,The nurse is concerned about infection for a client after an esophagogastrostomy for
esophageal cancer. Which actions should the nurse include in the client's plan of care?
(Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - CORRECT ANSWERS -Correct Answer:
A,B,C
Rationale:One hour post op is too soon to ambulate for this client. Visitors help support
the patient and are encouraged to visit. Oral care is necessary as the client will be NPO.
To decrease the risk of infection post operatively, implement routine pulmonary
exercises. The client will have an NG tube in place, likely to intermittent suction, to
decompress the stomach post surgery.
The client is return demonstrating wrapping of the left limb amputated above the knee.
The nurse evaluates the client is starting the wrapping method correctly when the client
places the end of the bandage at which point?
A.Around the waist
B.At the inner aspect of the left stump
C.At the outer aspect of the left stump
D.At the left groin area - CORRECT ANSWERS -Correct Answer: A
Rationale:The waist is the anchor point for the bandage for an above the knee
amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - CORRECT ANSWERS -Correct Answer: B
Rationale:Stooped posture results in the upper torso becoming the center of gravity for
older persons. The center of gravity for adults is the hips. However, as a person grows
older, a stooped posture is common because of changes caused by osteoporosis and
normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head
and neck and feet and legs are not the center of gravity in the older adult. Although the
arms comprise a part of the upper torso, they do not reflect the best and most complete
answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and
is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70
mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
,C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - CORRECT
ANSWERS -Correct Answer: A
Rationale:The client's blood pressure is within normal limits, indicating that the ramipril,
an antihypertensive, is having the desired effect and should be administered. Options B
and C would be appropriate if the client's blood pressure was excessively low (<100 mm
Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This
prescribed dose is within the normal dosage range, as defined by the manufacturer;
therefore, option D is not necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused assessment
related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties - CORRECT ANSWERS -Correct Answer: A,B
Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an
electric shock, in the area innervated by one or more branches of the trigeminal nerve
(cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
CORRECT ANSWERS -Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is
a medical emergency and should be reported to the health care provider immediately.
Options B and C are expected clinical manifestations of diverticulitis. Option D does not
warrant immediate intervention.
The nurse is caring for a client with a fractured right elbow. Which assessment finding
has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - CORRECT ANSWERS -Correct
Answer: B
Rationale:Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
, uncontrolled by opioids and neurovascular compromise. Option A is an expected
finding. Option C related to compartment syndrome cannot be seen, and any visible
edema is an expected finding related to the injury. Option D is an expected finding.
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - CORRECT ANSWERS -Correct Answer: B
Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys
in filtering waste from the blood. Dehydration, which could be caused by vomiting, would
cause an increased BUN level. Option A would affect serum enzyme levels, not the
BUN level. Option C would primarily affect the blood glucose level; renal failure that
could increase the BUN level would be unlikely in a client newly diagnosed with type 2
diabetes. Effects of option D might affect the complete blood count (CBC) but would not
directly increase the BUN level.
Which instruction is best for the nurse to provide to a client with emphysema and
chronic fatigue?
A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - CORRECT ANSWERS -Correct
Answer: A
Rationale:Manifestations of emphysema include an increase in AP diameter (referred to
as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to
promote energy management, such as pacing activities and scheduling rest periods.
Option B may result in a decreased drive to breathe. The client is not exhibiting any
symptoms of infection, so option C is not necessary. Option D is less beneficial than
option A.
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium.
C.Encourage adequate rest between activities.
D.Offer the client a sodium-enriched menu. - CORRECT ANSWERS -Correct Answer: A
Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the
adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels so that
esophageal cancer. Which actions should the nurse include in the client's plan of care?
(Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - CORRECT ANSWERS -Correct Answer:
A,B,C
Rationale:One hour post op is too soon to ambulate for this client. Visitors help support
the patient and are encouraged to visit. Oral care is necessary as the client will be NPO.
To decrease the risk of infection post operatively, implement routine pulmonary
exercises. The client will have an NG tube in place, likely to intermittent suction, to
decompress the stomach post surgery.
The client is return demonstrating wrapping of the left limb amputated above the knee.
The nurse evaluates the client is starting the wrapping method correctly when the client
places the end of the bandage at which point?
A.Around the waist
B.At the inner aspect of the left stump
C.At the outer aspect of the left stump
D.At the left groin area - CORRECT ANSWERS -Correct Answer: A
Rationale:The waist is the anchor point for the bandage for an above the knee
amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - CORRECT ANSWERS -Correct Answer: B
Rationale:Stooped posture results in the upper torso becoming the center of gravity for
older persons. The center of gravity for adults is the hips. However, as a person grows
older, a stooped posture is common because of changes caused by osteoporosis and
normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head
and neck and feet and legs are not the center of gravity in the older adult. Although the
arms comprise a part of the upper torso, they do not reflect the best and most complete
answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and
is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70
mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
,C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - CORRECT
ANSWERS -Correct Answer: A
Rationale:The client's blood pressure is within normal limits, indicating that the ramipril,
an antihypertensive, is having the desired effect and should be administered. Options B
and C would be appropriate if the client's blood pressure was excessively low (<100 mm
Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This
prescribed dose is within the normal dosage range, as defined by the manufacturer;
therefore, option D is not necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused assessment
related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties - CORRECT ANSWERS -Correct Answer: A,B
Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an
electric shock, in the area innervated by one or more branches of the trigeminal nerve
(cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
CORRECT ANSWERS -Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is
a medical emergency and should be reported to the health care provider immediately.
Options B and C are expected clinical manifestations of diverticulitis. Option D does not
warrant immediate intervention.
The nurse is caring for a client with a fractured right elbow. Which assessment finding
has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - CORRECT ANSWERS -Correct
Answer: B
Rationale:Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
, uncontrolled by opioids and neurovascular compromise. Option A is an expected
finding. Option C related to compartment syndrome cannot be seen, and any visible
edema is an expected finding related to the injury. Option D is an expected finding.
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - CORRECT ANSWERS -Correct Answer: B
Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys
in filtering waste from the blood. Dehydration, which could be caused by vomiting, would
cause an increased BUN level. Option A would affect serum enzyme levels, not the
BUN level. Option C would primarily affect the blood glucose level; renal failure that
could increase the BUN level would be unlikely in a client newly diagnosed with type 2
diabetes. Effects of option D might affect the complete blood count (CBC) but would not
directly increase the BUN level.
Which instruction is best for the nurse to provide to a client with emphysema and
chronic fatigue?
A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - CORRECT ANSWERS -Correct
Answer: A
Rationale:Manifestations of emphysema include an increase in AP diameter (referred to
as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to
promote energy management, such as pacing activities and scheduling rest periods.
Option B may result in a decreased drive to breathe. The client is not exhibiting any
symptoms of infection, so option C is not necessary. Option D is less beneficial than
option A.
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium.
C.Encourage adequate rest between activities.
D.Offer the client a sodium-enriched menu. - CORRECT ANSWERS -Correct Answer: A
Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the
adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels so that
