Exam 3 Practice Questions
. A nurse has instructed the client with myasthenia gravis to take drugs on time and to
eat meals 45 to 60 minutes after taking the anticholinesterase drugs. The client asks why
the timing of meals is so important. What is the nurse's best response?
a. "This timing allows the drug to have maximum effect, so it is easier for you to chew,
swallow, and not choke."
b. "This timing prevents your blood sugar level from dropping too low and causing you
to be at risk for falling."
c. "These drugs are very irritating to your stomach and could cause ulcers if taken too
long before meals."
d. "These drugs cause nausea and vomiting. By waiting for a while after you take the
medication, you are less likely to vomit." - ANS A
\. Which diagnosis would be considered the priority nursing diagnosis for the client with
Guillain-Barré syndrome?
a. Ineffective Breathing Pattern related to skeletal muscle weakness
b. Risk for Injury, Impaired Skin Integrity related to immobility
c. Self-care Deficit related to skeletal muscle weakness
d. Anxiety related to powerlessness - ANS A
\A 22-year-old patient with Escherichia coli O157:H7 food poisoning is admitted to the
hospital with bloody diarrhea and dehydration. All of the following orders are received.
Which order will the nurse question?
a. Infuse lactated Ringer's solution at 250 ml/hr.
b. Monitor blood urea nitrogen and creatinine daily.
c. Administer loperamide (Imodium) after each stool.
d. Provide a clear liquid diet and progress diet as tolerated. - ANS C
\A 42-year-old patient recently developed abdominal distention, weight loss, steatorrhea,
and flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The
nurse determines that teaching about the treatment of the disease has been effective
when the patient says,
a. "I must take folic acid for the rest of my life."
b. "I will avoid dietary wheat, rye, barley, and oats."
c. "I will be sure to take all of the ordered antibiotics."
d. "I should eat only very low-fat or fat-free foods." - ANS B
\A 67-year-old patient tells the nurse, "I have problems with constipation now that I am
older, so I use a suppository every morning." The most appropriate nursing action at this
time is to
a. encourage the patient to drink at least 3000 ml of fluid a day.
b. inform the patient that a daily bowel movement is not necessary.
c. perform a focused nursing assessment to identify risk factors for constipation.
d. suggest that the patient increase dietary intake of foods that are high in fiber. - ANS C
, \A client who experienced a spinal cord injury 1 hour ago is brought to the emergency
room. Which medication should the nurse prepare to administer to this client?
a. Intrathecal baclofen
b. Methylprednisolone
c. Atropine sulfate
d. Epinephrine - ANS B
-give within 8 hours of injury
\A client with paraplegia is scheduled to participate in a rehabilitation program. The client
does not understand the need for rehabilitation, because the paralysis will not go away
nor will it get better. What is the nurse's best response?
a. "If you would prefer, I will cancel the order."
b. "Your doctor ordered the rehabilitation program."
c. "Rehabilitation will teach you how to maintain the functional ability you have."
d. "When new discoveries are made regarding paraplegia, people in rehabilitation
programs will benefit first." - ANS C
\A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of
imbalanced nutrition: less than body requirements related to impaired swallowing. To
promote nutrition, the nurse suggests that before meals the patient should avoid
a. watching television.
b. talking on the phone.
c. typing on the computer.
d. ambulating in the halls. - ANS B
\A nurse is caring for an older client who has diminished touch sensation. What
instructions would be appropriate to provide to this client?
a. Instruct the client to walk barefoot whenever possible.
b. Instruct the client to use very warm bath water to increase circulation.
c. Instruct the client to look at the placement of the feet when walking.
d. Instruct the client to place throw rugs at the foot of the bed for cushioning. - ANS C
\A patient is admitted to the emergency department with possible fractures of the bones
of the left lower extremity. The initial action by the nurse should be to
a. splint the lower leg.
b. elevate the left leg.
c. check the popliteal, dorsalis pedis, and posterior tibial pulses.
d. obtain information about the patient's tetanus immunization status. - ANS C
\A patient is admitted unconscious to the emergency department (ED) after falling and
hitting the head on a rock while hiking. The patient's spouse and children stay at the
patient's side and constantly ask about the treatment being given. The nurse's best
approach to the patient's family is to
a. call the family's pastor or spiritual advisor to support them while initial care is given.
b. refer the family members to the hospital counseling service to deal with their anxiety.
c. allow the family to stay with the patient and explain all procedures thoroughly to them.
d. ask the family to stay in the waiting room while the initial assessment and care are
done. - ANS C
. A nurse has instructed the client with myasthenia gravis to take drugs on time and to
eat meals 45 to 60 minutes after taking the anticholinesterase drugs. The client asks why
the timing of meals is so important. What is the nurse's best response?
a. "This timing allows the drug to have maximum effect, so it is easier for you to chew,
swallow, and not choke."
b. "This timing prevents your blood sugar level from dropping too low and causing you
to be at risk for falling."
c. "These drugs are very irritating to your stomach and could cause ulcers if taken too
long before meals."
d. "These drugs cause nausea and vomiting. By waiting for a while after you take the
medication, you are less likely to vomit." - ANS A
\. Which diagnosis would be considered the priority nursing diagnosis for the client with
Guillain-Barré syndrome?
a. Ineffective Breathing Pattern related to skeletal muscle weakness
b. Risk for Injury, Impaired Skin Integrity related to immobility
c. Self-care Deficit related to skeletal muscle weakness
d. Anxiety related to powerlessness - ANS A
\A 22-year-old patient with Escherichia coli O157:H7 food poisoning is admitted to the
hospital with bloody diarrhea and dehydration. All of the following orders are received.
Which order will the nurse question?
a. Infuse lactated Ringer's solution at 250 ml/hr.
b. Monitor blood urea nitrogen and creatinine daily.
c. Administer loperamide (Imodium) after each stool.
d. Provide a clear liquid diet and progress diet as tolerated. - ANS C
\A 42-year-old patient recently developed abdominal distention, weight loss, steatorrhea,
and flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The
nurse determines that teaching about the treatment of the disease has been effective
when the patient says,
a. "I must take folic acid for the rest of my life."
b. "I will avoid dietary wheat, rye, barley, and oats."
c. "I will be sure to take all of the ordered antibiotics."
d. "I should eat only very low-fat or fat-free foods." - ANS B
\A 67-year-old patient tells the nurse, "I have problems with constipation now that I am
older, so I use a suppository every morning." The most appropriate nursing action at this
time is to
a. encourage the patient to drink at least 3000 ml of fluid a day.
b. inform the patient that a daily bowel movement is not necessary.
c. perform a focused nursing assessment to identify risk factors for constipation.
d. suggest that the patient increase dietary intake of foods that are high in fiber. - ANS C
, \A client who experienced a spinal cord injury 1 hour ago is brought to the emergency
room. Which medication should the nurse prepare to administer to this client?
a. Intrathecal baclofen
b. Methylprednisolone
c. Atropine sulfate
d. Epinephrine - ANS B
-give within 8 hours of injury
\A client with paraplegia is scheduled to participate in a rehabilitation program. The client
does not understand the need for rehabilitation, because the paralysis will not go away
nor will it get better. What is the nurse's best response?
a. "If you would prefer, I will cancel the order."
b. "Your doctor ordered the rehabilitation program."
c. "Rehabilitation will teach you how to maintain the functional ability you have."
d. "When new discoveries are made regarding paraplegia, people in rehabilitation
programs will benefit first." - ANS C
\A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of
imbalanced nutrition: less than body requirements related to impaired swallowing. To
promote nutrition, the nurse suggests that before meals the patient should avoid
a. watching television.
b. talking on the phone.
c. typing on the computer.
d. ambulating in the halls. - ANS B
\A nurse is caring for an older client who has diminished touch sensation. What
instructions would be appropriate to provide to this client?
a. Instruct the client to walk barefoot whenever possible.
b. Instruct the client to use very warm bath water to increase circulation.
c. Instruct the client to look at the placement of the feet when walking.
d. Instruct the client to place throw rugs at the foot of the bed for cushioning. - ANS C
\A patient is admitted to the emergency department with possible fractures of the bones
of the left lower extremity. The initial action by the nurse should be to
a. splint the lower leg.
b. elevate the left leg.
c. check the popliteal, dorsalis pedis, and posterior tibial pulses.
d. obtain information about the patient's tetanus immunization status. - ANS C
\A patient is admitted unconscious to the emergency department (ED) after falling and
hitting the head on a rock while hiking. The patient's spouse and children stay at the
patient's side and constantly ask about the treatment being given. The nurse's best
approach to the patient's family is to
a. call the family's pastor or spiritual advisor to support them while initial care is given.
b. refer the family members to the hospital counseling service to deal with their anxiety.
c. allow the family to stay with the patient and explain all procedures thoroughly to them.
d. ask the family to stay in the waiting room while the initial assessment and care are
done. - ANS C
