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Nursing Practice 3

1. A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings?
A.    Elevated serum calcium.
B.     Low serum parathyroid hormone (PTH).
C.     Elevated serum vitamin D.                                          Nursing Path
D.    Low urine calcium.

2. A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is NOT recommended?
A.    A diet high in grains.
B.     A diet with adequate caloric intake.
C.     A high protein diet.
D.    A restricted sodium diet.

3. A patient with a history of diabetes mellitus is in the second post-operative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient’s symptoms?
A.    Anesthesia reaction.
B.     Hyperglycemia. 
C.   Hypoglycemia.                                                  Nursing Path
D.    Diabetic ketoacidosis.

4. A nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern?
A.    Bowel perforation.
B.     Viral gastroenteritis.
C.     Colon cancer.
D.    Diverticulitis.

5. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation?
A.    Partial thromboplastin time.
B.     Prothrombin time.
C.     Platelet count.
D.    Hemoglobin       Nursing Path                        

6. A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission?
A.    Sexual contact with an infected partner.
B.     Contaminated food.
C.     Blood transfusion.
D.    Illegal drug use.

7. A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?
A.    A history of hepatitis C five years previously.
B.     Cholecystitis requiring cholecystectomy one year previously.
C.     Asymptomatic diverticulosis.
D.     Crohn’s disease in remission.

8. A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient?
A.    Naproxen sodium (Naprosyn).
B.     Calcium carbonate.
C.     Clarithromycin (Biaxin).                     Nursing Path
D.    Furosemide (Lasix).

9. The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate?
A.    The patient must maintain a low calorie diet.
B.     The patient must maintain a high protein/low carbohydrate diet.
C.     The patient should limit sweets and sugary drinks.
D.    The patient should limit fatty foods.

10. A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
A.    Slow, deep respirations.
B.     Stridor.
C.     Bradycardia.                  Nursing Path
D.    Air hunger.

11. A nurse caring for several patients on the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
A.    A patient admitted for myocardial infarction without cardiac muscle damage.
B.     A post-operative coronary bypass patient, recovering on schedule.
C.     A patient with a history of ventricular tachycardia and syncopal episodes.
D.    A patient with a history of atrial tachycardia and fatigue.

12. A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient?
A.    The patient is allergic to shellfish.
B.     The patient has a pacemaker.
C.     The patient suffers from claustrophobia.
D.    The patient takes anti-psychotic medication.

13. A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed?
A.    The patient is somnolent with decreased response to the family.
B.     The patient suddenly complains of chest pain and shortness of breath.
C.     The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs.     Nursing Path
D.    The patient has a fever, chills, and loss of appetite.

14. A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
A.    The patient will be admitted to the medicine unit for observation and medication.
B.     The patient will be admitted to the day surgery unit for sclerotherapy.
C.     The patient will be admitted to the surgical unit and resection will be scheduled.
D.    The patient will be discharged home to follow-up with his cardiologist in 24 hours.

15. A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included on the nursing care plan?
A.    Monitor for fever every 4 hours.
B.     Require visitors to wear respiratory masks and protective clothing.
C.     Consider transfusion of packed red blood cells.
D.    Check for signs of bleeding, including examination of urine and stool for blood.

16. A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
A.    Bulging anterior fontanel.
B.     Repeated vomiting.                  Nursing Path
C.     Signs of sleepiness at 10 PM.
D.    Inability to read short words from a distance of 18 inches.

17. A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
A.    Small blue-white spots are visible on the oral mucosa.
B.     The rash begins on the trunk and spreads outward.
C.     There is low-grade fever.
D.    The lesions have a “tear drop on a rose petal” appearance.

18. A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is NOT correct?
A.    Scarlet fever is caused by infection with group A Streptococcus bacteria.
B.     “Strawberry tongue” is a characteristic sign.
C.     Petechiae occur on the soft palate.
D.    The pharynx is red and swollen.

19. A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose?
A.    It is the correct dose.
B.     The dose is too low.
C.     The dose is too high.
D.     The dose should be increased or decreased, depending on the symptoms.

20. The mother of a 2-month-old infant brings the child to the clinic for a well baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate?
A.    Normally, the testes are descended by birth.
B.     The infant will likely require surgical intervention.
C.     The infant probably has with only one testis.
D.    Normally, the testes descend by one year of age.

21. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. 
A.    Partial thromboplastin time.
B.     Prothrombin time.
C.     Platelet count.   Nursing Path
D.    Hemoglobin
E.     Complete Blood Count
F.      White Blood Cell Count

22. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. 
A.    Weight loss.
B.     Increased clotting time.
C.     Hypertension.
D.    Headaches.

23. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.
A.    The inhaler is held upright.
B.     Head is tilted down while inhaling the medication
C.     Client waits 5 minutes between puffs.
D.    Mouth is rinsed with water following administration
E.     Client lies supine for 15 minutes following administration.

24. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply.
A.    Hearing loss
B.     Visual disturbance
C.     Headache           Nursing Path
D.    Orthopnea
E.     Gout
F.      Weight loss

25. Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
A.    Auscultation of breath sounds
B.     Auscultation of bowel sounds
C.     Presence of chest pain.
D.    Presence of peripheral edema
E.     Color of nail beds

26. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply.
A.    “I will need to dispose of my old clothing when I return home.”
B.      “I should always cover my mouth and nose when sneezing.”
C.      “It is important that I isolate myself from family when possible.”
D.     “I should use paper tissues to cough in and dispose of them properly.”
E.      “I can use regular plate and utensils whenever I eat.”

27. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply.
A.     Thirst
B.     Palpitations
C.     Diaphoresis       Nursing Path
D.    Slurred speech
E.     Hyperventilation

28. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply:
A.    Sweating
B.     Low PCO2
C.     Retinopathy
D.    Acetone breath
E.     Elevated serum bicarbonate

29. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.
A.    Assessing the client’s bowel sounds
B.     Providing skin care following bowel movements
C.     Evaluating the client’s response to antidiarrheal medications
D.    Maintaining intake and output records
E.     Obtaining the client’s weight.

30. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.
A.    Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
B.     Activity intolerance related to increased cardiac output.
C.     Decreased cardiac output related to structural and functional changes.
D.    Impaired gas exchange related to decreased sympathetic nervous system activity.

Answers and Rationales
1.      A. Elevated serum calcium. The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones.

2.      D. A restricted sodium diet. A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates, including grains.

3.      C. Hypoglycemia. A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia reaction would not occur on the second post-operative day. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.

4.      A. Bowel perforation. Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate advancing peritonitis. Viral gastroenteritis and colon cancer do not cause these symptoms. Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis.

5.      A.Partial thromboplastin time, B. Prothrombin time, and C. Platelet count. Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

6.      B. Contaminated food. Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Hepatitis B, C, and D are transmitted through infected bodily fluids.

7.      A. A history of hepatitis C five years previously. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis (gall bladder disease), diverticulosis, and history of Crohn’s disease do not preclude blood donation.

8.      A. Naproxen sodium (Naprosyn). Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Furosemide is a loop diuretic and is contraindicated in a patient with gastritis.

9.      D. The patient should limit fatty foods. Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.

10. D. Air hunger. Patients with pulmonary edema experience air hunger, anxiety, and agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing caused by laryngeal swelling or spasm and is not associated with pulmonary edema.

11. C. A patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. A patient recovering well from coronary bypass would not need the device. Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.

12. B. The patient has a pacemaker. The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Psychiatric medication is not a contraindication to MRI scanning.

13. B. The patient suddenly complains of chest pain and shortness of breath. Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia.

14. C. The patient will be admitted to the surgical unit and resection will be scheduled. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist.

15. D. Check for signs of bleeding, including examination of urine and stool for blood. A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Transfusion of red cells is indicated for severe anemia.

16. B. Repeated vomiting. Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. The anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is normal for a four year old. The average 4-year-old child cannot read yet, so this too is normal.

17. A. Small blue-white spots are visible on the oral mucosa. Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. The body rash typically begins on the face and travels downward. High fever is often present. “Tear drop on a rose petal” refers to the lesions found in varicella (chicken pox).

18. C. Petechiae occur on the soft palate. Petechiae on the soft palate are characteristic of rubella infection. Choices A, B, and D are characteristic of scarlet fever, a result of group A Streptococcus infection.

19. B. The dose is too low. This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should not be titrated based on symptoms without consulting a physician.

20. D. Normally, the testes descend by one year of age. Normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. Exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. If not, a full assessment will determine the appropriate treatment.

21. A, B, and C. Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

22. B, C, and D. Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.

23. A and D.

24. B, C, D and E. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

25. A, C, E. A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
26. B, D, E.

27. B, C, D. Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

28. B, D. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.

29. B, D, and E. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.

30. A and C. HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

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