Comprehensive Review CD Questions

Comprehensive Review CD Questions {COMP: Equations/Formulas: 1963; AQ questions: 1901, 1907, 1919, 1922, 1925, 1957; note multiple figures/figure credits for Question 1919.} {PLACE FIGURE HERE (Fig. 20) for Q#1901} Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 693. AQ1901. A nurse is checking the apical heart rate of a client with angina. The nurse places the stethoscope in which anatomical area? Answer: 4 Rationale: The apical heart rate is best assessed by placing the stethoscope in the mitral area, which is located in the fifth intercostal space on the left side of the chest at the apex of the heart. Erb’s point is located in the third intercostal space just left of the sternum. The aortic area is located in the second intercostal space just right of the sternum. The pulmonic area is located in the second intercostal space just left of the sternum. Test-Taking Strategy: Recalling that the apical heart rate is best assessed at the apex of the heart and knowledge that this area is located in the fifth intercostal space to the left of the sternum will direct you to option 4. Review the procedure for taking the apical heart rate if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular References: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 693. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 561. {PLACE FIGURE HERE (Fig. 20) for Q#1901} Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 693. 1902. A nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? 1. Legs are unsightly in appearance and distress the client 2. The client complains of aching and feelings of heaviness in the legs 3. The physician finds that the legs become distended when the tourniquet is released during the Trendelenburg test 4. The client complains of leg edema, and skin breakdown has started Answer: 4 Rationale: Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or 1 PN~CD~Questions~ - chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 3 describes the Trendelenburg test findings, which are indicative of varicose veins. In the test, the physician has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow. Test-Taking Strategy: Use the process of elimination and note the key words potential complication. Noting the words “skin breakdown” in option 4 will direct you to this option. If you had difficulty with this question, review the complications associated with varicose veins. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 343. 1903. A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and had an arterial blood gas test performed. Which of the following results would the nurse expect to note? 1. pO2 of 70 mm Hg and pCO2 of 50 mm Hg 2. pO2 of 68 mm Hg and pCO2 of 40 mm Hg 3. pO2 of 62 mm Hg and pCO2 of 40 mm Hg 4. pO2 of 60 mm Hg and pCO2 of 50 mm Hg Answer: 4 Rationale: During an acute exacerbation of COPD, the arterial blood gases deteriorate with a decreasing pO2 and an increasing pCO2. In the early stages of COPD, arterial blood gases demonstrate a mild to moderate hypoxemia with the pO2 in the high 60’s to high 70’s and normal arterial pCO2. As the condition advances, hypoxemia increases and hypercapnia may result. Test-Taking Strategy: Use the process of elimination and note the key words acute exacerbation. This will direct you to option 4. This is the option that indicates the lowest pO2 level. If you had difficulty with this question, review the physiological alterations that occur in COPD and the associated blood gas values. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity 2 PN~CD~Questions~ - Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 497-499. 1904. A client scheduled for a thyroidectomy says to the nurse, “I am so scared to get cut in my neck.” Based on the client’s statement, the nurse suggests including which nursing diagnosis in the plan of care? 1. Anxiety related to inadequate knowledge about the surgical procedure 2. Ineffective Coping related to fear about impending surgery 3. Situational Low Self Esteem related to changes in personal appearance 4. Impaired Home Maintenance related to the surgical procedure Answer: 2 Rationale: The client is having a difficult time coping with the scheduled surgery. The client is able to express fears but is frightened. There are no data in the question to support options 1, 3, and 4. Test-Taking Strategy: Use the process of elimination. Focusing specifically on the client’s statement in the question will direct you to option 2. Also note the relation between the words “scared” in the question and “fear” in the correct option. Review the defining characteristics for Ineffective Coping if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. . 1905. A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates the best understanding of this stress reduction measure? 1. “This works for me only if I am alone in a quiet area.” 2. “This will help only if I play music at the same time.” 3. “I need to do this only when I lie down in case I fall asleep.” 4. “The best thing about this is that I can use it anywhere, anytime.” Answer: 4 Rationale: Guided imagery involves the client’s creation of an image in the mind, concentrating on the image, and gradually become less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it. Test-Taking Strategy: Use the process of elimination and note the key words best understanding. Eliminate options 1, 2, and 3 because of the absolute word “only.” Review guided imagery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular 3 PN~CD~Questions~ - Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 914. 1906. A client who is 36-hours post-myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation was made? 1. Skin cool but slightly diaphoretic 2. Dyspnea noted only at the end of the exercise 3. Preactivity pulse rate 86 beats per minute, postactivity pulse rate 94 beats per minute 4. Preactivity blood pressure (BP) 140/84 mm Hg, postactivity BP 110/72 mm Hg Answer: 3 Rationale: The nurse checks vital signs and the level of fatigue with each activity. The client is not tolerating the activity if there is a drop in systolic BP greater than 20 mm Hg, changes in pulse rate of greater than 20 beats per minute, dyspnea, or chest pain. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise. Test-Taking Strategy: Use the process of elimination. The question asks about activity tolerance, which tells you that you are looking for normal data. Look for the option that identifies normal values or the least degree of variation. Options 1 and 2 clearly identify abnormal data. Option 4 identifies a significant drop in BP, indicating an abnormal condition. An increase in pulse rate as reflected in option 3 is a normal expectation after exercise. Review the effects of exercise on the cardiovascular system if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1474. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p 316. {PLACE FIGURE HERE (Fig. 21). For Q#1907} Wilson, S., & Giddens, J. (2005). Health assessment for nursing practice (3rd ed.). St. Louis: Mosby, p. 489. AQ1907. A nurse is preparing to auscultate bowel sounds on a postoperative client. The nurse places the stethoscope in which quadrant first? Answer: 3 Rationale: To auscultate bowel sounds, the nurse should begin at the ileocecal valve area in the right lower quadrant, because bowel sounds are normally present in this area. The diaphragm end piece is used because bowel sounds are relatively high-pitched. The stethoscope is held lightly against the skin because pushing too hard may stimulate more bowel sounds. Test-Taking Strategy: Knowledge regarding the anatomy and physiology of the gastrointestinal tract and the procedure for assessing bowel sounds is required to answer this question. Remember, begin at the ileocecal valve area in the right lower quadrant. If you are unfamiliar with the auscultation of bowel sounds, review this procedure. 4 PN~CD~Questions~ - Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 655. Wilson, S., & Giddens, J. (2005). Health assessment for nursing practice (3rd ed.). St. Louis: Mosby, p. 489. {PLACE FIGURE HERE (Fig. 21). For Q#1907} Wilson, S., & Giddens, J. (2005). Health assessment for nursing practice (3rd ed.). St. Louis: Mosby, p. 489. 1908. A nurse observes that a client’s nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube is still not draining. The nurse analyzes this problem as: 1. Channels of gastric secretions may be bypassing the holes in the tube, and turning the client will promote stomach emptying 2. Thick gastric secretions may be blocking the tube, and removing this tube and reinserting a new tube will correct the problem 3. It is a normal occurrence for a nasogastric tube to stop draining; no action is required 4. This is a potentially serious complication, and the physician must be notified immediately Answer: 1 Rationale: The nurse must check nasogastric tubes regularly to maintain the tube’s patency and ensure that it is draining properly. Nasogastric tubes are used to decompress the stomach. The gastric distention will be relieved only if the tube drains properly. One cause of improper tube drainage results from channels of gastric secretions forming along the walls of the stomach and bypassing the holes in the nasogastric tube. Turning the client regularly helps to collapse the channels and promotes gastric emptying. The tube has already been flushed, so it is unlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a potentially serious complication. Test-Taking Strategy: Use the process of elimination. Option 2 can be eliminated because the tube has just been flushed. Option 3 can be eliminated because it is not acceptable to ignore a tube that has suddenly stopped draining. Option 4 can be eliminated because there are nursing options available to reestablish nasogastric tube patency before notifying the physician. If you had difficulty with this question, review nursing care to the client with a nasogastric tube. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestina