HESI MedicalSurgical LPN -EXAM PACK BEST FOR 2022 EXAM

S - The Marketplace to Buy and Sell your Study Material HESI Medical- Surgical LPN -EXAM PACK BEST FOR 2022 EXAM Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Question 1 The nurse is providing care for a patient who is unhappy with the health care provider’s care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. What should the nurse include in the documentation of this event in the patient’s medical record or on the AMA form? 1. Documentation that the patient was informed that he or she cannot come back to the hospital 2. Documentation that thepatient was informed that he or she was leaving against medical advice 3. Documentation that therisks of leaving against medical advice were explained to the patient 4. Documentation of any discharge instructions given to the patient 5. Documentation indicating an incident reporthas been completed Correct Answer: 2,3,4 Rationale 1: It should be clearly documented that the patient was advised and understands that he or she can come back. Rationale 2: It should be clearly documented in the patient’s record andon the AMA form that the patient was advised that he or she was leaving against medical advice. Rationale 3: It should be clearly documented that the patient understands the risks of leaving against medical advice. Rationale 4: The AMA form includes the name of the person accompanying the patient and any discharge instructions given. Rationale 5: Facility policy may require that an incident report be completed, but it must not be referenced in the chart. The patient’s record is a legal document, so the nurse should never document that he or she filed an incident report. Question 2 A nurse documents this statement in a patient’s medical record: “2/25/–, 2235. At 2015 patient awoke suddenlyand complained of shortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard.” This documentation meets which documentation guidelines? Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 1. Documentation is timely 2. Documentation is concise 3. Documentation is objective 4. Documentation includes date and time of entry 5. Documentationiscomplete and accurate Correct Answer: 2,3,4,5 Rationale 1: The nurse should document as soon as possible after an observation is made or care is provided. The entry was made in the patient’s medical record at least 2 hours after the patient complaint and should be labeled late entry. Rationale 2: This entry describes the situation fully but is concise. Rationale 3: The nurse describes factual events that can be seen, heard, smelled, or touched. It is important to be objective and avoid vague statements that are subjective. Rationale 4: Both the date and the time of the entry are documented. Rationale 5: The nurse should document only facts: what he or she can see, hear, and do. Question 3 A nurse documents the following in a patient’s medical record: “2/1/ , 1500. Patient appears weak and faint. Patient’s skin is moist and cool, vomited bright red blood with clots. Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0.Pain medication will be given.” This documentation meets which documentation principle? 1. Documentobjectively. 2. Do not document procedures in advance. 3. Useapproved abbreviations. 4. Document changes inpatientcondition. Correct Answer: 4 Rationale 1: Documentation should be objective and avoid vague statements that are subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be described. The use of the word “appears” is subjective and could be manipulated later should the treatment or judgment be challenged. Rationale 2: The nurse has documented that pain medication will be given. This is documenting in advance. Rationale 3: The Joint Commission has designated the inappropriateness of “u” as an abbreviation. “U” should bewritten out as “unit(s).” If unsure whether the abbreviation is Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material correct, the nurse should spell out the word; “<” can be misinterpreted, so it should be spelled out as “less than.” Rationale 4: Ingeneral, employers as well as state, federal, and professional standards require documentation to include initial and ongoing assessments, any change in the patient’s condition, therapies given andpatient response,patient teaching, and relevant statements by the patient. Question 4 A nursing unit has changed its documentation system to documenting byexception. How will this system save time? 1. It eliminates lengthy or repetitivedocumentation. 2. It allowsflexibility and description in the documentation. 3. It allowsthe reader to easily locate information about aspecific problem. 4. It allows for quick and easy retrieval of information. Correct Answer: 1 Rationale 1: Documenting by exception eliminates lengthy or repetitive documentation. Rationale 2: Flexible and descriptive documentation is an advantage of the narrative system. Rationale 3: PIE charting allows easy location of information about a specific problem. Rationale 4: The electronic health record allowsfor quick and easy retrieval of information. Question 5 A hospital is considering changing its documentation system to reduce thenumber of medication errors. Which system should the hospital investigate? 1. Problem,intervention, evaluation (PIE)system 2. Electronic medical record 3. Problem-oriented medical record 4. Narrative system Correct Answer: 2 Rationale 1: The PIE system consists of alist of the patient’s problems, interventions taken to alleviate the problems, and evaluation of the patient’s response to the interventions. This system does not have the specific benefit of reducing medication errors. Rationale 2: The electronic medical record decreases errorsand allows for the reconciliation of the patient’s medications on admission, daily, and on discharge. Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 3: The five components of the problem-oriented medical record are baseline data, a problem list, a plan of care for each problem, multidisciplinary progress notes, and a discharge summary. This system does not have the specific benefit of reducing medication errors. Rationale 4: Narrative documentation does not have the specific benefit of reducing medication errors. Question 6 Which nursing activities are examples of independent functions of thenursing role? 1. Teaching asoon-to-be-discharged patient about the medication regimen that thehealth care provider has prescribed 2. Talking with the patient about his or her abilitiesto manage personal hygiene activities while in the usual state of health at home 3. Incorporating adaptive techniques into nursing care as recommended byoccupational therapy 4. Administering analgesic medication ordered bythe health care provider 5. Introducing oneself to, and interviewing, the patient to collect data about physical health status Correct Answer: 2,5 Rationale 1: Teaching the patient about medications prescribed bythehealth care provider is an interdependent activity. Rationale 2: This activity is part of the assessment process, which is an independent activity that nurses may perform, based on their education and skills. Rationale 3: Working in coordination with another health team member is an interdependent activity. Rationale 4: Administering medication prescribed by the health care provider is an example of a dependent activity. Rationale 5: These activities are included in assessment, which is an independent activity that nurses may perform, based on their education and skills. Question 7 The nurse is caring for a 70-year-old patient who was just admitted to an inpatient rehabilitation center. The patient had required total parenteral nutrition for several days, but recently resumed and is tolerating a regular diet. She has another 4 days left in a course of intravenous antibiotics to complete treatment ofa positive central line culture. Which nursing action, required in the care of this patient, is considered a dependent role function? Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 1. Requesting that the health care provider order aconsult because the patient states that her dentures no longer fit properly and she has trouble chewing 2. Asking the nursing assistant to demonstrate to the patient how to operate the call system 3. Interviewing the patient to assess whether she needs assistance with getting out of bed 4. Administering the antibiotics prescribed bythe health care provider Correct Answer: 4 Rationale 1: Assessing that the patient has a need that requires further assessment by other team members and communicating that need to the appropriate team member is an example of an interdependent activity. Rationale 2: This is an independent activity that nurses may perform or delegate, based on their and the delegate’s education and skills. Rationale 3: Assessment is an independent activity that nurses may perform, based on their education and skills. Rationale 4: Dependent activities are those prescribed by the health care provider and carried out by the nurse. Question 8 When asking a patient if a pain medication provided a few hours ago has been effective, the nurse is performing which step of the nursing process? 1. Planning 2. Implementation 3. Evaluation 4. Assessment Correct Answer: 3 Rationale 1: Planning consists of prioritizing among the chosen nursing diagnoses and determining interventions to move the patient to optimal health. Rationale 2: Implementation is the actual“doing” step of the nursing process. In this case, implementation occurred when the medication was administered. Rationale 3: Evaluation focuses ona patient’sbehavioral changes and compares them with the criteria stated in the objectives. It consists of both the patient’s status and the effectiveness of the nursing care. Both must be evaluated continuously, with the care plan modified as needed. Rationale 4: Assessment comprises examining the patient and identifying cues, collecting and analyzing data, and reaching conclusions. In this situation, assessment occurred when the nurse identified that the patient was in pain. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Question 9 The nursing instructor knows that further education is needed when astudent makes which statement? 1. “Assessmentprecedes nursing diagnosis andoutcome identification.” 2. “Planning follows nursing diagnosis and outcome identification and precedes implementation.” 3. “Evaluationfollows implementation and precedes planning.” 4. “Planningfollows assessment and precedes evaluation.” Correct Answer: 3 Rationale 1: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Rationale 2: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Rationale 3: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Rationale 4: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Question 10 A 16-year-old patient has been admitted for treatment of presumptive pelvic inflammatory disease. The patient’s hygiene is poor and she reports living “on the street” for a year. She is febrile and tachycardic and reports pain as 10 onthe 1-to-10 scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome statement is appropriate? 1. The patient’s comfort will be achieved and maintained. 2. The patient will be discharged to a safe living environment. 3. The patient will be reunited with her parents. 4. Thepatient’sinfection willbe eradicated. Correct Answer: 1 Rationale 1: Achieving and maintaining comfortaddresses the nursing diagnosis of acute pain related to possible pelvic inflammatory disease identified by the nurse. Rationale 2: The patient’s living environment is of concern but is not the correct outcome for the priority nursing diagnosis. Rationale 3: Reuniting the patient with her parents may not be a desired goal for this patient. It also does not match the nursing diagnosis chosen. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 4: Eradication of the infection is a desired outcome but does not match the chosen nursing diagnosis. Question 11 While assessing a female patient from the Middle East, the nurse observes that the patient makes no eye contact and answers questions by nodding or with only a few words. The nurse’s entry inthe patient’s record states that the patient “appears tobefrightened.” This isan example of which factor associated with assessment? 1. Personalinterpretation 2. Subjective data 3. Nursing diagnosis 4. Objective data Correct Answer: 1 Rationale 1: This is the nurse’s personal interpretation of the patient’s behavior. It has not been validated with the patient. These behaviorsmay indicate a number of possibilities such as physical, mental, and emotional status or cultural and social norms. Rationale 2: A direct quote from the patient would be subjective data. Rationale 3: This statement does not meet the criteria for anursing diagnosis. Rationale 4: A description of the patient’s behavior such as “makes no eye contact” would be objective data. Question 12 The patient tells the nurse that everything “tastes funny” since starting a new medication, making eating unpleasant. The nurse has given this medication to other patients and has not heard this complaint from any of them. The nurse checks the drug reference again to learn whether this is a known side effect of the medication and reads that it is. This information may be helpful in making a nursing diagnosis and determining how best to address this problem. Which data from this scenario is considered subjective? 1. The nurse rechecks the drug reference about known side effects of the medication. 2. The patienttells thenurse that everything “tastes funny.” 3. The nurse reads that this medication can cause a metallic taste in some patients. 4. Other patients who have taken this medication havenever reported this side effect to the nurse. Correct Answer: 2 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 1: Rechecking the drug reference is anexample of obtaining factual information about the medication, not data about the patient. Rationale 2: The statement bythe patient is subjective data because it reflects somethingthat only the patient, not the nurse, can perceive. Rationale 3: That this medication can cause a metallic taste is factual information about the medication, not data about the patient. Rationale 4: The nurse’s prior experience with this medication is not data about the patient. Question 13 Which statement represents anursing diagnosis? 1. High riskfor delayed maternal-infant bonding due to maternal-infant separation 2. Crohn’s disease 3. Hypertension 4. Appendicitis Correct Answer: 1 Rationale 1: This is an example of a nursing diagnosis. The statement indicates a clinical judgment that this new mother-baby couplet is at greater risk of experiencing a delay in bonding than other mother-baby couplets. Rationale 2: Crohn’s disease is a medical diagnosis. Rationale 3: Hypertension is acollaborative problem. Rationale 4: Appendicitis is a medical diagnosis. Question 14 Whichstatementsreflect collaborative problems? 1. Knowledge deficit related to infant safety as evidenced bymother leaving crib rail down 2. Sleep apnea 3. Neonatal abstinence syndrome 4. Gestational diabetes 5. Sleep pattern disturbance related tohospital environment androutines Correct Answer: 2,3,4 Rationale 1: The nurse can diagnose this knowledge deficit and use independent nursing interventions to address the problem. This is a nursing diagnosis. Rationale 2: Sleep apnea is a medical diagnosis and therefore a collaborative problem. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 3: Neonatal abstinence syndrome is amedical diagnosis and therefore a collaborative problem. Rationale 4: Gestational diabetes is amedical diagnosis andtherefore a collaborative problem. Rationale 5: The nurse can diagnose that a patient has disturbed sleep and can intervene to reduce noise and other disturbances in the environment. This is a nursing diagnosis. Question 15 The nurse is using critical thinking to better understand apatient. The nurse is working in which part of the nursing process? 1. Implementation 2. Nursing diagnosis and outcome identification 3. Assessment 4. Planning Correct Answer: 3 Rationale 1: Using critical thinking to reduce the risk of undesirable results is part of implementation. Rationale 2: Using critical thinking to identify actual and potential problems is associated with the diagnostic step of the nursing process. Rationale 3: The goal ofassessment is to learn as much as possible about the patient within the context of the nurse-patient relationship. One characteristic of the nurse-patient relationship is the nurse’s continuous focus on better understanding of the patient. Rationale 4: Using critical thinking to make decisions about an action is associated with planning. Question 16 Which aspect of critical thinking would the nurseuse when making a nursing diagnosis? 1. Making decisions about an action 2. Identifying potential and actual problems 3. Increasing the likelihood of obtaining good results 4. Getting abetter understanding of someone else Correct Answer: 2 Rationale 1: Making decisions about an action is associated with planning. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 2: Identifying potential and actual problems is analogous to identifying nursing diagnoses, potential and actual. Rationale 3: Increasing the likelihood of obtaining good results is relatedto evaluation. Rationale 4: Getting a better understanding of someone else is related toassessment. Question 17 Critical thinking empowers the nurse to recognize important situational cues and respond quickly to adapt interventions, optimizing their effectiveness and the likelihood of a good outcome. What is true about this aspect of critical thinking? 1. This method of thinking is similar to the way that a skilled nurse uses continued assessment and evaluation to adapt the patient’s care plan. 2. Using this method of critical thinking produces only one correct solution to a problem. 3. The need to change the plan of care indicates that critical thinking and the nursing process are not compatible. 4. The statement proves that critical thinking is another term for the nursing process. Rationale 1: The nurse uses critical thinking to continually assess the patient and evaluate response to interventions, then making changes to the plan of care to improve outcomes. Rationale 2: Critical thinking does not imply that there is only one correct answer to a problem; rather it demands that the nurse looks at information related to the question from many different viewpoints to identify the next step. Rationale 3: Thinking critically about patient response to interventions encourages the nurse to change portions of the care plan that are not effective. Rationale 4: Critical thinking and the nursing process are not synonymous; critical thinking enhances and complements the nursing process but is not identical to it. Question 18 The nurse is using the Kardex to plan a patient’s care. What information would the nurse expect to find in this document? 1. Nursing notes from the previous shift 2. Schedule of diagnostic tests 3. Level of activity 4. Diet 5. IV therapy Correct Answer: 2,3,4,5 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 1: Nursing notes are not found on the Kardex. Rationale 2: The patient’s schedule for diagnostic testing is recorded on the Kardex. Rationale 3: The patient’s level of activity is recorded on the Kardex. Rationale 4: The diet prescribed for the patient is recorded on the Kardex. Rationale 5: The fluid, additives, and rate of IV therapy are recorded on the Kardex. Question 19 Accordingtothe Health Insurance Portability andAccountability Act (HIPAA), which persons have legal access to the patient’s health record? 1. The patient 2. Any nurses working on the unit where the patient is hospitalized 3. Any physician who has credentials to admit patients to the hospital 4. The respiratory therapist who isproviding inhalation therapy for the patient 5. The nuclear medicine technician who providedcare during the patient’s last hospitalization Correct Answer: 1,4 Rationale 1: The information in the record belongs to the patient, who has the legal right to review it at any time. Rationale 2: The only nurses who have the legal right to review the record are the nurses involved with the patient’s care. Rationale 3: The only physicians who have the legal right to review the record are the physicians involved in the patient’s care. Rationale 4: The respiratory therapist who is involved in the patient’s care has the legal right to review the patient’s chart. Rationale 5: If the technician is not involved in caring for the patient on this admission, he or she has no legal right to review the chart. Question 20 During a routine breast examination of a patient, the nurse notes a small amount of nipple discharge. What nursing actions are indicated? 1. Tellthepatient shemayhavecancer. 2. Send the specimen to the lab. 3. Ask the patient if she has noticed discharge before. 4. Collect a specimen on a slide. 5. Document the finding. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Correct Answer: 2,3,4,5 Rationale 1: Telling the patient she has cancer is inappropriate; discharge is not always a sign of cancer. Rationale 2: The nipple drainage would be sent to the lab for analysis. Rationale 3: The nurse would question if this discharge has occurred before and when it began. Rationale 4: The drainage should be collected on a specimen slide. Rationale 5: The nurse would document the finding so that future comparisons can be made if the drainage continues. Question 21 During a routine pelvic examination, the nurse instructs the patient to bear down. The nurse explains that this motion makes it easier to assess for which conditions? 1. Rectoceles 2. Prolapsed uterus 3. Vaginal tumors 4. Ovarian cysts 5. Cystoceles Correct Answer: 1,2,5 Rationale 1: Rectocele, or relaxation ofthe posterior vaginal wall over therectum, is assessed by asking the patient to bear down so that the health care provider can determine the presence of the structures through the vagina. Rationale 2: Prolapsed uterus, or the protrusion of the uterus into the vaginal wall, is assessed by asking the patient to bear down so that the health care provider can determine the presence of the structures through the vagina. Rationale 3: Vaginal tumors may be detected by visual inspection of thepelvis through a speculum device. Rationale 4: Ovarian cysts are palpated manually, and the patient does not have to bear down to determine their presence. Rationale 5: Cystocele, or relaxation of the anterior vaginal wall under the urinary bladder, is assessed by asking the patient to bear down so that the health care provider can determine the presence of the structures through the vagina. Question 22 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material The nurse is instructing a female patient about changes in sexual functioning that may result from the aging process. Which nursing diagnoses would the nurse incorporate into the plan of care for this patient regarding sexual intercourse? 1. Risk for Injury 2. Risk for Infection 3. Impaired Skin Integrity 4. AlteredTissue Perfusion 5. Alteration in Comfort Correct Answer: 1,2,3,5 Rationale 1: The patient could be at risk of injury due to thinning vaginal tissues. Rationale 2: With intercourse, the vaginal tissuemay tear, and infection of the disrupted tissue could result. Rationale 3: Impaired Skin Integrity may result because of the thinning of the vaginal mucosa and loss of adipose tissue. Rationale 4: The aging process does not reduce the perfusion of the vaginal mucosa. Rationale 5: Intercourse may be painful because of the estrogen loss and drying of the vaginal mucosa. Question 23 A female patient who is experiencing hot flashes during menopause asks the nurse how long they will last. Which information should the nurse provide? 1. Hot flashes do not occur after the first year of menopause. 2. Hot flashes usually occur once a month. 3. The patient may have hot flashes for up to 5 years. 4. Hot flashes generally disappear after thefirst 2 years of menopause. Correct Answer: 3 Rationale 1: Hot flashes are unpredictable and may last longer than 1 year. Rationale 2: There is no indication that hot flashes occur only once a month. Rationale 3: Hot flashes are unpredictable and may last up to 5 years, especially if the patient is not taking hormone replacement therapy. Rationale 4: Hot flashes may last longer than 2 years. Question 24 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material A young adult male asks the nurse about the recommended frequency of testicular self-exams. How should the nurse respond? 1. “The more frequently exams are performed, the more beneficial they are.” 2. “You should havebeen taught to self-examine starting at age 12.” 3. “Not all experts believe that testicular self-examination is necessary orbeneficial for young men.” 4. “It is essential that you perform this exam each month.” Correct Answer: 3 Rationale 1: Guidelines do not indicate that testicular self-exams are beneficial the more they are performed. Rationale 2: There is no indication that a 12-year-old should be taught testicular self-examination. Rationale 3: Testicular self-exams for adolescents and young men have been shown to cause more harm than benefit, according to the United States Preventive Service Task Force (USPSTF). USPSTF guidelines state that routine exams should not be performed. Rationale 4: Not all experts believe that testicular exams are necessary for adolescents and young men. Question 25 A 20-year-old female asks the nurse when she should begin having pelvic examinations. Which question should the nurse ask before responding? 1. “Are you on any medications?” 2. “Do you have a boyfriend?” 3. “Are yousexually active?” 4. “Are you asking because you think you are pregnant?” Correct Answer: 3 Rationale 1: Asking about medications is too broad a question and does not give the nurse information about the patient’s sexual practices. Rationale 2: Having aboyfriend does not alwaysindicate sexual activity. Rationale 3: The United States Preventive Services Task Force (USPSTF) recommends that pelvic examinations begin about 3 years after theinitiation of sexual intercourse but no later than 21 years of age. Rationale 4: Pregnancy is a reason for a pelvic examination, but it is not the only reason. The nurse should also not assume that the patient may be pregnant. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Question 26 The patient asks whythe nurse is askingquestions about her mother’s obstetrical history. Which rationale for this questioning should the nurse provide? 1. “If your mother smoked while she was pregnant with you, your risk of lung cancer is higher.” 2. “Use of medications to prevent miscarriage may have an impact on yourhealth.” 3. “The government wants to know for a genetic study.” 4. “If your mother had bleeding after delivery, you should avoid aspirin if you become pregnant.” Correct Answer: 2 Rationale 1: There is no correlation between smoking during pregnancy and the development of lung cancer in the child. Rationale 2: Daughters of women who took diethylstilbesterol (DES) are at higher risk of developing cancer of the vagina and cervix. Rationale 3: This is not a reason to collect this information. Rationale 4: All pregnant women should avoid aspirin. There is no correlation between their mothers’ obstetric history and the need to avoid aspirin. Question 27 Which statement by apatient offers the nurse information about moliminal symptoms? 1. “I have headaches if I don’t eat regularly.” 2. “When I was pregnant, my feet and ankles wereswollen every day.” 3. “Mylast boyfriend gaveme hepatitis.” 4. “I get terrible cramps with myperiods.” Correct Answer: 4 Rationale 1: Headaches that occur when meals are missed may be due to hypoglycemia. This is not a moliminal symptom. Rationale 2: Swelling of the feet and ankles during pregnancy is not a moliminal symptom. Rationale 3: Hepatitis is not associated with moliminal symptoms. Rationale 4: Symptoms associated with menses are moliminal symptoms. Question 28 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material On assessment the nurse notes that a patient’s urinary opening is on the ventral side of the penis. How should the nurse document this finding? 1. Hypospadias 2. Hydrocele 3. Cryptorchidism 4. Varicocele Correct Answer: 1 Rationale 1: In hypospadias, the urinary opening is on the ventral or bottom side of the penis. Rationale 2: A hydrocele is swelling due to fluid accumulation in the scrotum. Rationale 3: Cryptorchidism is the presence of an undescended testicle. Rationale 4: Varicocele is varicosities of the veins of the scrotum. Question 29 Which precautions should the nurse conducting an assessment of the reproductive system take to avoid the cremasteric reflex? 1. Ask the patient to cough during the exam for inguinal hernia. 2. Ask the patient to breathe in slowly through the nose and out through the mouth. 3. Conduct the examination in a warm room. 4. Lubricate the finger used for theprostate exam. Correct Answer: 3 Rationale 1: Coughing during the exam for inguinal hernia intensifies the bulging. This is not the cremasteric reflex. Rationale 2: Slow breathing does not eliminate the cremasteric reflex. Rationale 3: The cremasteric reflex, in which the testicles rise in the scrotum to the abdominal cavity, can be reduced by conducting the exam in a warm room. Rationale 4: The cremasteric reflex is not relatedto theprostate exam. Question 30 During assessment, thenurse notes a third nipple about 4 inches below the patient’s costal margin. What nursing action is indicated? 1. Ask the patient when this nipple appeared. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Document this normal variant. 3. Discuss the finding with the health care provider because these nipples are commonly malignant. 4. Look for additional nipples on the patient’s back. Correct Answer: 2 Rationale 1: Patients are bornwith this condition. Rationale 2: Supernumerary nipples arenormal variants but should be documented in the medical record. Rationale 3: This is a benign condition. Rationale 4: These extra nipples appear down the “milk lines” that run from the axilla across the nipple and down the abdomen to the groin. They are not found on the back. Question 31 The patient has respiratory difficulty due to changes in anatomic dead space. The nurse plans interventions based on changes in which physiological process? 1. Beginning of the gas exchange process 2. Neutralizing the air 3. Filtering the air 4. Separatingthe air Correct Answer: 3 Rationale 1: The anatomical dead space includesthe structures from the nose to the terminal bronchioles. Air flows through the anatomical dead space, but these structures do not participate in gas exchange. Rationale 2: The anatomical dead space includesthe structures from the nose to the terminal bronchioles. Air flows through this space, but it is not neutralized. Rationale 3: The tracheais part of the anatomical dead space. It traps particulate matter to keep it from entering the lungs. Rationale 4: The anatomical dead space includesthe structures from the nose to the terminal bronchioles. The air is not separated in these structures. Question 32 During an assessment, a patient begins to cough. How would the nurse evaluate this finding? 1. The patient has a cold. 2. The patient is nervous. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Something other than air was entering the larynx. 4. The patient is not fully conscious. Correct Answer: 3 Rationale 1: A cough does not indicate the presence of a cold. Additional assessment would be necessary. Rationale 2: A cough is not sufficient assessment data to determine that apatient is nervous. Rationale 3: If anything other than air enters the larynx, a cough reflex expels the foreign substance before it can enter the lungs. Rationale 4: The protective reflex of coughing may not be present if the person is unconscious. A cough is not enough data to determine level of consciousness. Question 33 A patient is diagnosed with a low iron count. The nurse would be alert for which finding associated with this condition? 1. Increased carbon dioxide in the blood 2. Nausea 3. Anxiety 4. Poortissueoxygenation Correct Answer: 4 Rationale 1: Low iron would not increase carbon dioxide levels in the blood. Rationale 2: Nausea is not generally associated with low iron count. Rationale 3: Anxiety is not generally associatedwith low iron count. Rationale 4: Oxygen is carried in the blood either bound to hemoglobin or dissolved in the plasma. Oxygen is not very soluble in water, so almost all oxygen that enters the blood from the respiratory system is carried to the cells of the body by hemoglobin. Question 34 During the palpation of a patient’s chest for expansion, the nurse notices a decrease in expansion of the right side. This finding is consistent with which condition? 1. Emphysema 2. Pneumothorax 3. Flail chest 4. Heart failure Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 5. Influenza Correct Answer: 2,3 Rationale 1: Bilateral chest expansion is decreased in emphysema. Rationale 2: Thoracic expansion is altered on the affected side in patients with pneumothorax. Rationale 3: One side of the chest would not expand at the correct time if the patient has a flail chest. Rationale 4: Heart failure does not result in a change in chest expansion. Rationale 5: Thoracic expansion is not affected by influenza. Question 35 The nurse is preparing to auscultate a patient’s lungs. Which breath sounds would the nurse consider abnormal? 1. Crackles 2. Vesicular breath sounds 3. Bronchovesicular breath sounds 4. Wheezes 5. Bronchialbreath sounds Correct Answer: 1,4 Rationale 1: Crackles are caused by airways that collapse during expiration and “pop” open during inspiration or byair bubbles passing through fluid. They are not normal breath sounds. Rationale 2: Vesicular breath sounds are the soft, low-pitched soundsheard over the majority of lung fields. They are normal. Rationale 3: Bronchovesicular breath sounds represent air movement in the moderate airways between the main bronchi and smaller airways. They are normal breath sounds. Rationale 4: Wheezes are continuous musical sounds caused by air flowing across airways that are narrowed or obstructed. They are abnormal breath sounds. Rationale 5: Bronchial breath sounds are heard over the major airways and are normal. Question 36 During a bronchoscopy, the nurse is to initially give 1.5 mg of midazolam hydrochloride (Versed) and another 1.5 mg of Versed in 2 minutes. Based on a concentration of 5 mg/mL, the nurse will draw up a total of mL for the two doses. Correct Answer: 0.6 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale : 0.3 mL is to be given for the initial dose and another 0.3 mL in 2 minutes. 0.3 x 2 = 0.6 mL Question 37 A patient has these arterial blood gas (ABG) results. In analyzing the data, the nurse recognizes the patient has which condition? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Correct Answer: 3 Rationale 1: The PaO2 is 75–100 mmHg, HCO3 is 24–28 mEq/L, and the base excess (BE) is + 2 mEq/L, which would not indicate metabolic acidosis. Rationale 2: The PaO2 is 75–100 mmHg, HCO3 is 24–28 mEq/L, and the base excess (BE) is + 2 mEq/L, which would not indicate metabolic alkalosis. Rationale 3: The patient is in respiratory acidosis, as the pH is decreased below normal (7.35– 7.45) and the PaCO2 is increased from normal (35–45 mmHg). Rationale 4: The PaO2 is 75–100 mmHg, HCO3 is 24–28 mEq/L, and the base excess (BE) is + 2 mEq/L, which would not indicate respiratory alkalosis. Question 38 The nurse is conducting a health history on a patient with dyspnea. Place the questions in correct sequence. Choice 1. How would you describe the dyspnea? Choice 2. What severity rating would you assign the dyspnea? Choice 3. Does the dyspnea seem to affect both lungs? Choice 4. How long does the dyspnea last? Choice 5. What makes the dyspnea better or worse? Choice 6. When did the dyspnea start? Correct Answer: 6,5,1,3,2,4 Rationale 1: This question addresses the quality (Q) component of OPQRST. Rationale 2: This question addresses the severity (S) component of OPQRST. Rationale 3: This question addresses theradiation (R) component of OPQRST. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 4: This question addresses the timing (T) component of OPQRST. Rationale 5: This question addresses palliating orprovoking factors(P) component of OPQRST. Rationale 6: This question addresses the onset (O) component of OPQRST. Question 39 The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle accident. What is the primary rationale for this nursing action? 1. To ease the work of breathing 2. Tocompensate for the reduction in circulating oxygen 3. Toprovidecomfort 4. Toprevent shock Correct Answer: 2 Rationale 1: Breathing might be easier, but this is an additional benefit, not the primary reason. Rationale 2: As blood volume is lost, hemoglobin is lost. Oxygen is carried from the respiratory system to the cells by hemoglobin in the blood. Rationale 3: The patient might be more comfortable, but this is an additional benefit not the primary reason. Rationale 4: The risk of shock might be decreased through oxygen administration, but this is an additional benefit not the primary reason. Question 40 The nurse anticipates that a patient with multiple fractured ribs is at risk for which condition? 1. Decreased lung expansion 2. Increasedrespiratory rate 3. Prolonged expiratory phase 4. Low arterial carbon dioxide level Correct Answer: 1 Rationale 1: Due to the rib fractures, it might be difficult for the patient to have full rib cage expansion because of the pain. Rationale 2: The respiratory rate might tend to be slower and more shallow than usual. Rationale 3: The expiratory phase might be shortened due to the pain. Rationale 4: The carbon dioxide would be high rather than low. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Question 41 A patient admitted with probable emphysema is scheduled for diagnostictests. Which test would assess the patient’s acid-base balance? 1. Bronchoscopy 2. Sputum studies 3. Pulse oximetry 4. Arterial blood gases (ABGs) Correct Answer: 4 Rationale 1: A bronchoscopy provides visualization of internal respiratory structures. Rationale 2: Sputum studies can provide specificinformation about bacterial organisms. Rationale 3: Pulse oximetry is anoninvasive test that evaluates the oxygen saturation level of blood. Rationale 4: ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. Question 42 After auscultating a patient’s chest, the nurse reports the findings to thepreceptor. Which statement would indicate the need for immediate reassessment by the preceptor? 1. “I heard coarse cracklesearlier,butnow they sound finer.” 2. “I heard wheezing earlier, but now I don’t hear it.” 3. “There are coarse crackles that clear with coughing.” 4. “Thepatient was clear, butnow there arescattered wheezes bilaterally.” Correct Answer: 2 Rationale 1: Coarse and fine are descriptors for crackles. Rationale 2: The absence of wheezing in a patient who had wheezing before may indicate impending respiratory arrest. The preceptor should reassess the patient immediately. There is also a possibility that therapy has reduced the wheezes and that no emergency exists. Rationale 3: This finding is not indicative of the need for immediate action. Rationale 4: This finding is not indicative of the need for immediate action. Question 43 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material The nurse is planning a class for unlicensed assistive personnel. Which factors should the nurse describe as causing interference with accurate pulse oximeter readings? 1. Ambient light 2. Nail polish 3. Inhalation injuries 4. Arterial pulse deficit 5. Sensor placement on the ear Correct Answer: 1,2,3,4 Rationale 1: Ambient light can cause inaccurate readings. Rationale 2: Nail polishon finger- or toenails can cause inaccurate readings. Rationale 3: Inhalation injuries can cause inaccurate readings. Rationale 4: Inadequate arterial pulses can causeinaccurate readings. Rationale 5: As long as the sensor is not placed on cartilage, the reading should be accurate. Question 44 The nurse wants to assess the apex of a patient’s right lung. In which location should the nurse place the stethoscope? 1. Intercostal space, sixth rib near the sternum 2. Intercostal space, fourth rib near the axillary line 3. Below the scapula 4. Near the right clavicle Correct Answer: 4 Rationale 1: This placement is too low. Rationale 2: This placement is too low. Rationale 3: The scapulae are located posterior to the lungs. Rationale 4: The apex of each lung lies just below the clavicle, whereas the base of each lung rests on the diaphragm. Question 45 The nurse knows that the caregiver of apatient with arespiratory illness understands discharge teaching when the caregiver makes which statement? Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 1. “I can expect to hear adventitious sounds only in the mornings; the rest of the day, breath sounds should be normal.” 2. “If I hear extra sounds during a deep breath, I know I am hearing adventitious sounds.” 3. “Adventitious sounds maybe heard during inspiration or expiration because ofsecretions or inflammation.” 4. “I will know I am hearing adventitious breath sounds if I hear any sounds when I listen over the lower chest.” Correct Answer: 3 Rationale 1: Adventitious or abnormal breath sounds may be heard at any time of day or night. Rationale 2: The patient does not need to take a deep breath for adventitious or abnormal sounds to be heard. Rationale 3: Adventitious or abnormal breath sounds maybe heard during inspiration and expiration. Rationale 4: Adventitious or abnormal breath sounds may be heard over any portion of the chest or back. Question 46 A review of a patient’s medical record reveals that the patient is using accessory muscles to aid breathing. Which muscle groups would the nurse expect to see in use? 1. Abdominals 2. Scalene 3. Brachialis 4. Trapezius 5. Sternocleidomastoid Correct Answer: 1,2,4,5 Rationale 1: Abdominal muscles are used to augment respiratory effort. Rationale 2: Scalene muscles are the muscles of the lateral neck. These muscles can be used to augment respiratory effort. Rationale 3: The brachialis muscles are in the arm and are not useful in augmenting respiratory effort. Rationale 4: The trapezius muscles of the upper back can augment respiratory effort. Rationale 5: The sternocleidomastoid muscles are in the anterior neck and are often used to augment respiratory effort. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Question 47 A patient with pneumonia is experiencing shunt ventilation. The nurse plans care for the patient based on which considerations? 1. Shunt ventilation is the normal state for a patient who has pneumonia. 2. Blood flow to the alveoli is compromised. 3. Blood is flowing past the alveoli but is not being oxygenated. 4. Ventilation is inadequate at the alveolar level. 5. Hypoxia mayoccur if the unaffected lung cannot compensate. Correct Answer: 3,4,5 Rationale 1: Shunt ventilation is not normal and the patient maydecompensate quickly. Rationale 2: In shunt ventilation, blood flow to the alveoli is normal. Rationale 3: Blood is “shunting” past the alveoli,but oxygenation is not taking place. Rationale 4: Not enough oxygen is being delivered to the alveoli, and blood is not being oxygenated. Rationale 5: As long as the unaffected lung can supply sufficient oxygen, the patient may show few ill effects from shunt ventilation. However, should the unaffected lung fail to compensate, hypoxia will occur. Question 48 The nurse had planned to conduct apatient interview regarding pulmonary history. Which patient behaviors would indicate to the nurse that this interview should be delayed? 1. The patient cannot speak in complete sentences. 2. The patient is sitting up at the bedside. 3. The patient’s respiratoryrate has increased from 14 to 20. 4. The patient has assumed a forward leaning posture, braced on the hands. 5. The patient’s arterial blood gases reveal a pH of 7.38. Correct Answer: 1,3,4 Rationale 1: The patient who cannot speak in complete sentences may be suffering from respiratory distress. Thenurse should delay the interview and should conduct further physical assessment. Rationale 2: Finding the patient sitting up at the bedside is not a reason to delay the interview unless other, more specific, assessments are also made. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 3: Anincrease in respiratoryrate may indicate respiratory distress. The nurse should delay the interview and conduct additional physical assessment. Rationale 4: This position is called the “tripod” position and is a classic maneuver to expand lung fields. The patient may be in acute respiratory distress, so the interview should be delayed. Rationale 5: This is a normal arterial blood gas reading and does not indicate respiratory compromise. Question 49 A patient from Southeast Asia presents to the clinic with complaints of shortness of breath. The patient says, “I tried to coin my wind illness, but it did not work.” Which assessment finding would the nurse expect? 1. The patient is wearing an amulet shaped like a dragon. 2. The patient has burns on the inside of the nose and mouth. 3. The patient is pale from blood loss. 4. The patient has small scrapes across the back and chest. Correct Answer: 4 Rationale 1: The patient may be wearing an amulet, but probably not to treat the illness. Rationale 2: Treating “wind illness” does not include burning the inside of the nose and mouth. Rationale 3: There is no indication that cultural treatment for “wind illness” would cause large amounts of blood loss. Rationale 4: Coining is a cultural practice that involves scraping the skin of the thorax with a coin or spoon. The scraping may leave lesions. Question 50 The patient says, “I think I am allergic to something in my house. I feel better when I am away for a few days.” What should the nurse suggest? 1. “You might want tokeep your dog outside.” 2. “You might wantto consider having allergy testing done.” 3. “You should remove dust by vacuuming your house every day and gettingrid of your drapes and decorative pillows.” 4. “You should consider having your homeprofessionally cleaned.” Correct Answer: 2 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 1: The nurse has no reason to suspect that the patient is allergic to the dog. Rationale 2: Before efforts to rid a home of allergens begin, the patient should be aware of which substances are causing symptoms. Rationale 3: The nurse does not know if the patient is allergic to dust. Rationale 4: The nurse is not aware of what or if the patient is allergic to anything in the house. Chemical cleaners can also cause allergies. Question 51 The nurse is conducting a health history interview with a patient who has severe respiratory disease. The nurse asks specific questions abouthow the patient performs oral hygiene. What is the rationale for this questioning? 1. Oralinfections can result in pulmonary infections. 2. The ability to perform good oral hygiene reflects an ability to hold one’sbreath for several seconds. 3. Respiratory illness is associated with an increased risk for dental caries. 4. People who perform good oral hygiene typically also perform good hand hygiene. Correct Answer: 1 Rationale 1: This patient is at risk for pulmonary infection. Oral infections can travel down the pulmonary tree and cause pulmonary access formation. Rationale 2: This may be accurate, but it is not the rationale for this questioning. Rationale 3: There is no indication that respiratory illness causes tooth decay. Rationale 4: There is noassociation between these two hygiene practices that would serve as a rationale for these questions. Question 52 A patient with a preexisting pulmonary illness is being seen in the clinic for a routine assessment. The patient says, “My family and I are going skiing for our next vacation.” What information should the nurse provide? 1. “Going to high altitudes is not a good idea for your health.” 2. “You should bewatchful for any respiratory problems while you arethere.” 3. “You should go to the seashore instead.” 4. “Be certain to flydirectly to the resort if possible.” Correct Answer: 2 Rationale 1: High altitudes may or may not affect the patient’s health. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 2: High altitudes may cause decompensation of respiratory status for any person, but persons with preexisting pulmonary illness are at greater risk. Rationale 3: The nurse should not tell the patient where to go on vacation. Rationale 4: There is no indication that flying directly to the resort should be recommended. Question 53 A nurse researcher is planning a study regarding occupational exposure to asbestos and the development of asbestos-related pulmonary disease. The researcher should look to workers from which occupations as commonly having this exposure? 1. Firefighters 2. Auto mechanics 3. Those involved in new home construction 4. Teachers 5. Cooks Correct Answer: 1,2 Rationale 1: Older buildings may contain significant amounts of asbestos. Firefighters may be exposed during fire events. Rationale 2: Auto mechanics may be exposed to the asbestos in vehicle brake linings. Rationale 3: Asbestoshas been removed from modern construction materials. Construction workers in new home construction would not be likely to have high exposure rates. Rationale 4: There is no reason to believe that teachers are at risk for exposure to asbestos. Rationale 5: There is no reason to believe that cooks are at high risk for exposure to asbestos. Question 54 A review of a patient’s medical record reveals a 70-pack-year smoking history. The patient says he smokes two packs of cigarettes every day. The nurse calculates that this patient has been smoking for years. Correct Answer: 35 Rationale : Pack years are figured by the number of packs a day times the years smoked. This patient has a 70-pack-year history and smokes two packs per day. He has been smoking for approximately 35 years. Question 55 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material A patient has been admitted for exacerbation of a chronic pulmonary disease. The nurse would assign the nursing diagnosis Activity Intolerance when which assessment is made? 1. The patient’s heart rate increases by 20 beats per minute when she ambulates to the bathroom in her hospital room. 2. The patient’s husband reports that she sits in a recliner chair most of theday. 3. The patient complains of cramping in her legs at night. 4. The patient’s anklesdemonstrate 3+ edema bilaterally. Correct Answer: 1 Rationale 1: Increasing heart rate on exertion is a finding associated with intolerance of activity. Rationale 2: This is not enough evidence to support activity intolerance as a nursing diagnosis. The patient may be depressed or simply desire to stay in the chair. Rationale 3: Night leg cramps may or maynot be associated with activity intolerance. Rationale 4: Ankle edema may or may not be associated with activity intolerance. Question 56 A patient is admitted after falling down a flight of stairs. The nurse notes that thepatient’s larynx is slightly left of center. The nurse should assess for which conditions? 1. Right heart failure 2. Left hemothorax 3. Right pneumothorax 4. Right hemothorax 5. Central pneumothorax Correct Answer: 3,4 Rationale 1: Tracheal deviation does not indicateright heartfailure. Rationale 2: Left hemothorax is not occurring in this case. Rationale 3: Collection of fluid or air in the right chest cavity results in tracheal deviation to the left. Rationale 4: Collection of fluid or air in the right chest cavity results in tracheal deviation to the left. Rationale 5: Pneumothorax is classified as right or left, not central. Question 57 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material The nurse is assessing a patient for pedal edema. If using the correct technique, the nurse will depress the tissue for seconds. Correct Answer: 5 Rationale : To assess edema and to elicit pitting edema, the nurse would depress the tissue of the ankle for 5 seconds. Question 58 To establish the location of arespiratory sound, the nurse uses standard landmarks. The nurse locates the second rib as adjacent to which structure? 1. Supersternal notch 2. Sternal angle 3. Costal margin 4. Xiphoidprocess Correct Answer: 2 Rationale 1: The second rib is below this area. Rationale 2: The rib that is adjacent to the sternal angle is the second rib. Rationale 3: The costal margin is the bottom of the rib cage. Rationale 4: The xiphoid process is the distal end of the sternum and is closest to the seventh rib. Question 59 During auscultation of the thorax, the nurse hears alow-pitched creaking sound. What should be the nurse’s next action? 1. Have the patient cough to attempt to clear the sound. 2. Have the patient turn to the left side. 3. Collaboratewith the physician regarding achestX-ray. 4. Ask the patient to hold her breath. Correct Answer: 4 Rationale 1: Crackles may clear with coughing, but this description does not match that of crackles. Rationale 2: Positioning the patient will not change this assessment finding. Rationale 3: An X-ray will likely be ordered, but this is not the first action indicated. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 4: This assessment represents a rub. The next assessment step is to differentiate pleural rub from cardiac rub by asking the patient to hold the breath. If the sound disappears, it is a cardiac rub. Question 60 A parent has just started using a“red, yellow, green” peak flow meter tomonitor his young son’s pulmonary disease at home. The parent calls the clinic and reports that the last two results have been in the red zone. What advice should the nurse offer this parent? 1. “Rinse the meter out with warm salt water and repeat the test.” 2. “Bring your son and the meter to the clinic for evaluation.” 3. “Don’t bother using the meter until I can check your technique at next week’s appointment.” 4. “These are the results we hope to see, so it sounds like you are doing a good job managing your son’s illness.” Correct Answer: 2 Rationale 1: There is no indication that the meter needs any type of maintenance. Rationale 2: Two red readings may indicate respiratory complications. The patient should be evaluated. The nurse should also have the parent bring in the meter so his or her technique can be evaluated. Rationale 3: The parent’s technique may be wrong, but the patient may be experiencing significant respiratory changes. Assessment cannot wait until next week. Rationale4: Redreadings indicate potential respiratory complications. Question 61 A 40-year-old male has reported to the clinic with complaints of impotence. The nurse is reviewing the patient’s health history. Which statements by the patient warrant further investigation? 1. “I takemedications to control myblood pressure.” 2. “I had the mumps when I was a boy.” 3. “I had avasectomy 4 years ago.” 4. “I havehad diabetes for several years.” 5. “Mywife has a history ofcervical cancer.” Correct Answer: 1,4 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 1: Certain antihypertensive drugs may cause impotence. Rationale 2: The mumpsare arisk factor for male infertility, not impotence. Rationale 3: A vasectomy results in sterility, not impotence. Rationale 4: Diabetes mellitus over time may result in vascular damage, leading to impotence. Rationale 5: The presence of cervical cancer in a partner is not linked to impotence. Question 62 The nurse is preparing to obtain a sexual history from a male patient. Which question is of the highest importance in this assessment? 1. “Do you engage in same-sex activity?” 2. “Do you have sex frequently?” 3. “Do you enjoy sexual intercourse?” 4. “Do you engage in masturbation?” Correct Answer: 1 Rationale 1: Assessingfor therisk of sexually transmitted infections and preventing sexually transmitted infections are a priority for this patient. Sexual intercourse with same-sex partnersfurther increases the risk for HIV infection. Determination of same-sex activity by a man is key in assessing risk factors. Rationale 2: The frequency of sexual intercourse is part of the data collection but does not have the same importance as the determination of risk factors. Rationale 3: The enjoyment of sexual intercourse is part of the data collection but does not have the same importance as the determination of risk factors. Rationale 4: Masturbation may be included in the data collection, but it is not as important as the assessment of risk factors. Question 63 The nurse is providing instruction to apatient who has been diagnosed with prostate cancer. Which statement by the patient would indicate understanding of the nurse’s instruction? 1. “The prostate gland is where sperm are formed.” 2. “The prostate gland is located at the neck of my bladder.” 3. “Theprostate gland produces semen.” 4. “The prostate gland is normally very small, only about a quarter of an inch long.” Correct Answer: 2 Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material Rationale 1: Sperm are formed in the testes. Rationale 2: The prostate gland islocated at thebladder neck. Rationale 3: Semen is produced by seminal vesicles. Rationale 4: The normal size of the prostate gland is about 2.5 cm or about 1 inch.