The nurse is caring for a client scheduled for removal of a pituitary tumor using the
transsphenoidal approach. The nurse should be particularly alert to:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria - answer a. Nasal congestion
Why?
Removal of the pituitary gland is usually done by transsphernoidal approach through the
nose. Nasal congestion further interferes with the airway.
A client with cancer is a, admitted to the oncology unit. Stat lab values revel hgb 12.6, wbc
6500, k+1.9, uric acid 7.0, na+136, and platelets 178,000. The nurse evaluates that the client
is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis - answer b. Hypokalemia
Why?
1
,Hypokalemia is evident from the lab values listed. The other laboratory findings are within
normal limits. Making answers a,c and d incorrect
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is
the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work - answer a. Taking the vital signs
Why?
The primary responisblity of the nurse is to take the vital signs before any surgery.
Answers b,c and d are the responsibility of the doctor.
The nurse is working in the emergency room when a client arrives with severe burns of the
left arm, hands, face, and neck. Which action should receive priority?
A. Starting an iv?
B. Applying oxygen
C.obtaining blood gas
D. Medicating the client foe pain - answer b. Applying oxygen
Why?
The client with burns to the neck needs airway assessments and supplemental oxygen, so
applying oxygen is priority. The next action should be to start an iv and medicate for pain.
2
,The nurse is visiting a home health client with osteoporosis. The client has a new
prescription for alendronate (fosamax). Which instructions should be given to the client
A. Rest in bed after taking the medication for at least 30 mins
B. Avoid rapid movements after taking the medication
C. Take medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications -
answer c. Take medication with water only
Why?
Fosmax should be taken with water only. The client should also remain upright for at least 30
mins after taking the medication.
The nurse is making initial rounds on a client with a c5 fracture and crutchfield thongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair or wire cutters
D. A screwdriver - answer b. A torque wrench
Why?
A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws.
An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be:
3
, A. 10 pounds
B.12 pounds
C. 18 pounds
D. 21 pounds - answer d. 21 pounds
Why?
A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.
A client is admitted with a ewing's sacroma. Which symptoms would be expected due to this
tumor's location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain - answer d. Bone pain
Why?
Sacroma is a type of bone cancer, therefor, bone pain would be expected
The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(tegretol). Which labatory value might be a indicate a serious side effect of this drug?
A. Uric acid of 5mg/dl
B. Hematoccrit of 33%
C. Wbc 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter - answer c. Wbc 2,000 per cubic millimeter
4
transsphenoidal approach. The nurse should be particularly alert to:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria - answer a. Nasal congestion
Why?
Removal of the pituitary gland is usually done by transsphernoidal approach through the
nose. Nasal congestion further interferes with the airway.
A client with cancer is a, admitted to the oncology unit. Stat lab values revel hgb 12.6, wbc
6500, k+1.9, uric acid 7.0, na+136, and platelets 178,000. The nurse evaluates that the client
is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis - answer b. Hypokalemia
Why?
1
,Hypokalemia is evident from the lab values listed. The other laboratory findings are within
normal limits. Making answers a,c and d incorrect
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is
the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work - answer a. Taking the vital signs
Why?
The primary responisblity of the nurse is to take the vital signs before any surgery.
Answers b,c and d are the responsibility of the doctor.
The nurse is working in the emergency room when a client arrives with severe burns of the
left arm, hands, face, and neck. Which action should receive priority?
A. Starting an iv?
B. Applying oxygen
C.obtaining blood gas
D. Medicating the client foe pain - answer b. Applying oxygen
Why?
The client with burns to the neck needs airway assessments and supplemental oxygen, so
applying oxygen is priority. The next action should be to start an iv and medicate for pain.
2
,The nurse is visiting a home health client with osteoporosis. The client has a new
prescription for alendronate (fosamax). Which instructions should be given to the client
A. Rest in bed after taking the medication for at least 30 mins
B. Avoid rapid movements after taking the medication
C. Take medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications -
answer c. Take medication with water only
Why?
Fosmax should be taken with water only. The client should also remain upright for at least 30
mins after taking the medication.
The nurse is making initial rounds on a client with a c5 fracture and crutchfield thongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair or wire cutters
D. A screwdriver - answer b. A torque wrench
Why?
A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws.
An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be:
3
, A. 10 pounds
B.12 pounds
C. 18 pounds
D. 21 pounds - answer d. 21 pounds
Why?
A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.
A client is admitted with a ewing's sacroma. Which symptoms would be expected due to this
tumor's location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain - answer d. Bone pain
Why?
Sacroma is a type of bone cancer, therefor, bone pain would be expected
The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(tegretol). Which labatory value might be a indicate a serious side effect of this drug?
A. Uric acid of 5mg/dl
B. Hematoccrit of 33%
C. Wbc 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter - answer c. Wbc 2,000 per cubic millimeter
4
