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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 B: Hypokalemia is evident from the lab values listed. The other laboratory
findings are within normal limits, making answers A, C, and Dincorrect.
, A w24-year-old wfemale wclient wis wscheduled wfor wsurgery win wthe
w morning. wWhich wof wthewfollowing wis wthe wprimary wresponsibility wof wthe
w nurse?
A. Taking wthe wvital wsigns
B. Obtaining wthe wpermit
C. Explaining wthe wprocedure
D. Checking wthe wlab wwork
Answer wA: wThe wprimary wresponsibility wof wthe wnurse wis wto wtake wthe wvital
w signs wbefore wany wsurgery.wThe wactions win wanswers wB, wC, wand wD ware wthe
w responsibility wof wthe wdoctor wand, wtherefore, ware wincorrect wfor wthis wquestion.
The wnurse wis wworking win wthe wemergency wroom wwhen wa wclient warrives
w with wsevere wburns wofwthe wleft warm, whands, wface, wand wneck. wWhich waction
w should wreceive wpriority?
A. Starting wan wIV
B. Applying woxygen
C. Obtaining wblood wgases
D. Medicating wthe wclient wfor wpain