QUESTIONS
Morning surgery is scheduled for a client who is 24 years old. Which of the following is the
primary responsibility of the nurse?
A. collecting vital signs B. acquiring the license C. describing the process D. Checking the
lab work - ANS-A. taking the vital signs
why?
the primary responisblity of the nurse is to take the vital signs before any surgery.
The doctor is the one who is responsible for answers B, C, and D. A man in his 25s is
brought to the emergency room with an object lodged in his eye. Which action by the nurse
is correct?
A. Remove the item with a magnet. B. Rinse the eye thoroughly with saline
C. Cover both eyes with paper cups
D. Patch the affected eye only - ANS-C. Use paper cups to cover both eyes. why?
Covering both eyes prevents consensual movement of the affected eye.
A 5 year old is admitted to the unit following a tonsillectomy. Which of the following is
indicative of a surgical complication? A. diminished appetite B. A low-grade fever
C. Chest congestion
D. ANS- constant swallowing A child with cerebral palsy who is six years old can function
similarly to an 18-month-old. Which finding would support that assessment?
A. She makes her own clothes. B. She pulls a toy behind her
C. She can construct an eight-block tower. D. She can copy a horizontal or vertical line. -
ANS-
A client who is six months old is admitted with a possibility of being misled. Which question
during the nursing history is least helpful in obtaining information regarding this diagnosis?
A. "Speak to me about the suffering" B. "How does his vomit appear?" C." Describe his
usual diet."
D. " have you noticed changes in his adominal size?" - ANS-C." Please describe his typical
diet. why?
His usual diet-related questions are the least helpful. A, B, and D are useful in determining
the extent of disease process and thus, are incorrect
A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect.
Which conduct indicates unilateral neglect? A. By shaving only one side of his face, the
client is seen. B. The client is unable to distinguish between two tactile stimuli presented
simultaneously
C. The client is unable to complete a range a vision without turning his head side to side
D. The client is unable to carry out cognitive and motor activity at the same time - ANS-A.
The client is observed by shaving only one side of his face
why?
The client with unilateral neglect will neglect one side of the body
A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for:
, A. Position Trendelenburg B. Ice to the entire extremity
C. Bucks traction
D. ANS-C is a pillow for abduction. Bucks traction
why?
The client with a fractured femur will be placed in Bucks traction to realign the leg and
decrease spasms and pain.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which
lab finding indicates that the medication is having the desired effect?
A. Neutrophil count of 60%
B. Basophil count of 0.5%
C. Monocyte count of 2%
D. 1 percent reticlocyte count - ANS-D. Reticlocyte count of 1 %
why?
Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte
count of 1% indicates that it is having the desired effect.
An abdominal perineal resection is scheduled for a client who has rectal cancer. What
should be the top priority for nursing care following surgery? A. Teaching the illeostomy how
to be irrigated B. preventing the loss of electrolytes in the incisional area C. Encouraging a
high fiber diet
D. Facilitating perineal wound drainage - ANS-D. Facilitating perineal wound drainage
why?
the client with a perineal resection will have a perineal incision. Drains will be used to make
it easier for the wound to drain. This will help prevent infection of the surgical site. The client
will not undergo an illestomy, despite the fact that in answer A he will experience some
electrolyte loss; however, treatment is not geared toward preventing the loss, so answer B is
incorrect. Additionally, the high-fiber diet in response to question C is not recommended at
this time. A client in the cardiac step-down unit requires suctioning for excess mucous
secretions. The nurse should be most careful to monitor the client for which dysrhythmia
during this procedure?
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block - ANS-A. Bradycardia
why?
Suctioning can cause a vagal response and bradycardia.
A client is 2 days post-operative colon resection. After a coughing episode, the client's
wound eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4x4s
B. Use an ABD dressing and sterile 4x4 to cover the wound. C. Cover the wound with a
sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound - ANS-C. Cover the
wound with a sterile saline-soaked dressing.
why?
If the client eviscerates, the abdominal content should be covered with a sterile
saline-soaked dressing.
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of
170 meq/L. What behavioral changes would be common for this client?
A. Anger
, B. Mania
C. Depression
D. Pyschosis - ANS-B. Mania
why?
The patient has hypernatrimia and may exhibit manic behavior if their serum sodium level is
170 meq/L or higher. A patient is admitted with an Ewing's sacroma. Given the location of
this tumor, which symptoms should be expected? A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone Pain - ANS-D. Bone Anxiety why?
Since sacroma is a type of bone cancer, bone pain is normal. A client visits the clinic after
the death of a parent. Which statement made by the client's sister signifies abnormal
grieving?
A. "My sister still has episodes of crying and it's been 3 months since daddy died."
B. "Sally seems to have forgotten the bad things that daddy did in his lifetime."
C. "She really had a hard time after daddy's funeral. She said that she had a sense of
longing."
D. "Sally has not been sad at all by daddy's death. She behaves as though nothing has
occurred." - ANS-D. "Sally has not been at all affected by her father's passing. She acts as
though nothing has occurred." why?
Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to
grieve, it might be abnormal grieving. This family member might be suppressing feelings of
grief.
A client with acute leukemia develops a low white blood cell count. In addition to the
institute of isolation the nurse should:
A. Request that food be served with disposable utensils
B. Ask the client to wear a mask when visitors are present
C. Prep IV with mild soap, water, and alcohol
D. Provide foods in seal single serving packages - ANS-D. Provide foods in seal single
serving packages
why?
Because the client is immune-suppressed, foods should be served in sealed containers, to
avoid food contaminants.
A client with cancer develops xerostomia. The nurse can help alleviate the discomfort
associated with xerostomia by:
A. Offering a hard candy
B. Administering an analgesic medication
C. splinting joints with swelling D. Providing saliva substitue - ANS-D. providing an
alternative to saliva why?
Xerostomia is dry mouth, and offering the client a saliva substitute will help the most.
A client with cancer is a, admitted to the oncology unit. WBC 6500, K+1.9, uric acid 7.0,
Na+136, and platelets 178,000 are among the stat lab results. The nurse evaluates that the
client is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis - ANS-B. Hypokalemia
why?