Test Bank For Critical Care Nursing: Diagnosis and Managemen
n n n n n n n n
t 8th Edition By Linda D. Urden, DNSc, RN, CNS, NE-
n n n n n n n n n n
BC, FAAN, Kathleen M. Stacy, PhD, RN, CNS, CCRN, PCCN, CCNS
n n n n n n n n n n n
and Ma 9780323447522 Chapter 1-41 Complete Guide .
n n n n n n n
An56-year-oldnfemalenclientnisnreceivingnintracavitarynradiationnviananradiumnimplant.nWhich
nursenshouldnbenassignedntoncarenfornthisnclient?
A.nThennursenwhonisncaringnfornanothernclientnreceivingnintracavitarynradiation.
B.nAnnursenwithnMarfan'snsyndromenwhonisnpostmenopausal.
C.nAnnursenwithnoncologynexperiencenwhonmaynbenpregnant.
D.nThennursenwhonisncaringnfornanothernclientnwhonhasnClostridiumndifficile.n-
nANSWER:nB.nAnnursenwithnMarfan'snsyndromenwhonisnpostmenopausal.
RATIONALE:
Anclientnreceivingnintracavitynradiationnposesnanradiationnhazardnasnlongnasnthenintracavity
radiationnsourcenisninnplace.nAnnurse'snabilityntoncarenofnthisnclientnisnnotnaffectednbynMarfan's
syndromen(B),nwhichnisnanhereditaryndisordernofnconnectiventissues,nbones,nmuscles,nligaments
andnskeletalnstructures.nThengoalnisntonlimitnanynonenstaffnmember'snexposurentonthencalculated
timenspannbasednonnthenhalf-lifenofnradium,nsuchnasnthennumbernofnminutesnatnthenbedsidenpernday,
son(A)nshouldnnotnbenassigned.n(C)nshouldnnotnbenexposedntonthenradiationnduentonthenpossible
effectnonnthenfetus.nAnradiationnexposurendecreasesnthenimmunenresponseninnthenclientnwhonshould
notnbenexposedntonthenpotentialninadvertentntransmissionnofnanninfectiousnorganismn(D).
1.Anclientnwhonhasnactiventuberculosisn(TB)nisnadmittedntonthenmedicalnunit.nWhatnactionnisnmost
importantnfornthennursentonimplement?
A.nFitnthenclientnwithnanrespiratornmask.
B.nAssignnthenclientntonannegativenair-flownroom.
C.nDonnancleanngownnfornclientncare.
D.nPlacenannisolationncartninnthenhallwayn-nANSWER:nAssignnthenclientntonannegativenair-flownroom
RATIONALE:
Activentuberculosisnrequiresnimplementationnofnairbornenprecautions,nsonthenclientnshouldnbe
assignedntonannegativenpressurenair-flownroomn(D).nAlthoughn(AnandnC)nshouldnbenimplemented
fornclientsninnisolationnwithncontactnprecautions,nitnisnmostnimportantnthatnairnflownfromnthenroom
isnminimizednwhennthenclientnhasnTB.n(B)nshouldnbenimplementednwhennthenclientnleavesnthe
isolationnenvironment.
2.Anclientnisnreceivingnatenololn(Tenormin)n25nmgnPOnafternanmyocardialninfarction.nThennurse
determinesnthenclient'snapicalnpulsenisn65nbeatsnpernminute.nWhatnactionnshouldnthennurse
implement
next?
A.nMeasurenthenbloodnpressure.
B.nReassessnthenapicalnpulse.
C.nNotifynthenhealthcarenprovider.
D.nAdministernthenmedication.n-nANSWER:nAdministernthenmedication
RATIONALE:
Atenolol,nanbeta-blocker,nblocksnthenbetanreceptorsnofnthensinoatrialnnodentonreducenthenheartnrate,
sonthenmedicationnshouldnbenadministeredn(C)nbecausenthenclient'snapicalnpulsenisngreaternthann60.
(A,nB,nandnD)narennotnindicatednatnthisntime.
3.Thennursenisnassessingnanclientnandnidentifiesnanbruitnovernthenthyroid.nThisnfindingnisnconsistent
withnwhichninterpretation?
A.nHypothyroidism.
B.nThyroidncyst.
C.nThyroidncancer.
D.nHyperthyroidismn-nANSWER:nHyperthyroidism
,Rationale:Hyperthyroidismn(D)nisnannenlargementnofnthenthyroidngland,noftennreferredntonasnangoiter,na
ndna
bruitnmaynbenauscultatednovernthengoiternduentonannincreaseninnglandularnvascularitynwhich
increasesnasnthenthyroidnglandnbecomesnhyperactive.nAnbruitnisnnotncommonnwithn(A,nB,nandnC).
An6-year-
oldnchildnisnalertnbutnquietnwhennbroughtntonthenemergencyncenternwithnperiorbitalnecchymosisnandnec
chymosisnbehindnthenears.nThennursensuspectsnpotentialnchildnabusenandncontinuesntonassessnthenchild
nfornadditionalnmanifestationsnofnanbasilarnskullnfracture.nWhat
assessmentnfindingnwouldnbenconsistentnwithnanbasilarnskullnfracture?
A.nHematemesisnandnabdominalndistention.
B.nAsymmetrynofnthenfacenandneyenmovements.
C.nRhinorrhoeanornotorrhoeanwithnHalonsign.
D.nAbnormalnpositionnandnmovementnofnthenarm.n-
nANSWER:nRhinorrhoeanornotorrhoeanwithnHalonsign.
RATIONALE:
Raccoonneyesn(periorbitalnecchymosis)nandnBattle'snsignn(ecchymosisnbehindnthenearnovernthe
mastoidnprocess)narenbothnsignsnofnanbasilarnskullnfracture,nsonthennursenshouldnassessnfornpossible
meningealntearsnthatnmanifestnasnanHalonsignnwithnCSFnleakagenfromnthenearsnornnosen(D).n(A)nis
consistentnwithnorbitalnfractures.n(B)noccursnwithnwrenchingntraumasnofnthenshouldernornarm
fractures.n(C)noccursnwithnbluntnabdominalninjuries.
Thennursenisnassessingnanclientnwhoncomplainsnofnweightnloss,nracingnheartnrate,nandndifficulty
sleeping.nThennursendeterminesnthenclientnhasnmoistnskinnwithnfinenhair,nprominentneyes,nlid
retraction,nandnanstaringnexpression.nThesenfindingsnarenconsistentnwithnwhichndisorder?
A.nGrave'sndisease.
B.nMultiplensclerosis.
C.nAddison'sndisease.
D.nCushingnsyndrome.n-nANSWER:nGrave'sndisease
RATIONALE:
ThisnclientnisnexhibitingnsymptomsnassociatednwithnhyperthyroidismnornGrave'sndiseasen(A),
whichnisnannautoimmunenconditionnaffectingnthenthyroid.n(B,nC,nandnD)narennotnassociatednwith
thesensymptoms.
Thennursenisnassessingnannoldernclientnandndeterminesnthatnthenclient'snleftnupperneyelidndroops,
coveringnmorenofnthenirisnthannthenrightneyelid.nWhichndescriptionnshouldnthennursenusento
documentnthisnfinding?
A.nAnnystagmusnonnthenleft.
B.nExophthalmosnonnthenright.
C.nPtosisnonnthenleftneyelid.
D.nAstigmatismnonnthenright.n-nANSWER:nPtosisnonnthenleftneyelid
Rationale:nPtosisnisnthentermntondescribenanneyelidndroopnthatncoversnanlargenportionnofnthenirisn(A),nw
hich
maynresultnfromnoculomotornnervenorneyelidnmusclendisorder.n(B)nisncharacterizednbynrapid,
rhythmicnmovementnofnbothneyes.n(C)nisnandistortionnofnthenlensnofntheneye,ncausingndecreased
visualnacuity.n(D)nisnantermnusedntondescribenanprotrusionnofntheneyeballsnthatnoccursnwith
hyperthyroidism.
Thennursenisnassessingnanchild'snweightnandnheightnduringnanclinicnvisitnpriorntonstartingnschool.
Thennursenplotsnthenchild'snweightnonnthengrowthnchartnandnnotesnthatnthenchild'snweightnisninnthe
95thnpercentilenfornthenchild'snheight.nWhatnactionnshouldnthennursentake?
A.nQuestionnthentypenandnquantitynofnfoodsneatenninnantypicalnday.
B.nEncouragengivingntwonadditionalnsnacksneachndayntonthenchild.
C.nRecommendnandailynintakenofnatnleastnfournglassesnofnwholenmilk.
D.nAssessnfornsignsnofnpoornnutrition,nsuchnasnanpalenappearancen-
nANSWER:nA.nQuestionnthentypenandnquantitynofnfoodsneatenninnantypicalnday.
RATIONALE:
,Thenchildnisnoverweightnfornheight,nsonassessmentnofnthenchild'sndailyndietn(C)nshouldnbe
determined.nThenchildndoesnnotnneedn(AnornB),nbothnofnwhichnwillnincreasenthenchild'snweight.
Poornnutritionn(D)nisncommonlynseenninnunderweightnchildren,nnotnoverweight.
Anchildnisnreceivingnmaintenancenintravenousn(IV)nfluidsnatnthenratenofn1000nmLnfornthenfirstn10
kgnofnbodynweight,nplusn50nmL/kgnperndaynforneachnkilogramnbetweenn10nandn20.nHownmany
millilitersnpernhournshouldnthennursenprogramntheninfusionnpumpnfornanchildnwhonweighsn19.5nkg?
(Enternnumericnvaluenonly.nIfnroundingnisnrequired,nroundntonthennearestnwholennumber.)
A.n24
B.n61
C.n73
D.n58n-nANSWER:nB.n61
RATIONALE:
Thenformulanforncalculatingndailynfluidnrequirementsnis:n0nton10nkg,n100nmL/kgnpernday;norn10nto
20nkg,n1000nmLnfornthenfirstn10nkgnofnbodynweightnplusn50nmL/kgnperndaynforneachnkilogram
betweenn10nandn20.nTondeterminenannhourlynrate,ndividenthentotalnmillilitersnperndaynbyn24.n19.5
kgnxn50nmL/kgn=n475nmLn+n1000nmLn=n1475nmLn/n24nhoursn=n61nmL/hour
Thennursenobtainsnthenpulsenratenofn89nbeats/minutenfornanninfantnbeforenadministeringndigoxin
(Lanoxin).nWhichnactionnshouldnthennursentake?
A.nWithholdnthenmedicationnandncontactnthenhealthcarenprovider.
B.nGiventhenmedicationndosagenasnscheduled.
C.nAssessnrespiratorynratenfornonenminutennext.
D.nWaitn30nminutesnandngivenhalfnofnthendosagenofnmedication.n-
nANSWER:nA.nWithholdnthenmedicationnandncontactnthenhealthcarenprovider
RATIONALE:
Bradycardianisnannearlynsignnofndigoxinntoxicity,nsonifntheninfant'snpulsenratenisnlessnthann100
beats/minute,ndigoxinnshouldnbenwithheldnandnthenhealthcarenprovidernshouldnbennotifiedn(D).
Assessingnthenrespiratorynraten(A)nisnnotnindicatednbeforenadministeringnLanoxin.n(BnandnC)nplace
theninfantnatnfurthernrisknforndigoxinntoxicity.
ThennursenisndevelopingnanteachingnplannfornannadolescentnwithnanMilwaukeenbrace.nWhich
instructionnshouldnthennurseninclude?
A.nWearnthenbracenovernanT-shirtn23nhoursnpernday.
B.nDressnwithnthenbracenovernregularnclothing.
C.nShowernwithnthenbracendirectlynagainstnthenskin.
D.nRemoventhenbracenjustnbeforengoingntonbed.n-nANSWER:nA.nWearnthenbracenovernanT-
shirtn23nhoursnpernday.
RATIONALE:
Idiopathicnscoliosisnisnannabnormalnlateralncurvaturenofnthenspineninnadolescentnfemales.nEarly
treatmentnusesnanMilwaukeenbracenthatnplacesnpressurenagainstnthenlateralnspinalncurvature,nunder
thenneck,nandnagainstntheniliacncrest,nsonitnshouldnbenwornnforn23nhoursnperndaynovernanT-shirtn(D)
whichnreducesnfrictionnandnchafingnofnthenskin.n(A,nB,nandnC)nreducentheneffectivenessnofnthe
brace.
Anclientnwithnasthmanreceivesnanprescriptionnfornhighnbloodnpressurenduringnanclinicnvisit.
Whichnprescriptionnshouldnthennursenanticipatenthenclientntonreceiventhatnisnleastnlikelynto
exacerbatenasthma?
A.nCarteololn(Ocupress).
B.nPropranololnhydrochloriden(Inderal).
C.nPindololn(Visken).
D.nMetoprololntartraten(Lopressor)n-nANSWER:nD.nMetoprololntartraten(Lopressor).
RATIONALE:
Thenbestnantihypertensivenagentnfornclientsnwithnasthmanisnmetoprololn(Lopressor)n(C),nanbeta2
blockingnagentnwhichnisnalsoncardio-selectivenandnlessnlikelyntoncausenbronchoconstriction.
Pindololn(A)nisnanbeta2nblockernthatncanncausenbronchoconstrictionnandnincreasenasthmatic
symptoms.nAlthoughncarteololn(B)nisnanbetanblockingnagentnandnanneffectivenantihypertensive
, agentnusedninnmanagingnangina,nitncannincreasenanclient'snrisknfornbronchoconstrictionnduentonits
nonselectivenbetanblockernaction.nPropranololn(D)nalsonblocksnthenbeta2nreceptorsninnthenlungs,
causingnbronchoconstriction,nandnisnnotnindicatedninnclientsnwithnasthmanandnothernobstructive
pulmonaryndisorders.
Anmalenclientnwhonhasnbeenntakingnpropranololn(Inderal)nforn18nmonthsntellsnthennursenthatnthe
healthcarenproviderndiscontinuednthenmedicationnbecausenhisnbloodnpressurenhasnbeennnormalnfor
thenpastnthreenmonths.nWhichninstructionnshouldnthennursenprovide?
A.nObtainnanothernantihypertensivenprescriptionntonavoidnwithdrawalnsymptoms.
B.nStopnthenmedicationnandnkeepnannaccuratenrecordnofnbloodnpressure
C.nReportnanynuncomfortablensymptomsnafternstoppingnthenmedication.
D.nAsknthenhealthcarenprovidernaboutntaperingnthendrugndosenovernthennextnweek.n-
nANSWER:nD.nAsknthenhealthcarenprovidernaboutntaperingnthendrugndosenovernthennextnweek.
RATIONALE:
Althoughnthenhealthcarenproviderndiscontinuednthenpropranolol,nmeasuresntonpreventnrebound
cardiacnexcitation,nsuchnasnprogressivelynreducingnthendosenovernonentontwonweeksn(C),nshouldnbe
recommendedntonpreventnreboundntachycardia,nhypertension,nandnventricularndysrhythmias.
Abruptncessationn(AnandnB)nofnthenbeta-blockingnagentnmaynprecipitatentachycardianandnrebound
hypertension,nsongradualnweaningnshouldnbenrecommended.n(D)nisnnotnindicated.
Anclientnwhonisntakingnclonidinen(Catapres,nDuraclon)nreportsndrowsiness.nWhichnadditional
assessmentnshouldnthennursenmake?
A.nHasnthenclientnexperiencednconstipationnrecently?
B.nDidnthenclientnmissnanyndosesnofnthenmedication?
C.nHownlongnhasnthenclientnbeenntakingnthenmedication?
D.nDoesnthenclientnusenanyntobacconproducts?n-
nANSWER:nC.nHownlongnhasnthenclientnbeenntakingnthenmedication?
RATIONALE:
Drowsinessncannoccurninnthenearlynweeksnofntreatmentnwithnclonidinenandnwithncontinuednuse
becomesnlessnintense,nsonthenlengthnofntimenthenclientnhasnbeennonnthenmedicationn(A)nprovides
informationntondirectnadditionalninstruction.n(B,nC,nandnD)narennotnrelevant.
Thennursenisnpreparingntonadministernatropine,nannanticholinergic,ntonanclientnwhonisnscheduled
fornancholecystectomy.nThenclientnasksnthennursentonexplainnthenreasonnfornthenprescribed
medication.nWhatnresponsenisnbestnfornthennursentonprovide?
A.nProvidenanmorenrapidninductionnofnanesthesia.
B.nInducenrelaxationnbeforeninductionnofnanesthesia.
C.nDecreasenthenrisknofnbradycardianduringnsurgery.
D.nMinimizenthenamountnofnanalgesianneedednpostoperatively.n-
nANSWER:nC.nDecreasenthenrisknofnbradycardianduringnsurgery.
RATIONALE:
Atropinenmaynbenprescribednpreoperativelyntonincreasenthenautomaticitynofnthensinoatrialnnodenand
preventnandangerousnreductionninnheartnraten(B)nduringnsurgicalnanesthesia.n(A,nCnandnD)ndonnot
addressnthentherapeuticnactionnofnatropinenusenperioperatively.
Ann80-year-oldnclientnisngivennmorphinensulphatenfornpostoperativenpain.nWhichnconcomitant
medicationnshouldnthennursenquestionnthatnposesnanpotentialndevelopmentnofnurinarynretentionnin
thisngeriatricnclient?
A.nAntacids.
B.nTricyclicnantidepressants.
C.nNonsteroidalnanti-inflammatorynagents.
D.nInsulin.n-nANSWER:nB.nTricyclicnantidepressants.
RATIONALE:
Drugsnwithnanticholinergicnproperties,nsuchnasntricyclicnantidepressantsn(C),ncannexacerbate
urinarynretentionnassociatednwithnopioidsninnthenoldernclient.nAlthoughntricyclicnantidepressants
andnantihistaminesnwithnopioidsncannexacerbatenurinarynretention,nthenconcurrentnusenofn(AnandnB)
withnopioidsndonnot.nNonsteroidalnanti-inflammatorynagentsn(D)ncannincreasenthenrisknfor
n n n n n n n n
t 8th Edition By Linda D. Urden, DNSc, RN, CNS, NE-
n n n n n n n n n n
BC, FAAN, Kathleen M. Stacy, PhD, RN, CNS, CCRN, PCCN, CCNS
n n n n n n n n n n n
and Ma 9780323447522 Chapter 1-41 Complete Guide .
n n n n n n n
An56-year-oldnfemalenclientnisnreceivingnintracavitarynradiationnviananradiumnimplant.nWhich
nursenshouldnbenassignedntoncarenfornthisnclient?
A.nThennursenwhonisncaringnfornanothernclientnreceivingnintracavitarynradiation.
B.nAnnursenwithnMarfan'snsyndromenwhonisnpostmenopausal.
C.nAnnursenwithnoncologynexperiencenwhonmaynbenpregnant.
D.nThennursenwhonisncaringnfornanothernclientnwhonhasnClostridiumndifficile.n-
nANSWER:nB.nAnnursenwithnMarfan'snsyndromenwhonisnpostmenopausal.
RATIONALE:
Anclientnreceivingnintracavitynradiationnposesnanradiationnhazardnasnlongnasnthenintracavity
radiationnsourcenisninnplace.nAnnurse'snabilityntoncarenofnthisnclientnisnnotnaffectednbynMarfan's
syndromen(B),nwhichnisnanhereditaryndisordernofnconnectiventissues,nbones,nmuscles,nligaments
andnskeletalnstructures.nThengoalnisntonlimitnanynonenstaffnmember'snexposurentonthencalculated
timenspannbasednonnthenhalf-lifenofnradium,nsuchnasnthennumbernofnminutesnatnthenbedsidenpernday,
son(A)nshouldnnotnbenassigned.n(C)nshouldnnotnbenexposedntonthenradiationnduentonthenpossible
effectnonnthenfetus.nAnradiationnexposurendecreasesnthenimmunenresponseninnthenclientnwhonshould
notnbenexposedntonthenpotentialninadvertentntransmissionnofnanninfectiousnorganismn(D).
1.Anclientnwhonhasnactiventuberculosisn(TB)nisnadmittedntonthenmedicalnunit.nWhatnactionnisnmost
importantnfornthennursentonimplement?
A.nFitnthenclientnwithnanrespiratornmask.
B.nAssignnthenclientntonannegativenair-flownroom.
C.nDonnancleanngownnfornclientncare.
D.nPlacenannisolationncartninnthenhallwayn-nANSWER:nAssignnthenclientntonannegativenair-flownroom
RATIONALE:
Activentuberculosisnrequiresnimplementationnofnairbornenprecautions,nsonthenclientnshouldnbe
assignedntonannegativenpressurenair-flownroomn(D).nAlthoughn(AnandnC)nshouldnbenimplemented
fornclientsninnisolationnwithncontactnprecautions,nitnisnmostnimportantnthatnairnflownfromnthenroom
isnminimizednwhennthenclientnhasnTB.n(B)nshouldnbenimplementednwhennthenclientnleavesnthe
isolationnenvironment.
2.Anclientnisnreceivingnatenololn(Tenormin)n25nmgnPOnafternanmyocardialninfarction.nThennurse
determinesnthenclient'snapicalnpulsenisn65nbeatsnpernminute.nWhatnactionnshouldnthennurse
implement
next?
A.nMeasurenthenbloodnpressure.
B.nReassessnthenapicalnpulse.
C.nNotifynthenhealthcarenprovider.
D.nAdministernthenmedication.n-nANSWER:nAdministernthenmedication
RATIONALE:
Atenolol,nanbeta-blocker,nblocksnthenbetanreceptorsnofnthensinoatrialnnodentonreducenthenheartnrate,
sonthenmedicationnshouldnbenadministeredn(C)nbecausenthenclient'snapicalnpulsenisngreaternthann60.
(A,nB,nandnD)narennotnindicatednatnthisntime.
3.Thennursenisnassessingnanclientnandnidentifiesnanbruitnovernthenthyroid.nThisnfindingnisnconsistent
withnwhichninterpretation?
A.nHypothyroidism.
B.nThyroidncyst.
C.nThyroidncancer.
D.nHyperthyroidismn-nANSWER:nHyperthyroidism
,Rationale:Hyperthyroidismn(D)nisnannenlargementnofnthenthyroidngland,noftennreferredntonasnangoiter,na
ndna
bruitnmaynbenauscultatednovernthengoiternduentonannincreaseninnglandularnvascularitynwhich
increasesnasnthenthyroidnglandnbecomesnhyperactive.nAnbruitnisnnotncommonnwithn(A,nB,nandnC).
An6-year-
oldnchildnisnalertnbutnquietnwhennbroughtntonthenemergencyncenternwithnperiorbitalnecchymosisnandnec
chymosisnbehindnthenears.nThennursensuspectsnpotentialnchildnabusenandncontinuesntonassessnthenchild
nfornadditionalnmanifestationsnofnanbasilarnskullnfracture.nWhat
assessmentnfindingnwouldnbenconsistentnwithnanbasilarnskullnfracture?
A.nHematemesisnandnabdominalndistention.
B.nAsymmetrynofnthenfacenandneyenmovements.
C.nRhinorrhoeanornotorrhoeanwithnHalonsign.
D.nAbnormalnpositionnandnmovementnofnthenarm.n-
nANSWER:nRhinorrhoeanornotorrhoeanwithnHalonsign.
RATIONALE:
Raccoonneyesn(periorbitalnecchymosis)nandnBattle'snsignn(ecchymosisnbehindnthenearnovernthe
mastoidnprocess)narenbothnsignsnofnanbasilarnskullnfracture,nsonthennursenshouldnassessnfornpossible
meningealntearsnthatnmanifestnasnanHalonsignnwithnCSFnleakagenfromnthenearsnornnosen(D).n(A)nis
consistentnwithnorbitalnfractures.n(B)noccursnwithnwrenchingntraumasnofnthenshouldernornarm
fractures.n(C)noccursnwithnbluntnabdominalninjuries.
Thennursenisnassessingnanclientnwhoncomplainsnofnweightnloss,nracingnheartnrate,nandndifficulty
sleeping.nThennursendeterminesnthenclientnhasnmoistnskinnwithnfinenhair,nprominentneyes,nlid
retraction,nandnanstaringnexpression.nThesenfindingsnarenconsistentnwithnwhichndisorder?
A.nGrave'sndisease.
B.nMultiplensclerosis.
C.nAddison'sndisease.
D.nCushingnsyndrome.n-nANSWER:nGrave'sndisease
RATIONALE:
ThisnclientnisnexhibitingnsymptomsnassociatednwithnhyperthyroidismnornGrave'sndiseasen(A),
whichnisnannautoimmunenconditionnaffectingnthenthyroid.n(B,nC,nandnD)narennotnassociatednwith
thesensymptoms.
Thennursenisnassessingnannoldernclientnandndeterminesnthatnthenclient'snleftnupperneyelidndroops,
coveringnmorenofnthenirisnthannthenrightneyelid.nWhichndescriptionnshouldnthennursenusento
documentnthisnfinding?
A.nAnnystagmusnonnthenleft.
B.nExophthalmosnonnthenright.
C.nPtosisnonnthenleftneyelid.
D.nAstigmatismnonnthenright.n-nANSWER:nPtosisnonnthenleftneyelid
Rationale:nPtosisnisnthentermntondescribenanneyelidndroopnthatncoversnanlargenportionnofnthenirisn(A),nw
hich
maynresultnfromnoculomotornnervenorneyelidnmusclendisorder.n(B)nisncharacterizednbynrapid,
rhythmicnmovementnofnbothneyes.n(C)nisnandistortionnofnthenlensnofntheneye,ncausingndecreased
visualnacuity.n(D)nisnantermnusedntondescribenanprotrusionnofntheneyeballsnthatnoccursnwith
hyperthyroidism.
Thennursenisnassessingnanchild'snweightnandnheightnduringnanclinicnvisitnpriorntonstartingnschool.
Thennursenplotsnthenchild'snweightnonnthengrowthnchartnandnnotesnthatnthenchild'snweightnisninnthe
95thnpercentilenfornthenchild'snheight.nWhatnactionnshouldnthennursentake?
A.nQuestionnthentypenandnquantitynofnfoodsneatenninnantypicalnday.
B.nEncouragengivingntwonadditionalnsnacksneachndayntonthenchild.
C.nRecommendnandailynintakenofnatnleastnfournglassesnofnwholenmilk.
D.nAssessnfornsignsnofnpoornnutrition,nsuchnasnanpalenappearancen-
nANSWER:nA.nQuestionnthentypenandnquantitynofnfoodsneatenninnantypicalnday.
RATIONALE:
,Thenchildnisnoverweightnfornheight,nsonassessmentnofnthenchild'sndailyndietn(C)nshouldnbe
determined.nThenchildndoesnnotnneedn(AnornB),nbothnofnwhichnwillnincreasenthenchild'snweight.
Poornnutritionn(D)nisncommonlynseenninnunderweightnchildren,nnotnoverweight.
Anchildnisnreceivingnmaintenancenintravenousn(IV)nfluidsnatnthenratenofn1000nmLnfornthenfirstn10
kgnofnbodynweight,nplusn50nmL/kgnperndaynforneachnkilogramnbetweenn10nandn20.nHownmany
millilitersnpernhournshouldnthennursenprogramntheninfusionnpumpnfornanchildnwhonweighsn19.5nkg?
(Enternnumericnvaluenonly.nIfnroundingnisnrequired,nroundntonthennearestnwholennumber.)
A.n24
B.n61
C.n73
D.n58n-nANSWER:nB.n61
RATIONALE:
Thenformulanforncalculatingndailynfluidnrequirementsnis:n0nton10nkg,n100nmL/kgnpernday;norn10nto
20nkg,n1000nmLnfornthenfirstn10nkgnofnbodynweightnplusn50nmL/kgnperndaynforneachnkilogram
betweenn10nandn20.nTondeterminenannhourlynrate,ndividenthentotalnmillilitersnperndaynbyn24.n19.5
kgnxn50nmL/kgn=n475nmLn+n1000nmLn=n1475nmLn/n24nhoursn=n61nmL/hour
Thennursenobtainsnthenpulsenratenofn89nbeats/minutenfornanninfantnbeforenadministeringndigoxin
(Lanoxin).nWhichnactionnshouldnthennursentake?
A.nWithholdnthenmedicationnandncontactnthenhealthcarenprovider.
B.nGiventhenmedicationndosagenasnscheduled.
C.nAssessnrespiratorynratenfornonenminutennext.
D.nWaitn30nminutesnandngivenhalfnofnthendosagenofnmedication.n-
nANSWER:nA.nWithholdnthenmedicationnandncontactnthenhealthcarenprovider
RATIONALE:
Bradycardianisnannearlynsignnofndigoxinntoxicity,nsonifntheninfant'snpulsenratenisnlessnthann100
beats/minute,ndigoxinnshouldnbenwithheldnandnthenhealthcarenprovidernshouldnbennotifiedn(D).
Assessingnthenrespiratorynraten(A)nisnnotnindicatednbeforenadministeringnLanoxin.n(BnandnC)nplace
theninfantnatnfurthernrisknforndigoxinntoxicity.
ThennursenisndevelopingnanteachingnplannfornannadolescentnwithnanMilwaukeenbrace.nWhich
instructionnshouldnthennurseninclude?
A.nWearnthenbracenovernanT-shirtn23nhoursnpernday.
B.nDressnwithnthenbracenovernregularnclothing.
C.nShowernwithnthenbracendirectlynagainstnthenskin.
D.nRemoventhenbracenjustnbeforengoingntonbed.n-nANSWER:nA.nWearnthenbracenovernanT-
shirtn23nhoursnpernday.
RATIONALE:
Idiopathicnscoliosisnisnannabnormalnlateralncurvaturenofnthenspineninnadolescentnfemales.nEarly
treatmentnusesnanMilwaukeenbracenthatnplacesnpressurenagainstnthenlateralnspinalncurvature,nunder
thenneck,nandnagainstntheniliacncrest,nsonitnshouldnbenwornnforn23nhoursnperndaynovernanT-shirtn(D)
whichnreducesnfrictionnandnchafingnofnthenskin.n(A,nB,nandnC)nreducentheneffectivenessnofnthe
brace.
Anclientnwithnasthmanreceivesnanprescriptionnfornhighnbloodnpressurenduringnanclinicnvisit.
Whichnprescriptionnshouldnthennursenanticipatenthenclientntonreceiventhatnisnleastnlikelynto
exacerbatenasthma?
A.nCarteololn(Ocupress).
B.nPropranololnhydrochloriden(Inderal).
C.nPindololn(Visken).
D.nMetoprololntartraten(Lopressor)n-nANSWER:nD.nMetoprololntartraten(Lopressor).
RATIONALE:
Thenbestnantihypertensivenagentnfornclientsnwithnasthmanisnmetoprololn(Lopressor)n(C),nanbeta2
blockingnagentnwhichnisnalsoncardio-selectivenandnlessnlikelyntoncausenbronchoconstriction.
Pindololn(A)nisnanbeta2nblockernthatncanncausenbronchoconstrictionnandnincreasenasthmatic
symptoms.nAlthoughncarteololn(B)nisnanbetanblockingnagentnandnanneffectivenantihypertensive
, agentnusedninnmanagingnangina,nitncannincreasenanclient'snrisknfornbronchoconstrictionnduentonits
nonselectivenbetanblockernaction.nPropranololn(D)nalsonblocksnthenbeta2nreceptorsninnthenlungs,
causingnbronchoconstriction,nandnisnnotnindicatedninnclientsnwithnasthmanandnothernobstructive
pulmonaryndisorders.
Anmalenclientnwhonhasnbeenntakingnpropranololn(Inderal)nforn18nmonthsntellsnthennursenthatnthe
healthcarenproviderndiscontinuednthenmedicationnbecausenhisnbloodnpressurenhasnbeennnormalnfor
thenpastnthreenmonths.nWhichninstructionnshouldnthennursenprovide?
A.nObtainnanothernantihypertensivenprescriptionntonavoidnwithdrawalnsymptoms.
B.nStopnthenmedicationnandnkeepnannaccuratenrecordnofnbloodnpressure
C.nReportnanynuncomfortablensymptomsnafternstoppingnthenmedication.
D.nAsknthenhealthcarenprovidernaboutntaperingnthendrugndosenovernthennextnweek.n-
nANSWER:nD.nAsknthenhealthcarenprovidernaboutntaperingnthendrugndosenovernthennextnweek.
RATIONALE:
Althoughnthenhealthcarenproviderndiscontinuednthenpropranolol,nmeasuresntonpreventnrebound
cardiacnexcitation,nsuchnasnprogressivelynreducingnthendosenovernonentontwonweeksn(C),nshouldnbe
recommendedntonpreventnreboundntachycardia,nhypertension,nandnventricularndysrhythmias.
Abruptncessationn(AnandnB)nofnthenbeta-blockingnagentnmaynprecipitatentachycardianandnrebound
hypertension,nsongradualnweaningnshouldnbenrecommended.n(D)nisnnotnindicated.
Anclientnwhonisntakingnclonidinen(Catapres,nDuraclon)nreportsndrowsiness.nWhichnadditional
assessmentnshouldnthennursenmake?
A.nHasnthenclientnexperiencednconstipationnrecently?
B.nDidnthenclientnmissnanyndosesnofnthenmedication?
C.nHownlongnhasnthenclientnbeenntakingnthenmedication?
D.nDoesnthenclientnusenanyntobacconproducts?n-
nANSWER:nC.nHownlongnhasnthenclientnbeenntakingnthenmedication?
RATIONALE:
Drowsinessncannoccurninnthenearlynweeksnofntreatmentnwithnclonidinenandnwithncontinuednuse
becomesnlessnintense,nsonthenlengthnofntimenthenclientnhasnbeennonnthenmedicationn(A)nprovides
informationntondirectnadditionalninstruction.n(B,nC,nandnD)narennotnrelevant.
Thennursenisnpreparingntonadministernatropine,nannanticholinergic,ntonanclientnwhonisnscheduled
fornancholecystectomy.nThenclientnasksnthennursentonexplainnthenreasonnfornthenprescribed
medication.nWhatnresponsenisnbestnfornthennursentonprovide?
A.nProvidenanmorenrapidninductionnofnanesthesia.
B.nInducenrelaxationnbeforeninductionnofnanesthesia.
C.nDecreasenthenrisknofnbradycardianduringnsurgery.
D.nMinimizenthenamountnofnanalgesianneedednpostoperatively.n-
nANSWER:nC.nDecreasenthenrisknofnbradycardianduringnsurgery.
RATIONALE:
Atropinenmaynbenprescribednpreoperativelyntonincreasenthenautomaticitynofnthensinoatrialnnodenand
preventnandangerousnreductionninnheartnraten(B)nduringnsurgicalnanesthesia.n(A,nCnandnD)ndonnot
addressnthentherapeuticnactionnofnatropinenusenperioperatively.
Ann80-year-oldnclientnisngivennmorphinensulphatenfornpostoperativenpain.nWhichnconcomitant
medicationnshouldnthennursenquestionnthatnposesnanpotentialndevelopmentnofnurinarynretentionnin
thisngeriatricnclient?
A.nAntacids.
B.nTricyclicnantidepressants.
C.nNonsteroidalnanti-inflammatorynagents.
D.nInsulin.n-nANSWER:nB.nTricyclicnantidepressants.
RATIONALE:
Drugsnwithnanticholinergicnproperties,nsuchnasntricyclicnantidepressantsn(C),ncannexacerbate
urinarynretentionnassociatednwithnopioidsninnthenoldernclient.nAlthoughntricyclicnantidepressants
andnantihistaminesnwithnopioidsncannexacerbatenurinarynretention,nthenconcurrentnusenofn(AnandnB)
withnopioidsndonnot.nNonsteroidalnanti-inflammatorynagentsn(D)ncannincreasenthenrisknfor
