2024 ngn nclex (1).pdf

Stuvia.com - The Marketplace to Buy and Sell your Study Material 1Follow for more study materials https://www.facebook.com/groups/772671407426795/ NCLEX RN January/ Feb 2024 NGN Actual Questions & Answers Bank with Rationales 100% Verified 450 Q&A [email protected] Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 NCLEX RN January/ Feb 2024 NGN Actual Questions & Answers Bank with Rationales 1. 1. Question 1 point(s) Category: Management of Care The nurse is managing care for several clients in the outpatient clinic. Among the following clients who called, which one should the nurse prioritize in responding to first? o A. A client with hepatitis A who states, “My arms and legs are itching.” o B. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.” o C. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.” o D. A client with rheumatoid arthritis who states, “I am having trouble sleeping.” Correct Answer: B. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.” It may indicate neurovascular compromise, requiring immediate assessment. Option A: Bilirubin levels in hepatitis A may increase, and itching is a common symptom. Option C: A client feeling nauseous may require consultation but is not a priority. Option D: Clients with rheumatoid arthritis may feel pain in the affected areas at night. They may need a prescription for painkillers but it is not urgent. 2. 2. Question 1 point(s) Category: Management of Care A nurse on the surgical floor is prioritizing care for clients after receiving the report from the previous shift. Which of the following patients should the nurse assess first? Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 A. A 35-year-old patient admitted three hours ago for a gunshot wound, with a 1.5 cm area of dark drainage noted on the dressing. B. A 43-year-old patient who underwent a mastectomy two days ago, with 23 ml of serosanguinous fluid in the Jackson-Pratt drain. C. A 59-year-old patient with a history of a collapsed lung from an accident, with no drainage noted in the chest tube in the past eight hours. E. A 54-year-old patient with a total knee replacement two days ago, with moderate swelling at the surgical site. E. A 47-year-old patient who had a laparoscopic cholecystectomy yesterday, complaining of mild pain at the incision site. F. A 62-year-old patient who had an abdominal-perineal resection three days ago, now reporting chills. Correct Answer: F. A 62-year-old patient who had an abdominal-perineal resection three days ago, now reporting chills. The client is at risk for peritonitis; should be assessed for further symptoms and infection. 3. 3. Question 1 point(s) Category: Physiological Adaptation A nurse in a post-surgical unit is monitoring a 46-year-old patient who underwent a thyroidectomy 12 hours ago for the treatment of Grave’s disease. Which of the following observations should most concern the nurse? A. Blood pressure 138/82 mmHg, respirations 16 per minute, oral temperature 37.2ºC or 99º F. B. The patient carefully supports their head and neck when turning their head to the right. C. The patient expresses difficulty in swallowing but can manage liquids. D. The patient appears drowsy and complains of a sore throat. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 E. The patient shows involuntary flexion of their wrist when blood pressure is measured. F. The patient has a hoarse voice when speaking. Correct Answer: E. The patient shows involuntary flexion of their wrist when blood pressure is measured. Carpal spasms (Trousseau’s sign) indicate hypocalcemia which can occur after thyroidectomy due to accidental removal or damage to the parathyroid glands. Hypocalcemia is a serious complication and requires immediate attention. The other options, while they might warrant monitoring, are not as immediately concerning as a potential sign of hypocalcemia. Option A: The vital signs are all within the normal range. Option B: Supporting the head and neck while turning protects the surgical site from dehiscence. Option C: Common side effect of neck surgery. Option D: Drowsiness may be a side effect of the anesthesia used during surgery and will fade away eventually; a sore throat is a normal finding after thyroid surgery. Option F: Hoarseness of voice is a common side effect of post-op thyroidectomy due to one or more of the nerves irritated during the procedure of due to inflammation that occurs after surgery. 4. 4. Question 1 point(s) Category: Physiological Adaptation A 38-year-old patient is admitted to the emergency department with severe pain in the lower right quadrant of the abdomen, nausea, and a low-grade fever, raising concerns about possible appendicitis. The nurse is considering pain relief strategies. Which of the following actions should the nurse prioritize? A. Encourage the patient to change positions frequently in bed. B. Administer Demerol 50 mg IM q 4 hours and PRN, as prescribed. C. Apply warmth to the abdomen with a heating pad. D. Use comfort measures and pillows to position the patient comfortably. E. Administer an antiemetic as prescribed for nausea relief. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 5 Correct Answer: D. Use comfort measures and pillows to position the patient comfortably. Using comfort measures and pillows to position the client is a non- pharmacological method of pain relief. Option A: Gentle position changes can help alleviate pain, but changing positions often might aggravate the pain felt by the client. Option B: Demerol may be given if prescribed by the physician. Option C: The client may be experiencing acute appendicitis; warm compresses may cause rupture of the inflamed appendix. Option E: Addressing associated symptoms like nausea can improve overall comfort but is not the priority as of the moment. 5. 5. Question 1 point(s) Category: Physiological Adaptation A 56-year-old patient, recently diagnosed with end-stage renal disease, is preparing for their first peritoneal dialysis session in a clinic. The patient has a history of diabetes and hypertension, and has been experiencing increasing fatigue and fluid retention. Upon arrival, the nurse notes that the patient appears anxious about the procedure. The patient’s vital signs are stable, with a blood pressure of 150/90 mmHg, pulse 78 bpm, and respiratory rate 16 breaths per minute. The nurse reviews the physician’s orders, which indicate the type and volume of dialysate to be used. The peritoneal dialysis catheter had been placed a week earlier, and there’s no sign of infection at the site. The patient is settled in a comfortable position in the dialysis room, which is equipped with all necessary emergency equipment. Considering this scenario, which of the following actions should the nurse prioritize? A. Assess for a bruit and a thrill. B. Warm the dialysate solution. C. Position the client on the left side. D. Insert a Foley catheter E. Assess the patient's understanding of the peritoneal dialysis procedure. F. Address the patient's anxiety and provide emotional support. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 6 Correct Answer: B. Warm the dialysate solution. Cold dialysate increases discomfort. The solution should be warmed to body temperature in a warmer or heating pad; don’t use a microwave oven. Option A: Assessing for bruit and thrill can be done to check for the patency of the fistula. Option C: The client may resume a position that will be comfortable for him. Option D: A Foley catheter is unnecessary during peritoneal dialysis. 6. 6. Question 1 point(s) Category: Health Promotion and Maintenance A 75-year-old male patient with a history of right-sided hemiplegia due to a recent stroke is learning how to use a cane under the guidance of the nurse. The patient expresses a desire to be as independent as possible in mobility. During the teaching session, the nurse observes the patient’s ability to use the cane correctly. Which of the following behaviors, if demonstrated by the patient, indicates that the teaching was effective? A. The client holds the cane with his right hand, moves the cane forward followed by the right leg, and then moves the left leg. B. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg. C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. D. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg. Correct Answer: C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. The cane acts as a support and aids in weight-bearing for the weaker right leg. Option A: The client should hold the cane with his left hand because this side provides more stable support than the injured side. Option B: The right side should act as the weight-bearing side because the left side is weaker. Option D: Always move the affected leg first; in this case, the right leg. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 7 7. 7. Question 1 point(s) Category: Physiological Adaptation An 82-year-old female patient with a history of mild cognitive impairment and Parkinson’s disease is admitted to a nursing home. The patient occasionally exhibits confusion and has an unsteady gait. The nurse is assessing the patient’s needs and environment to promote safety and comfort. Which of the following actions, if taken by the nurse, is most appropriate? A. Ask the woman’s family to provide personal items such as photos or mementos. B. Select a room with a bed by the door so the woman can look down the hall. C. Suggest the woman eat her meals in the room with her roommate. D. Encourage the woman to ambulate in the halls twice a day. Correct Answer: A. Ask the woman’s family to provide personal items such as photos or mementos. Photos and mementos provide visual stimulation to reduce sensory deprivation. Providing personal items can help in orienting the patient to the new environment and can be comforting, especially for someone with mild cognitive impairment. Option B: The client is often confused and may wander outside her room and easily get lost. Option C: The client may take her meals with a roommate or in the dining hall. Option D: This may lead to incidence of falls or injury because the client’s gait is unsteady. Assistance during ambulation is most appropriate. 8. 8. Question 1 point(s) Category: Health Promotion and Maintenance A 78-year-old male patient with a recent hip replacement surgery is learning to use a standard aluminum walker under the guidance of the nurse. The patient has mild arthritis in both hands and experiences occasional shortness of breath. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 8 Which of the following behaviors, if demonstrated by the patient, indicates that the nurse’s teaching was effective? A. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker. B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. C. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker. D. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance. E. The patient places the walker ahead, leans on it with one hand while holding his hip with the other, and then steps forward. F. The patient holds the sides of the walker, takes a step forward, and then moves the walker to align with his new position. Correct Answer: B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. Lifting the walker slightly, moving it forward a short distance (10 inches), and then taking steps is the recommended method. This technique ensures stability and minimizes the risk of falls. A walker needs to be picked up, placed down on all legs. Option A: Teach the client to lift, not push, the walker forward, and not to lean on it to avoid falls. Option C: The client should not put his weight on the walker as it may lead to incidents of falls. Option D: A walker should be lifted, not slide. Option E: Leaning on the walker with one hand while holding the hip with the other does not provide adequate support and may lead to imbalance. Option F: The patient should lift and move the walker slightly forward, not just hold its sides and step forward. This method might not provide sufficient stability. 9. 9. Question 1 point(s) Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 9 Category: Health Promotion and Maintenance A nurse is supervising a diverse group of elderly clients aged 75-90 years in a residential home setting. Many of these clients have varied health conditions, including vision and hearing impairments, limited mobility, and chronic illnesses that require medication. The nurse is assessing factors that could contribute to sensory deprivation in these clients. Which of the following reasons is most likely to increase the risk of sensory deprivation in this elderly group? A. Increased sensitivity to the side effects of medications. B. Decreased visual, auditory, and gustatory abilities. C. Isolation from their families and familiar surroundings. D. Decrease musculoskeletal function and mobility. Correct Answer: B. Decreased visual, auditory, and gustatory abilities. Gradual loss of sight, hearing, and taste interferes with normal functioning. Option A: The side effects of medications do not usually affect the senses in the elderly. Option C: Isolation is not the reason for developing sensory deprivation. Option D: Decrease in mobility and functioning does not cause sensory deprivation. 10. 10. Question 1 point(s) A 68-year-old male patient with a history of chronic emphysema presents in the clinic with symptoms of increasing restlessness and confusion. He has a history of smoking and reports difficulty in breathing. The nurse is assessing the patient to determine the best immediate course of action. What step should the nurse take next? A. Encourage the client to perform pursed-lip breathing. B. Check the client’s temperature. C. Assess the client’s potassium level. D. Increase the client’s oxygen flow rate. Correct Answer: A. Encourage the client to perform pursed-lip breathing. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 10 Pursed lip breathing prevents the collapse of the lung unit and helps client control the rate and depth of breathing. Option B: Checking the temperature is unnecessary especially if the client is restless. Option C: Emphysema does not significantly affect potassium levels. Option D: Do not increase the oxygen levels in a client with emphysema. 11. 11. Question 1 point(s) Category: Reduction of Risk Potential A 45-year-old male patient who recently underwent a kidney transplant is being monitored in the post-operative period. During a routine check-up, the patient reports feeling generally unwell and expresses discomfort in the area of the transplant. The nurse is vigilant for signs of organ rejection. Which of the following assessments would most strongly prompt the nurse to suspect organ rejection? A. Sudden weight loss B. Polyuria C. Hypertension D. Shock Correct Answer: C. Hypertension Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection. 12. 12. Question 1 point(s) A 52-year-old male patient, who is overweight and has a history of mild hypertension, presents to the healthcare facility with symptoms of severe flank pain and hematuria. The patient has been diagnosed with ureteral colic. The nurse is focusing on the immediate management of the patient’s condition. What should be the immediate objective of nursing care for this patient? A. Decrease pain. B. Decrease weight. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 11 C. Decrease hematuria. D. Decrease hypertension. E. Increase fluid intake. F. Initiate dietary modifications. G. Administer antibiotics. Correct Answer: A. Decrease pain. Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by urethral distention and smooth muscle spasm; relief from pain is the priority. 13. 13. Question 1 point(s) Category: Pharmacological and Parenteral Therapies A 38-year-old female patient with a diagnosis of hyperthyroidism is scheduled to receive Lugol’s iodine solution as a preoperative preparation before undergoing a subtotal thyroidectomy. The patient experiences symptoms including rapid heart rate, weight loss, and anxiety. The nurse is preparing to administer the medication and educates the patient on its purpose. What is the primary reason for administering Lugol’s iodine solution to this patient? A. Decrease the total basal metabolic rate. B. Maintain the function of the parathyroid glands. C. Block the formation of thyroxine by the thyroid gland. D. Decrease the size and vascularity of the thyroid gland. E. Prevent postoperative hypocalcemia. F. Stabilize the patient’s heart rate. Correct Answer: D. Decrease the size and vascularity of the thyroid gland. Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed. 14. 14. Question 1 point(s) Category: Physiological Adaptation Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 12 A 30-year-old male patient, recently diagnosed with type 1 diabetes, is being educated by the nurse on potential complications of diabetes, including acute hypoglycemia. The patient is keen to understand how different health conditions might interact with his diabetes. The nurse is discussing other conditions that might also predispose a patient to develop acute hypoglycemia. Which of the following conditions can also lead to acute hypoglycemia? A. Liver disease B. Hypertension C. Type 2 diabetes D. Hyperthyroidism Correct Answer: A. Liver Disease The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen. Option B: The hemodynamic changes associated with hypoglycemia include an increase in heart rate and peripheral systolic blood pressure, a fall in the central blood pressure, reduced peripheral arterial resistance, and increased myocardial contractility, stroke volume, and cardiac output. Option C: Type 2 diabetes is an islet paracrinopathy in which the reciprocal relationship between the glucagon-secreting alpha cell and the insulin- secreting beta-cell is lost, leading to hyperglucagonemia and hence the consequent hyperglycemia. Option D: Hyperthyroidism is usually associated with poor blood glucose control and a need for additional insulin. An increased metabolism “clears” insulin from the system at a faster rate, and increased production and absorption of glucose can raise blood sugars. 15. 15. Question 1 point(s) Category: Physiological Adaptation A 55-year-old female patient is receiving combination chemotherapy for the treatment of metastatic carcinoma. The patient has been experiencing fatigue and nausea. The nurse is closely monitoring the patient for potential systemic Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 13 side effects of the chemotherapy treatment. Which of the following systemic side effects should the nurse monitor for in this patient? A. Ascites B. Nystagmus C. Leukopenia D. Polycythemia Correct Answer: C. Leukopenia Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression. Option A: Ascites is common in some cancers that have reached the advanced stages and spread in the abdominal area. Sometimes chemotherapy might help manage ascites; it is not a side effect of chemotherapy. Option B: Platinum-based chemotherapy is an effective antineoplastic intervention that is used for a variety of human malignancies. There were reports of spontaneous nystagmus in 7 out of 10 patients (70%) and positional nystagmus (60%). Option D: While polycythemia vera is not a side effect of chemotherapy, it can become drug-induced with the excess use of rHuEPO or anabolic steroids. 16. 16. Question 1 point(s) Category: Health Promotion and Maintenance A 60-year-old female patient with a recent colostomy is adjusting to her new lifestyle. She expresses concerns to the nurse about the inability to control the passage of gas, especially in social situations. The patient is seeking advice on dietary modifications to help manage this issue. What should the nurse suggest to the patient to help control the passage of gas from the colostomy? A. Eliminate foods high in cellulose. B. Decrease fluid intake at mealtimes. C. Avoid foods that in the past caused flatus. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 14 D. Adhere to a bland diet prior to social events. Correct Answer: C. Avoid foods that in the past caused flatus. Foods that bothered a person preoperatively will continue to do so after a colostomy. Option A: Cellulose is just one of the several types of dietary fiber that naturally occur in food sources. Examples are green, leafy vegetables, Brussels sprouts, and green peas. Option B: Increased fluid intake aids in the easy passage of stools and improves the consistency of colostomy stools. Option D: Bland foods such as broccoli, cabbage, cauliflower, cucumber, green peppers, and corn increase passage of gas. 17. 17. Question 1 point(s) Category: Health Promotion and Maintenance A 56-year-old male patient who recently underwent surgery for a colostomy is learning colostomy irrigation techniques from the nurse. The patient is anxious about managing his colostomy independently and is attentive to the instructions. The nurse wants to ensure that the patient has understood the process correctly. Which of the following statements by the patient would indicate to the nurse that the instructions for colostomy irrigation have been understood correctly? A. "I should lie on my left side while instilling the irrigating solution.” B. "I should keep the irrigating container less than 18 inches above the stoma.” C. "I should instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.” D. "I should insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.” Correct Answer: B. Keep the irrigating container less than 18 inches above the stoma.” This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated. Option A: The client must turn on the appropriate side to allow the nurse to do the procedure without difficulty. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 15 Option C: Ask the physician how much water is needed to irrigate. Option D: Cramping during an irrigation may mean that the water is too cold, the irrigation bag is too high, or the water is going too fast. Clamp off the tubing if this occurs. 18. 18. Question 1 point(s) Category: Physiological Adaptation A 62-year-old male patient, in the oliguric phase of acute tubular necrosis, presents with fluid and electrolyte imbalances. The patient exhibits confusion, nausea, and muscle weakness. As part of the medical management to correct these imbalances, the nurse is preparing to administer the prescribed therapy. Which of the following interventions would the nurse expect to be part of the prescribed therapy to correct the electrolyte imbalance in this patient? A. Administer Kayexalate B. Restrict foods high in protein C. Increase oral intake of cheese and milk. D. Administer large amounts of normal saline via I.V. E. Administer a diuretic to increase urine output. F. Provide supplementation of potassium orally. Correct Answer: A. Administer Kayexalate Kayexalate, a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level. Option B: Higher protein intake can increase intraglomerular pressure, which is useful in the short term when the client eats a large protein meal with high-protein content so that one can ensure effective clearance of nitrogenous end products that are produced from eating too much protein. Option C: Phosphorus, which is abundant in dairy products, draws calcium out of the bones when it builds up in the blood. Clients with renal diseases may eat some of these foods in very small amounts. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 16 Option D: Although 0.9% saline and balanced fluids can both lead to renal volume expansion, interstitial fluid retention, and adverse intra-renal microvascular effects are more pronounced with 0.9% saline infusion. 19. 19. Question 1 point(s) Category: Pharmacological and Parenteral Therapies Mario has a burn injury. After 48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: A. 18 gtt/min B. 28 gtt/min C. 32 gtt/min D. 36 gtt/min Correct Answer: B. 28 gtt/min This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) Option A: This amount is inadequate according to the formula used. Option C: 32 gtts/min is more than the prescribed gtts/min given. Option D: This amount is incorrect according to the formula used to get the correct flow rate. 20. 20. Question 1 point(s) Category: Physiological Adaptation A 40-year-old male patient suffered a burn injury in a household accident. The burns cover his face, neck, right upper arm, and upper trunk. The nurse is using the rule of nines to estimate the total body surface area (TBSA) affected by the burns to guide treatment planning. According to the rule of nines, which area has the largest percent of burns? A. Face and neck B. Right upper arm and penis Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 17 C. Right thigh and penis D. Upper trunk Correct Answer: D. Upper trunk The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%. Option A: The face and neck is 9%. Option B: The right upper arm is 9% and the penis is only 1%. Option C: The right thigh is 9% and the penis is 1%. 21. 21. Question 1 point(s) Category: Physiological Adaptation A 45-year-old male, working as a construction engineer, is brought to the emergency department after an accident where he fell from a 2-story building. Upon arrival, he is found to be unconscious with no external signs of injury except for minor abrasions. The patient’s medical history is significant for hypertension, controlled with medication. There is no information available about the circumstances of the fall or the exact nature of the impact. The nurse’s assessment focuses on identifying immediate life-threatening injuries, particularly those related to potential head trauma, spinal injury, or internal bleeding. Given this scenario, which of the following assessment findings should the nurse be most concerned about? A. Reactive pupils B. A depressed fontanel C. Bleeding from ears D. An elevated temperature Correct Answer: C. Bleeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures, and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 18 Option A: The normal pupil size varies from 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. The pupils are generally equal in size. They constrict to direct illumination and to illumination of the opposite eye. The pupil dilates in the dark. Both pupils constrict when the eye is focused on a near object. Option B: The anterior fontanelle remains soft until about 18 months to 2 years of age. The posterior fontanelle usually closes first, during the first several months of an infant’s life. Option D: Hypothermic trauma patients are less likely to survive their injuries when compared to similar patients who are normothermic. Hypothermia in conjunction with metabolic acidosis and impair coagulation creates a “lethal triad”, which significantly worsens the chances of recovery from a critical injury. 22. 22. Question 1 point(s) Category: Health Promotion and Maintenance A 67-year-old male patient who recently had a permanent artificial pacemaker implanted is receiving education from the nurse about managing his health and lifestyle with the device. The patient enjoys an active lifestyle and is keen to understand what activities and precautions are necessary with his new pacemaker. He also uses various electrical appliances at home and is concerned about how they might affect his pacemaker. In this scenario, which piece of information provided by the nurse indicates a knowledge deficit regarding the management of a patient with an artificial cardiac pacemaker? A. "Take your pulse rate once a day, in the morning upon awakening." B. "You may use electrical appliances but maintain a safe distance from high- powered devices." C. "Regular follow-up care is important to ensure the pacemaker is functioning correctly." D. "You may engage in contact sports." Correct Answer: D. may engage in contact sports The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 19 Option A: The physician may advise to take and record the pulse rate often to gauge the heart rate. This allows comparison of the heart rate to the acceptable range to determine if the pacemaker is working effectively. Option B: Use of electrical appliances is allowed, but the client must maintain a distance from the appliances. Devices such as anti-theft systems, metal detectors, cell phones, mp3 players/headphones, radios, power-generating equipment, magnets, etc may interfere with a pacemaker. Option C: Modern pacemakers are built to last. Still, it needs to be checked periodically to assess the battery and find out how the wires are working, so it is a must to keep pacemaker checkup appointments. 23. 23. Question 1 point(s) Category: Physiological Adaptation A 68-year-old male patient with a history of Chronic Obstructive Pulmonary Disease (COPD) is admitted to the hospital with exacerbation of his respiratory symptoms. He is experiencing shortness of breath and his blood oxygen levels are low. The nurse is planning the oxygen therapy for this patient, considering the specific needs of patients with COPD. Which statement reflects the most relevant knowledge about oxygen administration to a patient with COPD? A. "Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing." B. "Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breathe." C. "Oxygen is administered best using a non-rebreathing mask." D. "Blood gases are monitored using a pulse oximeter." Correct Answer: A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive. Option B: The hypoxic state of the client is the stimulus for breathing. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 20 Option C: The client may use the Venturi mask as a high flow device that delivers a fixed oxygen concentration and is best for clients with COPD. Option D: Blood gas analysis or arterial blood gas (ABG) test measures the amount of oxygen and carbon dioxide in the blood. It may also be used to determine the pH of the blood, or how acidic it is. 24. 24. Question 1 point(s) Category: Physiological Adaptation A 58-year-old male patient has recently undergone a left thoracotomy and a partial pneumonectomy to treat lung cancer. Post-surgery, chest tubes are inserted, and one-bottle water-seal drainage is instituted. In the postanesthesia care unit, the nurse positions the client in Fowler’s position on his right side or on his back. The nurse understands that this positioning is critical for postoperative recovery. Understanding the implications of postoperative positioning, the nurse is aware that placing the patient in Fowler’s position on either his right side or on his back primarily: A. Reduce incisional pain. B. Facilitate ventilation of the left lung. C. Equalize pressure in the pleural space. D. Increase venous return. Correct Answer: B. Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining left lung by positioning the client on the opposite unoperated side. Option A: This position may reduce the pressure on the surgical incision site, but it is not its priority. Option C: Fowler’s position is associated with improvement of functional residual capacity, oxygenation, and reduction of work of breathing. Option D: On the transition from sitting to standing, blood is pooled in the lower extremities as a result of gravitational forces. Venous return is reduced, which leads to a decrease in cardiac stroke volume, a decline in Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 21 arterial blood pressure, and an immediate decrease in blood flow to the brain. 25. 25. Question 1 point(s) Category: Reduction of Risk Potential A 42-year-old female patient is scheduled for a bronchoscopy to investigate recent breathing difficulties and a persistent cough. Post-procedure care is crucial for her safety and recovery. The nurse is providing the patient with pre-procedure education, emphasizing the most important aspects of post-procedure care. In teaching the patient what to expect and how to care for herself after the bronchoscopy, what is the highest priority information the nurse should provide? A. Food and fluids will be withheld for at least 2 hours. B. Warm saline gargles will be done q 2h. C. Coughing and deep-breathing exercises will be done q2h. D. Only ice chips and cold liquids will be allowed initially. Correct Answer: A. Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctors spray the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours. Option B: Warm saline gargles may help soothe the throat after bronchoscopy. Option C: Coughing should not be done after bronchoscopy to avoid initiating bleeding. Option D: The client should be on NPO status after bronchoscopy until gag reflex has returned. 26. 26. Question 1 point(s) Category: Physiological Adaptation A 55-year-old male patient is admitted with acute renal failure and is under the care of a nurse. The patient’s recent blood work shows a significantly elevated potassium level, which is a common complication in acute renal failure. The nurse Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 22 is preparing for the prescribed treatment to address this electrolyte imbalance. Given the patient’s condition and laboratory results, for which of the following conditions should the nurse expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used? A. Hypernatremia. B. Hypokalemia. C. Hyperkalemia. D. Hypercalcemia. Correct Answer: C. Hyperkalemia. Hyperkalemia is a common complication of acute renal failure. It’s life- threatening if immediate action isn’t taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate, if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Option A: Hypernatremia is believed to be due to post-acute kidney injury diuresis in the face of inability to maximally concentrate the urine because of renal failure. The diuresis caused a disproportionate loss of water in excess of that of sodium in the absence of replenishment of the water loss. Option B: Hypokalemia is related to increased use of diuretics, decreased use of RAS blockade, and malnutrition, all of which may impose additive deleterious effects on renal outcomes. Option D: Hypocalcemia is a frequent accompaniment of acute renal failure, but paradoxically hypercalcemia also has been described in association with acute renal failure. This may be caused by dissolution of dystrophic calcifications in traumatized muscle and may lead to severe metastatic calcifications. 27. 27. Question 1 point(s) Category: Physiological Adaptation A 32-year-old female presents to the clinic with a recent diagnosis of condylomata acuminata (genital warts). She is concerned about the implications of her diagnosis and future health risks. Which of the following statements by the nurse is most appropriate? Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 23 A. "This condition increases your risk for cervical cancer. It's important to have a Papanicolaou (Pap) smear annually." B. "The usual treatment for this is metronidazole (Flagyl), which typically resolves the issue within 7 to 10 days." C. "Using condoms every time during sexual intercourse significantly reduces, but does not completely eliminate, the risk of transmitting the virus to your partner." D. "The human papillomavirus (HPV), responsible for your condition, can still be transmitted during oral sex." Correct Answer: A. “This condition increases your risk for cervical cancer. It’s important to have a Papanicolaou (Pap) smear annually.” Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Option B: Genital warts may be treated with imiquimod, podophyllin and podofilox, trichloroacetic acid, and sinecatechins. These are all topical treatments that the physician or even the client may apply. Option C: Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners. Option D: HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. 28. 28. Question 1 point(s) A 45-year-old individual presents to the emergency department with flank pain and a recent diagnosis of a genitourinary problem. The nurse prepares to palpate the patient’s kidneys, keeping in mind relevant anatomical facts. Which statement is correct regarding the location and size of kidneys? A. The left kidney usually is slightly higher than the right one. B. The kidneys are situated just above the adrenal glands. C. The average kidney is approximately 5 cm (2 inches) long and 2 to 3 cm 3/4 inch to 1 1/8 inch) wide. D. The kidneys lie between the 10th and 12th thoracic vertebrae. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 24 Correct Answer: A. The left kidney usually is slightly higher than the right one. The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. Option C: The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2 1/4”) wide, and 2.5 cm (1″) thick. Option B: The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. Option D: They lie between the 12th thoracic and 3rd lumbar vertebrae. 29. 29. Question 1 point(s) Category: Reduction of Risk Potential A 60-year-old male with a history of hypertension and diabetes is admitted to the urology unit with symptoms of fatigue, decreased urine output, and nausea. He has a known diagnosis of chronic renal failure (CRF). The nurse reviews his recent laboratory test results. Which result is most consistent with a diagnosis of CRF? A. Increased pH with decreased hydrogen ions. B. Increased serum levels of potassium, magnesium, and calcium. C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl. D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%. Correct Answer: C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated, reflecting CRF and the kidneys’ decreased ability to remove nonprotein nitrogen waste from the blood. Option A: CRF causes decreased pH and increased hydrogen ions — not vice versa. Option B: CRF also increases serum levels of potassium, magnesium, and phosphorus, and decreases serum levels of calcium. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 25 Option D: A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%. 30. 30. Question 1 point(s) Category: Physiological Adaptation A 35-year-old female patient, presenting with a history of irregular menstrual cycles and recent abnormal vaginal discharge, receives an abnormal result on a Papanicolaou (Pap) smear test. After unintentionally viewing her chart, the patient inquires about the meaning of ‘dysplasia’ noted in her results. The nurse should provide which definition of dysplasia? A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin. B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ. C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found. D. Alteration in the size, shape, and organization of differentiated cells. Correct Answer: D. Alteration in the size, shape, and organization of differentiated cells Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. Option A: The presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin is called anaplasia. Option B: An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Option C: Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found is called metaplasia. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 26 1. 1. Question 1 point(s) Category: Pharmacological and Parenteral Therapies The nurse is caring for a 65-year-old male client with a history of ischemic heart disease who has been admitted to the ICU following a myocardial infarction. The client is currently receiving lidocaine I.V. to manage his ventricular ectopy, which has been persistent. Which of the following factors would be most important for the nurse to consider in relation to the administration of this medication? o A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter o B. Increase in systemic blood pressure o C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor o D. Increase in intracranial pressure (ICP) o E. A drop in serum potassium levels as indicated in the latest lab results o F. Observation of a widening QRS complex on the ECG Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. In the context of acute myocardial infarction, the priority is to manage life- threatening arrhythmias. Lidocaine is specifically indicated for the treatment of ventricular arrhythmias, such as PVCs, which can be indicative of an increased risk for more serious arrhythmias like ventricular tachycardia or ventricular fibrillation. The presence of PVCs on a cardiac monitor would be the most immediate concern that lidocaine can address in this scenario. While the other factors listed are important to monitor, they are not the primary indications for lidocaine administration in the context of arrhythmia management. 2. 2. Question 1 point(s) Category: Pharmacological and Parenteral Therapies A 72-year-old male patient with a history of atrial fibrillation and controlled hypertension has been initiated on warfarin therapy. Upon assessment of the patient’s history, it was revealed that he has a history of peptic ulcer. This patient Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 27 also has a recent history of a peptic ulcer. Given the client’s medical history and current medication regimen, which of the following instructions should the nurse prioritize when providing discharge teaching? o A. Report incidents of diarrhea o B. Avoid foods high in vitamin K o C. Use a straight razor when shaving o D. Take aspirin for pain relief o E. Monitor for signs of bleeding, such as bruising or black tarry stools o F. Check blood pressure regularly at home o G. Inform all healthcare providers about the anticoagulant therapy Correct Answer: B. Avoid foods high in vitamin K Clients taking warfarin should be educated about maintaining a consistent intake of vitamin K, as it is necessary for the clotting cascade, and warfarin works by inhibiting the effects of vitamin K, thereby reducing the blood’s ability to clot. Sudden increases in vitamin K intake can decrease the effectiveness of warfarin and increase the risk of clot formation. Clients should also be advised to report any incidents of diarrhea (A) since it can affect the absorption of the medication and potentially lead to unstable anticoagulation levels. Using a straight razor (C) is not advised due to the increased risk of bleeding; a safety razor or electric razor would be safer alternatives. Taking aspirin for pain relief (D) is not recommended without a physician’s approval because aspirin can increase the risk of bleeding when taken with an anticoagulant. Monitoring for signs of bleeding (E), checking blood pressure regularly (F), and informing all healthcare providers about anticoagulant therapy (G) are also important instructions for a patient on warfarin therapy, but avoiding foods high in vitamin K is directly related to the effectiveness of the anticoagulant medication and is thus the priority teaching point. 3. 3. Question 1 point(s) Category: Reduction of Risk Potential Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 28 In a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-year- old patient who is scheduled for elective surgery and has a notably hairy forearm where the I.V. is to be placed. The patient is allergic to a variety of adhesives and has sensitive skin that is prone to irritation. Given these considerations, how should the nurse manage excess hair at the intended catheter insertion site? o A. Leaving the hair intact o B. Shaving the area o C. Clipping the hair in the area o D. Removing the hair with a depilatory o E. Applying a small amount of water-soluble gel to tame the hair without cutting o F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible without causing abrasions Correct Answer: C. Clipping the hair in the area Clipping is preferred over shaving in this scenario because it reduces the potential for creating microabrasions that can increase infection risk, which is especially important in a patient with sensitive skin. Chemical depilatories (D) are not recommended due to the patient’s history of allergies and sensitive skin. Leaving the hair intact (A) could interfere with the securement of the I.V. and increase the risk of infection. Water-soluble gel (E) is not standard practice for managing hair at an I.V. site and does not address the infection control issue. A sterile surgical scalpel (F) is not typically recommended for hair removal in preparation for I.V. insertion due to the risk of cuts and abrasions. Clipping is the safest option that balances the need to reduce infection risk with the patient’s sensitivity and allergy concerns. 4. 4. Question 1 point(s) Category: Health Promotion and Maintenance A nurse is tasked with the education of an elderly female patient who has been recently diagnosed with osteoporosis. The patient leads a sedentary lifestyle, has Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 29 a diet low in calcium, has undergone menopause ten years prior, and has a visibly kyphotic posture. In planning the education for this patient, which of the following complications should the nurse emphasize as the most significant risk associated with osteoporosis, especially considering the patient’s profile? o A. Increased susceptibility to bone fractures from minimal trauma o B. Consequences of long-term estrogen deficiency post-menopause o C. The impact of sustained negative calcium balance on bone density o D. The progression of spinal deformities such as a kyphotic curvature o E. Potential for height loss over time due to vertebral compression o F. Risk of developing chronic pain associated with skeletal weakness Correct Answer: A. Increased susceptibility to bone fractures from minimal trauma. Given the patient’s diagnosis of osteoporosis, a sedentary lifestyle, and poor dietary habits, the most significant and immediate complication is the risk of bone fractures, particularly hip, wrist, and spine fractures, which can result from minimal stress. The patient’s visible kyphosis also indicates a history of spinal bone loss, which compounds this risk. Estrogen deficiency (B) is a contributing factor to the development of osteoporosis but is not a direct complication. Negative calcium balance (C) is a concern that should be addressed as it contributes to bone density loss; however, it is not a complication but rather a contributing factor. Progression of spinal deformities (D), height loss (E), and chronic pain (F) are all concerns associated with osteoporosis. Still, the priority education should focus on preventing fractures, which can have immediate and severe consequences on the patient’s mobility and quality of life. 5. 5. Question 1 point(s) Category: Health Promotion and Maintenance A community health nurse is conducting a workshop on breast health for a group of women with diverse backgrounds, ranging from those who have never performed Breast Self-Examination (BSE) to some who have had benign breast conditions in the past. As part of the educational session, the nurse emphasizes the importance of BSE for the early detection of potential breast anomalies. What Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 30 should the nurse identify as the primary goal for these women in performing regular BSE? o A. To detect any cancerous lumps early in their development o B. To identify areas of thickness or fullness that differ from the rest of the breast tissue o C. To notice any changes in the breast tissue from what is normal for each individual o D. To differentiate between fibrocystic masses and other types of breast lumps o E. To promote self-awareness of breast health and encourage routine health screening o F. To understand the normal texture and appearance of their breast tissue for future comparison Correct Answer: C. To notice any changes in the breast tissue from what is normal for each individual. The primary purpose of BSE is for individuals to become familiar with their own breasts so they can detect any changes early, which could be indicative of breast cancer or other breast conditions. Detecting cancerous lumps (A) is an important aspect of BSE, but the emphasis is on noticing any change, not only cancer. Identifying areas of thickness or fullness (B) and differentiating types of masses (D) are part of noticing changes, but these are not the primary goals. Promoting self-awareness and encouraging routine screening (E), as well as understanding normal breast tissue (F), are also critical educational points, but the main goal remains the detection of any new or unusual changes since the last examination. 6. 6. Question 1 point(s) Category: Basic Care and Comfort A nurse is managing the care of a 32-year-old female client diagnosed with hyperthyroidism. The client reports experiencing palpitations, unintentional weight loss, and intermittent bouts of excessive sweating. The treatment plan includes antithyroid medications. In addition to administering medication, what Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 31 nursing interventions should be prioritized to manage the client’s condition best? o A. Ensure the client is provided with extra blankets and clothing to maintain a warm environment due to heightened sensitivity to cold. o B. Closely monitor the client for increased signs of restlessness, sweating, and significant weight loss. o C. Create a balance between the client's periods of activity and rest to manage fatigue without exacerbating symptoms. o D. Encourage increased physical activity to counteract the sedative effects of the medication and prevent constipation. o E. Regularly check the client’s temperature as they are prone to developing fevers. o F. Offer a low-iodine diet and coordinate with a dietitian to manage dietary influences on thyroid function. Correct Answer: C. Create a balance between the client’s periods of activity and rest to manage fatigue without exacerbating symptoms. Clients with hyperthyroidism may experience symptoms like fatigue and muscle weakness. Balancing activity with rest helps to conserve energy and prevent exacerbation of symptoms. Option A: Providing extra blankets is more associated with patients with hypothyroidism. Option B: Monitoring for signs of restlessness and sweating is essential, but this option refers more to the assessment of potential overmedication rather than an intervention. Option D: Encouraging the client to be active to prevent constipation (D) is less specific to hyperthyroidism, where diarrhea is more common than constipation. Options E and F: Checking for fever (E) and offering a low-iodine diet (F) are additional supportive measures. However, they do not directly address managing the client’s current symptoms and treatment plan as effectively as balancing activity and rest. 7. 7. Question Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 32 1 point(s) Category: Health Promotion and Maintenance A nurse is providing discharge education to a 55-year-old client who has been hospitalized with symptoms leading to a diagnosis of atherosclerosis. The client has a sedentary lifestyle, a high-stress job, and a diet high in saturated fats. As part of the client’s comprehensive care plan to manage and reduce the progression of atherosclerosis, which of the following lifestyle modifications should the nurse emphasize? A. Emphasize the importance of not focusing solely on weight as a health measure, but rather on overall cardiovascular health. B. Recommend an incremental increase in physical activity, starting with low-intensity exercises such as walking or swimming. C. Advise adherence to a heart-healthy diet, rich in fruits, vegetables, whole grains, and lean proteins, while limiting saturated fats and cholesterol. D. Counsel on stress management techniques and the importance of incorporating relaxation activities into daily routines. E. Discuss smoking cessation strategies if applicable and avoid exposure to secondhand smoke. F. Suggest regular monitoring of blood pressure and cholesterol levels with follow-up appointments to assess cardiovascular health. Correct Answer: B. Recommend an incremental increase in physical activity, starting with low-intensity exercises such as walking or swimming. Increasing physical activity is a key intervention for a client with atherosclerosis in managing and slowing the disease’s progression. While the other options are valid health measures, they are less directly impactful on atherosclerosis than increasing physical activity. A heart-healthy diet (C) and stress management (D) are also essential but support the primary intervention of increased physical activity. Smoking cessation (E) is critical if the client smokes, and regular monitoring (F) is part of ongoing management, but these options were not specified in the original question. 8. 8. Question 1 point(s) Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 33 Category: Physiological Adaptation In a postoperative unit, a nurse is caring for a client who has recently undergone a laminectomy to relieve spinal cord compression. The client is alert but has been instructed to minimize movement to prevent post-surgical complications. In addition to monitoring for the usual postoperative signs such as infection or bleeding, which technique should the nurse use to reposition the client to promote comfort and prevent injury safely? A. Logroll the client carefully to maintain spinal alignment, ensuring that the head, back, and legs move as one unit. B. Assist the client to dangle on the side of the bed before standing to promote circulation and reduce the risk of orthostatic hypotension. C. Encourage the client to use an overhead trapeze when self-repositioning to enhance independence and strengthen upper body muscles. D. Instruct the client to perform gentle range-of-motion exercises to the lower extremities to prevent venous stasis and deep vein thrombosis. E. Utilize a transfer board when moving the client from the bed to a chair to reduce shearing forces on the healing spine. F. Apply gentle traction to the client's legs when turning to decrease pressure on the surgical site and alleviate pain. Correct Answer: A. Logroll the client carefully to maintain spinal alignment, ensuring that the head, back, and legs move as one unit. After a laminectomy, it is essential to avoid twisting the spine to prevent damage to the surgical site. Logrolling is a technique used to turn the client while keeping the spine neutral. The additional choices, while they may be appropriate for other postoperative scenarios, do not specifically address the needs of a client who has had a laminectomy. 9. 9. Question 1 point(s) Category: Health Promotion and Maintenance A 55-year-old client who just had cataract removal with an intraocular lens implant is being prepared for discharge. The client has a history of hypertension and is moderately active. The client’s postoperative recovery has been uneventful, Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 34 but they express anxiety about ensuring a proper recovery. The nurse needs to provide comprehensive discharge instructions. In addition to avoiding activities that could increase ocular pressure, which of the following should be included in the discharge education? A. Restrict fluids to limit the need for frequent urination. B. Avoid lifting objects heavier than 5 lb (2.25 kg) and engage in light activities like walking. C. Remain in a prone position while resting to facilitate healing. D. Keep living spaces dimly lit to avoid glare and discomfort in the healing eye. E. Refrain from straining during bowel movements and avoid bending at the waist. Correct Answer: E. Refrain from straining during bowel movements and avoid bending at the waist to prevent pressure on the eye. After cataract surgery, clients must avoid activities that can increase intraocular pressure, affecting the surgical site and the newly placed intraocular lens. Straining during bowel movements and bending at the waist can increase intraocular pressure and, therefore, should be avoided. Option A: Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb. Option B: Instruct the client when lying in bed to lie on either the side or back. Option C: The client should avoid bright light by wearing sunglasses. Option D: Excessively bright light should be avoided, but appropriate ambient lighting is necessary to prevent accidents and ensure safety. 10. 10. Question 1 point(s) Category: Health Promotion and Maintenance George, a 17-year-old individual, is attending a health education session at a community clinic. The clinic is conducting screenings and teaching about early detection of common health issues in young adults. George has a family history of testicular cancer and is seeking information on how to reduce his risk. The nurse should include education on testicular self-examinations as part of the Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 35 session. At what age should the nurse emphasize the initiation of regular testicular self-examinations? A. At the onset of sexual activity to ensure sexual health is maintained. B. After the age of 69, as part of a routine examination for senior health. C. Starting after age 40, coinciding with increased risk for other male health issues. D. Prior to the age of 20, to establish early detection habits during the peak incidence of testicular cancer. E. During the annual physical examination, regardless of age, to ensure consistency. Correct Answer: D. Prior to the age of 20, to establish early detection habits during the peak incidence of testicular cancer. Educating George and other young individuals about the importance of regular testicular self-examinations can lead to the early detection of abnormalities, which is crucial for early intervention, especially given George’s family history of testicular cancer. Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens. 11. 11. Question 1 point(s) Category: Physiological Adaptation A 50-year-old male client with a history of colorectal cancer has recently undergone a colon resection. Postoperatively, while assisting the client to turn in bed for routine care, the nurse notices the surgical wound site has suddenly dehisced, and there is evisceration of abdominal contents. In prioritizing the immediate actions to take, which step should the nurse perform first to address this acute complication? A. Promptly notify the surgeon to report the critical incident and seek further orders. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 36 B. Immediately cover the eviscerated tissue with a dressing moistened with sterile normal saline. C. Check the client's vital signs to assess for shock or other immediate life- threatening conditions. D. Attempt to gently approximate the wound edges without applying pressure to the eviscerated organs. E. Prepare the client for emergency surgery while ensuring the preservation of the exposed tissues. F. Administer prescribed analgesia to manage the client's pain due to the dehiscence. Correct Answer: B. Immediately cover the eviscerated tissue with a dressing moistened with sterile normal saline. This action is critical to maintain the viability of the exposed organs and prevent further contamination and infection. It is the most immediate and appropriate first step in the event of evisceration. Once this is done, the nurse should then perform other actions, such as notifying the surgeon (A), assessing vital signs (C), and preparing the client for emergency intervention (E). Attempting to close the wound (D) or administering pain medication (F) should only be done under the direct instruction of a physician, as they are not initial emergency measures. 12. 12. Question 1 point(s) Category: Physiological Adaptation The nurse is monitoring a 78-year-old male patient who has experienced a significant cerebrovascular accident resulting in extensive brain damage. During a comprehensive evaluation, the nurse observes the patient’s respiratory pattern and identifies a cycle of respirations that increase and decrease in depth and rate, culminating in periods where breathing temporarily ceases. This observation is most consistent with which of the following descriptions? A. Progressively deeper breaths followed by shallower breaths with apneic periods. B. Rapid, deep breathing with abrupt pauses between each breath. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 37 C. Rapid, deep breathing and irregular breathing without pauses. D. Shallow breathing with an increased respiratory rate. Correct Answer: A: Progressively deeper breaths followed by shallower breaths with apneic periods. The pattern described is indicative of Cheyne-Stokes respirations, which are often seen in patients with conditions that affect the brain’s respiratory centers, such as following a severe stroke. Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath and equal depth between each breath. Option C: Kussmaul’s respirations are rapid, deep breathing without pauses. Option D: Tachypnea is shallow breathing with increased respiratory rate. 13. 13. Question 1 point(s) Category: Physiological Adaptation The nurse is evaluating a 63-year-old female patient who has been admitted with worsening heart failure. During the physical examination, the nurse uses a stethoscope to listen to the patient’s lung fields. The patient presents with shortness of breath, a cough that worsens when lying down, and fatigue. Which type of breath sounds is the nurse most likely to auscultate that are typically associated with heart failure? A. Tracheal B. Fine crackles C. Coarse crackles D. Friction rubs E. Wheezes F. Stridor G. Pleural knock Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 38 Correct Answer: B. Fine crackles This choice is the most consistent with fluid accumulation in the air spaces of the lungs, a common complication in patients with heart failure. Fine crackles are created by the opening of small airways and alveoli that are compromised by fluid, which is often present in heart failure due to the heart’s reduced ability to pump effectively. 14. 14. Question 1 point(s) Category: Physiological Adaptation A nurse is attending to a 35-year-old patient with a history of asthma who presents to the emergency department in the midst of an acute asthma exacerbation. The patient, who was initially wheezing loudly, suddenly has no audible wheezing and the nurse cannot auscultate breath sounds. The patient appears anxious and is using accessory muscles to breathe. Considering the change in respiratory status, what is the most likely explanation for the absence of wheezing? A. The asthma attack has resolved. B. The airways are so constricted that air cannot pass through. C. The inflammation within the airways has subsided. D. Fine crackles have replaced the wheezes due to fluid in the airways. E. The patient is holding their breath subconsciously due to anxiety. F. A foreign body has obstructed the airway passage. Correct Answer: B. The airways are so swollen that no air cannot get through. This indicates that the airway constriction has worsened to a critical level, often resulting in a silent chest, which is a sign of a severe and life-threatening asthma attack. Immediate intervention is necessary to open the airways and restore adequate ventilation. 15. 15. Question 1 point(s) Category: Safety and Infection Control Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 39 A nurse is caring for a 22-year-old individual with a known diagnosis of epilepsy. During the nurse’s shift, the patient begins to have a tonic-clonic seizure. During the active phase of the seizure, which of the following actions should the nurse take? Select all that apply. A. Place the patient on their back, remove dangerous objects from the immediate vicinity, and insert a padded tongue depressor. B. Place the patient in a lateral position (on their side), remove any hazardous objects nearby, and prepare to use a bite block if needed. C. Position the patient supine (on their back), clear the area of any items that might cause injury, and restrain their limbs gently. D. Turn the patient to a side-lying position, ensure the environment is safe from potential hazards, and use a pillow or a hand to protect the head. E. Keep the patient in a prone position, secure the perimeter for safety, and monitor their respiratory status closely. F. Roll the patient onto their side to prevent aspiration, remove objects that could cause harm, and observe for cessation of seizure activity. Correct Answers: B, D, and F. During a seizure, it is important to prevent injury to the patient. Placing the patient on their side can help maintain an open airway and allow any oral secretions or vomitus to drain, preventing aspiration. Removing dangerous objects helps to minimize the risk of injury. While a bite block may be used in some situations to prevent the patient from biting their tongue, it is not recommended to insert anything into the mouth of someone who is actively seizing due to the risk of injury or aspiration. Protecting the head is also crucial to prevent trauma during convulsive movements. 16. 16. Question 1 point(s) Category: Reduction of Risk Potential After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for? Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 40 A. Infection of the lung B. Kinked or obstructed chest tube C. Excessive water in the water-seal chamber D. Excessive chest tube drainage Correct Answer: B. Kinked or obstructed chest tube Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Option A: Infection of the lung won’t cause a tension pneumothorax. A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Option C: Excessive water won’t affect the chest tube drainage. The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation. Option D: An excessive chest tube drainage cannot cause tension pneumothorax. Chest tubes drain blood, fluid, or air from around the lungs, heart, or esophagus. The tube around the lung is placed between the ribs and into the space between the inner lining and the outer lining of the chest cavity. 17. 17. Question 1 point(s) Category: Safety and Infection Control The nurse is providing lunch to a 68-year-old male patient with a history of stroke which has affected his swallowing reflex. As the patient begins to eat, he suddenly starts choking on a piece of food but is coughing loudly and forcefully. Observing this, what should the nurse do? A. Assist the patient to stand up and perform the abdominal thrust maneuver immediately. B. Lay the patient down and prepare to perform back blows and chest thrusts. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 41 C. Exit the room quickly to summon for additional help from the healthcare team. D. Stay with the patient, encourage him to keep coughing, and monitor him closely. E. Provide a drink of water to help the patient swallow the obstructing food. Correct Answer: D. Stay with the patient, encourage him to keep coughing, and monitor him closely. When an individual is choking but still able to cough forcefully, it indicates that the airway is not completely blocked and air is still passing through. The coughing reflex is the most effective way to expel an obstruction from the airway. Therefore, the nurse should closely observe the client and encourage them to continue coughing. Performing abdominal thrusts or back blows when the individual is still able to cough may worsen the situation or cause unnecessary harm. 18. 18. Question 1 point(s) Category: Health Promotion and Maintenance While conducting an initial health assessment, the nurse is collecting information from an 84-year-old female patient who has recently been admitted to the geriatric ward due to chronic hypertension and mild cognitive impairment. Which of the following pieces of information would be most beneficial for the nurse to gather in order to tailor an individualized care plan? A. An overview of the patient's general health and major illnesses over the past decade. B. Details of the patient's engagement in current health promotion activities, such as diet and exercise. C. A comprehensive family history of chronic diseases like diabetes or cardiovascular conditions. D. The patient's marital status and living arrangements to understand social support structures. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 42 E. The patient's medication adherence and understanding of the diabetes management plan. F. Previous experiences with hospitalizations or surgeries that might affect current health status. Correct Answer: B. Details of the patient’s engagement in current health promotion activities, such as diet and exercise. When taking the health history of an elderly client, it is important to understand their current health promotion activities. This information provides insight into the client’s level of engagement in maintaining or improving their health, which is crucial for planning care that is tailored to their needs and capabilities. It helps to identify the client’s current health practices and can guide the nurse in formulating a care plan that supports these activities, introduces new ones, or modifies existing ones. This allows the nurse to plan care that supports the patient’s active involvement in managing his health conditions, which is particularly important given the recent diagnosis of type 2 diabetes and the presence of other chronic diseases. 19. 19. Question 1 point(s) Category: Physiological Adaptation The nurse is preparing to provide oral care for a 76-year-old female patient who is comatose following a cerebral hemorrhage. The patient is unable to manage her secretions and has a history of chronic obstructive pulmonary disease (COPD). To minimize the risk of aspiration and ensure proper oral hygiene, what should the nurse do? A. Frequently apply lemon glycerin swabs to moisturize the patient’s lips and oral mucosa. B. Brush the patient’s teeth while she is lying flat on her back to ensure a thorough cleaning. C. Position the patient in a side-lying position and lower the head of the bed before starting oral care. D. Use hydrogen peroxide to cleanse the patient’s mouth to eliminate bacteria and debris. Follow for more study materials https://www.facebook.com/groups/772671407426795/ Downloaded by: adriannajxo | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material 43 E. Utilize a suction toothbrush to simultaneously remove plaque and oral secretions. F. Moisten the oral mucosa with water before and after oral care to maintain hydration. Correct Answer: C. Place the client in a side-lying position, with the head of the bed lowered. When performing oral care on a comatose client, it is essential to prevent aspiration, which can lead to pneumonia or other complications. Placing the client in a side-lying position with the head of the bed lowered allows for drainage of oral secretions and reduces the risk of aspiration. Lemon glycerin and hydrogen peroxide are not recommended for regular oral care as they can dry out the mucous membranes or cause irritation. Brushing teeth with the client lying supine also increases the risk of aspiration. 20. 20. Question 1 point(s) Category: Physiological Adaptation A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the fo

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