RNPedia - PNLE NP3 Test 1 with !| !| !| !| !| !| !|
correct answers & rationales !| !| !|
1. Nurse Michelle should know that the drainage is normal 4 days after a
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
sigmoid colostomy when the stool is: !| !| !| !| !|
A. Green liquid
!| !|
B. Solid formed
!| !|
C. Loose, bloody
!| !|
D. Semi formed - Correct answer ✔Answer: (C) Loose, bloody.
!| !| !| !| !| !| !| !| !| !|
Normal bowel function and soft-formed stool usually do not occur until
!| !| !| !| !| !| !| !| !| !| !|
around the seventh day following surgery. The stool consistency is related to
!| !| !| !| !| !| !| !| !| !| !| !|
how much water is being absorbed.
!| !| !| !| !|
2. Where would nurse Kristine place the call light for a male client with a
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
right-sided brain attack and left homonymous hemianopsia? !| !| !| !| !| !|
A. On the client's right side
!| !| !| !| !|
B. On the client's left side
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C. Directly in front of the client
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D. Where the client like - Correct answer ✔Answer: (A) On the client's right
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
side. !|
The client has left visual field blindness. The client will see only from the
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
right side. !|
,3. A male client is admitted to the emergency department following an
!| !| !| !| !| !| !| !| !| !| !| !|
accident. What are the first nursing actions of the nurse?
!| !| !| !| !| !| !| !| !|
A. Check respiration, circulation, neurological response.
!| !| !| !| !|
B. Align the spine, check pupils, and check for hemorrhage.
!| !| !| !| !| !| !| !| !|
C. Check respirations, stabilize spine, and check circulation.
!| !| !| !| !| !| !|
D. Assess level of consciousness and circulation. - Correct answer ✔Answer:
!| !| !| !| !| !| !| !| !| !| !|
(C) Check respirations, stabilize spine, and check circulation.
!| !| !| !| !| !| !| !|
Checking the airway would be priority, and a neck injury should be
!| !| !| !| !| !| !| !| !| !| !| !|
suspected.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it
!| !| !| !| !| !| !| !| !| !| !| !| !|
reduces preload and relieves angina by:
!| !| !| !| !|
A. Increasing contractility and slowing heart rate.
!| !| !| !| !| !|
B. Increasing AV conduction and heart rate.
!| !| !| !| !| !|
C. Decreasing contractility and oxygen consumption.
!| !| !| !| !|
D. Decreasing venous return through vasodilation. - Correct answer
!| !| !| !| !| !| !| !| !|
✔Answer: (D) Decreasing venous return through vasodilation.
!| !| !| !| !| !|
The significant effect of nitroglycerin is vasodilation and decreased venous
!| !| !| !| !| !| !| !| !| !|
return, so the heart does not have to work hard.
!| !| !| !| !| !| !| !| !|
,5. Nurse Patricia finds a female client who is post-myocardial infarction (MI)
!| !| !| !| !| !| !| !| !| !| !| !|
slumped on the side rails of the bed and unresponsive to shaking or
!| !| !| !| !| !| !| !| !| !| !| !| !|
shouting. Which is the nurse next action? !| !| !| !| !| !|
A. Call for help and note the time.
!| !| !| !| !| !| !|
B. Clear the airway
!| !| !|
C. Give two sharp thumps to the precordium and check the pulse.
!| !| !| !| !| !| !| !| !| !| !|
D. Administer two quick blows. - Correct answer ✔Answer: (A) Call for help
!| !| !| !| !| !| !| !| !| !| !| !| !|
and note the time.
!| !| !| !|
Having established, by stimulating the client, that the client is unconscious
!| !| !| !| !| !| !| !| !| !| !|
rather than sleep, the nurse should immediately call for help. This may be
!| !| !| !| !| !| !| !| !| !| !| !| !|
done by dialing the operator from the client's phone and giving the hospital
!| !| !| !| !| !| !| !| !| !| !| !| !|
code for cardiac arrest and the client's room number to the operator, of if the
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
phone is not available, by pulling the emergency call button. Noting the time
!| !| !| !| !| !| !| !| !| !| !| !| !|
is important baseline information for cardiac arrest procedure.
!| !| !| !| !| !| !|
6. Nurse Monett is caring for a client recovering from gastro-intestinal
!| !| !| !| !| !| !| !| !| !| !|
bleeding. The nurse should: !| !| !|
A. Plan care so the client can receive 8 hours of uninterrupted sleep each
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
night.
B. Monitor vital signs every 2 hours.
!| !| !| !| !| !|
C. Make sure that the client takes food and medications at prescribed
!| !| !| !| !| !| !| !| !| !| !| !|
intervals.
D. Provide milk every 2 to 3 hours. - Correct answer ✔Answer: (C) Make sure
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
that the client takes food and medications at prescribed intervals.
!| !| !| !| !| !| !| !| !| !| !|
, Food and drug therapy will prevent the accumulation of hydrochloric acid,
!| !| !| !| !| !| !| !| !| !| !|
or will neutralize and buffer the acid that does accumulate.
!| !| !| !| !| !| !| !| !|
7. A male client was on warfarin (Coumadin) before admission, and has
!| !| !| !| !| !| !| !| !| !| !| !|
been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT)
!| !| !| !| !| !| !| !| !| !| !| !|
is 68 seconds. What should Nurse Carla do?
!| !| !| !| !| !| !|
A. Stop the I.V. infusion of heparin and notify the physician.
!| !| !| !| !| !| !| !| !| !|
B. Continue treatment as ordered.
!| !| !| !|
C. Expect the warfarin to increase the PTT.
!| !| !| !| !| !| !|
D. Increase the dosage, because the level is lower than normal. - Correct
!| !| !| !| !| !| !| !| !| !| !| !| !|
answer ✔Answer: (B) Continue treatment as ordered.
!| !| !| !| !| !| !|
The effects of heparin are monitored by the PTT is normally 30 to 45
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
seconds; the therapeutic level is 1.5 to 2 times the normal level.
!| !| !| !| !| !| !| !| !| !| !|
8. A client undergone ileostomy, when should the drainage appliance be
!| !| !| !| !| !| !| !| !| !| !|
applied to the stoma? !| !| !|
A. 24 hours later, when edema has subsided.
!| !| !| !| !| !| !|
B. In the operating room.
!| !| !| !|
C. After the ileostomy begin to function.
!| !| !| !| !| !|
D. When the client is able to begin self-care procedures. - Correct answer
!| !| !| !| !| !| !| !| !| !| !| !| !|
✔Answer: (B) In the operating room. !| !| !| !| !| !|
The stoma drainage bag is applied in the operating room. Drainage from the
!| !| !| !| !| !| !| !| !| !| !| !| !|
ileostomy contains secretions that are rich in digestive enzymes and highly
!| !| !| !| !| !| !| !| !| !| !|
irritating to the skin. Protection of the skin from the effects of these enzymes
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
correct answers & rationales !| !| !|
1. Nurse Michelle should know that the drainage is normal 4 days after a
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
sigmoid colostomy when the stool is: !| !| !| !| !|
A. Green liquid
!| !|
B. Solid formed
!| !|
C. Loose, bloody
!| !|
D. Semi formed - Correct answer ✔Answer: (C) Loose, bloody.
!| !| !| !| !| !| !| !| !| !|
Normal bowel function and soft-formed stool usually do not occur until
!| !| !| !| !| !| !| !| !| !| !|
around the seventh day following surgery. The stool consistency is related to
!| !| !| !| !| !| !| !| !| !| !| !|
how much water is being absorbed.
!| !| !| !| !|
2. Where would nurse Kristine place the call light for a male client with a
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
right-sided brain attack and left homonymous hemianopsia? !| !| !| !| !| !|
A. On the client's right side
!| !| !| !| !|
B. On the client's left side
!| !| !| !| !|
C. Directly in front of the client
!| !| !| !| !| !|
D. Where the client like - Correct answer ✔Answer: (A) On the client's right
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
side. !|
The client has left visual field blindness. The client will see only from the
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
right side. !|
,3. A male client is admitted to the emergency department following an
!| !| !| !| !| !| !| !| !| !| !| !|
accident. What are the first nursing actions of the nurse?
!| !| !| !| !| !| !| !| !|
A. Check respiration, circulation, neurological response.
!| !| !| !| !|
B. Align the spine, check pupils, and check for hemorrhage.
!| !| !| !| !| !| !| !| !|
C. Check respirations, stabilize spine, and check circulation.
!| !| !| !| !| !| !|
D. Assess level of consciousness and circulation. - Correct answer ✔Answer:
!| !| !| !| !| !| !| !| !| !| !|
(C) Check respirations, stabilize spine, and check circulation.
!| !| !| !| !| !| !| !|
Checking the airway would be priority, and a neck injury should be
!| !| !| !| !| !| !| !| !| !| !| !|
suspected.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it
!| !| !| !| !| !| !| !| !| !| !| !| !|
reduces preload and relieves angina by:
!| !| !| !| !|
A. Increasing contractility and slowing heart rate.
!| !| !| !| !| !|
B. Increasing AV conduction and heart rate.
!| !| !| !| !| !|
C. Decreasing contractility and oxygen consumption.
!| !| !| !| !|
D. Decreasing venous return through vasodilation. - Correct answer
!| !| !| !| !| !| !| !| !|
✔Answer: (D) Decreasing venous return through vasodilation.
!| !| !| !| !| !|
The significant effect of nitroglycerin is vasodilation and decreased venous
!| !| !| !| !| !| !| !| !| !|
return, so the heart does not have to work hard.
!| !| !| !| !| !| !| !| !|
,5. Nurse Patricia finds a female client who is post-myocardial infarction (MI)
!| !| !| !| !| !| !| !| !| !| !| !|
slumped on the side rails of the bed and unresponsive to shaking or
!| !| !| !| !| !| !| !| !| !| !| !| !|
shouting. Which is the nurse next action? !| !| !| !| !| !|
A. Call for help and note the time.
!| !| !| !| !| !| !|
B. Clear the airway
!| !| !|
C. Give two sharp thumps to the precordium and check the pulse.
!| !| !| !| !| !| !| !| !| !| !|
D. Administer two quick blows. - Correct answer ✔Answer: (A) Call for help
!| !| !| !| !| !| !| !| !| !| !| !| !|
and note the time.
!| !| !| !|
Having established, by stimulating the client, that the client is unconscious
!| !| !| !| !| !| !| !| !| !| !|
rather than sleep, the nurse should immediately call for help. This may be
!| !| !| !| !| !| !| !| !| !| !| !| !|
done by dialing the operator from the client's phone and giving the hospital
!| !| !| !| !| !| !| !| !| !| !| !| !|
code for cardiac arrest and the client's room number to the operator, of if the
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
phone is not available, by pulling the emergency call button. Noting the time
!| !| !| !| !| !| !| !| !| !| !| !| !|
is important baseline information for cardiac arrest procedure.
!| !| !| !| !| !| !|
6. Nurse Monett is caring for a client recovering from gastro-intestinal
!| !| !| !| !| !| !| !| !| !| !|
bleeding. The nurse should: !| !| !|
A. Plan care so the client can receive 8 hours of uninterrupted sleep each
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
night.
B. Monitor vital signs every 2 hours.
!| !| !| !| !| !|
C. Make sure that the client takes food and medications at prescribed
!| !| !| !| !| !| !| !| !| !| !| !|
intervals.
D. Provide milk every 2 to 3 hours. - Correct answer ✔Answer: (C) Make sure
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
that the client takes food and medications at prescribed intervals.
!| !| !| !| !| !| !| !| !| !| !|
, Food and drug therapy will prevent the accumulation of hydrochloric acid,
!| !| !| !| !| !| !| !| !| !| !|
or will neutralize and buffer the acid that does accumulate.
!| !| !| !| !| !| !| !| !|
7. A male client was on warfarin (Coumadin) before admission, and has
!| !| !| !| !| !| !| !| !| !| !| !|
been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT)
!| !| !| !| !| !| !| !| !| !| !| !|
is 68 seconds. What should Nurse Carla do?
!| !| !| !| !| !| !|
A. Stop the I.V. infusion of heparin and notify the physician.
!| !| !| !| !| !| !| !| !| !|
B. Continue treatment as ordered.
!| !| !| !|
C. Expect the warfarin to increase the PTT.
!| !| !| !| !| !| !|
D. Increase the dosage, because the level is lower than normal. - Correct
!| !| !| !| !| !| !| !| !| !| !| !| !|
answer ✔Answer: (B) Continue treatment as ordered.
!| !| !| !| !| !| !|
The effects of heparin are monitored by the PTT is normally 30 to 45
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
seconds; the therapeutic level is 1.5 to 2 times the normal level.
!| !| !| !| !| !| !| !| !| !| !|
8. A client undergone ileostomy, when should the drainage appliance be
!| !| !| !| !| !| !| !| !| !| !|
applied to the stoma? !| !| !|
A. 24 hours later, when edema has subsided.
!| !| !| !| !| !| !|
B. In the operating room.
!| !| !| !|
C. After the ileostomy begin to function.
!| !| !| !| !| !|
D. When the client is able to begin self-care procedures. - Correct answer
!| !| !| !| !| !| !| !| !| !| !| !| !|
✔Answer: (B) In the operating room. !| !| !| !| !| !|
The stoma drainage bag is applied in the operating room. Drainage from the
!| !| !| !| !| !| !| !| !| !| !| !| !|
ileostomy contains secretions that are rich in digestive enzymes and highly
!| !| !| !| !| !| !| !| !| !| !|
irritating to the skin. Protection of the skin from the effects of these enzymes
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
