NURSING MISC NCSBN ON-LINE REVIEW
x x x x
1.Axclientxhasxbeenxhospitalizedxafterxanxautomobilexaccident.xAxfullxlegxcastxwasxappliedxinxthexem
ergencyxroom.xxThexmostximportantxreasonxforxthexnursextoxelevatexthexcastedxlegxisxto
A) Promotexthexclient'sxcomfort
B) Reducexthexdryingxtime
C) DecreasexirritationxtoxthexskinxxxxxxxxxxxxxxxxxD)xxImprovexvenousxreturn
D:xImprovexvenousxreturn.xElevatingxthexlegxbothximprovesxvenousxreturnxandxreducesxswellin
g.xxClientxcomfortxxwillxbeximprovedxasxwell.x
2. Thexnursexisxreviewingxwithxaxclientxhowxtoxcollectxaxcleanxcatchxurinexspecimen.xWhatxisxthexa
ppropriatexsequencextoxteachxthexclient?
A) Cleanxthexmeatus,xbeginxvoiding,xthenxcatchxurinexstream
B) Voidxaxlittle,xcleanxthexmeatus,xthenxcollectxspecimen
C) Cleanxthexmeatus,xthenxurinatexintoxcontainer
D) Voidxcontinuouslyxandxcatchxsomexofxthexurine
A:xCleanxthexmeatus,xbeginxvoiding,xthenxcatchxurinexstream.xAxcleanxcatchxurinexisxdifficultxtox
obtainxandxrequiresxclearxdirections.xInstructingxthexclientxtoxcarefullyxcleanxthexmeatus,xthenxv
oidxnaturallyxwithxaxsteadyxstreamxpreventsxsurfacexbacteriaxfromxcontaminatingxthexurinexspec
imen.xAsxstartingxandxstoppingxflowxcanxbexdifficult,xoncexthexclientxbeginsxvoidingxit’sxbestxtoxj
ustxslipxthexcontainerxintoxthexstream.xOtherxresponsesxdoxnotxreflectxcorrectxtechnique
3. Followingxchange-of-
shiftxreportxonxanxorthopedicxunit,xwhichxclientxshouldxthexnursexseexfirst?
A) 16xyear-oldxwhoxhadxanxopenxreductionxofxaxfracturedxwristx10xhoursxago
B) 20xyear-oldxinxskeletalxtractionxforx2xweeksxsincexaxmotorxcyclexaccident
C) 72xyear-oldxrecoveringxfromxsurgeryxafterxaxhipxreplacementx2xhoursxago
D) 75xyear-oldxwhoxisxinxskinxtractionxpriorxtoxplannedxhipxpinningxsurgery.
C:xxxLookxforxthexclientxwhoxhasxthexmostximminentxrisksxandxacutexvulnerability.xThexclientxwh
oxreturnedxfromxsurgeryx2xhoursxagoxisxatxriskxforxlifexthreateningxhemorrhagexandxshouldxbexse
enxfirst.xThex16xyear-oldxshouldxbexseenxnextxbecausexitxisxstillxthexfirstxpost-
opxday.xThex75xyear-oldxisxpotentiallyxvulnerablextoxage-
relatedxphysicalxandxcognitivexconsequencesxinxskinxtractionxshouldxbexseenxnext.xThexclientxw
hoxcanxsafelyxbexseenxlastxisxthex20xyear-oldxwhoxisx2xweeksxpost-injury.
4. AxclientxwithxGuillainxBarrexisxinxaxnonresponsivexstate,xyetxvitalxsignsxarexstablexandxbreathingx
isxindependent.xWhatxshouldxthexnursexdocumentxtoxmostxaccuratelyxdescribexthexclient'sxcondit
ion?
A) Comatose,xbreathingxunlabored
B) GlascowxComaxScalex8,xrespirationsxregular
C) Appearsxtoxbexsleeping,xvitalxsignsxstable
D) GlascowxComaxScalex13,xnoxventilatorxrequired
B:xGlascowxComaxScalex8,xrespirationsxregular.xThexGlascowxComaxScalexprovidesxaxstandardx
referencexforxassessingxorxmonitoringxlevelxofxconsciousness.xAnyxscorexlessxthanx13xindicatesx
axneurologicalximpairment.xUsingxthextermxcomatosexprovidesxtooxmuchxroomxforxinterpretatio
nxandxisxnotxveryxprecise.
5. Whenxcaringxforxaxclientxreceivingxwarfarinxsodiumx(Coumadin),xwhichxlabxtestxwouldxthexnurs
, A) Bleedingxtime
B) Coagulationxtime
C) Prothrombinxtime
D) Partialxthromboplastinxtime
C:xProthrombinxtime.xCoumadinxisxorderedxdaily,xbasedxonxthexclient''sxprothrombinxtimex(PT).
xThisxtestxevaluatesxthexadequacyxofxthexextrinsicxsystemxandxcommonxpathwayxinxthexclottingxc
ascade;xCoumadinxaffectsxthexVitaminxKxdependentxclottingxfactors.
6.Axclientxwithxmoderatexpersistentxasthmaxisxadmittedxforxaxminorxsurgicalxprocedure.xOnxadmissi
onxthexpeakxflowxmeterxisxmeasuredxatx480xliters/minute.xPost-
operativelyxthexclientxisxcomplainingxofxchestxtightness.xThexpeakxflowxhasxdroppedxtox200xliter
s/minute.xWhatxshouldxthexnursexdoxfirst?
A) Notifyxbothxthexsurgeonxandxprovider
B) Administerxthexprnxdosexofxalbuterol
C) Applyxoxygenxatx2xlitersxperxnasalxcannula
D) Repeatxthexpeakxflowxreadingxinx30xminutes
B:xAdministerxthexprnxdosexofxalbuterol.xPeakxflowxmonitoringxduringxexacerbationsxofxasthmax
isxrecommendedxforxclientsxwithxmoderate-to-
severexpersistentxasthmaxtoxdeterminexthexseverityxofxthexexacerbationxandxtoxguidexthextreatme
nt.xAxpeakxflowxreadingxofxlessxthanx50%xofxthexclient''sxbaselinexreadingxisxaxmedicalxalertxcond
itionxandxaxshort-actingxbeta-agonistxmustxbextakenximmediately.
7.Axclientxhadx20xmgxofxLasixx(furosemide)xPOxatx10xAM.xWhichxwouldxbexessentialxforxthexnursext
oxincludexatxthexchangexofxshiftxreport?
A) Thexclientxlostx2xpoundsxinx24xhours
B) Thexclient’sxpotassiumxlevelxisx4xmEq/liter.
C) Thexclient’sxurinexoutputxwasx1500xccxinx5xhours
D) ThexclientxisxtoxreceivexanotherxdosexofxLasixxatx10xPM
C:xThexclient’sxurinexoutputxwasx1500xccxinx5xhours.xAlthoughxallxofxthesexmayxbexcorrectxinfor
mationxtoxincludexinxreport,xthexessentialxpiecexwouldxbexthexurinexoutput.
8.AxclientxhasxbeenxtentativelyxdiagnosedxwithxGraves'xdiseasex(hyperthyroidism).xWhichxofxthesex
findingsxnotedxonxthexinitialxnursingxassessmentxrequiresxquickxinterventionxbyxthexnurse?
A) axreportxofx10xpoundsxweightxlossxinxthexlastxmonth
B) axcommentxbyxthexclientx"Ixjustxcan'txsitxstill."
C) thexappearancexofxeyeballsxthatxappearxtox"pop"xoutxofxthexclient'sxeyexsockets
D) axreportxofxthexsuddenxonsetxofxirritabilityxinxthexpastx2xweeks
C:xthexappearancexofxeyeballsxthatxappearxtox"pop"xoutxofxthexclient''sxeyexsockets.xExophthalm
osxorxprotrudingxeyeballsxisxaxdistinctivexcharacteristicxofxGraves''xDisease.xItxcanxresultxinxcorn
ealxabrasionsxwithxseverexeyexpainxorxdamagexwhenxthexeyelidxisxunablextoxblinkxdownxoverxthex
protrudingxeyeball.xEyexdropsxorxointmentxmayxbexneeded.
9.xThexnursexhasxperformedxthexinitialxassessmentsxofx4xclientsxadmittedxwithxanxacutexepisodexofxas
thma.xWhichxassessmentxfindingxwouldxcausexthexnursextoxcallxthexproviderximmediately?
A) prolongedxinspirationxwithxeachxbreath
, C) expectorationxofxlargexamountsxofxpurulentxmucous
D) appearancexofxthexusexofxabdominalxmusclesxforxbreathing
B:xexpiratoryxwheezesxthatxarexsuddenlyxabsentxinx1xlobe.xAcutexasthmaxisxcharacterizedxbyxexp
iratoryxwheezesxcausedxbyxobstructionxofxthexairways.xWheezesxarexaxhighxpitchedxmusicalxsou
ndsxproducedxbyxairxmovingxthroughxnarrowedxairways.xClientsxoftenxassociatexwheezesxwithxt
hexfeelingxofxtightnessxinxthexchest.xHowever,xsuddenxcessationxofxwheezingxisxanxominousxorxb
adxsignxthatxindicatesxanxemergencyx--xthexsmallxairwaysxarexnowxcollapsed.
10.Duringxthexinitialxhomexvisit,xaxnursexisxdiscussingxthexcarexofxaxclientxnewlyxdiagnosedxwithxAlz
heimer'sxdiseasexwithxfamilyxmembers.xWhichxofxthesexinterventionsxwouldxbexmostxhelpfulxatx
thisxtime?
A) leavexaxbookxaboutxrelaxationxtechniques
B) writexoutxaxdailyxexercisexroutinexforxthemxtoxassistxthexclientxtoxdo
C) listxactionsxtoximprovexthexclient'sxdailyxnutritionalxintake
D) suggestxcommunicationxstrategies
D:xsuggestxcommunicationxstrategies.xAlzheimer''sxdisease,xaxprogressivexchronicxillness,xgreat
lyxchallengesxcaregivers.xThexnursexcanxbexofxgreatestxassistancexinxhelpingxthexfamilyxtoxusexco
mmunicationxstrategiesxtoxenhancextheirxabilityxtoxrelatextoxthexclient.xByxusexofxselectxverbalxan
dxnonverbalxcommunicationxstrategiesxthexfamilyxcanxbestxsupportxthexclient’sxstrengthsxandxco
pexwithxanyxaberrantxbehavior.
11.Anx80xyear-
oldxclientxadmittedxwithxaxdiagnosisxofxpossiblexcerebralxvascularxaccidentxhasxhadxaxbloodxpressur
exfromx160/100xtox
180/110xoverxthexpastx2xhours.xThexnursexhasxalsoxnotedxincreasedxlethargy.xWhichxassessmentx
findingxshouldxthexnursexreportximmediatelyxtoxthexprovider?
A) Slurredxspeech
B) Incontinence
C) MusclexweaknessD)xxRapidxpulse
A:xSlurredxspeech.xChangesxinxspeechxpatternsxandxlevelxofxconsciousxcanxbexindicatorsxofxconti
nuedxintracranialxbleedingxorxextensionxofxthexstroke.xFurtherxdiagnosticxtestingxmayxbexindicat
ed.
12. Axschool-
agedxchildxhasxhadxaxlongxlegx(hipxtoxankle)xsyntheticxcastxappliedx4xhoursxago.xWhichxstatemen
txfromxthexparentxindicatesxthatxteachingxhasxbeenxinadequate?
A) "Ixwillxkeepxthexcastxuncoveredxforxthexnextxdayxtoxpreventxburningxofxthexskin."
B) "Ixcanxapplyxanxicexpackxoverxthexareaxtoxrelievexitchingxinsidexthexcast."
C) "Thexcastxshouldxbexproppedxonxatxleastx2xpillowsxwhenxmyxchildxisxlyingxdown."
D) "IxthinkxIxrememberxthatxmyxchildxshouldxnotxstandxuntilxafterx72xhours."
D:x"IxthinkxIxrememberxthatxmyxchildxshouldxnotxstandxuntilxafterx72xhours.".xSyntheticxcastsxwil
lxtypicallyxsetxupxinx30xminutesxandxdryxinxaxfewxhours.xThus,xthexclientxmayxstandxwithinxthexini
tialx24xhours.xWithxplasterxcasts,xthexsetxupxandxdryingxtime,xespeciallyxinxaxlongxlegxcastxwhichx
isxthickerxthanxanxarmxcast,xcanxtakexupxtox72xhours.xBothxtypesxofxcastsxgivexoffxaxlotxofxheatxwh
enxdryingxandxitxisxpreferablextoxkeepxthexcastxuncoveredxforxthexfirstx24xhours.xClientsxmayxcom
plainxofxaxchillxfromxthexwetxcastxandxthereforexcanxsimplyxbexcoveredxlightlyxwithxaxsheetxorxbla
nket.xApplyingxicexisxaxsafexmethodxofxrelievingxthexitching.
13. Whichxbloodxserumxfindingxinxaxclientxwithxdiabeticxketoacidosisxalertsxthexnursexthatximmediat
, pHxbelowx7.3
A)
B) Potassiumxofx5.0
C) HCTxofx60
D) PaxO2xofx79%
C:xHCTxofx60.xThisxhighxhematocritxisxindicativexofxseverexdehydrationxwhichxrequiresxpriority
x attentionxinxdiabeticxketoacidosis.xWithoutxsufficientxhydration,xallxsystemsxofxthexbodyxarexatxr
iskxforxhypoxiaxfromxaxlackxofxorxsluggishxcirculation.xInxthexabsencexofxinsulin,xwhichxfacilitat
esxthextransportxofxglucosexintoxthexcell,xthexbodyxbreaksxdownxfatsxandxproteinsxtoxsupplyxenerg
yxketones,xaxby-
productxofxfatxmetabolism.xThesexaccumulatexcausingxmetabolicxacidosisx(pHx<x7.3),xwhichxwo
uldxbexthexsecondxconcernxforxthisxclient.xThexpotassiumxandxPaO2xlevelsxarexnearxnormal.
14. Thexnursexisxpreparingxaxclientxwithxaxdeepxveinxthrombosisx(DVT)xforxaxVenousxDopplerxevalu
ation.xWhichxofxthexfollowingxwouldxbexnecessaryxforxpreparingxthexclientxforxthisxtest?
A) ClientxshouldxbexNPOxafterxmidnight
B) Clientxshouldxreceivexaxsedativexmedicationxpriorxtoxthextest
C) Discontinuexanti-coagulantxtherapyxpriorxtoxthextest
D) Noxspecialxpreparationxisxnecessary
D:xNoxspecialxpreparationxisxnecessary.xThisxisxaxnon-
invasivexprocedurexandxdoesxnotxrequirexpreparationxotherxthanxclientxeducation.
15. Axclientxisxadmittedxwithxinfectivexendocarditisx(IE).xWhichxfindingxwouldxalertxthexnursextoxaxc
omplicationxofxthisxcondition?
A) dyspnea
B) heartxmurmur
C) macularxrashD)xxHemorrhage
B:xheartxmurmur.xLarge,xsoft,xrapidlyxdevelopingxvegetationsxattachxtoxthexheartxvalves.xTheyxh
avexaxtendencyxtoxbreakxoff,xcausingxembolixandxleavingxulcerationsxonxthexvalvexleaflets.xThes
exembolixproducexfindingsxofxcardiacxmurmur,xfever,xanorexia,xmalaisexandxneurologicxsequela
exofxemboli.xFurthermore,xthexvegetationsxmayxtravelxtoxvariousxorgansxsuchxasxspleen,xkidney,x
coronaryxartery,xbrainxandxlungs,xandxobstructxbloodxflow.
16. Thexnursexexplainsxanxautograftxtoxaxclientxscheduledxforxexcisionxofxaxskinxtumor.xThexnursexkn
owsxthexclientxunderstandsxthexprocedurexwhenxthexclientxsays,x"Ixwillxreceivextissuexfrom
axtissuexbank."
A)
axpig."
B)
C) myxthigh."
D) syntheticxskin."
C:xmyxthigh.".xAutograftsxarexdonexwithxtissuextransplantedxfromxthexclient''sxownxskin.
17.Axclientxisxadmittedxtoxthexemergencyxroomxfollowingxanxacutexasthmaxattack.xWhichxofxthexfoll
owingxassessmentsxwouldxbexexpectedxbyxthexnurse?
x x x x
1.Axclientxhasxbeenxhospitalizedxafterxanxautomobilexaccident.xAxfullxlegxcastxwasxappliedxinxthexem
ergencyxroom.xxThexmostximportantxreasonxforxthexnursextoxelevatexthexcastedxlegxisxto
A) Promotexthexclient'sxcomfort
B) Reducexthexdryingxtime
C) DecreasexirritationxtoxthexskinxxxxxxxxxxxxxxxxxD)xxImprovexvenousxreturn
D:xImprovexvenousxreturn.xElevatingxthexlegxbothximprovesxvenousxreturnxandxreducesxswellin
g.xxClientxcomfortxxwillxbeximprovedxasxwell.x
2. Thexnursexisxreviewingxwithxaxclientxhowxtoxcollectxaxcleanxcatchxurinexspecimen.xWhatxisxthexa
ppropriatexsequencextoxteachxthexclient?
A) Cleanxthexmeatus,xbeginxvoiding,xthenxcatchxurinexstream
B) Voidxaxlittle,xcleanxthexmeatus,xthenxcollectxspecimen
C) Cleanxthexmeatus,xthenxurinatexintoxcontainer
D) Voidxcontinuouslyxandxcatchxsomexofxthexurine
A:xCleanxthexmeatus,xbeginxvoiding,xthenxcatchxurinexstream.xAxcleanxcatchxurinexisxdifficultxtox
obtainxandxrequiresxclearxdirections.xInstructingxthexclientxtoxcarefullyxcleanxthexmeatus,xthenxv
oidxnaturallyxwithxaxsteadyxstreamxpreventsxsurfacexbacteriaxfromxcontaminatingxthexurinexspec
imen.xAsxstartingxandxstoppingxflowxcanxbexdifficult,xoncexthexclientxbeginsxvoidingxit’sxbestxtoxj
ustxslipxthexcontainerxintoxthexstream.xOtherxresponsesxdoxnotxreflectxcorrectxtechnique
3. Followingxchange-of-
shiftxreportxonxanxorthopedicxunit,xwhichxclientxshouldxthexnursexseexfirst?
A) 16xyear-oldxwhoxhadxanxopenxreductionxofxaxfracturedxwristx10xhoursxago
B) 20xyear-oldxinxskeletalxtractionxforx2xweeksxsincexaxmotorxcyclexaccident
C) 72xyear-oldxrecoveringxfromxsurgeryxafterxaxhipxreplacementx2xhoursxago
D) 75xyear-oldxwhoxisxinxskinxtractionxpriorxtoxplannedxhipxpinningxsurgery.
C:xxxLookxforxthexclientxwhoxhasxthexmostximminentxrisksxandxacutexvulnerability.xThexclientxwh
oxreturnedxfromxsurgeryx2xhoursxagoxisxatxriskxforxlifexthreateningxhemorrhagexandxshouldxbexse
enxfirst.xThex16xyear-oldxshouldxbexseenxnextxbecausexitxisxstillxthexfirstxpost-
opxday.xThex75xyear-oldxisxpotentiallyxvulnerablextoxage-
relatedxphysicalxandxcognitivexconsequencesxinxskinxtractionxshouldxbexseenxnext.xThexclientxw
hoxcanxsafelyxbexseenxlastxisxthex20xyear-oldxwhoxisx2xweeksxpost-injury.
4. AxclientxwithxGuillainxBarrexisxinxaxnonresponsivexstate,xyetxvitalxsignsxarexstablexandxbreathingx
isxindependent.xWhatxshouldxthexnursexdocumentxtoxmostxaccuratelyxdescribexthexclient'sxcondit
ion?
A) Comatose,xbreathingxunlabored
B) GlascowxComaxScalex8,xrespirationsxregular
C) Appearsxtoxbexsleeping,xvitalxsignsxstable
D) GlascowxComaxScalex13,xnoxventilatorxrequired
B:xGlascowxComaxScalex8,xrespirationsxregular.xThexGlascowxComaxScalexprovidesxaxstandardx
referencexforxassessingxorxmonitoringxlevelxofxconsciousness.xAnyxscorexlessxthanx13xindicatesx
axneurologicalximpairment.xUsingxthextermxcomatosexprovidesxtooxmuchxroomxforxinterpretatio
nxandxisxnotxveryxprecise.
5. Whenxcaringxforxaxclientxreceivingxwarfarinxsodiumx(Coumadin),xwhichxlabxtestxwouldxthexnurs
, A) Bleedingxtime
B) Coagulationxtime
C) Prothrombinxtime
D) Partialxthromboplastinxtime
C:xProthrombinxtime.xCoumadinxisxorderedxdaily,xbasedxonxthexclient''sxprothrombinxtimex(PT).
xThisxtestxevaluatesxthexadequacyxofxthexextrinsicxsystemxandxcommonxpathwayxinxthexclottingxc
ascade;xCoumadinxaffectsxthexVitaminxKxdependentxclottingxfactors.
6.Axclientxwithxmoderatexpersistentxasthmaxisxadmittedxforxaxminorxsurgicalxprocedure.xOnxadmissi
onxthexpeakxflowxmeterxisxmeasuredxatx480xliters/minute.xPost-
operativelyxthexclientxisxcomplainingxofxchestxtightness.xThexpeakxflowxhasxdroppedxtox200xliter
s/minute.xWhatxshouldxthexnursexdoxfirst?
A) Notifyxbothxthexsurgeonxandxprovider
B) Administerxthexprnxdosexofxalbuterol
C) Applyxoxygenxatx2xlitersxperxnasalxcannula
D) Repeatxthexpeakxflowxreadingxinx30xminutes
B:xAdministerxthexprnxdosexofxalbuterol.xPeakxflowxmonitoringxduringxexacerbationsxofxasthmax
isxrecommendedxforxclientsxwithxmoderate-to-
severexpersistentxasthmaxtoxdeterminexthexseverityxofxthexexacerbationxandxtoxguidexthextreatme
nt.xAxpeakxflowxreadingxofxlessxthanx50%xofxthexclient''sxbaselinexreadingxisxaxmedicalxalertxcond
itionxandxaxshort-actingxbeta-agonistxmustxbextakenximmediately.
7.Axclientxhadx20xmgxofxLasixx(furosemide)xPOxatx10xAM.xWhichxwouldxbexessentialxforxthexnursext
oxincludexatxthexchangexofxshiftxreport?
A) Thexclientxlostx2xpoundsxinx24xhours
B) Thexclient’sxpotassiumxlevelxisx4xmEq/liter.
C) Thexclient’sxurinexoutputxwasx1500xccxinx5xhours
D) ThexclientxisxtoxreceivexanotherxdosexofxLasixxatx10xPM
C:xThexclient’sxurinexoutputxwasx1500xccxinx5xhours.xAlthoughxallxofxthesexmayxbexcorrectxinfor
mationxtoxincludexinxreport,xthexessentialxpiecexwouldxbexthexurinexoutput.
8.AxclientxhasxbeenxtentativelyxdiagnosedxwithxGraves'xdiseasex(hyperthyroidism).xWhichxofxthesex
findingsxnotedxonxthexinitialxnursingxassessmentxrequiresxquickxinterventionxbyxthexnurse?
A) axreportxofx10xpoundsxweightxlossxinxthexlastxmonth
B) axcommentxbyxthexclientx"Ixjustxcan'txsitxstill."
C) thexappearancexofxeyeballsxthatxappearxtox"pop"xoutxofxthexclient'sxeyexsockets
D) axreportxofxthexsuddenxonsetxofxirritabilityxinxthexpastx2xweeks
C:xthexappearancexofxeyeballsxthatxappearxtox"pop"xoutxofxthexclient''sxeyexsockets.xExophthalm
osxorxprotrudingxeyeballsxisxaxdistinctivexcharacteristicxofxGraves''xDisease.xItxcanxresultxinxcorn
ealxabrasionsxwithxseverexeyexpainxorxdamagexwhenxthexeyelidxisxunablextoxblinkxdownxoverxthex
protrudingxeyeball.xEyexdropsxorxointmentxmayxbexneeded.
9.xThexnursexhasxperformedxthexinitialxassessmentsxofx4xclientsxadmittedxwithxanxacutexepisodexofxas
thma.xWhichxassessmentxfindingxwouldxcausexthexnursextoxcallxthexproviderximmediately?
A) prolongedxinspirationxwithxeachxbreath
, C) expectorationxofxlargexamountsxofxpurulentxmucous
D) appearancexofxthexusexofxabdominalxmusclesxforxbreathing
B:xexpiratoryxwheezesxthatxarexsuddenlyxabsentxinx1xlobe.xAcutexasthmaxisxcharacterizedxbyxexp
iratoryxwheezesxcausedxbyxobstructionxofxthexairways.xWheezesxarexaxhighxpitchedxmusicalxsou
ndsxproducedxbyxairxmovingxthroughxnarrowedxairways.xClientsxoftenxassociatexwheezesxwithxt
hexfeelingxofxtightnessxinxthexchest.xHowever,xsuddenxcessationxofxwheezingxisxanxominousxorxb
adxsignxthatxindicatesxanxemergencyx--xthexsmallxairwaysxarexnowxcollapsed.
10.Duringxthexinitialxhomexvisit,xaxnursexisxdiscussingxthexcarexofxaxclientxnewlyxdiagnosedxwithxAlz
heimer'sxdiseasexwithxfamilyxmembers.xWhichxofxthesexinterventionsxwouldxbexmostxhelpfulxatx
thisxtime?
A) leavexaxbookxaboutxrelaxationxtechniques
B) writexoutxaxdailyxexercisexroutinexforxthemxtoxassistxthexclientxtoxdo
C) listxactionsxtoximprovexthexclient'sxdailyxnutritionalxintake
D) suggestxcommunicationxstrategies
D:xsuggestxcommunicationxstrategies.xAlzheimer''sxdisease,xaxprogressivexchronicxillness,xgreat
lyxchallengesxcaregivers.xThexnursexcanxbexofxgreatestxassistancexinxhelpingxthexfamilyxtoxusexco
mmunicationxstrategiesxtoxenhancextheirxabilityxtoxrelatextoxthexclient.xByxusexofxselectxverbalxan
dxnonverbalxcommunicationxstrategiesxthexfamilyxcanxbestxsupportxthexclient’sxstrengthsxandxco
pexwithxanyxaberrantxbehavior.
11.Anx80xyear-
oldxclientxadmittedxwithxaxdiagnosisxofxpossiblexcerebralxvascularxaccidentxhasxhadxaxbloodxpressur
exfromx160/100xtox
180/110xoverxthexpastx2xhours.xThexnursexhasxalsoxnotedxincreasedxlethargy.xWhichxassessmentx
findingxshouldxthexnursexreportximmediatelyxtoxthexprovider?
A) Slurredxspeech
B) Incontinence
C) MusclexweaknessD)xxRapidxpulse
A:xSlurredxspeech.xChangesxinxspeechxpatternsxandxlevelxofxconsciousxcanxbexindicatorsxofxconti
nuedxintracranialxbleedingxorxextensionxofxthexstroke.xFurtherxdiagnosticxtestingxmayxbexindicat
ed.
12. Axschool-
agedxchildxhasxhadxaxlongxlegx(hipxtoxankle)xsyntheticxcastxappliedx4xhoursxago.xWhichxstatemen
txfromxthexparentxindicatesxthatxteachingxhasxbeenxinadequate?
A) "Ixwillxkeepxthexcastxuncoveredxforxthexnextxdayxtoxpreventxburningxofxthexskin."
B) "Ixcanxapplyxanxicexpackxoverxthexareaxtoxrelievexitchingxinsidexthexcast."
C) "Thexcastxshouldxbexproppedxonxatxleastx2xpillowsxwhenxmyxchildxisxlyingxdown."
D) "IxthinkxIxrememberxthatxmyxchildxshouldxnotxstandxuntilxafterx72xhours."
D:x"IxthinkxIxrememberxthatxmyxchildxshouldxnotxstandxuntilxafterx72xhours.".xSyntheticxcastsxwil
lxtypicallyxsetxupxinx30xminutesxandxdryxinxaxfewxhours.xThus,xthexclientxmayxstandxwithinxthexini
tialx24xhours.xWithxplasterxcasts,xthexsetxupxandxdryingxtime,xespeciallyxinxaxlongxlegxcastxwhichx
isxthickerxthanxanxarmxcast,xcanxtakexupxtox72xhours.xBothxtypesxofxcastsxgivexoffxaxlotxofxheatxwh
enxdryingxandxitxisxpreferablextoxkeepxthexcastxuncoveredxforxthexfirstx24xhours.xClientsxmayxcom
plainxofxaxchillxfromxthexwetxcastxandxthereforexcanxsimplyxbexcoveredxlightlyxwithxaxsheetxorxbla
nket.xApplyingxicexisxaxsafexmethodxofxrelievingxthexitching.
13. Whichxbloodxserumxfindingxinxaxclientxwithxdiabeticxketoacidosisxalertsxthexnursexthatximmediat
, pHxbelowx7.3
A)
B) Potassiumxofx5.0
C) HCTxofx60
D) PaxO2xofx79%
C:xHCTxofx60.xThisxhighxhematocritxisxindicativexofxseverexdehydrationxwhichxrequiresxpriority
x attentionxinxdiabeticxketoacidosis.xWithoutxsufficientxhydration,xallxsystemsxofxthexbodyxarexatxr
iskxforxhypoxiaxfromxaxlackxofxorxsluggishxcirculation.xInxthexabsencexofxinsulin,xwhichxfacilitat
esxthextransportxofxglucosexintoxthexcell,xthexbodyxbreaksxdownxfatsxandxproteinsxtoxsupplyxenerg
yxketones,xaxby-
productxofxfatxmetabolism.xThesexaccumulatexcausingxmetabolicxacidosisx(pHx<x7.3),xwhichxwo
uldxbexthexsecondxconcernxforxthisxclient.xThexpotassiumxandxPaO2xlevelsxarexnearxnormal.
14. Thexnursexisxpreparingxaxclientxwithxaxdeepxveinxthrombosisx(DVT)xforxaxVenousxDopplerxevalu
ation.xWhichxofxthexfollowingxwouldxbexnecessaryxforxpreparingxthexclientxforxthisxtest?
A) ClientxshouldxbexNPOxafterxmidnight
B) Clientxshouldxreceivexaxsedativexmedicationxpriorxtoxthextest
C) Discontinuexanti-coagulantxtherapyxpriorxtoxthextest
D) Noxspecialxpreparationxisxnecessary
D:xNoxspecialxpreparationxisxnecessary.xThisxisxaxnon-
invasivexprocedurexandxdoesxnotxrequirexpreparationxotherxthanxclientxeducation.
15. Axclientxisxadmittedxwithxinfectivexendocarditisx(IE).xWhichxfindingxwouldxalertxthexnursextoxaxc
omplicationxofxthisxcondition?
A) dyspnea
B) heartxmurmur
C) macularxrashD)xxHemorrhage
B:xheartxmurmur.xLarge,xsoft,xrapidlyxdevelopingxvegetationsxattachxtoxthexheartxvalves.xTheyxh
avexaxtendencyxtoxbreakxoff,xcausingxembolixandxleavingxulcerationsxonxthexvalvexleaflets.xThes
exembolixproducexfindingsxofxcardiacxmurmur,xfever,xanorexia,xmalaisexandxneurologicxsequela
exofxemboli.xFurthermore,xthexvegetationsxmayxtravelxtoxvariousxorgansxsuchxasxspleen,xkidney,x
coronaryxartery,xbrainxandxlungs,xandxobstructxbloodxflow.
16. Thexnursexexplainsxanxautograftxtoxaxclientxscheduledxforxexcisionxofxaxskinxtumor.xThexnursexkn
owsxthexclientxunderstandsxthexprocedurexwhenxthexclientxsays,x"Ixwillxreceivextissuexfrom
axtissuexbank."
A)
axpig."
B)
C) myxthigh."
D) syntheticxskin."
C:xmyxthigh.".xAutograftsxarexdonexwithxtissuextransplantedxfromxthexclient''sxownxskin.
17.Axclientxisxadmittedxtoxthexemergencyxroomxfollowingxanxacutexasthmaxattack.xWhichxofxthexfoll
owingxassessmentsxwouldxbexexpectedxbyxthexnurse?
