PNLE 3 – CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL intracranial pressure?
ALTERATIONS Blood pressure is decreased from 160/90 to 110/70.
1. Nurse Michelle should know that the drainage is normal 4
days after a sigmoid colostomy when the stool is:
Green liquid
Solid formed
Loose, bloody
Semiformed
2. Where would nurse Kristine place the call light for a male client
with a right-sided brain attack and left homonymous
hemianopsia? On the client’s right side
On the client’s left side
Directly in front of the
client Where the client like
3. A male client is admitted to the emergency department
following an accident. What are the first nursing actions of the
nurse?
Check respiration, circulation, neurological response.
Align the spine, check pupils, and check for hemorrhage.
Check respirations, stabilize spine, and check circulation.
Assess level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should
know that it reduces preload and relieves angina by:
Increasing contractility and slowing heart rate.
Increasing AV conduction and heart rate.
Decreasing contractility and oxygen
consumption. Decreasing venous return through
vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial
infarction (MI) slumped on the side rails of the bed and
unresponsive to shaking or shouting. Which is the nurse next
action?
Call for help and note the
time. Clear the airway
Give two sharp thumps to the precordium, and check the pulse.
Administer two quick blows.
6. Nurse Monett is caring for a client recovering from
gastro- intestinal bleeding. The nurse should:
Plan care so the client can receive 8 hours of uninterrupted
sleep each night.
Monitor vital signs every 2 hours.
Make sure that the client takes food and medications at
prescribed intervals.
Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and
has been receiving heparin I.V. for 2 days. The partial
thromboplastin time (PTT) is 68 seconds. What should Nurse Carla
do?
Stop the I.V. infusion of heparin and notify the physician.
Continue treatment as ordered.
Expect the warfarin to increase the PTT.
Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage
appliance be applied to the stoma?
24 hours later, when edema has
subsided. In the operating room.
After the ileostomy begin to function.
When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that
the nurse immediately position the client in:
On the side, to prevent obstruction of airway by tongue.
Flat on back.
On the back, with knees flexed 15 degrees.
Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor
vehicle accident, which assessment data suggest increasing
,Pulse is increased from 87 to 95, with an occasional skipped beat. osteoporosis. When teaching the client, the nurse should include
The client is oriented when aroused from sleep, and goes information about which major complication:
back to sleep immediately. Bone fracture
The client refuses dinner because of anorexia.
11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which
of the following symptoms may appear first?
Altered mental status and
dehydration Fever and chills
Hemoptysis and Dyspnea
Pleuritic chest pain and
cough
12. A male client has active tuberculosis (TB). Which of the
following symptoms will be exhibit?
Chest and lower back pain
Chills, fever, night sweats, and hemoptysis
Fever of more than 104°F (40°C) and
nausea Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency
department. He’s tachypneic and afebrile and has a respiratory
rate of 36 breaths/minute and has a nonproductive cough. He
recently had a cold. Form this history; the client may have which
of the following conditions?
Acute asthma
Bronchial
pneumonia
Chronic obstructive pulmonary disease
(COPD) Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping
and her respiratory rate is 4 breaths/minute. If action isn’t taken
quickly, she might have which of the following reactions?
Asthma attack
Respiratory
arrest Seizure
Wake up on his own
15. A 77-year-old male client is admitted for elective knee
surgery. Physical examination reveals shallow respirations but no
sign of respiratory distress. Which of the following is a normal
physiologic change related to aging?
Increased elastic recoil of the lungs
Increased number of functional capillaries in the alveoli
Decreased residual volume
Decreased vital capacity
16. Nurse John is caring for a male client receiving lidocaine
I.V. Which factor is the most relevant to administration of
this medication?
Decrease in arterial oxygen saturation (SaO2) when measured
with a pulse oximeter.
Increase in systemic blood pressure.
Presence of premature ventricular contractions (PVCs) on a
cardiac monitor.
Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant.
The nurse should teach the client to:
Report incidents of
diarrhea. Avoid foods high
in vitamin K
Use a straight razor when
shaving. Take aspirin to pain
relief.
18. Nurse Lhynnette is preparing a site for the insertion of an
I.V. catheter. The nurse should treat excess hair at the site by:
Leaving the hair intact
Shaving the area
Clipping the hair in the area
Removing the hair with a
depilatory.
19. Nurse Michelle is caring for an elderly female with
,Loss of estrogen Friction rubs
Negative calcium
balance Dowager’s
hump
20. Nurse Len is teaching a group of women to perform BSE.
The nurse should explain that the purpose of performing the
examination is to discover:
Cancerous lumps
Areas of thickness or fullness
Changes from previous
examinations. Fibrocystic masses
21. When caring for a female client who is being treated
for hyperthyroidism, it is important to:
Provide extra blankets and clothing to keep the client warm.
Monitor the client for signs of restlessness, sweating, and
excessive weight loss during thyroid replacement therapy.
Balance the client’s periods of activity and rest.
Encourage the client to be active to prevent constipation.
22. Nurse Kris is teaching a client with history of atherosclerosis. To
decrease the risk of atherosclerosis, the nurse should encourage
the client to:
Avoid focusing on his
weight. Increase his activity
level.
Follow a regular diet.
Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta
must logroll a client following a:
Laminectomy
Thoracotomy
Hemorrhoidectomy
Cystectomy.
24. A 55-year old client underwent cataract removal with
intraocular lens implant. Nurse Oliver is giving the client discharge
instructions. These instructions should include which of the
following?
Avoid lifting objects weighing more than 5 lb (2.25 kg).
Lie on your abdomen when in bed
Keep rooms brightly lit.
Avoiding straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations
during: when sexual activity starts
After age 69
After age 40
Before age 20.
26. A male client undergone a colon resection. While turning
him, wound dehiscence with evisceration occurs. Nurse Trish first
response is to:
Call the physician
Place a saline-soaked sterile dressing on the
wound. Take a blood pressure and pulse.
Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has suffered a
severe cerebrovascular accident. During routine assessment, the
nurse notices Cheyne- Strokes respirations. Cheyne-strokes
respirations are:
A progressively deeper breaths followed by shallower breaths
with apneic periods.
Rapid, deep breathing with abrupt pauses between each breath.
Rapid, deep breathing and irregular breathing without pauses.
Shallow breathing with an increased respiratory rate.
28. Nurse Bea is assessing a male client with heart failure. The
breath sounds commonly auscultated in clients with heart
failure are:
Tracheal
Fine crackles
Coarse crackles
, 29. The nurse is caring for Kenneth experiencing an acute asthma student A 33-year-old day-care worker
attack. The client stops wheezing and breath sounds aren’t A 43-yesr-old homeless man with a history of
audible. The reason for this change is that: alcoholism A 54-year-old businessman
The attack is over.
The airways are so swollen that no air cannot get
through. The swelling has decreased.
Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During the active
seizure phase, the nurse should:
Place the client on his back remove dangerous objects, and
insert a bite block.
Place the client on his side, remove dangerous objects, and
insert a bite block.
Place the client o his back, remove dangerous objects, and hold
down his arms.
Place the client on his side, remove dangerous objects, and
protect his head.
31. After insertion of a cheat tube for a pneumothorax, a client
becomes hypotensive with neck vein distention, tracheal shift,
absent breath sounds, and diaphoresis. Nurse Amanda
suspects a tension pneumothorax has occurred. What cause of
tension pneumothorax should the nurse check for?
Infection of the lung.
Kinked or obstructed chest tube
Excessive water in the water-seal
chamber Excessive chest tube drainage
32. Nurse Maureen is talking to a male client, the client begins
choking on his lunch. He’s coughing forcefully. The nurse
should: Stand him up and perform the abdominal thrust
maneuver from behind.
Lay him down, straddle him, and perform the
abdominal thrust maneuver.
Leave him to get assistance
Stay with him but not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old
client. Which information will be most useful to the nurse for
planning care?
General health for the last 10
years. Current health promotion
activities. Family history of
diseases.
Marital status.
34. When performing oral care on a comatose client, Nurse
Krina should:
Apply lemon glycerin to the client’s lips at least every 2
hours. Brush the teeth with client lying supine.
Place the client in a side lying position, with the head of the
bed lowered.
Clean the client’s mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of
dehydration and change in mental status. He’s being hydrated
with
L.V. fluids. When the nurse takes his vital signs, she notes he has a
fever of 103°F (39.4°C) a cough producing yellow sputum and
pleuritic chest pain. The nurse suspects this client may have which
of the following conditions?
Adult respiratory distress syndrome
(ARDS) Myocardial infarction (MI)
Pneumoni
a
Tuberculos
is
36. Nurse Oliver is working in a out patient clinic. He has been
alerted that there is an outbreak of tuberculosis (TB). Which of
the following clients entering the clinic today most likely to have
TB?
A 16-year-old female high school
ALTERATIONS Blood pressure is decreased from 160/90 to 110/70.
1. Nurse Michelle should know that the drainage is normal 4
days after a sigmoid colostomy when the stool is:
Green liquid
Solid formed
Loose, bloody
Semiformed
2. Where would nurse Kristine place the call light for a male client
with a right-sided brain attack and left homonymous
hemianopsia? On the client’s right side
On the client’s left side
Directly in front of the
client Where the client like
3. A male client is admitted to the emergency department
following an accident. What are the first nursing actions of the
nurse?
Check respiration, circulation, neurological response.
Align the spine, check pupils, and check for hemorrhage.
Check respirations, stabilize spine, and check circulation.
Assess level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should
know that it reduces preload and relieves angina by:
Increasing contractility and slowing heart rate.
Increasing AV conduction and heart rate.
Decreasing contractility and oxygen
consumption. Decreasing venous return through
vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial
infarction (MI) slumped on the side rails of the bed and
unresponsive to shaking or shouting. Which is the nurse next
action?
Call for help and note the
time. Clear the airway
Give two sharp thumps to the precordium, and check the pulse.
Administer two quick blows.
6. Nurse Monett is caring for a client recovering from
gastro- intestinal bleeding. The nurse should:
Plan care so the client can receive 8 hours of uninterrupted
sleep each night.
Monitor vital signs every 2 hours.
Make sure that the client takes food and medications at
prescribed intervals.
Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and
has been receiving heparin I.V. for 2 days. The partial
thromboplastin time (PTT) is 68 seconds. What should Nurse Carla
do?
Stop the I.V. infusion of heparin and notify the physician.
Continue treatment as ordered.
Expect the warfarin to increase the PTT.
Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage
appliance be applied to the stoma?
24 hours later, when edema has
subsided. In the operating room.
After the ileostomy begin to function.
When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that
the nurse immediately position the client in:
On the side, to prevent obstruction of airway by tongue.
Flat on back.
On the back, with knees flexed 15 degrees.
Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor
vehicle accident, which assessment data suggest increasing
,Pulse is increased from 87 to 95, with an occasional skipped beat. osteoporosis. When teaching the client, the nurse should include
The client is oriented when aroused from sleep, and goes information about which major complication:
back to sleep immediately. Bone fracture
The client refuses dinner because of anorexia.
11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which
of the following symptoms may appear first?
Altered mental status and
dehydration Fever and chills
Hemoptysis and Dyspnea
Pleuritic chest pain and
cough
12. A male client has active tuberculosis (TB). Which of the
following symptoms will be exhibit?
Chest and lower back pain
Chills, fever, night sweats, and hemoptysis
Fever of more than 104°F (40°C) and
nausea Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency
department. He’s tachypneic and afebrile and has a respiratory
rate of 36 breaths/minute and has a nonproductive cough. He
recently had a cold. Form this history; the client may have which
of the following conditions?
Acute asthma
Bronchial
pneumonia
Chronic obstructive pulmonary disease
(COPD) Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping
and her respiratory rate is 4 breaths/minute. If action isn’t taken
quickly, she might have which of the following reactions?
Asthma attack
Respiratory
arrest Seizure
Wake up on his own
15. A 77-year-old male client is admitted for elective knee
surgery. Physical examination reveals shallow respirations but no
sign of respiratory distress. Which of the following is a normal
physiologic change related to aging?
Increased elastic recoil of the lungs
Increased number of functional capillaries in the alveoli
Decreased residual volume
Decreased vital capacity
16. Nurse John is caring for a male client receiving lidocaine
I.V. Which factor is the most relevant to administration of
this medication?
Decrease in arterial oxygen saturation (SaO2) when measured
with a pulse oximeter.
Increase in systemic blood pressure.
Presence of premature ventricular contractions (PVCs) on a
cardiac monitor.
Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant.
The nurse should teach the client to:
Report incidents of
diarrhea. Avoid foods high
in vitamin K
Use a straight razor when
shaving. Take aspirin to pain
relief.
18. Nurse Lhynnette is preparing a site for the insertion of an
I.V. catheter. The nurse should treat excess hair at the site by:
Leaving the hair intact
Shaving the area
Clipping the hair in the area
Removing the hair with a
depilatory.
19. Nurse Michelle is caring for an elderly female with
,Loss of estrogen Friction rubs
Negative calcium
balance Dowager’s
hump
20. Nurse Len is teaching a group of women to perform BSE.
The nurse should explain that the purpose of performing the
examination is to discover:
Cancerous lumps
Areas of thickness or fullness
Changes from previous
examinations. Fibrocystic masses
21. When caring for a female client who is being treated
for hyperthyroidism, it is important to:
Provide extra blankets and clothing to keep the client warm.
Monitor the client for signs of restlessness, sweating, and
excessive weight loss during thyroid replacement therapy.
Balance the client’s periods of activity and rest.
Encourage the client to be active to prevent constipation.
22. Nurse Kris is teaching a client with history of atherosclerosis. To
decrease the risk of atherosclerosis, the nurse should encourage
the client to:
Avoid focusing on his
weight. Increase his activity
level.
Follow a regular diet.
Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta
must logroll a client following a:
Laminectomy
Thoracotomy
Hemorrhoidectomy
Cystectomy.
24. A 55-year old client underwent cataract removal with
intraocular lens implant. Nurse Oliver is giving the client discharge
instructions. These instructions should include which of the
following?
Avoid lifting objects weighing more than 5 lb (2.25 kg).
Lie on your abdomen when in bed
Keep rooms brightly lit.
Avoiding straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations
during: when sexual activity starts
After age 69
After age 40
Before age 20.
26. A male client undergone a colon resection. While turning
him, wound dehiscence with evisceration occurs. Nurse Trish first
response is to:
Call the physician
Place a saline-soaked sterile dressing on the
wound. Take a blood pressure and pulse.
Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has suffered a
severe cerebrovascular accident. During routine assessment, the
nurse notices Cheyne- Strokes respirations. Cheyne-strokes
respirations are:
A progressively deeper breaths followed by shallower breaths
with apneic periods.
Rapid, deep breathing with abrupt pauses between each breath.
Rapid, deep breathing and irregular breathing without pauses.
Shallow breathing with an increased respiratory rate.
28. Nurse Bea is assessing a male client with heart failure. The
breath sounds commonly auscultated in clients with heart
failure are:
Tracheal
Fine crackles
Coarse crackles
, 29. The nurse is caring for Kenneth experiencing an acute asthma student A 33-year-old day-care worker
attack. The client stops wheezing and breath sounds aren’t A 43-yesr-old homeless man with a history of
audible. The reason for this change is that: alcoholism A 54-year-old businessman
The attack is over.
The airways are so swollen that no air cannot get
through. The swelling has decreased.
Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During the active
seizure phase, the nurse should:
Place the client on his back remove dangerous objects, and
insert a bite block.
Place the client on his side, remove dangerous objects, and
insert a bite block.
Place the client o his back, remove dangerous objects, and hold
down his arms.
Place the client on his side, remove dangerous objects, and
protect his head.
31. After insertion of a cheat tube for a pneumothorax, a client
becomes hypotensive with neck vein distention, tracheal shift,
absent breath sounds, and diaphoresis. Nurse Amanda
suspects a tension pneumothorax has occurred. What cause of
tension pneumothorax should the nurse check for?
Infection of the lung.
Kinked or obstructed chest tube
Excessive water in the water-seal
chamber Excessive chest tube drainage
32. Nurse Maureen is talking to a male client, the client begins
choking on his lunch. He’s coughing forcefully. The nurse
should: Stand him up and perform the abdominal thrust
maneuver from behind.
Lay him down, straddle him, and perform the
abdominal thrust maneuver.
Leave him to get assistance
Stay with him but not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old
client. Which information will be most useful to the nurse for
planning care?
General health for the last 10
years. Current health promotion
activities. Family history of
diseases.
Marital status.
34. When performing oral care on a comatose client, Nurse
Krina should:
Apply lemon glycerin to the client’s lips at least every 2
hours. Brush the teeth with client lying supine.
Place the client in a side lying position, with the head of the
bed lowered.
Clean the client’s mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of
dehydration and change in mental status. He’s being hydrated
with
L.V. fluids. When the nurse takes his vital signs, she notes he has a
fever of 103°F (39.4°C) a cough producing yellow sputum and
pleuritic chest pain. The nurse suspects this client may have which
of the following conditions?
Adult respiratory distress syndrome
(ARDS) Myocardial infarction (MI)
Pneumoni
a
Tuberculos
is
36. Nurse Oliver is working in a out patient clinic. He has been
alerted that there is an outbreak of tuberculosis (TB). Which of
the following clients entering the clinic today most likely to have
TB?
A 16-year-old female high school
