Online NCLEX Practice Test about
Reduction of Risk Potential I
1. After insertion of tympanostomy tubes, which of the following instructions would the nurse include in a child’s discharge plan for the parents?
a. Insert ear plugs into the canals when the child bathes
b. Blow the nose forcibly during a cold
c. Administer the prescribed antibiotic while the tubes are in place
d. Disregard any drainage from the ear after 1 week
2. After teaching then parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she speak, turns blue, and does which of the following?
3. When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which of the following would the nurse expect to include?
a. Restriction of the child’s activities for the next 3 weeks
b. Use of sponge baths until the stitches are removed
c. Use of prophylactic antibiotics before receiving any dental work
d. Maintenance of a pressure dressing until a return visit with the physician
4. The physician orders pulse assessment several times through the night for a child with rheumatic fever who has a daytime heart rate of 120 bpm. The nurse explains to the mother that the primary reason for obtaining a sleeping pulse rate is to ensure that the elevation in the child’s pulse rate is unrelated to which of the following?
a. Morning dose of digitalis
b. Normal activity during waking hours
c. Warmer environment during the day than at night
d. Variations in pulse rates obtained during the day and evening hours
5. Which of the following would the nurse perform to help alleviate a child’s joint pain associated with rheumatic fever?
a. Maintaining the joints in an extended position
b. Applying gentle traction to the child’s affected joints
c. Supporting proper alignment with rolled pillows
d. Using a bed cradle to avoid the weight of bed linens on joints
6.A newborn with the diagnosis of imperforate anus is to be scheduled for radiographic examination. The nurse explains to the parents that this examination is done to determine the distance between the anal dimple and which of the following?
b. Closed end of the rectum
d. Rectovesical pouch
7. A 5-year-old with a history of asthma is brought to the clinic in respiratory distress. The nurse notes the following: respiratory rate, 36 breathes/minute; heart rate, 150 beats/minute; and an anxious child. The nurse should be most concerned about:
a. Child’s loose cough
b. Prolonged expiratory phase
c. Absence of wheezing
d. Whistling sound on inspiration
8. The nurse is teaching parents of an infant with hypospadia. The nurse should tell the parents to avoid:
a. Using disposable diapers
b. Positioning the infant on the back to sleep
c. Bathing the infant in an infant bathtub
d. having the infant circumcised
9. A toddler is admitted to the pediatric unit with a diagnosis of nephroblastoma. When providing routine care for this toddler, the nurse should avoid:
a. Palpating the toddler’s abdomen
b. Positioning the toddler on the side
c. Bathing the toddler
d. Loosening the toddler’s clothing
10. The physician orders bed rest for a client with cellulitis of the leg. The nurse understands that the primary purpose of bed rest for this client is to:
a. Decrease catabolism to promote healing at the site of injury
b. Lower the metabolic rate in an attempt to help reduce the fever
c. Reduce the energy demands on the body in the presence of infection
d. Limit muscle contractions that would force causative organism into the bloodstream
11. A client develops an infection of an abdominal incision and overhears the nurses say that it is a nosocomial infection. The client asks the nurse what this means. The nurse should reply:
a. “The infection you had prior to hospitalization has flared up.”
b. “You are acquired the infection after being admitted to the hospital.”
c. “This is highly contagious infection requiring protective isolation.”
d. “As a result of medical treatment, you have developed a secondary infection.”
12. A nurse deflates the balloon on a pulmonary artery catheter after obtaining a wedge pressure reading. Which of the following rationales for this is most correct?
a. Prevent cardiac arrhythmias
b. Prevent pulmonary tissue infarction
c. Obtain cardiac output measurements
d. Obtain accurate left ventricular pressure reading
13. Which of the following statements by a client with chronic arterial disease indicates further teaching is needed?
a. “I’m going to stop smoking.”
b. “I’m going to have the podiatrist check my feet.”
c. “I’m going to keep the heat in my house at 80 F.”
d. “I’m going to walk short distances every morning.”
14. A 30-year-old woman with a history of systemic lupus erythematosus was admitted with a severe viral respiratory infection and flu. The nurse observed diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client’s recent:
a. Quality and quantity of food intake
b. Type and amount of fluid intake
c. Weakness, fatigue, and ability to get around
d. Length and amount of menstrual flow
15. When a client with thrombocytopenia complains of a severe headache, the nurse interprets that this may indicate which of the following?
a. Stress of the disease
b. Cerebral bleeding
c. A migraine headache
d. Sinus congestion
16. The nurse evaluates that the client correctly understands how to report signs of bleeding when she makes which of the following statements?
a. “Petechiae are large red skin bruises.”
b. “Ecchymoses are large purple skin bruises.”
c. “Purpura is an open cut on the skin.”
d. “Abrasion is small pinpoint red dots on the skin.”
17. A client with allergic rhinitis asks the nurse what he should do to decrease her symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
a. “Use your nasal decongestant spray regularly to help clear your nasal passages.”
b. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”
c. “It is important to increase your activity. A daily brisk walk will help promote drainage.”
d. “Keep a diary of when your symptoms occur. This can help identify what precipitates your attacks.”
18. An 80-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client’s health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most likely be a predisposing factor for the diagnosis of pneumonia?
c. Vegetarian diet
d. Daily bathing
19. A client with bacterial pneumonia is to be started on IV antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins?
b. Sputum culture
c. Chest radiograph
d. Red blood cell count
20. Which of the following health promotion activities should the nurse include in the discharge plan for a client with asthma?
a. Incorporate physical exercise as tolerated into the daily routine
b. Monitor peak flow numbers after meals and at bedtime
c. Eliminate stressors in the work and home environment
d. Use sedative to ensure uninterrupted sleep at night
21. Which of the following would be an expected outcome for a client with peptic ulcer disease?
a. The client will demonstrate appropriate use of analgesics to control pain
b. The client will explain the rationale for eliminating alcohol from the diet
c. The client will verbalize the importance of monitoring hemoglobin and hematocrit every 3 months
d. The client will eliminate contact sports from his or her lifestyle
22. A client with suspected gastric cancer undergoes endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?
a. The client complains of a sore throat
b. The client displays signs of sedation
c. The client experiences a sudden increase in temperature
d. The client demonstrates a lack of appetite
23. A client with DM asks the nurse to recommend something to remove corns from his toes. The nurse should advise him to:
a. Apply a high-quality corn plaster to the area
b. Consult his physician or podiatrist about removing the corns
c. Apply iodine to the corns before peeling them off
d. Soak his feet in borax solution to peel off the corns
24. When using crutches, the client should be instructed to bear weight primarily:
a. On the axillae
b. On the elbows
c. On the upper arms
d. On the hands
25. Which of the following statements indicates that a client needs additional teaching after cataract surgery?
a. “I’ll avoid eating until the nausea subsides.”
b. “I can’t wait to pick up my granddaughter.”
c. “I’ll avoid bending over to tie my shoelaces.”
d. “I’ll avoid touching the dropper to my eye when using my eye drops.”
26. The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which of the following interventions would be most appropriate?
a. Fitting the diaper under the straps
b. Leaving the harness off while the infant sleeps
c. Checking for skin redness under straps every other day
d. Putting powder on the skin under the straps every day
27. After receiving orders for laboratory tests and antibiotics for a child with osteomyelitis, the nurse would expect to start the antibiotic after blood is drawn for which of the following?
d. WBC count
28. A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible side effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the side effects include which of the following?
b. Bleeding gums
c. Slow pulse
29. The nurse is teaching a 35-year-old woman how to perform self-monitoring blood glucose using a blood glucose monitor. Which of the following actions, if performed by the client would indicate that the teaching was successful?
a. The client elevates her hand on a pillow before the procedure
b. The client allows a large drop of blood to touch the test strip
c. The client washes hers hands in cold water before the procedure
d. The client sticks the center of the proximal phalanx
30. The nurse cares for a 4-week-old boy with pyloric stenosis. Immediately after feeding, the nurse should place him in which of the following positions?
a. On his right side with the head of the bed elevated 60 degrees
b. On his left side with he head of the bed elevated 90 degrees
c. On his abdomen with his head turned to the right side
d. On his right side with the head of the bed flat
31. A 42-year-old woman is returned to her room following a cholecystectomy with a T-tube in place. During the first 12 hours after surgery, the T-tube drains 300 ml of greenish-brown fluid. Which of the following actions should the nurse take initially?
a. Irrigate the T-tube to assess for patency
b. Clamp the tube to prevent further fluid loss
c. Milk the T-tube to encourage additional drainage
d. Document the amount and description of drainage
32. The nurse teaches a patient scheduled for surgery how to perform postoperative leg exercises. Which of the following actions, if performed by the patient, would indicate to the nurse the need for further teaching?
a. The patient points his toes toward the bottom of the bed, and then toward his face
b. The patient bends his knee, raises his leg off the bed, and then swings it to the side
c. The patient makes circles with his ankles, first to the left, and then to the right
d. The patient bends his knees, and pushes the balls of his feet into the bed
33. Which of the following findings would indicate to the nurse that a client’s bronchoscopy scheduled for 10 A.M. should be postponed?
a. The client had his dentures replaced by the dentist yesterday
b. The client took secobarbital (Seconal) at 10 P.M. last night
c. The client consumed a cup of coffee and a sweet roll at 6 A.M.
d. The client is wearing a red allergy bracelet
34. The nurse plans care for a patient who has a double-lumen tracheostomy tube with a cuff. It is most important for the nurse to:
a. Suction the tracheostomy tube before changing the dressing
b. Remove soiled tracheostomy ties before replacing them with sterile ties
c. Remove the inner cannula of the tracheostomy during mealtimes
d. Cut the gauze pads so they fit securely around the tracheostomy tube
35. While attempting to get out of bed, a patient accidentally disconnects the chest tube from the Pleur-evac drainage system. Which of the following actions should the nurse take first?
a. Insert the end of the chest tube in a container of sterile solution
b. Clamp the chest tube near the Pleur-evac drainage system
c. Raise the end of the chest tube above the level of the insertion of the chest tube
d. Apply pressure dressing to the chest tube insertion site
36. The nurse is caring for a 56-year-old man several hours after insertion of a central venous line. An IV of 0.9% NaCl is infusing through the line at 75 ml/hour. The patient becomes restless and appears short of breath. The nurse should:
a. Place the patient in a supine position
b. Check the IV flow rate and insertion site
c. Obtain chest tube for insertion of a chest tube
d. Reassure the patient that everything will be OK
37. When caring for a client who is receiving total parenteral nutrition (TPN), which of the following complications would be most important for the nurse to assess?
a. Chest pain
b. Hemorrhage and air embolus
c. Pneumonia and hyperglycemia
d. Electrolyte imbalance and sepsis
38. The nurse should stop the oxytocin (Pitocin)-stimulation during labor should which of the following warning signs occur?
a. Contractions every 50 seconds every 5 minutes
b. Fetal heart rate (FHR) is 175 bpm for longer than 10 minutes
c. Fetal heart rate (FHR) drops from its baseline of 145 between contractions to 135 within contractions, resolving as the contraction ends
d. The woman starts complaining of pain with her contractions
39. A client with diabetes mellitus has just had a below-the-knee amputation of the right limb and has a bandage applied. The nurse explains to the client that the primary purpose of the compression bandage is to:
a. Shape the stump for a prosthetic appliance
b. Promote the arterial blood flow
c. Reduce the probability of infection
d. Avoid flexion contractures
40. Of which of the following aspects of a client’s medical history should the nurse be aware before administering propranolol HCl (Inderal)?
a. History of migraines
b. History of deep venous thrombosis (DVT)
c. History of asthma
d. History of peptic ulcer disease
41. At the height of a contraction, a laboring woman’s membranes rupture. The nurse’s initial nursing action is to:
a. Change the woman’s position
b. Assess the fetal heart rate
c. Monitor contraction status
d. Assess the woman’s blood pressure
42. Client is worried about what to expect after having a Whipple procedure for cancer of the pancreas. When assisting the client to plan, it would be most important for the nurse to know:
a. Any history of alcohol or tobacco use
b. The state and grade of the client’s cancer
c. Any previous exposure to known carcinogens
d. The survival rate for individuals with pancreatic cancer
43. an automobile accident, a client who sustained multiple injuries is oriented as to person and place but is confused as to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. A significant nursing intervention would be to:
a. Keep the client alert and responsive
b. Prevent unnecessary movement by the client
c. Prepare the client for the administration of mannitol
d. Monitor the client for symptoms of increased intracranial pressure
44. Client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. It is important for the nurse to routinely assess this client for:
b. Blood in the stool
c. Any food intolerances
d. Complaints of nausea
45. A client with peptic ulcer is scheduled for a subtotal gastrectomy. Nursing intervention directed toward minimizing the postoperative complication of dumping syndrome includes teaching the client to:
a. Ambulate after every meal
b. Remain on a diet low in fat
c. Eat in a semi-recumbent position
d. Increase the fluid intake with meals
46. The nurse is preparing a client for an IVP tomorrow. The client tells the nurse that she gets a rash and becomes short of breath after eating lobster. Given this information, the nurse knows that the client:
a. Should be visited by a dietitian while in the hospital
b. Is not a candidate for IVP
c. Is at risk for an allergic reaction
d. Will require an antihistamine before her IVP
47. A 25-year-old male is admitted to an in-patient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the nurse most immediate action?
a. Assess and stabilize the client’s medical needs
b. Assess and stabilize the client’s psychological needs
c. Attempt to locate the nearest family members to get an accurate history
d. Arrange a transfer to the nearest medical facility
48. The nurse is caring for a 77-year-old man hospitalized for bilateral pneumonia. Shortly after admission, he became extremely belligerent, confused, hypotensive and developed tachypnea. The nurse prepares the patient for intubation, administers anti-infective STAT, and requests that the computed tomography (CT) scan of his head be delayed. What is the reason for this?
a. His change in mental status was related to hypoxia, metabolic encephalopathy, and sepsis
b. Taking this client to the radiology department would jeopardize his condition
c. The client exhibited no signs of focal neurologic impairment
d. His prognosis was poor and didn’t justify a CT scan
49. The nurse is diagnosed with anorexia nervosa. In addition to monitoring the client’s eating, the nurse would do which of the following after meals?
a. Encourage the client to go for a walk to get some exercise
b. Prevent the client form using the bathroom for 2 hours after eating
c. Tell the client to lie down for 2 hours after eating
d. Instruct the client to get plenty of exercise
50. The client, a multigravida in her 38th week of gestation, has come to the emergency department complaining of chest pain. She tells the nurse that she has recently inhaled crack cocaine. The nurse’s highest priority is to assess the patient for:
a. Abruptio placenta
b. Placenta previa
51. The nurse is planning care for a child who must remain in a croup tent continuously. Which goal is of highest priority?
a. The tent will remain closed, except for feedings and hygiene
b. The child will maintain normal body temperature and have dry linens
c. The tent will deliver mist and cooled air simultaneously while the child is inside
d. The child will find entertainment within the tent to encourage compliance
52. A 4-year-old complains of a sudden onset of pain in the ankle, which is swollen, red, and extremely sensitive to pressure. A diagnosis of acute gout is made. The client asks the nurse about gout. The nurse teaches him that gout is:
a. A metabolic disorder that results in elevated serum uric acid levels
b. An infection of the synovial membrane by microorganisms, resulting in inflammation
c. A disease of cartilage resulting in destruction of the cartilage and the underlying bone, causing severe pain
d. Inflammation of the bursal sac accompanied by formation of large calcium deposits, which cause swelling and joint pain
53. An adult is prepared for discharge following a bilateral adrenalectomy. The patient understands discharge instructions when she states:
a. “The surgery cured my disease, now I won't have to take any medications.”
b. “I should wear a Medic-alert bracelet or necklace at all times.”
c. “I will need to take replacement doses of steroids daily for one to two months.”
d. “I will probably develop a round a face and gain weight now that I will take cortisol daily.”
54. The nurse is caring for an adult with a T4 spinal cord transaction. Which activity by the client indicates adequate learning regarding urinary tract care?
a. Avoiding the Valsalva maneuver when the bladder is full
b. Cleaning the urinary meatus every two hours
c. Checking the bladder distention frequently
d. Limiting fluids to 100 ml per 24 hours
55. When caring for a client with a casted extremity, frequent assessments of neurologic and circulatory status of the affected extremity are required. Which of the following assessment findings should be recognized by the nurse as abnormal?
a. Client reports the extremity feels “like it’s asleep.”
b. Capillary refill time is less than 5 seconds
c. The area distal to the cast is warm to touch
d. Client reports dull aching in the casted extremity
56. After a transurethral prostatectomy, a client returns to the recovery room with a three-way Foley catheter with continuous bladder irrigation. An initial nursing priority in the client’s care plan would be to:
a. Observe for signs of confusion and agitation
b. Maintain in a semi Fowler’s position
c. Observe the suprapubic dressing for drainage
d. Force fluids by mouth as soon as the gag reflex returns
57. Two days following a myocardial infarction, a client has a temperature of 100.2F. The nurse should:
a. Auscultate the chest for diminished breath sounds
b. Notify the physician immediately about the temperature
c. Encourage deep breathing and coughing every 2 hours
d. Record the temperature and monitor vital signs at routine intervals
58. When giving discharge instructions to the parents of a child with cystic fibrosis, the nurse realizes that further explanation about the problems caused by cystic fibrosis is needed when the parents state:
a. “We will keep our child in an air-conditioned room.”
b. “We will give our child the pancreatic enzymes with meals.”
c. “We will provide our child skin care after each bowel movement.”
d. “We will move to Florida where the climate is better for our child.”
59. A client has a nasogastric tube after a gastric resection. The nurse should expect to observe:
b. Gastric distention
c. Intermittent periods of diarrhea
d. Bloody drainage for the first 12 hours
60. Which of the following findings in the affected extremity would most clearly indicate that a client has sustained a fracture of the femoral neck?
a. A large hematoma on the upper thigh
b. Spasms of the thigh muscles
c. A shortened, adducted, and externally rotated leg
d. Continuous, severe pain in the leg
61. Immediately following a femoral artery approach for a cardiac catheterization, it would be most important to include which of the following measures in the client’s care?
a. Auscultating the lungs and cardiac sounds
b. Observing the insertion site for infection
c. Elevating the head of the bed to 60-90 degrees
d. Maintaining strict bedrest for 4-6 hours
62. When assessing the client for hyperkalemia, the nurse is likely to note which of the following signs and symptoms?
a. Decreased bowel sounds and constipation
b. Abdominal cramping and diarrhea
c. Extreme thirst and lethargy
d. Vomiting and polyuria
63. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?
a. The client complains of sore throat
b. The client displays signs of sedation
c. The client experiences a sudden increase in temperature
d. The client demonstrates a lack of appetite
64. The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would most accurate?
a. “Surgery is usually required, although medical treatment is attempted first.”
b. “Hiatal symptoms can usually be successfully managed with diet modifications, medication, and lifestyle.”
c. “Surgery is not performed for this type of hernia.”
d. “A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned.”
65. Which of the following risk factor have been identified as a potential risk for the development of colon cancer?
a. Chronic constipation
b. Long-term use of laxatives
c. History of colorectal polyps
d. History of smoking
e. History of inflammatory bowel disease
f. High fat diet
66. A 35-year-old female client has been diagnosed with hemorrhoids. Which of the following factors are most likely to cause hemorrhoids?
a. Portal hypertension
b. Her age
c. Three vaginal delivery pregnancies
d. Her job as a schoolteacher
e. Varicosities in her legs
f. Chronic constipation.
67. The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that barium enema:
a. Can perforate an intestinal abscess
b. Would greatly increase the client’s pain
c. Is of minimal diagnostic value in diverticulitis
d. Is too lengthy a procedure for the client to tolerate
68. An adult client states that it hurts too much to cough and deep breathe following abdominal surgery. Which of the following approaches would the nurse take first?
a. Inform the client that coughing is not a matter of choice and must be done
b. Call the respiratory therapist in to talk with the client
c. Notify the surgeon that the client refuses to cough
d. Coordinate a pain medication and respiratory exercise schedule
69. When planning care for the client with multiple myeloma, the nurse should include:
a. Fluid restriction
b. Administration of potassium supplements
c. Assisting with mobility
d. Administration of aspirin to control bone pain
ANSWERS AND RATIONALE
- placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. Blowing the nose forcibly during a cold causes organisms to ascend through the Eustachian tube, possibly leading to otitis media. It is not necessary to administer antibiotics continuously to a child with a tympanostomy tube. Antibiotics are appropriate only when an ear infection is present. Drainage from the ear may be a sign of middle ear infection and should be reported to health care provider.
- the three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis) and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur. Gasping, a sudden intake of air indicates that the child is still able to inhale. When the child is choking, air is not being exchanged, so gagging will not occur.
- prophylactic antibiotics are suggested for children with heart defects before dental work is done to reduce the risk of bacterial infection. Typically, activities are not restricted after a cardiac catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary. Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is discharged.
- an above average pulse rate that is out of proportion to the degree of activity is an early sign of cardiac failure in a client with rheumatic fever. The sleeping pulse is used to determine whether mild tachycardia continues during sleep (inactivity) or whether it is the result of daytime activity. Digitalis lowers the heart rate, so the heart rate would be decreased during the daytime. The environmental temperature would need to be quite warms before it could influence the heart rate.
- for a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight the linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joint is not recommended because traction is usually used to relieved muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client’s position are recommended, but these measures are not likely to relieve pain.
- for the child with an imperforate anus, the purpose of the radiographic examination is to ascertain the distance between the anal dimple and the closed end of the rectum.
- the most likely explanation for the respiratory distress is an acute asthma attack. These episodes usually begin with a cough, expiratory wheezing, and a prolonged expiratory phase, and then may progress to more obvious symptoms, such as wheezing on inspiration, shortness of breath and tight cough. The absence of wheezing during an attack indicates that the child is probably hypoxic and needs medical attention immediately.
- the parents should be instructed to avoid having the infant circumcised because the foreskin may be needed during surgical repair. The parents would be permitted to use disposable diapers for the infant. The parents should be instructed to place their child on his back to sleep to decrease the risk of sudden infant death syndrome. It’s acceptable for the parents to bathe the infant in an infant bathtub.
- the nurse shouldn’t palpate the toddler’s abdomen and should prevent others from doing so because it may disseminate cancer cells to other sites. The toddler may be carefully positioned on his side. The toddler may be bathed but must be handles carefully. The toddler’s clothes should be loosened around the abdomen.
- exercise would promote extension of the local infection from the leg into the circulation, causing septicemia.
- nosocomial infection, by definition, is acquired during hospitalization.
- if the balloon on the pulmonary artery catheter is left inflated, it would stay in a wedged position and occlude the area distal to it. This would result in infarction of tissue, the functions of a pulmonary artery catheter include obtaining left ventricular pressure readings and cardiac output measurements, but this isn’t why the balloon is deflated. Preventing cardiac arrhythmias is secondary.
- clients with peripheral vascular disease need to be at a comfortable temperature because of impaired circulation. Having the heat at 80 F is too warm. The other choices are all appropriate interventions for a client with peripheral vascular disease.
- a recent viral infection in a female client between the ages of 20 to 30 years with a history of systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic thrombocytopenia purpura (ITTP). It is important to ask whether the client’s recent menses have been lengthened or are heavier. Determining her ability to clot can help determine her risk for increased bleeding tendency until a platelet count is drawn. Petechiae are not caused by poor nutrition. Because of poor food and fluid intake or weakness and fatigue, the client may have gotten bruises from falling or bumping into things, but not petechiae.
- when the platelet count is very low, red blood cells leak out of the blood vessels and into the tissue. If the BP is elevated and the platelet count falls to less than 15,000/mm3, internal bleeding in the brain can occur. A severe headache occurs from meningeal irritation. When a client has thrombocytopenia, the nurse should always assess for cerebral bleeding by checking vital signs and performing neurological checks.
- large purplish skin lesions caused by hemorrhage are called ecchymoses. Small, flat, red pinpoint lesions are petechiae. Numerous petechiae result in a reddish, bruised appearance called purpura. An abrasion is a wound caused by scraping.
- it is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the client’s symptom; in fact, walking outdoors may increase them if the client is allergic to pollen.
- the client’s age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated clients. Other predisposing factors include smoking, upper respiratory infections, malnutrition, Immunosuppression, and the presence of chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia.
- sputum is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum may alter the results of the test. Neither a urinalysis, a chest radiograph, nor a red blood cell count needs to be obtained before initiation of antibiotic therapy for pneumonia.
- Physical exercises are beneficial and should be incorporated as tolerated into the client’s schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client’s life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended.
- alcohol is a gatric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client’s hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.
- the most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedative during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process.
- a client with diabetes should be advised to consult a physician or podiatrist for corn removal because of the danger of traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a physician.
- the proper use of crutches requires supporting the body weight primarily on the hands. Improper use of crutches can cause nerve damage from excess pressure on the axillary nerve.
- lifting, often involving the Valsalva maneuver, increases intraocular pressure (IOP) and strain on the surgical site. Preventing nausea and subsequent vomiting will prevent increased IOP, as will avoiding bending or placing the head in a dependent position. Touching the dropper to the eye will contaminate the dropper and thus, the entire bottle of medication.
- Pavlik harness is worn over a diaper. Knee socks are also worn to prevent the straps and foot and leg pieces from rubbing the skin. For maximum results, the infant needs to wear the harness continuously. The skin should be inspected several times a day, not every other day, for signs of redness or irritation. Lotions and powders are to be avoided because they can irritate the skin.
- antibiotic therapy starts after blood culture is drawn. The blood cultures determine the causative organism
- a slowed pulse, bradycardia, is normal for the first 7 days postpartum as the body begins to adjust to the prepregnancy state. Side effects of heparin therapy suggesting hemorrhage include hematuria, epistaxis, ecchymosis, increased lochial flow, and bleeding gums. Typically tachycardia, not Bradycardia, would be associated with hemorrhage.
- large drop of blood is necessary for proper interaction with chemicals on strip; don’t smear or allow finger to touch strip. Washing hands in cold water causes vasoconstriction.
- pylorus (opening from stomach into small intestine) opens into duodenum on right side; gravity facilitates gastric emptying; high-Fowler’s position is the head of bed elevated 60-90 degrees.
- bile is collected and measured every 24 hours; color and character are documented; drainage at first is bloody and then greenish-brown; it is measured as output, with 500 to 1,000 ml/day. 300 ml drainage in 12 hours is sufficient; there is no need to irrigate the T-tube.
- the patient should flex his knee and thigh, straighten the leg into the air, hold for 5 seconds before lowering it to the bed; should repeat 10 times each hour. Option 1 and 3 should be performed 10 times each hour. Option 4 contracts and relaxes thigh and calf muscles to prevent thrombus formation.
- the client should be NPO at least 8 hours before the procedure to decrease the danger of aspiration.
- the nurse should change the tracheostomy dressing aseptically every 8 hours and PRN; this prevents infection; use a pre-cut gauze pad.
- the nurse should cut off contaminated tip of the tubing before inserting into sterile saline; this prevents air from returning to the chest by maintaining the water-seal. The drainage system must be kept below the level of the insertion of the chest tube. Applying pressure is done when the tube is removed; pressure dressing is applied to prevent entrance of air into pleural cavity, preventing infection.
- the complication from the procedure is puncture of lung resulting in pneumothorax; symptoms include dyspnea, tachycardia, and anxiety.
- electrolyte imbalances as well as catheter-related sepsis, air embolus, and pneumothorax are potential complications of TPN. Hemorrhage and pneumonia is not a common complication although, hyperglycemia can occur.
- an FHR of 175 bpm is tachycardia, a sign that the fetal central nervous system is being compromised, most often a result of hypoxia. The normal FHR is 120-160 bpm. Other options are normal occurrence.
- a compression bandage is used to support soft tissues and provide uniform compression for prosthetic limb shaping.
- propranolol HCl (Inderal) is a nonselective beta-blocking agent and can, therefore, cause bronchospasms in the client with asthma. Inderal has no effect on coagulation or on acid production in the stomach.
- when the membranes rupture, the FHR should be checked. If the rupture of the membranes occurs along with a sudden gush of fluid and the head is not engaged, the umbilical cord may be prolapsed downward and be compressed between the presenting part and the cervix. The resulting cord compression may be reflected as variable decelerations of the FHR.
- individualized information would be the basis for predicting the outcome of the therapy. Option 1 would not be helpful in understanding the likelihood of additional problems associated with the current cancer.
- limitation of increased ICP and resultant brain damage depends on frequent, systematic observation. Mannitol is administered to reduce cerebral edema; there is no indication yet that this will be needed.
- erosion of blood vessels may lead to hemorrhage, a life threatening situation further complicated by decreased prothrombin production. Assessment for bleeding takes priority.
- eating in a semi-recumbent position slows gastric emptying, thereby preventing premature gastric dumping of contents.
- People who are allergic to shellfish (iodine) are at risk for allergic reactions to the contrast material (iodine) are used for an IVP.
- the possibility of frostbite must be evaluated first before other interventions. Option 2, 3, and 4 don’t address the client’s important medical needs.
- severe functional abnormalities and confusion are often cause by non-neurologic disease, especially in the elderly. Encephalopathies such as these are reversible as the underlying cause is treated. The other choices are incorrect because poor prognosis, absence of signs of focal neurologic impairment, and an unstable condition aren’t appropriate justifications for delaying a diagnostic CT scan.
- after observing the client while she eats, the nurse should prevent the client from using the bathroom at least 2 hours to break the purging cycle. Exercise should be restricted until the client has shown adequate weight gain, and then it should be encouraged in moderation. It isn’t necessary for the client to lie down for 2 hours after eating.
- the use of crack cocaine during pregnancy is associated with abruption placenta, along with hypertension, CVA, tachycardia, hemorrhage, low birth weight, and preterm neonates. Crack cocaine isn’t associated with placenta accrete (unusually deep attachment of the placenta to the uterine myometrium) or hypotension. Although malnutrition may exist, it isn’t life-threatening at this point.
- if the air intake tubings are not delivering room air and /or oxygen, the carbon dioxide level in the tent will increase, causing hypoxia. If the humidity reservoir is allowed to run dry, the blowing air will dry the mucous membranes and cause more edema.
- or gouty arthritis, is a systemic disease in which urate crystals are deposited in joints and other body tissues. Elevated uric acid levels occur as a result of improper metabolism of purines, resulting in excessive production of uric acid, which the kidneys are unable to adequately eliminate. This causes hyperuricemia and leads to formation of sodium urate crystals, which are deposited in the synovium and other tissues.
- the Medic-alert bracelet is essential to warn health care providers that the adrenals have been removed and that glucocorticoids and mineralocorticoids replacement is essential for life. Failure to supply replacement doses will precipitate severe hypotension, shock, coma, and vasomotor collapse.
- checking for bladder distention frequently will prevent distention of the ureters and renal pelvis. If the client is on intermittent self-catheterization, this must be done at least every 3 to 4 hours. Bladder distention may cause primary urinary tract infections because the pressure exerted on the bladder wall will impair the blood supply to the bladder. A full bladder is often the cause of autonomic dysreflexia.
- paresthesia, such as numbness or tingling (often describe by the client as “feeling like it’s asleep”), occur when compression of the tissue deprives the nerves of part of their circulation or when something presses directly on the nerve. This is an indication of both neurologic and circulatory problems.
- clients may develop cerebral edema caused by excessive absorption of irrigating solution by the venous sinusoids during surgery.
- myocardial necrosis causes a rise in body temperature within the first 24 to 48 hours, which gradually returns to normal within a week.
- hot climates are contraindicated for children with cystic fibrosis because sweating brings about excessive loss of sodium chloride. Other options are correct
- drainage is bright red initially and gradually becomes darker during the first 24 hours. If nasogastric is functioning correctly, secretions will be removed, vomiting and gastric distention will not occur. Because the bowel was emptied before surgery and the client is now NPO, there would be no expected intestinal activity.
- a shortened, adducted, and externally rotated affected extremity is a definite sign of a fracture of the femoral neck.
- maintaining strict bedrest for 4-6 hours is very important in order to prevent bleeding by promoting a stable clot without hematoma formation. Movement would interfere with clot formation.
- hyperkalemia cause smooth muscle hyperactivity, especially of the GI tract, which can cause nausea, abdominal cramping, and diarrhea, which is an early sign.
- the most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given the sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure if completed. A lack of appetite could be the result of many factors, including the disease process.
- most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modification. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms
65) C, D, and F
- a history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high fat diet.
66) A, C, and F
- hemorrhoids are associated with prolonged sitting or standing, portal hypertension, chronic constipation, and prolonged increased intra-abdominal pressure, as associated with pregnancy and the strain of vaginal delivery. Other options are not related to the development of hemorrhoids.
- barium enema and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be ordered after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis
- the first step is to relieve or lessen pain so the client can cooperate and achieve the goal of coughing. A planned schedule for pain medication can help achieve this goal.
- mobility is important for the client with multiple myeloma. Weight bearing promotes movement of calcium into weakened bones, helping to maintain their strength. This will also reduce the risk of Hypercalcemia, which is a common complication of multiple myeloma. The client will need assistance with mobility because the bones are weak.