Nursing 308 Exam multiple choice !| !| !| !| !|
Questions with answers & !| !| !| !|
rationales
The nurse is caring for the following clients. Which client should the nurse
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assess FIRST? !|
!| A. the client whose partial thromboplastin time (PTT) is 38 seconds.
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B. The client whose hemoglobin is 14 g/dl and hematocrit is 45%.
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C. The client whose platelet count is 75,000 per cubic millimeter of blood.
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D. The client whose red blood cell count is 4.8 x 10^6/mm^3. - Correct
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answer ✔Answer: C !| !|
Rationale:
A normal range for PTT is 32 to 39 seconds.
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These are normal hemoglobin/hematocrit levels for either a male or female
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client.
A PLATELET COUNT OF LESS THAN 100,000 PER CUBIC MILLIMETER
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OF BLOOD INDICATES THROMBOCYTOPENIA.
!| !| !|
This is a normal red blood cell count.
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Which cast care instructions should the nurse provide to a client who just
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had a plaster cast applied to the right forearm? Select all that apply.
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a. Keep the cast clean and dry
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b. Allow the cast 24-72 hours to dry
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,c. Keep the cast and extremity elevated
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d. Use a hairdryer set on warm to hot setting to dry the cast
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e. Use a soft padded object that will fit under the cast to scratch the skin
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under the cast - Correct answer ✔Answer:
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A: Keep the cast clean and dry.
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B: Allow cast 24-72 hours to dry
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C: Keep the cast and extremity elevated
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Rationale: A plaster cast takes 24-72 hours to dry (synthetic casts dry in 20
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
minutes). The cast and extremity should be elevated to reduce edema if
!| !| !| !| !| !| !| !| !| !| !| !|
prescribed. A wet cast is handled with the palms of the hand until it is dry,
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
and the extremity is turned (unless contraindicated) so that all sides of the
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wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
cast (heat can not be used on a plaster cast because the cast heats us and
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
burns skin). The cast needs to be kept clean and dry, and the client is
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
instructed not to stick anything under the cast because of the risk of
!| !| !| !| !| !| !| !| !| !| !| !| !|
breaking skin integrity. The client is instructed to monitor the extremity for
!| !| !| !| !| !| !| !| !| !| !| !|
circulatory impairment, such as pain, swelling, discoloration, tingling,
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numbness, coolness, or diminished pulse. The health care provider is notified
!| !| !| !| !| !| !| !| !| !| !|
immediately if circulatory impairment occurs. !| !| !| !|
The nurse is caring for a patient with a diagnosis of COPD, bronchitis-type, in
!| !| !| !| !| !| !| !| !| !| !| !| !|
the long-term care facility. The patient is wheezing, and his oxygen
!| !| !| !| !| !| !| !| !| !| !| !|
saturation is 85%. Four hours ago, the oxygen saturation was 88 percent. It is
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
MOST important for the nurse to take which of the following actions?
!| !| !| !| !| !| !| !| !| !| !|
A. administer beclomethasone (Vanceril), two puffs per metered dose inhaler
!| !| !| !| !| !| !| !| !|
B. listen to breath sounds
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,C. increase oxygen to 4 L per mask
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D. administer albuterol (Proventil), two puffs per metered dose inhaler -
!| !| !| !| !| !| !| !| !| !| !|
Correct answer ✔D. administer albuterol (Proventil), two puffs per metered
!| !| !| !| !| !| !| !| !| !|
dose inhaler !|
What is the most important nursing priority for a client who has been
!| !| !| !| !| !| !| !| !| !| !| !| !|
admitted for a possible kidney stone? !| !| !| !| !|
A. Reducing dairy products in the diet
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B. Straining all urine
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C. Measuring intake and output
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D. Increasing fluid intake - Correct answer ✔CORRECT ANSWER: B:
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Straining all urine !| !|
RATIONALE: Straining all urine (B) is the most important nursing action to !| !| !| !| !| !| !| !| !| !| !| !|
take in this case. Encouraging fluid intake (D) is important for any client who
!| !| !| !| !| !| !| !| !| !| !| !| !|
may have a kidney stone, but is even more important to strain all urine.
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Straining urine will enable the nurse to determine when the kidney stone
!| !| !| !| !| !| !| !| !| !| !| !|
has been passed and may prevent the need for surgery. (C) is not the highest
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priority action. (A) is usually not recommended until the stone is obtained
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and the content of the stone is determined. Even then, dietary restrictions
!| !| !| !| !| !| !| !| !| !| !| !|
are controversial.
!|
After receiving a change-of-shift report at 7:00 AM, the nurse should assess
!| !| !| !| !| !| !| !| !| !| !| !|
which of these clients first? !| !| !| !|
A. A 23-year-old with a migraine headache who has severe nausea associated
!| !| !| !| !| !| !| !| !| !| !| !|
with retching. !|
, B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
preoperative teaching. !|
C. A 59-year-old with Parkinson's disease who will need a swallowing
!| !| !| !| !| !| !| !| !| !| !|
assessment before breakfast. !| !|
D. A 63-year-old with multiple sclerosis who has an oral temperature of
!| !| !| !| !| !| !| !| !| !| !| !|
101.8^\circF and flank pain. - Correct answer ✔Answer: D: A 63-year-old !| !| !| !| !| !| !| !| !| !| !|
with MS who has an oral temperature of 101.8 and flank pain.
!| !| !| !| !| !| !| !| !| !| !|
Rationale: Urinary tract infections are a frequent complication in clients with
!| !| !| !| !| !| !| !| !| !| !|
multiple sclerosis because of the effect on bladder function; therefore, that
!| !| !| !| !| !| !| !| !| !| !|
client should been seen first by the nurse. The elevated temperature and
!| !| !| !| !| !| !| !| !| !| !| !|
flank pain suggest that this patient may have pyelonephritis. The physician
!| !| !| !| !| !| !| !| !| !| !|
should be notified immediately so that antibiotic therapy can be started
!| !| !| !| !| !| !| !| !| !| !|
quickly. The other clients should be assessed soon, but do not have needs as
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
urgent as this client. (Billings & Hensel, 2014, p. 599)
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The nurse employed in an emergency department is assigned to triage clients
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coming to the emergency department for treatment on the evening shift. The
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nurse should assign priority to which client?
!| !| !| !| !| !|
A. A client complaining of muscle aches, a headache, and malaise
!| !| !| !| !| !| !| !| !| !|
B. A client who twisted her ankle when she fell while rollerblading
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C. A client with a minor laceration on the index finger while cutting an
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eggplant
D. A client with chest pain who states that he just ate pizza that was made
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with a very spicy sauce - Correct answer ✔Answer: D. A client with chest
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paint who states that he just ate pizza that was made with a very spicy sauce.
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Questions with answers & !| !| !| !|
rationales
The nurse is caring for the following clients. Which client should the nurse
!| !| !| !| !| !| !| !| !| !| !| !| !|
assess FIRST? !|
!| A. the client whose partial thromboplastin time (PTT) is 38 seconds.
!| !| !| !| !| !| !| !| !| !| !|
B. The client whose hemoglobin is 14 g/dl and hematocrit is 45%.
!| !| !| !| !| !| !| !| !| !| !|
C. The client whose platelet count is 75,000 per cubic millimeter of blood.
!| !| !| !| !| !| !| !| !| !| !| !|
D. The client whose red blood cell count is 4.8 x 10^6/mm^3. - Correct
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answer ✔Answer: C !| !|
Rationale:
A normal range for PTT is 32 to 39 seconds.
!| !| !| !| !| !| !| !| !|
These are normal hemoglobin/hematocrit levels for either a male or female
!| !| !| !| !| !| !| !| !| !| !|
client.
A PLATELET COUNT OF LESS THAN 100,000 PER CUBIC MILLIMETER
!| !| !| !| !| !| !| !| !| !|
OF BLOOD INDICATES THROMBOCYTOPENIA.
!| !| !|
This is a normal red blood cell count.
!| !| !| !| !| !| !|
Which cast care instructions should the nurse provide to a client who just
!| !| !| !| !| !| !| !| !| !| !| !| !|
had a plaster cast applied to the right forearm? Select all that apply.
!| !| !| !| !| !| !| !| !| !| !| !|
a. Keep the cast clean and dry
!| !| !| !| !| !|
b. Allow the cast 24-72 hours to dry
!| !| !| !| !| !| !|
,c. Keep the cast and extremity elevated
!| !| !| !| !| !|
d. Use a hairdryer set on warm to hot setting to dry the cast
!| !| !| !| !| !| !| !| !| !| !| !| !|
e. Use a soft padded object that will fit under the cast to scratch the skin
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
under the cast - Correct answer ✔Answer:
!| !| !| !| !| !|
A: Keep the cast clean and dry.
!| !| !| !| !| !| !|
B: Allow cast 24-72 hours to dry
!| !| !| !| !| !|
C: Keep the cast and extremity elevated
!| !| !| !| !| !| !|
Rationale: A plaster cast takes 24-72 hours to dry (synthetic casts dry in 20
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
minutes). The cast and extremity should be elevated to reduce edema if
!| !| !| !| !| !| !| !| !| !| !| !|
prescribed. A wet cast is handled with the palms of the hand until it is dry,
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
and the extremity is turned (unless contraindicated) so that all sides of the
!| !| !| !| !| !| !| !| !| !| !| !| !|
wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
cast (heat can not be used on a plaster cast because the cast heats us and
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
burns skin). The cast needs to be kept clean and dry, and the client is
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
instructed not to stick anything under the cast because of the risk of
!| !| !| !| !| !| !| !| !| !| !| !| !|
breaking skin integrity. The client is instructed to monitor the extremity for
!| !| !| !| !| !| !| !| !| !| !| !|
circulatory impairment, such as pain, swelling, discoloration, tingling,
!| !| !| !| !| !| !| !|
numbness, coolness, or diminished pulse. The health care provider is notified
!| !| !| !| !| !| !| !| !| !| !|
immediately if circulatory impairment occurs. !| !| !| !|
The nurse is caring for a patient with a diagnosis of COPD, bronchitis-type, in
!| !| !| !| !| !| !| !| !| !| !| !| !|
the long-term care facility. The patient is wheezing, and his oxygen
!| !| !| !| !| !| !| !| !| !| !| !|
saturation is 85%. Four hours ago, the oxygen saturation was 88 percent. It is
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
MOST important for the nurse to take which of the following actions?
!| !| !| !| !| !| !| !| !| !| !|
A. administer beclomethasone (Vanceril), two puffs per metered dose inhaler
!| !| !| !| !| !| !| !| !|
B. listen to breath sounds
!| !| !| !|
,C. increase oxygen to 4 L per mask
!| !| !| !| !| !| !|
D. administer albuterol (Proventil), two puffs per metered dose inhaler -
!| !| !| !| !| !| !| !| !| !| !|
Correct answer ✔D. administer albuterol (Proventil), two puffs per metered
!| !| !| !| !| !| !| !| !| !|
dose inhaler !|
What is the most important nursing priority for a client who has been
!| !| !| !| !| !| !| !| !| !| !| !| !|
admitted for a possible kidney stone? !| !| !| !| !|
A. Reducing dairy products in the diet
!| !| !| !| !| !|
B. Straining all urine
!| !| !|
C. Measuring intake and output
!| !| !| !|
D. Increasing fluid intake - Correct answer ✔CORRECT ANSWER: B:
!| !| !| !| !| !| !| !| !| !|
Straining all urine !| !|
RATIONALE: Straining all urine (B) is the most important nursing action to !| !| !| !| !| !| !| !| !| !| !| !|
take in this case. Encouraging fluid intake (D) is important for any client who
!| !| !| !| !| !| !| !| !| !| !| !| !|
may have a kidney stone, but is even more important to strain all urine.
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Straining urine will enable the nurse to determine when the kidney stone
!| !| !| !| !| !| !| !| !| !| !| !|
has been passed and may prevent the need for surgery. (C) is not the highest
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
priority action. (A) is usually not recommended until the stone is obtained
!| !| !| !| !| !| !| !| !| !| !| !|
and the content of the stone is determined. Even then, dietary restrictions
!| !| !| !| !| !| !| !| !| !| !| !|
are controversial.
!|
After receiving a change-of-shift report at 7:00 AM, the nurse should assess
!| !| !| !| !| !| !| !| !| !| !| !|
which of these clients first? !| !| !| !|
A. A 23-year-old with a migraine headache who has severe nausea associated
!| !| !| !| !| !| !| !| !| !| !| !|
with retching. !|
, B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
preoperative teaching. !|
C. A 59-year-old with Parkinson's disease who will need a swallowing
!| !| !| !| !| !| !| !| !| !| !|
assessment before breakfast. !| !|
D. A 63-year-old with multiple sclerosis who has an oral temperature of
!| !| !| !| !| !| !| !| !| !| !| !|
101.8^\circF and flank pain. - Correct answer ✔Answer: D: A 63-year-old !| !| !| !| !| !| !| !| !| !| !|
with MS who has an oral temperature of 101.8 and flank pain.
!| !| !| !| !| !| !| !| !| !| !|
Rationale: Urinary tract infections are a frequent complication in clients with
!| !| !| !| !| !| !| !| !| !| !|
multiple sclerosis because of the effect on bladder function; therefore, that
!| !| !| !| !| !| !| !| !| !| !|
client should been seen first by the nurse. The elevated temperature and
!| !| !| !| !| !| !| !| !| !| !| !|
flank pain suggest that this patient may have pyelonephritis. The physician
!| !| !| !| !| !| !| !| !| !| !|
should be notified immediately so that antibiotic therapy can be started
!| !| !| !| !| !| !| !| !| !| !|
quickly. The other clients should be assessed soon, but do not have needs as
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
urgent as this client. (Billings & Hensel, 2014, p. 599)
!| !| !| !| !| !| !| !| !|
The nurse employed in an emergency department is assigned to triage clients
!| !| !| !| !| !| !| !| !| !| !| !|
coming to the emergency department for treatment on the evening shift. The
!| !| !| !| !| !| !| !| !| !| !| !|
nurse should assign priority to which client?
!| !| !| !| !| !|
A. A client complaining of muscle aches, a headache, and malaise
!| !| !| !| !| !| !| !| !| !|
B. A client who twisted her ankle when she fell while rollerblading
!| !| !| !| !| !| !| !| !| !| !|
C. A client with a minor laceration on the index finger while cutting an
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
eggplant
D. A client with chest pain who states that he just ate pizza that was made
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
with a very spicy sauce - Correct answer ✔Answer: D. A client with chest
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
paint who states that he just ate pizza that was made with a very spicy sauce.
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
