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Questions with Answers and Explanation
The nurse is caring for a client with epilepsy who is being treated with
carbamazepine (Tegretol). Which laboratory value might indicate a serious side
effect of this drug?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood
cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side
effects of the drug. Answers A and D are within normal limits, and answer B is a
lower limit of normal; therefore, answers A, B, and D are incorrect.
A 6-month-old client is admitted with possible intussuception. Which
question during the nursing history is least helpful in obtaining information
regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B,
and D are useful in determining the extent of disease process and, thus, are
,incorrect.
The nurse is assisting a client with diverticulosis to select appropriate
foods. Which food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C: The client with diverticulitis should avoid foods with seeds. The foods
in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent
constipation.
A client has rectal cancer and is scheduled for an abdominal perineal
resection. What should be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
Answer D: The client with a perineal resection will have a perineal incision.
Drains will be used to facilitate wound drainage. This will help prevent infection of
the surgical site. The client will not have an illeostomy, as in answer A; he will
have some electrolyte loss, but treatment is not focused on preventing the loss, so
answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.
The nurse is performing discharge teaching on a client with diverticulitis
who has been placed on a low-roughage diet. Which food would have to be
eliminated from this client’s diet?
A. Roasted chicken
,B. Noodles
C. Cooked broccoli
D. Custard
Answer C: The client with diverticulitis should avoid eating foods that are
gas forming and that increase abdominal discomfort, such as cooked broccoli.
Foods such as those listed in answers A, B, and D are allowed.
The nurse is caring for a client scheduled for removal of a pituitary
tumor using the transsphenoidal approach. The nurse should be particularly
alert for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal
approach, through the nose. Nasal congestion further interferes with the airway.
Answers B, C, and D are not correct because they are not directly associated with
the pituitary gland.
A client with cancer is admitted to the oncology unit. Stat lab values reveal 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?
E. Hypernatremia
F. Hypokalemia
G. Myelosuppression
H. Leukocytosis
, Answer cB: cHypokalemia cis cevident cfrom cthe clab cvalues clisted. cThe cother
laboratory cfindings carecwithin cnormal climits, cmaking canswers cA, cC, cand
c
c Dincorrect.
A c24-year-old cfemale cclient cis cscheduled cfor csurgery cin cthe
c morning. cWhich cof cthecfollowing cis cthe cprimary cresponsibility cof cthe
c nurse?
A. Taking cthe cvital csigns
B. Obtaining cthe cpermit
C. Explaining cthe cprocedure
D. Checking cthe clab cwork
Answer cA: cThe cprimary cresponsibility cof cthe cnurse cis cto ctake cthe cvital csigns
before cany csurgery.cThe cactions cin canswers cB, cC, cand cD care cthe cresponsibility
c
c of cthe cdoctor cand, ctherefore, care cincorrect cfor cthis cquestion.
The cnurse cis cworking cin cthe cemergency croom cwhen ca cclient carrives
with csevere cburns cofcthe cleft carm, chands, cface, cand cneck. cWhich caction
c
c should creceive cpriority?
A. Starting can cIV
B. Applying coxygen