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 -correct answerA. 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 -correct answerB. Hypokalemia
why?
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 -correct answerA. 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 -correct answerB. 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.
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 -correct
answerC. 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 -correct answerB. 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:
A. 10 pounds
B.12 pounds
C. 18 pounds
D. 21 pounds -correct answerD. 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 -correct answerD. 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 -correct answerC. WBC 2,000 per cubic millimeter
why?
Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab
value of WBC 2,000 per cubic millimeter indicates side effects of the drug.
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 the pain"
B."what does his vomit look like?"
C." Describe his usual diet."
D. " have you noticed changes in his adominal size?" -correct answerC." Describe his usual
diet."
why?
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
transsphenoidal approach. the nurse should be particularly alert to:
A. Nasal congestion
B. Abdominal Tenderness
C. Muscle Tetany
D. Oliguria -correct answerA. 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 -correct answerB. Hypokalemia
why?
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 -correct answerA. 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 -correct answerB. 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.
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 -correct
answerC. 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 -correct answerB. 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:
A. 10 pounds
B.12 pounds
C. 18 pounds
D. 21 pounds -correct answerD. 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 -correct answerD. 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 -correct answerC. WBC 2,000 per cubic millimeter
why?
Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab
value of WBC 2,000 per cubic millimeter indicates side effects of the drug.
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 the pain"
B."what does his vomit look like?"
C." Describe his usual diet."
D. " have you noticed changes in his adominal size?" -correct answerC." Describe his usual
diet."
why?
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
