastric acid production and mechanical irritation Take at bedtime to provide protective coating during night time hours.

8 Practice Question 43 A client who has returned from a percutaneous liver biopsy should be placed in what position? 1. Left side. 2. Right side. 3. Semi-Fowler’s 4. Supine

9 Practice Question 43 A client who has returned from a percutaneous liver biopsy should be placed in what position? 1. Left side. 2. Right side. 3. Semi-Fowler’s 4. Supine Client placed on operative side (right side) Pillow placed under the costal margin to compress the liver Wt of client’s body will apply pressure to the liver and decr incidence of bleeding

10 Respiratory

11 Causes of Ventilator Alarms High Pressure Alarm:  Increased secretions in the airway  Wheezing or bronchospasm (causing decreased airway size)  Endotracheal tube displaced  Ventilator tubing obstructed Water in tubing (condensation) Kink in tubing (under pt, caught in siderail)  Client coughs, gags, bites endotracheal tube  Client anxious and ‘fights” ventilator

12 Causes of Ventilator Alarms Low Pressure Alarm:  Disconnection of ventilator tubing  Leak in the ventilator tubing  Leak in the Endotracheal tube airway cuff  Client stops spontaneous breathing

13 Practice Question 44 A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse plans to 1. assess for a disconnection. 2. evaluate the cuff for a leak. 3. notify the respiratory therapist. 4. suction secretions from the client.

14 A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse plans to 1. assess for a disconnection. This would not cause the high pressure alarm to go off. 2. evaluate the cuff for a leak. This would not cause the high pressure alarm to go off. 3. notify the respiratory therapist. Delays necessary tx. 4. suction secretions from the client. High pressure alarm suggests an obstruction. Empty water from tubing…sx pt…check equipment…check pt (could be waking up and fighting the ventilator).

15 Practice Question 45 A client has a chest tube attached to a Pleur-evac drainage system. The nurse would ensure that 1. the connection between the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site. 2. the amount of drainage into the chest tube is noted & recorded every 24 hours in the client’s record. 3. the suction control chamber has sterile water added every shift & that the system is kept below waist level. 4. the water seal chamber has continuous bubbling and that assessment for crepitus is done once a shift.

16 A client has a chest tube attached to a Pleur-evac drainage system. The nurse would ensure that 1. the connection between the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site. 2. the amount of drainage into the chest tube is noted & recorded every 24 hours in the client’s record. Drainage noted and recorded qhr in the 1 st 24 hrs then q8 and prn. 3. the suction control chamber has sterile water added every shift & that the system is kept below waist level. Sterile water is added at initial set up and then only as needed (which is rare) 4. the water seal chamber has continuous bubbling and that assessment for crepitus is done once a shift. Continuous bubbling in the sx chamber. Bubbling in the water seal is a sign of an air leak. Assess for Crepitus q8hrs.

17 Practice Question 46 The nurse caring for a client with a closed chest drainage system notes that the tidaling in the water seal compartment has stopped. Based on this finding, the nurse would suspect that 1. the chest tubes are obstructed. 2. suction needs to be increased. 3. the system needs changing. 4. suction needs to be decreased.

18 Practice Question 46 The nurse caring for a client with a closed chest drainage system notes that the tidaling in the water seal compartment has stopped. Based on this finding, the nurse would suspect that 1. the chest tubes are obstructed. Or the pneumothorax is resolved…fluctuation continues until the thorax is resolved. 2. suction needs to be increased. Amt of sx is irrelevant…controlled via sx control chamber ;usu set at the system needs changing. Only change when drainage collection device is full or the device is damaged in some way. 4. suction needs to be decreased. Sx is often discontinued once drainage stops – waterseal is adequate for the resolution of the pneumothorax.

19 Practice Question 47 The client with tuberculosis asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when 1. 3 sputum cultures are negative sputum cultures are negative. 3. a sputum culture & a chest x-ray film are negative. 4. a sputum culture & a Mantoux test are negative.

20 Practice Question 47 The client with tuberculosis asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when 1. 3 sputum cultures are negative sputum cultures are negative. 3. a sputum culture & a chest x-ray film are negative. 4. a sputum culture & a Mantoux test are negative. Mantoux will always be positive once it becomes positive. Do not repeat once the pt has a positive.

21 Practice Question 48 Which of the following should be performed prior to drawing arterial blood gases from the radial artery? 1. Allen’s test 2. Babinski’s reflex 3. Brudzinski’s sign. 4. Homans’ sigh

22 Practice Question 48 Which of the following should be performed prior to drawing arterial blood gases from the radial artery? 1. Allen’s test assesses for the adequ of ulnar circulation. 2. Babinski’s reflex performed on the sole of the foot – unrelated to a procedure performed on the radial artery. 3. Brudzinski’s sign. Assessment for nuchal rigidity by bending the head down toward the chest. 4. Homans’ sign sharp dorsiflexion of the feet – used to assess for thrombophlebitis.

23 Practice Question 49 A client with tuberculosis is to be started on rifampin (Rifadin). The nurse provides instructions to the client and tells the client 1. that yellow-colored skin is common. 2. to wear glasses instead of soft contact lens. 3. always to take the medication on an empty stomach. 4. that as soon as the cultures come back negative, the medication may be stopped.

24 A client with tuberculosis is to be started on rifampin (Rifadin). The nurse provides instructions to the client and tells the client 1. that yellow-colored skin is common. Indication of jaundice. Should report jaundice to MD. 2. to wear glasses instead of soft contact lens. Soft contacts may be damaged permanently by the orange discoloration that rifampin causes in body fluids. 3. always to take the medication on an empty stomach. Eliminate because of the word “always”- may take with food if client is unable to tolerate on an empty stomach. 4. that as soon as the cultures come back negative, the medication may be stopped. Client will be on the meds a LONG time – as much as 12 months even if the cultures come back negative.

25 Practice Question 50 A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. The nurse develops a plan of care for the client and includes which of the following? 1. Providing the client with short, frequent walks. 2. Measuring the client’s pulse each shift. 3. Eliminating sources of caffeine from meal trays. 4. Limiting fluids given orally and IV.

26 A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. The nurse develops a plan of care for the client and includes which of the following? 1. Providing the client with short, frequent walks. Exercise will not alleviate tachycardia. 2. Measuring the client’s pulse each shift. Will not alleviate s/s and HR should be measured more freq. than qshift. 3. Eliminating sources of caffeine from meal trays. Cause exacerbation of the s/s. Caffeine is a stimulate. 4. Limiting fluids given orally and IV. Exercise will not alleviate tachycardia.

27 Practice Question 51 A client is experiencing an acute asthmatic attack. Which nursing action would improve the respiratory status of the client? 1. Help the client to attain a slow, prolonged expiration. 2. Have client forcefully exhale. 3. Provide rest by leaving client alone and in supine position. 4. Assist the client to breathe into a paper bag.

28 A client is experiencing an acute asthmatic attack. Which nursing action would improve the respiratory status of the client? 1. Help the client to attain a slow, prolonged expiration. This allows the client to exhale a greater volume and facilitates incr oxygenation. 2. Have client forcefully exhale. Used to measure peak airflow. 3. Provide rest by leaving client alone and in supine position. Client should be sitting or in high- Fowler’s position. Do not leave alone. 4. Assist the client to breathe into a paper bag. This will incr PCO2 and not improve the pt’s overall condition.

29 Practice Question 52 A client with a pneumothorax has a chest tube inserted & connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe? 1. Continuous bubbling in the water-seal chamber. 2. Slight fluctuation of the water in the water-seal chamber. 3. Increased bloody drainage in the collection chamber. 4. Constant bubbling in the collection chamber.

30 A client with a pneumothorax has a chest tube inserted & connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe? 1. Continuous bubbling in the water-seal chamber. In the sx control chamber OK – in water seal suggests an air leak. 2. Slight fluctuation of the water in the water-seal chamber. Should fluctuate with breathing. 3. Increased bloody drainage in the collection chamber. Incr bloody drainage is never normal. 4. Constant bubbling in the collection chamber. Bubbling in the sx control chamber OK – collection chamber should not have bubbling.

31 A B C Fluid/drainage collection chamber Water seal chamber Suction control chamber

32 Practice Question 53 The nurse would anticipate which nursing observation in the client with symptoms of early laryngotracheobronchitis? 1. Elevated temperature & prostration. 2. Flushed face & labored expirations. 3. Kussmaul respirations & bradycardia. 4. Tachypnea & inspiratory stridor.

33 Practice Question 53 The nurse would anticipate which nursing observation in the client with symptoms of early laryngotracheobronchitis? 1. Elevated temperature & prostration. Temperature not charactoristic 2. Flushed face & labored expirations. Could occur – but are not charactoristic – esp. early. 3. Kussmaul respirations & bradycardia. Deep rapid resp but are not noisy 4. Tachypnea & inspiratory stridor. Rapid, noisy resp. Occurs as air is drawn through a narrowed airway.

34 Practice Question 54 What are the nursing precautions during a tubing change of a central venous pressure (CVP) line? 1. Flush catheter with 3 ml of NS & then heparin before disconnecting the line. 2. Position client on right side & then have him take a deep breath. 3. Elevate HOB & disconnect tubing from fluid container before disconnecting from client. 4. Position client flat & have him take a deep breath & hold it while the line is disconnected & a new one connected.

35 Practice Question 54 What are the nursing precautions during a tubing change of a central venous pressure (CVP) line? 1. Flush catheter with 3 ml of NS & then heparin before disconnecting the line. Not necessarily. 2. Position client on right side & then have him take a deep breath. Position flat. 3. Elevate HOB & disconnect tubing from fluid container before disconnecting from client. Position flat. 4. Position client flat & have him take a deep breath & hold it while the line is disconnected & a new one connected. Increases intrathoracic pressure and so decr possibility that the client will experience an air embolus during the tubing change.

36 Practice Question 55 A client has thick pulmonary secretions. The nurse would anticipate which classification of medication to be ordered? 1. Antihistamine 2. Bronchodilator. 3. Decongestant. 4. Expectorant.

37 Practice Question 55 A client has thick pulmonary secretions. The nurse would anticipate which classification of medication to be ordered? 1. Antihistamine block the release of histamine – used to tx mild allergic disorders. 2. Bronchodilator. Indicated when airways are inflamed and narrowed. 3. Decongestant. Produce vasoconstriction of dilated arterioles – leads to reduction in congestions. 4. Expectorant. Stimulate secr and reduce the viscosity of the mucus.

38 Practice Question 56 The nurse is monitoring a client who is receiving IV theophylline (aminophylline) for control of an acute episode of his chronic respiratory condition.What nursing observations would cause the nurse the most concern? 1.Blurred vision, halos around lights and diplopia. 2. HypoKalemia, diarrhea, and bradycardia. 3. Restlessness, tachycardia, nausea, and vomiting. 4. Tachycardia, pulse oximetry of 90%, irregular respirations.

39 The nurse is monitoring a client who is receiving IV theophylline (aminophylline) for control of an acute episode of his chronic respiratory condition.What nursing observations would cause the nurse the most concern? 1.Blurred vision, halos around lights and diplopia. Does not relate to theophylline use. 2. Hypokalemia, diarrhea, and bradycardia. Does not relate to theophylline use. 3. Restlessness, tachycardia, nausea, and vomiting. Indicates toxic levels of theophylline. Lab work must be done to monitor the theophylline levels. Normal range is mcg/ml. 4. Tachycardia, pulse oximetry of 90%, irregular respirations. Does not relate to theophylline use.

40 Practice Question 57 A nurse has an order to remove the NG tube from a first postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client? 1. Abdomen is slightly distended. 2. Bowel sounds are absent. 3. NG tube drainage is Hematest negative. 4. The client is drowsy.

41 A nurse has an order to remove the NG tube from a first postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client? 1. Abdomen is slightly distended. Cause for concern – but if active BS the distention should be resolved soon. 2. Bowel sounds are absent. GI system will continue to produce secretions even if pt is NPO – if no BS present they will remain in abdomen and present as an aspiration risk. 3. NG tube drainage is Hematest negative. This indicates a normal finding. 4. The client is drowsy. Drowsiness is not an indication for an NG tube

42 Adult Health II Developed by Dare Domico, RN, DSN Revised by: Jill Ray

43 Cardiovascular

44 Practice Question 1 A nurse is preparing to defibrillate a client in ventricular fibrillation. After placing the paddles on the client's chest and before discharging them, which of the following should be done? 1.Ensure that the client has been intubated 2.Set the defibrillator to the “synchronize” mode 3.Administer lidocaine hydrochloride (Xylocaine). 4.Confirm that the rhythm is actually ventricular fibrillation.

45 A nurse is preparing to defibrillate a client in ventricular fibrillation. After placing the paddles on the client's chest and before discharging them, which of the following should be done? 1.Ensure that the client has been intubated does not have to be intubated to defibrillate 2.Set the defibrillator to the “synchronize” mode synchronize mode used with cardioversion 3.Administer lidocaine hydrochloride (Xylocaine). Can be administered after defibrillation 4.Confirm that the rhythm is actually ventricular fibrillation. Practice Question 1

46 Practice Question 2 Which of the following best describes the rhythm represented on the EKG strip? 1.Normal sinus rhythm 2.Ventricular tachycardia 3.Atrial fibrillation 4.Ventricular fibrillation

47 Which of the following best describes the rhythm represented on the EKG strip? 1.Normal sinus rhythm note the presence of a P wave before ea qrs 2.Ventricular tachycardia 3.Atrial fibrillation 4.Ventricular fibrillation Practice Question 2

48

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50 Practice Question 3 A nurse is administering a dose of hydralazine (Apresoline) IV to a client. The nurse ensured that which of the following items is in place before injecting the medication? 1. Central line. 2. Foley catheter 3. Pulse oximeter 4. Blood pressure cuff.

51 A nurse is administering a dose of hydralazine (Apresoline) IV to a client. The nurse ensured that which of the following items is in place before injecting the medication? 1. Central line. Administration via a peripheral IV is OK 2. Foley catheter not necessary to monitor u/o. 3. Pulse oximeter not necessary to monitor oxygen sat post adm. 4. Blood pressure cuff. Medication used to lower the BP. Monitor BP and pulse after administration of hydralazine. Practice Question 3

52 Practice Question 4 Which of the following items would the nurse assess to gain the best information about a client’s left ventricular function? 1. Breath sounds. 2. Hepatojugular reflux 3. Jugular vein distention 4. Peripheral edema

53 Which of the following items would the nurse assess to gain the best information about a client’s left ventricular function? 1. Breath sounds. Left and lungs. 2. Hepatojugular reflux sign of right sided heart failure. 3. Jugular vein distention sign of right sided heart failure. 4. Peripheral edema sign of right sided heart failure. Practice Question 4

54 Practice Question 5 Which statement by the client indicates that he understands how to take sublingual nitroglycerin? 1.“If I have a chest pain, I’ll immediately stop what I am doing, sit down, & take the medication.” 2.“I’ll chew 1 tablet then let it dissolve in my mouth if the chest pain last more than 5 minutes. 3.“Ill take only 1 dose, & stop what I am doing. If the pain doesn’t stop, I’ll call the doctor.” 4.“If I have chest pain, I’ll call the doctor & put 2 tablets under my tongue.

55 Which statement by the client indicates that he understands how to take sublingual nitroglycerin? 1.“If I have a chest pain, I’ll immediately stop what I am doing, sit down, & take the medication.” 2.“I’ll chew 1 tablet then let it dissolve in my mouth if the chest pain last more than 5 minutes. Don’t chew… 3.“I’ll take only 1 dose, & stop what I am doing. If the pain doesn’t stop, I’ll call the doctor.” Take the medication immediately – don’t wait to see if the pain goes away; must also sit or lie down…causes orthostatic hypotension 4.“If I have chest pain, I’ll call the doctor & put 2 tablets under my tongue. Take one tablet, must sit or lie down. Practice Question 5

56 Practice Question 6 The nurse teaches dietary restrictions to a client with new onset congestive heart failure. Which statement by the client indicates that further teaching is needed? 1.“I’m going to have a ham & cheese sandwich with potato chips for lunch.” 2.”I’m going to weigh myself daily to be sure I don’t gain too much fluid.” 3.”I can have most fresh fruits and fresh vegetables.” 4. “I’m not supposed to eat cold cuts.”

57 The nurse teaches dietary restrictions to a client with new onset congestive heart failure. Which statement by the client indicates that further teaching is needed? 1.“I’m going to have a ham & cheese sandwich with potato chips for lunch.” need to reduce Na intake – ham, cheese, & chips are high in Na. 2.”I’m going to weigh myself daily to be sure I don’t gain too much fluid.” true 3.”I can have most fresh fruits and fresh vegetables.” true 4. “I’m not supposed to eat cold cuts.” true, high in Na Practice Question 6

58 Which of the cardiac changes if noted on the cardiac monitor would indicate the presence of hypokalemia? 1. Tall, peaked T wave 2. ST segment depression 3. Widening of the QRS complex 4. Prolonged PR interval Practice Question 7

59 Which of the cardiac changes if noted on the cardiac monitor would indicate the presence of hypokalemia? 1. Tall, peaked T wave - Flat T wave with hypokalemia. findings noted with hyperkalemia. 2. ST segment depression 3. Widening of the QRS complex findings noted with hyperkalemia. 4. Prolonged PR interval findings noted with hyperkalemia. Practice Question 7

60 Practice Question 8 A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 1.Review the intake and output records for the last 2 days. 2. Change the time of diuretic administration from morning to evening. 3.Request a sodium restriction of 1 g/day from the physician 4. Order daily weights starting on the following morning.

61 A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 1.Review the intake and output records for the last 2 days. 2. Change the time of diuretic administration from morning to evening. Must complete assessment before beginning interventions…also diuretic adm at night not recommended unless a f/c is in place. 3.Request a sodium restriction of 1 g/day from the physician Must complete assessment before beginning interventions…also 4. Order daily weights starting on the following morning. This is an assessment but #1 would be performed first. Practice Question 8

62 Practice Question 9 A client with deep vein thrombosis is receiving a continuous IV infusion of heparin sodium. The client’s aPPT is 65 seconds; the baseline aPTT before initiation of therapy was 30 seconds. A nurse anticipates which action is needed? 1. Shutting off the heparin infusion. 2.Decreasing the rate of the heparin infusion. 3.Leaving the rate of the heparin infusion as is. 4. Increasing the rate of the heparin infusion.

63 A client with deep vein thrombosis is receiving a continuous IV infusion of heparin sodium. The client’s aPPT is 65 seconds; the baseline aPTT before initiation of therapy was 30 seconds. A nurse anticipates which action is needed? 1. Shutting off the heparin infusion. 2.Decreasing the rate of the heparin infusion. 3.Leaving the rate of the heparin infusion as is. Activated partial thromboplastin time seconds nml WNL times normal is therapeutic level. 4. Increasing the rate of the heparin infusion. Practice Question 9

64 Practice Question 10 The nurse is reviewing the EKG rhythm strip on a client with a myocardial infarction. The nurse notes the PR interval is 0.20 seconds. The nurse determines that this is 1. a normal finding. 2. indicative of atrial flutter. 3. indicative of impending reinfarction. 4. indicative of atrial fibrillation.

65 The nurse is reviewing the EKG rhythm strip on a client with a myocardial infarction. The nurse notes the PR interval is 0.20 seconds. The nurse determines that this is 1. a normal finding. Time it takes for the cardiac impulse to spread from atria to the ventricles WNL 2. indicative of atrial flutter. 3. indicative of impending reinfarction. 4. indicative of atrial fibrillation. Practice Question 10

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67 Practice Question 11 The nurse is providing instructions to a client who will be taking captopril (Capoten). Which statement by the client indicates a need for further instructions? 1.”I need to drink increased amounts of water.” 2.”I need to change positions slowly.” 3.“I need to avoid taking hot baths or showers.” 4.“I need to sit down and rest if dizziness or light- headedness occurs.

68 The nurse is providing instructions to a client who will be taking captopril (Capoten). Which statement by the client indicates a need for further instructions? 1.”I need to drink increased amounts of water.” 2.”I need to change positions slowly.” can cause orthostatic hypotension 3.“I need to avoid taking hot baths or showers.” vasodilatation can precipitate orthostatic hypotension 4.“I need to sit down and rest if dizziness or light- headedness occurs. can cause orthostatic hypotension Practice Question 11

69 Practice Question 12 A nurse is caring for a client with acute pulmonary edema. The physician tells the nurse that medication will be prescribed to help reduce preload and afterload. The nurse anticipates that the physician will prescribe which medication? 1. Digoxin (Lanoxin) 2. Nitroprisside sodium (Nipride) 3. Morphine sulfate 4. Furosemide (Lasix)

70 A nurse is caring for a client with acute pulmonary edema. The physician tells the nurse that medication will be prescribed to help reduce preload and afterload. The nurse anticipates that the physician will prescribe which medication? 1. Digoxin (Lanoxin) cardiac glycoside – incr cardiac contractility. 2. Nitroprisside sodium (Nipride) potent vasodilator that reduces preload and afterload. 3. Morphine sulfate narcotic analgesic, used post MI because it reduces preload and afterload. 4. Furosemide (Lasix) loop diuretic that can reduce preload by enhancing renal excretion of Na and water. Practice Question 12

71 Practice Question 13 A nurse is assisting to position the client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client 1. lying on left side with a pillow under the chest wall. 2. lying on right side with a pillow under the head. 3. supine with the head of bed elevated in a 45 to 60 degree angle. 4. supine with slight Trendelenburg position.

72 A nurse is assisting to position the client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client 1. lying on left side with a pillow under the chest wall. 2. lying on right side with a pillow under the head. 3. supine with the head of bed elevated in a 45 to 60 degree angle. Places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. 4. supine with slight Trendelenburg position. Practice Question 13

73 Practice Question 14 A nurse has given the client with atrial fibrillation instructions to take one aspirin daily. Which explanation by the nurse is most correct? “This will 1. help prevent clot formation in your heart as a result of your heart rhythm.” 2. prevent any inflammation from occurring on the walls of your heart.” 3. most likely keep you from ever having a heart attack.” 4. keep you from experiencing chest pain.”

74 A nurse has given the client with atrial fibrillation instructions to take one aspirin daily.Which explanation by the nurse is most correct? “This will 1. help prevent clot formation in your heart as a result of your heart rhythm.” atrial fib puts the client at risk for mural thrombi because of the sluggish blood flow through the atria that occurs as a result of loss of the effective contraction of the atria. 2. prevent any inflammation from occurring on the walls of your heart.” “any” in the answer eliminates this as a choice. ASA does have anti-inflammatory properties it cannot prevent “any inflammation”. 3. most likely keep you from ever having a heart attack.” not rationale for this therapy. 4. keep you from experiencing chest pain.” low dose ASA does not have analgesic impact. Practice Question 14

75 Practice Question 15 A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? 1. Encourage the client to cough and deep breathe. 2. Premedicate the client with prescribed analgesic. 3. Provide the client with a walker. 4. Remove telemetry equipment.

76 A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? 1. Encourage the client to cough and deep breathe. will not actively help with endurance. 2. Premedicate the client with prescribed analgesic. Encourage regular use of prn med for hrs post surgery because analgesia will promote rest, decr myocardial oxygen consumption resulting from pain, and allow better participation in post op activities. 3. Provide the client with a walker. Will not aid in tolerance of ambulation…do not make dependent on asst device. 4. Remove telemetry equipment. Contraindicated and cannot remove unless ordered by MD Practice Question 15

77 Practice Question 16 A client with cardiac disease turns on his call light and tells the nurse he is experiencing chest pain. What is the first nursing action? 1. Begin oxygen administration at a rate of 4 L/min via a nasal cannula. 2. Listen to heart sounds for ectopic beats. 3. Ausculate breath sounds and maintain airway. 4. Determine what the client was doing before onset of pain.

78 A client with cardiac disease turns on his call light and tells the nurse he is experiencing chest pain. What is the first nursing action? 1. Begin oxygen administration at a rate of 4 L/min via a nasal cannula. Angina is the result of an imbalance betw oxygen supply and demand… 2. Listen to heart sounds for ectopic beats. Not indicated 3. Ausculate breath sounds and maintain airway. Not indicated 4. Determine what the client was doing before onset of pain. Could provided significant info – but pt has hx of cardiac disease – angina indicates the need for an intervention to prevent cardiac damage. This intervention is appro after the acute episode has been resolved. Practice Question 16

79 Practice Question 17 The client who is receiving digoxin (Lanoxin) and furosemide (Lasix) is at risk for developing digitalis toxicity. Which of the following serum lab values would the nurse correlate with this problem? 1. Sodium level of 135 mEq/L 2. BUN of 35 mg/dl 3. Calcium level of 6 mg/dl 4. Potassium level of 3.0 mEq/L

80 The client who is receiving digoxin (Lanoxin) and furosemide (Lasix) is at risk for developing digitalis toxicity. Which of the following serum lab values would the nurse correlate with this problem? 1. Sodium level of 135 mEq/L ( mEq/L) 2. BUN of 35 mg/dL (9-25 mg/dL). Elevated levels indicate a slowing of the glomerular filtration rate) 3. Calcium level of 6 mg/dL ( mg/dL) decr level. 4. Potassium level of 3.0 mEq/L ( mEq/L) pt on Digoxin is very sensitive to serum levels of potassium Practice Question 17

81 Practice Question 18 A client has developed pulmonary edema secondary to hypertension & CHF. He was experiencing peripheral edema & paroxysmal nocturnal dyspnea prior to admission.The nurse administers Lasix 40 mg IV push. What would the nurse observe as the desired response? 1. Decrease in respiratory rate & in difficulty breathing. 2. BP goes from 160/100 to 150/ Urine output increases to 100 cc per hour for 3 hours. 4. Peripheral edema begins to decrease in 24 hours.

82 A client has developed pulmonary edema secondary to hypertension & CHF. He was experiencing peripheral edema & paroxysmal nocturnal dyspnea prior to admission.The nurse administers Lasix 40 mg IV push. What would the nurse observe as the desired response? 1. Decrease in respiratory rate & in difficulty breathing. Secondary to a decrease in the fluid collecting in the lungs. 2. BP goes from 160/100 to 150/94. Decrease in BP is also a desired response…not the primary desired response. 3. Urine output increases to 100 cc per hour for 3 hours. Increase in u/o desired response also – but the improvement in breathing pattern is the best choice. 4. Peripheral edema begins to decrease in 24 hours. Could also see a decrease in peripheral edema as the circulating blood volume decrease. Practice Question 18

83 Practice Question 19 A nurse has given instructions to the client with Raynaud’s disease about self-management of the disease process. The nurse determines that the client needs further reinforcement if the client states that: 1.Smoking cessation is important 2.Sources of caffeine should be eliminated from the diet 3.Taking nifedipine (Procardia) as prescribed will decrease vessel spasm 4.Moving to a warmer climate is needed.

84 A nurse has given instructions to the client with Raynaud’s disease about self-management of the disease process. The nurse determines that the client needs further reinforcement if the client states that: 1.Smoking cessation is important advised to stop smoking 2.Sources of caffeine should be eliminated from the diet advised to eliminate caffeine from the diet. 3.Taking nifedipine (Procardia) as prescribed will decrease vessel spasm inhibits vessel spasms 4.Moving to a warmer climate is needed. Least desirable option. Can avoid exposure to cold via a variety of means. Symptoms could still occur with the use of air conditioning and ruing periods of cooler weather. Practice Question 19

85 Renal

86 Practice Question 20 A client has just had a Foley catheter removed and is to be started on a bladder retraining program. Which intervention will provide the most useful information about the client’s ability to empty the bladder? 1.Calculating total fluid intake for the shift. 2.Measuring post void residual using a bladder scan. 3.Assisting the client to the bathroom every 2 hours 4.Recording the amount of the client’s voiding.

87 A client has just had a Foley catheter removed and is to be started on a bladder retraining program. Which intervention will provide the most useful information about the client’s ability to empty the bladder? 1.Calculating total fluid intake for the shift. Does not provide specific info re: the emptying of the bladder. 2.Measuring post void residual using a bladder scan. “most useful” and “ability to empty the bladder”. 3.Assisting the client to the bathroom every 2 hours assisting the client to the bathroom and recording intake and output are general interventions that provide estimates of the ability to empty the bladder, but not specific information. 4.Recording the amount of the client’s voiding. Provides an estimate, but Does not provide specific info re: the emptying of the bladder. Practice Question 20

88 Practice Question 21 The nurse is caring for a client in the immediate postoperative period after a kidney transplant. What would the nurse anticipate regarding the administration of IV fluid therapy? 1. Infused at a rate of 100 ml/hr to maintain renal perfusion. 2. Fluid administered at a rate to keep blood pressure within a normal range. 3.Amount to be infused would be determined hourly based on urinary output. 4. Adequate fluids to maintain clear urine without evidence of blood clots.

89 The nurse is caring for a client in the immediate postoperative period after a kidney transplant. What would the nurse anticipate regarding the administration of IV fluid therapy? 1. Infused at a rate of 100 ml/hr to maintain renal perfusion. Based on u/o for first hrs. 2. Fluid administered at a rate to keep blood pressure within a normal range. Based on u/o for first hrs. 3.Amount to be infused would be determined hourly based on urinary output. For the 1 st hrs. 4. Adequate fluids to maintain clear urine without evidence of blood clots. Notify MD if gross hematuria and clots are noted in the urine…urine may be pink/bloody initially but gradually returns to normal after several days to weeks. Practice Question 21

90 Practice Question 22 The nurse is assisting the client with cystitis with diet selection of an acid-ash diet. The nurse encourages the client to select which of the following foods.? 1. Low-fat milk 2. Baked haddock 3. Garden peas 4. Apples

91 The nurse is assisting the client with cystitis with diet selection of an acid-ash diet. The nurse encourages the client to select which of the following foods.? 1. Low-fat milk alkaline ash: Reduces the acidity of the urine. Include: fruits (exclude cranberries, plums, prunes), milk, most veges, rhubarb, small amts of beef, halibut, veal, trout, salmon 2. Baked haddock acid-ash: incr acidity of urine. With cystitis want urine pH (5.5) Include bread, cereal, whole grains, cheese, eggs, fish, meat, corn and legumes, meat, fish, oysters, poultry, pastries, cranberries, prunes, plums, tomatoes… 3. Garden peas alkaline ash 4. Apples alkaline ash Practice Question 22

92 Renal Stones/prescribed diet Acid Ash Diet:  Ca Phospate Stones  Ca oxalate stones  Stuvite stones Alkaline Ash Diet:  Uric acid stones: Reduce urinary purine content. Decrease intake of high- purine fds: organ meats, gravies, red wines, sardines  Cystine stones: alkaline ash foods

93 Practice Question 23 The nurse develops a plan of care for a client who had a renal transplant. The plan includes monitoring the client for signs of acute graft rejection. Which are the signs of acute graft rejection? 1. Hypotension, graft tenderness, and hypothermia. 2. Hypertension, polyuria, and thirst. 3. Fever, hypotension, and polyuria. 4. Fever, hypertension, and graft tenderness.

94 The nurse develops a plan of care for a client who had a renal transplant. The plan includes monitoring the client for signs of acute graft rejection. Which are the signs of acute graft rejection? 1. Hypotension, graft tenderness, and hypothermia. Pt would be hyperthermic with rejection. 2. Hypertension, polyuria, and thirst. Polyuria and thirst could be s/s of high output renal failure – not graft rejection. 3. Fever, hypotension, and polyuria. Hypertension is seen with graft refection. 4. Fever, hypertension, and graft tenderness. Practice Question 23

95 Practice Question 24 Which of the following statements made by a patient about continuous ambulatory peritoneal dialysis indicates an accurate understanding? 1. “A portable hemodialysis machine is used so that I will be able to ambulate during the treatment.” 2.“A cycling machine is used so the risk for infection is minimized.” 3.“No machinery is involved, and I can pursue my usual activities.” 4.“The drainage system can be used once during the day and a cycling machine for three cycles at night.”

96 Which of the following statements made by a patient about continuous ambulatory peritoneal dialysis indicates an accurate understanding? 1. “A portable hemodialysis machine is used so that I will be able to ambulate during the treatment.” no machinery involved 2.“A cycling machine is used so the risk for infection is minimized.” no machinery involved 3.“No machinery is involved, and I can pursue my usual activities.” 4.“The drainage system can be used once during the day and a cycling machine for three cycles at night.” no machinery involved Practice Question 24

97 Eye & Ear Review administration of eye drops Review administration of ear drops

98 Practice Question 25 The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? 1.Whisper a statement while the client blocks both ears 2.Whisper a statement with the examiner’s back facing the client 3.Whisper a statement and ask the client to repeat it while blocking one ear. 4.Stand 4 feet away form the client to ensure that the client can hear at this distance.

99 The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? 1.Whisper a statement while the client blocks both ears not assessing hearing if both ears are blocked. 2.Whisper a statement with the examiner’s back facing the client 3.Whisper a statement and ask the client to repeat it while blocking one ear. 4.Stand 4 feet away form the client to ensure that the client can hear at this distance. Not assessing distance hearing Practice Question 25

100 Practice Question 26 A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1.Increase sodium in the diet 2.Avoid sudden head movements 3.Lie still and watch the television 4.Increase fluid intake to 3000 ml/day.

101 A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1.Increase sodium in the diet reduce Na in the diet 2.Avoid sudden head movements 3.Lie still and watch the television option could work but would limit mobility/independence… 4.Increase fluid intake to 3000 ml/day. Fluid restriction is indicated. Practice Question 26

102 Practice Question 27 Which of the following will facilitate communication with a client who is hearing impaired? 1.Stand beside the client’s good ear and talk loudly. 2.Stand behind the client and yell into his good ear. 3.Face the client and talk loudly. 4.Face the client and talk in a lowered voice.

103 Which of the following will facilitate communication with a client who is hearing impaired? 1.Stand beside the client’s good ear and talk loudly. 2.Stand behind the client and yell into his good ear. 3.Face the client and talk loudly. 4.Face the client and talk in a lowered voice. The client will be better able to hear lower tones – yelling and talking loudly often raises the pitch of the voice and makes it harder to hear. Practice Question 27

104 Practice Question 28 A client who sustained an eye injury arrives at the ER. The initial nursing action would be to 1. flush the eye with sterile saline solution. 2. obtain a history regarding the cause of the injury. 3. place an ice pack on the eye. 4. instill an antibiotic solution.

105 A client who sustained an eye injury arrives at the ER. The initial nursing action would be to 1.flush the eye with sterile saline solution. Chemical burn 2.obtain a history regarding the cause of the injury. Must finish the assessment before implemented intervention. Tx of the injury will be dependent on the cause of the injury. 3.place an ice pack on the eye. contusion 4.instill an antibiotic solution. Must be prescribed by MD – not usu indicated with an eye injury. Practice Question 28

106 Practice Question 29 A nurse is caring for a client who had surgery for glaucoma. The nurse tells the client to avoid 1. bending at the waist. 2. reading books with small type. 3. reading books with larger type. 4. watching television.

107 A nurse is caring for a client who had surgery for glaucoma. The nurse tells the client to avoid 1. bending at the waist. Increases intraocular pressure. 2. reading books with small type. 3. reading books with larger type. 4. watching television. Avoid activities that increase IOP (intraocular pressure). Reading and watching TV have no impact on IOP. Practice Question 29

108 Practice Question 30 The nurse is developing a teaching plan for the client with chronic glaucoma. Which of the following instructions would the nurse include in the plan? 1. Avoid overuse of the eyes. 2. Decrease fluid intake to control the intraocular pressure. 3. Decrease the amount of salt in the diet. 4. Eye medications will need to be administered lifelong.

109 The nurse is developing a teaching plan for the client with chronic glaucoma. Which of the following instructions would the nurse include in the plan? 1. Avoid overuse of the eyes. 2. Decrease fluid intake to control the intraocular pressure. Minimal impact on the fluid levels in the eye. 3. Decrease the amount of salt in the diet. Minimal impact on the fluid levels in the eye. 4. Eye medications will need to be administered lifelong. Practice Question 30

110 Practice Question 31 The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the physician has prescribed atropine sulfate (Isopto-Atropine) and pilocarpine hydrochloride (Isopto-Carpine) eye drops for a client diagnosed with glaucoma. The nurse contacts the physician before the home visit to 1. clarify the order for the atropine sulfate. 2. clarify the order for the pilocarpine hydrochloride. 3. determine the date of the follow-up physician visit. 4. determine the extent of the intraocular pressure.

111 The home care nurse is reviewing the record of a cline newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the physician has prescribed atropine sulfate (Isopto-Atropine) and pilocarpine hydrochloride (Isopto-Carpine) eye drops for a client diagnosed with glaucoma. The nurse contacts the physician before the home visit to 1. clarify the order for the atropine sulfate. Contraindicated: anticholinergic. Causes vasodilation 2. clarify the order for the pilocarpine hydrochloride. Miotic: reduce intraocular pressure by constricting the pupil and contracting the ciliary muscle. 3. determine the date of the follow-up physician visit. Not necessary unless the pt has need for clarification of this. The nurse can contact MD during/after the visit if needed. 4. determine the extent of the intraocular pressure. Extent of the Intraocular pressure increase is not needed to plan for this pt’s care. Practice Question 31

112 Peripheral iridectomy Allows aqueous humor to flow from the posterior to the anterior chamber.

113 Chronic glaucoma Miotics: constrict the pupil Carbonic anhydrase inhibitors: decr the production of aqueous humor Beta blockers: decr the production of aqueous humor Medication use will be lifelong Avoid anticholinergic medications: Atropine, Cyclopentolate, Homatropine, Scopolamine, Tropicamide. Cause vasodilation…

114 Practice Question 32 The nurse is caring for a client following enoculation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate? 1. Continue to monitor the drainage. 2. Document the finding. 3. Mark the drainage on the dressing and monitor for any increase in bleeding. 4. Notify the physician.

115 The nurse is caring for a client following enoculation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate? 1. Continue to monitor the drainage. true 2. Document the finding. true 3. Mark the drainage on the dressing and monitor for any increase in bleeding. No pressure over the eye area. 4. Notify the physician. Postop eye surgery always report 1 and 2 are also true – but 4 is best response. Practice Question 32

116 Neurological

117 Practice Question 33 A nurse performing a neurological examination is assessing eye movement. The nurse would perform which of the following to obtain this assessment data? 1. Turn a flashlight on directly in front of the eye and watch for a response. 2. Ask the client to alternate looking straight ahead and then at the examiner’s finger. 3. Instruct the client to look straight ahead and then shine a flashlight into the eye. 4. Ask the client to follow the examiner’s finger through the six cardinal positions of gaze.

118 A nurse performing a neurological examination is assessing eye movement. The nurse would perform which of the following to obtain this assessment data? 1. Turn a flashlight on directly in front of the eye and watch for a response. Pupil response: reaction to light 2. Ask the client to alternate looking straight ahead and then at the examiner’s finger. Pupil response: accommodation 3. Instruct the client to look straight ahead and then shine a flashlight into the eye. Pupil response: reaction to light 4. Ask the client to follow the examiner’s finger through the six cardinal positions of gaze. Practice Question 33

119 Practice Question 34 A client with Parkinson’s disease is taking benztropine mesylate (Cogentin) daily. The nurse tells the spouse to report which side effect of the medication if it occurs? 1. Decreased appetite 2. Inability to urinate. 3. Irregular bowel movements. 4. Shuffling gait.

120 A client with Parkinson’s disease is taking benztropine mesylate (Cogentin) daily. The nurse tells the spouse to report which side effect of the medication if it occurs? 1. Decreased appetite 2. Inability to urinate. s/e of med that would need to be addressed by the MD 3. Irregular bowel movements. Can cause constipation 4. Shuffling gait. Sign of Parkinson’s disease Most common s/e are constipation and urinary retention. Important to initiate preventive measures when the client begins the drug. Med tends to have cumulative effects and the s/e may occur early or after it has been taken for some time. Cogentin enhances mobility by decr tremors. Practice Question 34

121 Practice Question 35 A client with myasthenia gravis is taking neostigmine (Prostigmin). The client has frequent exacerbations of myasthenic crisis & cholinergic crisis. The nurse teaches the client that it is important that this medication be 1. double dosed if one dose is missed. 2. taken on an empty stomach. 3. taken on time. 4. titrated for dosage depending on the symptoms.

122 A client with myasthenia gravis is taking neostigmine (Prostigmin). The client has frequent exacerbations of myasthenic crisis & cholinergic crisis. The nurse teaches the client that it is important that this medication be 1. double dosed if one dose is missed. Excessive doses can lead to cholinergic crisis 2. taken on an empty stomach. Adm 30 min before meals with milk and crackers to reduce GI upset. 3. taken on time. Crisis can be caused by inadequ med, fatigue, stress, infection 4. titrated for dosage depending on the symptoms. Not true. Practice Question 35

123 Used to dx myasthenia gravis –Adm tensilon –Improvement in muscle strength positive for myasthenia gravis –No Improvement in muscle strength negative for myasthenia gravis Differentiate between myasthenia crisis and cholinergic crisis –myasthenia crisis: Adm tensilon Strength improves pt needs more med for s/s MG –cholinergic crisis Adm tensilon Weakness more severe too much med for myasthenia gravis Tensilon Test (med used to tx myasthenia gravis)

124 Practice Question 36 A client has an order to receive valproic acid (Depakene) 250 mg once daily. To maximize the client’s safety, the nurse schedules administration of the medication 1. after breakfast. 2. at bedtime. 3. before breakfast. 4. with lunch.

125 A client has an order to receive valproic acid (Depakene) 250 mg once daily. To maximize the client’s safety, the nurse schedules administration of the medication 1. after breakfast. 2. at bedtime. Safety… 3. before breakfast. 4. with lunch. Anticonvulsant that causes CNS depression. S/e sedation, drowsiness, dizziness. Single daily dose at hs negates risk of injury. Practice Question 36

126 Practice Question 37 The nurse is planning care for the client with a left hemisphere stroke. The nurse would incorporate in the care plan to place objects 1. within the client’s reach on the right side. 2. within the client’s reach on the left side. 3. just out of the client’s reach on the right side. 4. just out of the client’s reach on the left side

127 The nurse is planning care for the client with a left hemisphere stroke. The nurse would incorporate in the care plan to place objects 1. within the client’s reach on the right side. 2. within the client’s reach on the left side. 3. just out of the client’s reach on the right side. 4. just out of the client’s reach on the left side Left brain CVA affects motor fx on right side. Place on left side to maintain the pt’s optimal level of independence Practice Question 38

128 Left-brain damage Hemiplegia right side Impaired speech/language (impacts language center as well as motor speech) Impaired right/left discrimination Slow performance, cautious Aware of deficits: depression, anxiety Impaired comprehension r/t language, math

129 Practice Question 39 The nurse is providing dietary instructions to a client about the food items that are high in niacin. Which food item is highest in niacin? 1. Milk 2. Potatoes 3. Strawberroes 4. Tomatoes

130 The nurse is providing dietary instrutions to a client about the food items that are high in niacin. Which food item is highest in niacin? 1. Milk dairy, meat, eggs 2. Potatoes 3. Strawberroes 4. Tomatoes Tomatoes, potatoes, strawberries are high in ascorbic acid (vitamin C) Practice Question 39

131 Practice Question 40 Acetazolamide (diamox) is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that the primary action of the medication is to 1.Decrease cerebrospinial fluid production 2.Maintain an adequate blood pressure for cerebral perfusion 3.Prevent hyperthermia 4.Prevent hypertension

132 Acetazolamide (diamox) is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that the primary action of the medication is to 1.Decrease cerebrospinial fluid production carbonic anhydrase inhibitor that is used to decr CSF production. 2.Maintain an adequate blood pressure for cerebral perfusion 3.Prevent hyperthermia 4.Prevent hypertension Note that supratentorial lesion clues the test taker that this is a problem with the brain…preventing incr of ICP is a primary goal for most…. Practice Question 40

133 Practice Question 41 A nurse is caring for a client with trigeminal neuralgia. The client asks for a snack. The nurse determines that the most appropriate choice to meet nutritional needs is 1. Cocoa with honey and toast. 2. Hot herbal tea with graham crackers. 3. Iced coffee and peanut butter crackers. 4. Vanilla wafers and room temperature water.

134 A nurse is caring for a client with trigeminal neuralgia. The client asks for a snack. The nurse determines that the most appropriate choice to meet nutritional needs is 1. Cocoa with honey and toast. Honey is “thick” and could make chewing more difficult. 2. Hot herbal tea with graham crackers. “hot” tea 3. Iced coffee and peanut butter crackers. “iced” coffee and peanut butter 4. Vanilla wafers and room temperature water. Sensory disorder that causes severe facial pain. Mild tactile stimulation of the face can trigger pain.…avoid wind, hot/cold liquids, foods that are mechanically difficult to chew…anything that would cause CNV to spasm and cause the pain. Practice Question 41

135 Practice Question 42 A client is diagnosed with Bell’s palsy. The nurse assessing the client expects to note which of the following? 1. A symmetrical smile. 2. Difficulty closing the eyelid on the affected side. 3. Narrowing of the palpebral fissure on the affected side. 4 Paroxysms of excruciating pain in the lips and cheek on the affected side.

136 A client is diagnosed with Bell’s palsy. The nurse assessing the client expects to note which of the following? 1. A symmetrical smile. Smile would be asymmetrical. 2. Difficulty closing the eyelid on the affected side. Facial drooping/muscle weakness on the affected side. Affects CN VII 3. Narrowing of the palpebral fissure on the affected side. Palpebral fissure is the anatomical name for the space between the upper and lower eyelids. 4 Paroxysms of excruciating pain in the lips and cheek on the affected side. Trigeminal neuralgia. Practice Question 42

137 Practice Question 43 A nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which of the following as the most critical index of CNS dysfunction? 1. Ability to speak 2. Blood pressure 3. Level of consciousness 4. Temperature

138 A nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which of the following as the most critical index of CNS dysfunction? 1. Ability to speak 2. Blood pressure 3. Level of consciousness 4. Temperature Changes in LOC can indicate clinical improvement or deterioration. BP, temp, ability to speak are components so of t his assessment. LOC provides an index of the overall CNS Practice Question 43

139 Practice Question 44 The nurse is caring for a client who is 24 hours postoperative for a craniotomy to remove a brain tumor. In what position would it be important for the nurse to maintain the client? 1. Flat with blocks under the head of the bed. 2. Lateral with pillows under the arms & knees. 3. On the back with the head of the bed elevated °. 4. Prone with the head of the bed elevated 35°

140 The nurse is caring for a client who is 24 hours postoperative for a craniotomy to remove a brain tumor. In what position would it be important for the nurse to maintain the client? 1. Flat with blocks under the head of the bed. 2. Lateral with pillows under the arms & knees. Infratentorial surgery…because of concerns re: edema. 3. On the back with the head of the bed elevated °. Choice that most clearly has the HOB higher than 15 degrees. Keep in semi-fowler’s position (on back with HOB elevated) to enhance venous drainage from the cranial vault to asst in preventing the development of incr ICP. 4. Prone with the head of the bed elevated 35° Practice Question 44

141 Practice Question 45 The nurse is caring for a client who has had a stroke. The nurse has assigned a nursing aide to assist the client with eating. What observation of the aide’s activities would cause the nurse the most concern? The aide 1. Places the client in high-Flower’s position. 2. Is placing the food on the affected side of the mouth. 3. Is talking with the client as she is feeding him. 4. Provides liquids that have been thickened.

142 The nurse is caring for a client who has had a stroke. The nurse has assigned a nursing aide to assist the client with eating. What observation of the aide’s activities would cause the nurse the most concern? The aide 1. Places the client in high-Flower’s position. 2. Is placing the food on the affected side of the mouth. Place on unaffected side of mouth 3. Is talking with the client as she is feeding him. 4. Provides liquids that have been thickened. Practice Question 45

143 Musculoskeletal System

144 Practice Question 46 After fitting a client with crutches the nurse is assessing to determine if they fit properly. What observation would cause the nurse the most concern? 1. When the client is standing, with the hands placed on the hand supports, the arms are straight. 2.There is space of about 1 1/2 to 2 inches between the axillary fold and the top of the crutch. 3. The client can place crutches about 6-8 inches lateral to the to the foot when walking. 4. The arms are flexed about 30° and resting on the hand supports when the client is standing.

145 After fitting a client with crutches the nurse is assessing to determine if they fit properly. What observation would cause the nurse the most concern? 1. When the client is standing, with the hands placed on the hand supports, the arms are straight. Elbows should be slightly flexed. 2.There is space of about 1 1/2 to 2 inches between the axillary fold and the top of the crutch. 2 finger breadth 3. The client can place crutches about 6-8 inches lateral to the to the foot when walking. correct 4. The arms are flexed about 30° and resting on the hand supports when the client is standing. Allows for wt bearing on the hand supports and not under the arm when the client begins to walk. Practice Question 46

146 Practice Question 47 Postoperatively, following a lumbar laminectomy, the client complains of the same low back pain as before surgery. The nurse knows that this is caused by what problem? 1. Failure of the surgery to remove the herniated disk. 2. Limitation of movement from spinal fusion. 3. Swelling of the operative area that compresses adjacent structures. 4. Twisting of the spine when turning side to side.

147 Postoperatively, following a lumbar laminectomy, the client complains of the same low back pain as before surgery. The nurse knows that this is caused by what problem? 1. Failure of the surgery to remove the herniated disk. 2. Limitation of movement from spinal fusion. Limitation of movement will decr pain. 3. Swelling of the operative area that compresses adjacent structures. After surgery edema may cause compression of structure in the operative area. This results in similar pain as experienced by pt preop. 4. Twisting of the spine when turning side to side. Twisting will cause pain – but it is usu a different pain than the pain preop. Practice Question 47

148 Practice Question 48 A client has a long leg plaster cast applied. What nursing actions are implemented while the cast is still wet? 1. Keep the client and cast covered with blankets. 2. Place a heat lamp directly over the cast. 3. Support the cast on plastic-covered pillows. 4. Use only the fingertips when moving the cast.

149 A client has a long leg plaster cast applied. What nursing actions are implemented while the cast is still wet? 1. Keep the client and cast covered with blankets. Covering the cast with blankets will not promote drying. 2. Place a heat lamp directly over the cast. Do not apply heat to damp cast. 3. Support the cast on plastic-covered pillows. Support the cast on a pillow that will not absorb the moisture. 4. Use only the fingertips when moving the cast. Palms of hands used to turn client. Practice Question 48

150 Practice Question 49 A client has a fractured hip and is currently in Buck’s traction awaiting surgery. How is the countertraction achieved in Buck’s traction for a fractured hip? 1. Applying a 10-pound counterweight at the knee. 2. Elevating the foot of the bed frame and allowing the weights to hang freely. 3. Elevating the knee gatch and elevating the head of the bed about 30°. 4. Placing shock blocks under the head of the bed.

151 A client has a fractured hip and is currently in Buck’s traction awaiting surgery. How is the countertraction achieved in Buck’s traction for a fractured hip? 1. Applying a 10-pound counterweight at the knee. 2. Elevating the foot of the bed frame and allowing the weights to hang freely. 3. Elevating the knee gatch and elevating the head of the bed about 30°. 4. Placing shock blocks under the head of the bed. Practice Question 49

152 For any client in traction, a nsg priority is to determine the correct amt of wt and to assess for effectiveness of countertraction. Wts must hang freely for countertraction to be effective. In Buck’s traction the entire foot of the bed is elevated to prevent the client from moving toward the end of the bed.

153 Buck’s Traction

154 Practice Question 50 The nursing care plan for a postoperative client who has had a right leg amputation includes what measures to decrease edema? 1. Administer anti-inflammatory medications as ordered. 2. Apply ice packs to the stump for 72 hours. 3. Elevate the stump by raising the foot of the bed for 24 to 48 hours. 4. Wrap the stump with Ace bandages from proximal to distal area.

155 The nursing care plan for a postoperative client who has had a right leg amputation includes what measures to decrease edema? 1. Administer anti-inflammatory medications as ordered. Used for pain relief, not to prevent edema. 2. Apply ice packs to the stump for 72 hours. Ice packs are not used postop amputation. 3. Elevate the stump by raising the foot of the bed for 24 to 48 hours. Elevation indicated to prevent edema – some texts recommend using blocks to elevate the FOB. 4. Wrap the stump with Ace bandages from proximal to distal area. Wrap distal to proximal Practice Question 50

156 Practice Question 51 What is important assessment information to obtain from a client who is being admitted with a tentative diagnosis of a fractured hip? 1. Amount of pain that the fracture is causing. 2. Amount of swelling around the fracture site. 3. Circulation and sensation distal to the fracture. 4. Status of the range of motion in the extremity.

157 What is important assessment information to obtain from a client who is being admitted with a tentative diagnosis of a fractured hip? 1. Amount of pain that the fracture is causing. Also a correct response…use ABC’s to select “3”. 2. Amount of swelling around the fracture site. Important, but the primary concern re: swelling is impact on circulation and neurosensory deficits. 3. Circulation and sensation distal to the fracture. 4. Status of the range of motion in the extremity. ROM should not be attempted/assessed on this pt. Practice Question 51

158 Practice Question 52 The nursing care plan for a 2-month-old infant in a left hip spica cast includes what nursing measures? 1. Blanch the skin of areas proximal to the casted left leg. 2. Check cast for tightness by inserting fingers between skin and cast. 3. Maintain constant traction on the affected left leg. 4. Palpate the left brachial artery and compare it with the right.

159 The nursing care plan for a 2-month-old infant in a left hip spica cast includes what nursing measures? 1. Blanch the skin of areas proximal to the casted left leg. Circulation is checked distal to the cast. 2. Check cast for tightness by inserting fingers between skin and cast. Make sure the cast is not too tight as this would impair circulation. 3. Maintain constant traction on the affected left leg. Child is not in traction 4. Palpate the left brachial artery and compare it with the right. The arms are not being treated Practice Question 52

160 Spica Cast

161 Practice Question 53 The nursing care for the client in Russell traction includes what measures? 1. Allowing client to sit in a chair at bedside. 2. Checking distal circulation of affected leg. 3. Maintaining client in semi-Fowler’s position to promote deep breathing. 4. Turning client every 2 hours to unaffected side.

162 The nursing care for the client in Russell traction includes what measures? 1. Allowing client to sit in a chair at bedside. client in traction not generally allowed OOB. Note that traction would not be moved so that it would be maintained while the pt was OOB. 2. Checking distal circulation of affected leg. Always monitor circulation distal to the area of injury in an orthopedic injury. 3. Maintaining client in semi-Fowler’s position to promote deep breathing. Could position this client in semi-Fowler’s but it is not a requirement of the traction. 4. Turning client every 2 hours to unaffected side. Generally maintained supine to promote straight pull of traction. Might release traction, turn s/s for hygienic purposes or skin care, then re-establish the traction. Practice Question 53

163 Russell Traction

164 Practice Question 54 Which of the statements by the client following a total hip replacement indicates a lack of understanding of mobility limitations? 1. “I should not bend down to put on shoes or socks.” 2. “It is OK to cross my legs while sitting in a chair.” 3. “I should put a pillow between my legs when lying on my side.” 4. “I should not sit in low chairs or low toilet seats.”

165 Which of the statements by the client following a total hip replacement indicates a lack of understanding of mobility limitations? 1. “I should not bend down to put on shoes or socks.” true. 2. “It is OK to cross my legs while sitting in a chair.” Operative leg cannot be brought across midline. (Abduction of leg is contraindicated) 3. “I should put a pillow between my legs when lying on my side.” maintains adduction, prevents abduction of the affected leg. 4. “I should not sit in low chairs or low toilet seats.” usu sent home with a device that raises the height of the toilet seat. Practice Question 54

166 Practice Question 55 Which assessment finding would cause the nurse concern regarding development of compartment syndrome following a fractured fibula repaired with an external fixator? Select all that apply. 1. Decrease in pulse rate on affected leg. 2. Paresthesia distal to area of injury. 3.Toes on affected leg cool to touch and edematous. 4. Complaints that pins are hurting 5. Complaints of pain unrelieved by analgesics. 6. Client angry & calling loudly to the nurse every 10 minutes

167 Which assessment finding would cause the nurse concern regarding development of compartment syndrome following a fractured fibula repaired with an external fixator? Select all that apply. 1. Decrease in pulse rate on affected leg. A decrease in the quality of the pulse would be cause for alarm. 2. Paresthesia distal to area of injury. 3.Toes on affected leg cool to touch and edematous. 4. Complaints that pins are hurting pins do cause discomfort. 5. Complaints of pain unrelieved by analgesics. 6. Client angry & calling loudly to the nurse every 10 minutes many clients are angry re: immobility /do not always use effective coping mechanisms. Practice Question 55

168 Compartment Syndrome Tough fascia surrounds muscle groups forming compartments from which arteries, veins, nerve enter and exit An increase in pressure in one or more of these compartments leads to decr blood flow, tissue ischemia, neurovascular impairment Irreversible nerve damage can occur in 4-6 hrs after the onset of compartment syndrome Notify MD immediately…

169 Immune

170 Practice Question 56 The nurse would anticipate which laboratory finding in a client with joint pain, “butterfly rash,’ photosensitivity, weight loss, and fever? 1. Glycosuria 2. Increased red blood cell and white blood cell counts. 3. Negative serum complement level. 4. Presence of antinuclear antibodies.

171 The nurse would anticipate which laboratory finding in a client with joint pain, “butterfly rash,’ photosensitivity, weight loss, and fever? 1. Glycosuria seen with DM 2. Increased red blood cell and white blood cell counts. Not seen 3. Negative serum complement level. Elevated erythrocyte sedimentation rate (ESR) 4. Presence of antinuclear antibodies. Positive ANA. Also see leucopenia, thrombocytopenia, lymphopenia, and a positive lupus erythematosus cell prep. Proteinurea with cellular casts if often noted. Practice Question 56

172 Practice Question 57 The nurse is preparing discharge teaching for a woman newly diagnosed with systemic lupus erythematosus (SLE). What will be important for the nurse to include? Select all that apply. 1. Wear sunscreen & clothing when in sunlight. 2. Avoid NSAIDS to prevent bleeding. 3. Plan activities that use ROM in extremities. 4. Pregnancy is contraindicated. 5. Observe fingertips for changes in circulation 6. Assist to prioritize self-care activities.

173 The nurse is preparing discharge teaching for a woman newly diagnosed with systemic lupus erythematosus (SLE). What will be important for the nurse to include? Select all that apply. 1. Wear sunscreen & clothing when in sunlight. Photosensitive: Avoid exposure to sunlight & ultraviolet light 2. Avoid NSAIDS to prevent bleeding. Use NSAIDS to tx pain and inflammation 3. Plan activities that use ROM in extremities. Must keep joints mobilized because of the invasion of the lupus erythematosus cells into the joints. Pace activities to conserve energy – need to maintain ROM 4. Pregnancy is contraindicated. Creates extra stress on body but is OK. Should be advised re: progress of her disease and implications fro pregnancy – but can carry and deliver healthy infant. 5. Observe fingertips for changes in circulation s/s asso with Reynaud’s Phenomenon occur. 2 nd to circulatory inflammation and irritation. 6. Assist to prioritize self-care activities. Pace activities to minimize fatigue – maintain independence as long as possible. Practice Question 57

174 Practice Question 58 The nurse is caring for a client who is categorized as HIV+, Category A. What would the nurse anticipate finding on the nursing assessment? 1. Confusion, disorientation, loss of coordination. 2. Dyspnea, tachycardia on exertion, fever. 3.Fatigue, weight loss, night sweats. 4. Red, raised lesions on neck and face, fever.

175 The nurse is caring for a client who is categorized as HIV+, Category A. What would the nurse anticipate finding on the nursing assessment? 1. Confusion, disorientation, loss of coordination. Not asso with category A 2. Dyspnea, tachycardia on exertion, fever. Not asso with category A 3. Fatigue, weight loss, night sweats. Category A is when the primary condition is identified or the client has recently been infected. May be asymptomatic or may have symptoms of early nonspecific changes. 4. Red, raised lesions on neck and face, fever. Not asso with category A Practice Question 58

176 Practice Question 59 A child has chicken pox. What type immunity will this child have on his recovery? 1.Actively acquired immunity 2.Artificially acquired immunity 3.Natural passive immunity 4.Naturally acquired active immunity

177 A child has chicken pox. What type immunity will this child have on his recovery? 1.Actively acquired immunity injection of human or animal serum 2.Artificially acquired immunity immunizations 3.Natural passive immunity placental transfer 4.Naturally acquired active immunity a child who contracts chicken pox for the first time develops antibodies during the period of infection. These antibodies cerate a naturally acquired, lifelong type of active immunity. Practice Question 59

178 Practice Question 60 The nurse is caring for a client who is experiencing a severe anaphylactic reaction to penicillin. After beginning oxygen administration and determining that vital signs, including respiration are adequate, the next most important nursing action would be to: 1.Administer analgesics to reliever the pain 2.Start an IV for fluid administration 3.Insert a catheter to determine urinary output 4.Obtain a history of possible reactions to penicillin.

179 The nurse is caring for a client who is experiencing a severe anaphylactic reaction to penicillin. After beginning oxygen administration and determining that vital signs, including respiration are adequate, the next most important nursing action would be to: 1.Administer analgesics to reliever the pain should be not pain 2.Start an IV for fluid administration Shock is a common problem in anaphylactic reactions. Important to establish an IV for fluid and med administration. 3.Insert a catheter to determine urinary output no reason client cannot void on his own. 4.Obtain a history of possible reactions to penicillin. History important but can be addressed later. Practice Question 60

180 Extra Adult Health

181 Extra Practice Question 1 A nurse is teaching a client with angina pectoris about disease management. Which statement by the client indicates a need for further teaching” 1. “I will take nitroglycerin whenever chest discomfort begins.” 2. “I will use muscle relaxation to cope with stressful situations” 3. “It is best to exercise once a week for an hour. 4. “I will avoid using table salt with meals.”

182 A nurse is teaching a client with angina pectoris about disease management. Which statement by the client indicates a need for further teaching” 1. “I will take nitroglycerin whenever chest discomfort begins.” true 2. “I will use muscle relaxation to cope with stressful situations” good idea to teach stress reduction techniques 3. “It is best to exercise once a week for an hour”. Exercise 3 times a week for minutes. 4. “I will avoid using table salt with meals.” true Extra Practice Question 1

183 Extra Practice Question 2 A nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. “I need to substitute eggs for meat.” 2. “I should eliminate all cholesterol and fat from my diet.” 3. “I should use polyunsaturated oils.” 4. “I’ll need to become a strict vegetarian.”

184 A nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. “I need to substitute eggs for meat.” needs to avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. 2. “I should eliminate all cholesterol and fat from my diet.” note the use of the word “all” 3. “I should use polyunsaturated oils.” recommended to control hypercholesterolemia. 4. “I’ll need to become a strict vegetarian.” not necessary. Extra Practice Question 2

185 Extra Practice Question 3 A client returning to the unit following cardiac catheterization has a stat order to receive a dose of procainamide (Pronestyl). The nurse uses which equipment to determine most adequately the client’s response to the medication? 1. Cardiac monitor 2. Glucometer 3. Noninvasive blood pressure cuff 4. Pulse oximeter

186 A client returning to the unit following cardiac catheterization has a stat order to receive a dose of Procainamide (Pronestyl). The nurse uses which equipment to determine most adequately the client’s response to the medication? 1. Cardiac monitor used to tx ventricular dysrythmias. Procainamide is an antidysrhythmic. 2. Glucometer not indicated 3. Noninvasive blood pressure cuff good to have as an improvement in rhythm would improve CO and BP…not best choice. 4. Pulse oximeter…good to have as this provides general info about the client’s cardiovascular status…not best choice. Extra Practice Question 3

187 A client with a myocardial infarction calls the nurse because he is experiencing chest pain. The nurse administers a sublingual nitroglycerin.The chest pain is unrelieved. The next nursing action is which of the following? 1. Administer another nitroglycerin tablet. 2. Increase the flow rate of the oxygen. 3. Contact the physician. 4. Call the client’s family. Extra Practice Question 4

188 A client with a myocardial infarction calls the nurse because he is experiencing chest pain. The nurse administers a sublingual nitroglycerin.The chest pain is unrelieved. The next nursing action is which of the following? 1. Administer another nitroglycerin tablet. Adm one tablet q5min times three for chest pain if SBP is 100 or greater. 2. Increase the flow rate of the oxygen. If prescribed by MD this would be next action 3. Contact the physician. If 3 NTG tablets do not relieve the pain contact the MD. 4. Call the client’s family. Extra Practice Question 4

189 The client is having difficulty coughing and deep breathing because of pain after a nephrectomy. Which action by the nurse would be least helpful in promoting optimal respiratory function? 1.Administering pain medication only before ambulation 2.Encouraging use of incentive Spiro meter hourly 3.Assisting the client to splint the incision during respiratory exercise 4.Offering prn pain medication every 4 hours when due. Extra Practice Question 5

190 The client is having difficulty coughing and deep breathing because of pain after a nephrectomy. Which action by the nurse would be least helpful in promoting optimal respiratory function? 1.Administering pain medication only before ambulation Insufficient – needs more often than before ambulation. 2.Encouraging use of incentive Spiro meter hourly very helpful in promoting respiratory function 3.Assisting the client to splint the incision during respiratory exercise very helpful, asst to breath deeply and makes the exercises more efficient. 4.Offering prn pain medication every 4 hours when due. Extra Practice Question 5

191 A child is receiving propylthiouracil (PTU) for treatment of hyperthyroidism. The parents and child should be taught to recognize and report immediately which of the following symptoms? 1.Ear pain 2.Headache 3.Fever, sore throat 4.Gastrointestinal infection Extra Practice Question 6

192 A child is receiving propylthiouracil (PTU) for treatment of hyperthyroidism. The parents and child should be taught to recognize and report immediately which of the following symptoms? 1.Ear pain not necessarily an indication of primary infection. 2.Headache not necessarily an indication of primary infection 3.Fever, sore throat earliest indications of agranulocytosis, which is the most serious toxic effect of this medication. Watch for other s/s of URI also. 4.Gastrointestinal infection Extra Practice Question 6

193 A nurse will administer phenytoin (Dilantin) IV push through an IV line of 0.9% sodium chloride. Write the numbers representing each action in order from first action to last action. 1. Check the client’s ID bracelet. 2. Pinch off the IV tubing above the injection port. 3. Draw up the medication in a 3 ml syringe. 4. Check the compatibility of phenytoin with the IV solution 5. Inject the medication. 6. Document that the medication was given. Extra Practice Question 7

194 A nurse will administer phenytoin (Dilantin) IV push through an IV line of 0.9% sodium chloride. Write the numbers representing each action in order from first action to last action. 1. Check the client’s ID bracelet. 2. Pinch off the IV tubing above the injection port. 3. Draw up the medication in a 3 ml syringe. 4. Check the compatibility of phenytoin with the IV solution 5. Inject the medication. 6. Document that the medication was given. 4,3,1,2,5,6 Extra Practice Question 7

195 Extra Practice Question 8 The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Diilantin). Which statement make by the client indicates understanding about this medication? “I should 1. take my medication before having a blood level drawn.” 2. adjust my dose depending of the severity of the side effects.” 3. drink alcohol in moderation.” 4. perform good oral hygiene.”

196 The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Diilantin). Which statement make by the client indicates understanding about this medication? “I should 1. take my medication before having a blood level drawn.” take med as prescribed by MD. 2. adjust my dose depending of the severity of the side effects.” Never adjust dose of any med without consulting MD 3. drink alcohol in moderation.” avoid alcohol 4. perform good oral hygiene.” Can cause gum problems. Extra Practice Question 8

197 A client has systemic lupus erythematosus (SLE). What statement best describes this client’s immune response? 1. An immediate reaction to prior exposure. 2. An immune complex that forms with antibody production. 3. Delayed hypersensitivity that is cell mediated. 4. The immune system no longer recognizes normal body tissue. Extra Practice Question 9

198 A client has systemic lupus erythematosus (SLE). What statement best describes this client’s immune response? 1. An immediate reaction to prior exposure. Characteristic of a transplant rejection or a reaction to TB skin testing. 2. An immune complex that forms with antibody production. Type I reaction characterized by a prior exposure to the antigen; as occurs with anaphylaxis. 3. Delayed hypersensitivity that is cell mediated. Type III response that occurs with acute glomerulonephritis. 4. The immune system no longer recognizes normal body tissue. Autoimmune disorder. The body begins to invad and destroy normal tissue. Extra Practice Question 9

199 Extra Practice 10 A client comes into the ER; he states that he had a kidney transplant a month ago. What symptoms would cause the nurse the most concern? 1. Fever, increased blood pressure, and increased fatigue. 2. Inflamed joints and pitting edema in lower extremities. 3. Nausea, vomiting and diarrhea for the past 6 hours. 4. Urine dark with a specific gravity of

200 A client comes into the ER; he states that he had a kidney transplant a month ago. What symptoms would cause the nurse the most concern? 1. Fever, increased blood pressure, and increased fatigue. Fever and fatigue are the most freq. early symptom of acute rejection. 2. Inflamed joints and pitting edema in lower extremities. Pitting edema is not common – esp in the early stages of rejection. 3. Nausea, vomiting and diarrhea for the past 6 hours. Not asso with early stages of rejection 4. Urine dark with a specific gravity of Indicates that the kidneys are able to concentrate urine – normal. Extra Practice 10

201 Extra Practice 11 A client with a diagnosis of AID’S has developed Pneumocystis carnii pneumonia (PCP). What will be important for the nurse to include in the nursing care plan? 1. Explain to the client why he cannot go outside his room. 2. Put a mask on the client whenever he has visitors in his room. 3. Wear a mask and gown when providing direct care to the client. 4. Wear a gown and gloves when assisting client with personal hygiene.

202 A client with a diagnosis of AID’S has developed Pneumocystis carnii pneumonia (PCP). What will be important for the nurse to include in the nursing care plan? 1. Explain to the client why he cannot go outside his room. 2. Put a mask on the client whenever he has visitors in his room. 3. Wear a mask and gown when providing direct care to the client. 4. Wear a gown and gloves when assisting client with personal hygiene. Not transmitted person to person. Do not need airborne or droplet precautions but standard precautions must be strictly adhered to. Extra Practice 11

203 Extra Practice Question 12 A client has a problem with severe painful osteoarthritis. A regimen of heat, massage, and exercise has been ordered. What is the desired response to this treatment? 1. Assist the client to effectively cope with pain. 2. Help relax muscles and relieve pain and stiffness. 3.prevent the inflammatory process. 4. Restore range of motion previously lost.

204 A client has a problem with severe painful osteoarthritis. A regimen of heat, massage, and exercise has been ordered. What is the desired response to this treatment? 1. Assist the client to effectively cope with pain. Makes client more comfortable, does not asst in coping with pain. 2. Help relax muscles and relieve pain and stiffness. 3.prevent the inflammatory process. Does not prevent inflammatory process – heat would asst in relieving… 4. Restore range of motion previously lost. Usu does not restore lost ROM...hope prevents further ROM loss Extra Practice Question 12


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