Respiratory System

1. A child admitted with pneumonia has also been diagnosed with Werdnig-Hoffman disease. The nurse should include which of the following in this child’s care plan?
   • 1   –   Assess the child for atrophy of smooth muscles.
   • 2   –   Provide assistance for all activities of daily living.
   • 3   –   Assess the child’s muscular involvement, as some clients don’t experience progressive loss of strength or function.
   • 4   –   Have a parent stay with the child whenever possible.

   RATIONALE: Werdnig-Hoffman disease is primarily wasting of skeletal muscles, not smooth muscles. The amount of involvement varies from client to client, so each client must be assessed individually. Not all clients require help with activities of daily living. Having a parent stay with the child is desirable but doesn’t address what the nurse should do.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Safety and infection control
   COGNITIVE LEVEL: Application

2. A client complains of dyspnea. To help correct this problem, the nurse should place the client in which of the following positions?
   • 1   –   Trendelenburg’s
   • 2   –   Sims’
   • 3   –   Fowler’s
   • 4   –   Supine

   RATIONALE: Fowler’s position – the posture assumed by the client when the head of the bed is elevated 40 to 60 degrees – promotes breathing by allowing expansion of the thoracic cavity. The other options don’t facilitate lung expansion and oxygenation.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Knowledge

3. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client’s care, the nurse should include which of the following interventions?
   • 1   –   Increase fluids to 2,500 ml/day.
   • 2   –   Teach the client how to deep breathe and cough.
   • 3   –   Improve airway clearance.
   • 4   –   Suction the client every 2 hours.

   RATIONALE: Interventions should address the cause of the client’s problem – poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client’s condition but doesn’t address poor coughing. Improving airway clearance is too vague. Suctioning isn’t indicated unless other measures fail to clear the airway.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Comprehension

4. A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should:
   • 1   –   turn the client every 2 hours.
   • 2   –   elevate the head of the bed 30 degrees.
   • 3   –   encourage increased fluid intake.
   • 4   –   maintain a cool room temperature.

   RATIONALE: Increasing the client’s intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn’t liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn’t liquefy secretions. Maintaining a cool room temperature would increase the client’s comfort but wouldn’t liquefy secretions.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Comprehension

5. A client is admitted to the health care facility with active tuberculosis. The nurse should include which of the following interventions in the care plan?

   • 1   –   Putting on a respirator when entering the client’s room
   • 2   –   Instructing the client to wear a mask at all times
   • 3   –   Wearing a gown and gloves when providing direct care
   • 4   –   Keeping the door to the client’s room open to observe the client

   RATIONALE: Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a respirator when entering the client’s room. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client’s blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Safety and infection control
   COGNITIVE LEVEL: Comprehension

6. A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which of the following actions is most important in the initial care plan?
   • 1   –   Assessing the client’s temperature every 8 hours
   • 2   –   Placing the client in respiratory isolation
   • 3   –   Monitoring the client’s fluid intake and output
   • 4   –   Wearing gloves during all client contact

   RATIONALE: Because the client’s signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn’t frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Safety and infection control
   COGNITIVE LEVEL: Evaluation

7. A client who suffered a cerebrovascular accident has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which of the following interventions would help meet this goal?

   • 1   –   Repositioning the client every 2 hours
   • 2   –   Restricting fluids to 1,000 ml/24 hours
   • 3   –   Administering oxygen by cannula, as ordered
   • 4   –   Keeping the head of the bed at a 30-degree angle

   RATIONALE: Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle may ease respirations and make them more effective but wouldn’t help mobilize secretions.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Analysis

8. Ampicillin 250 mg has been ordered for your client being treated for sinusitis. The pharmacy dispenses an oral suspension containing 125 mg/5 ml. How many milliliters will you administer to your client?
   • –

   RATIONALE: The nurse should calculate the client’s dose using this method:
   (125 mg 9 5 ml) = (250 mg 9 X)
   125X = 1,250
   X = 10 ml
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Application

9. During assessment, the nurse measures a client’s respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which of the following terms?
   • 1   –   Eupnea
   • 2   –   Bradypnea
   • 3   –   Apnea
   • 4   –   Tachypnea

   RATIONALE: A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea. Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. Apnea refers to absence of breathing.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Comprehension

10. The nurse is caring for a client recently admitted with acute respiratory distress syndrome (ARDS). The nurse is aware that there are several signs and symptoms associated with this condition. Select all signs and symptoms that apply.

    • 1   –   Motor dysfunction
    • 2   –   Hypertension
    • 3   –   Metabolic acidosis
    • 4   –   Respiratory alkalosis
    • 5   –   Tachycardia
    • 6   –   Decreased respiratory rate

    RATIONALE: Signs and symptoms of ARDS include motor dysfunction related to hypoxia, tachycardia resulting from the heart’s effort to deliver more oxygen to the cells and vital organs, and metabolic acidosis, which results from failure of compensatory mechanisms. Complications associated with ARDS include hypotension and respiratory acidosis. Respiratory acidosis occurs when carbon dioxide accumulates in the blood and oxygen levels decrease.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Application

11. The nurse’s assignment for the day includes a 3-day postoperative thoracotomy client with two chest tubes in place. When making the morning assessments on this client, the nurse notes that the fluid in the water-seal chamber isn’t fluctuating. Which of the following statements provides the most likely explanation?
    • 1   –   The chest tubes aren’t positioned correctly.
    • 2   –   The lung has reexpanded.
    • 3   –   The water-seal chamber needs more sterile water.
    • 4   –   The suction should be increased.

    RATIONALE: Fluctuations of fluid in the water-seal chamber will stop when the lung has expanded, the tubing is occluded, or the suction apparatus malfunctions. Proper chest tube placement is a medical determination and not reflected in fluid fluctuation. A low water level will be visible but won’t affect the fluctuation of the water. Increasing suction when fluctuations stop would be harmful.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

12. The pathophysiology of an asthma attack is a progressive process. Place the following phases in the sequence in which an asthma attack occurs. (Use all options.)
    • 1   –   Histamine attaches to sites in large bronchi
    • 2   –   Leukotrienes affix to sites in small bronchi
    • 3   –   Mucus fills lungs; ventilation is inhibited
    • 4   –   Bronchial lumen narrows
    • 5   –   Mast cells respond to antigen exposure
    • 6   –   Smooth muscles swell

    RATIONALE: When exposed to certain antigens, mast cells in the lung interstitium release histamine and leukotrienes. Histamine attaches to receptor sites in the larger bronchi and swelling of smooth muscle occurs. Mucous membranes become inflamed, irritated, and swollen. Leukotrienes attach to receptor sites in the smaller bronchi causing local swelling of the smooth muscle. Histamine stimulates the mucous membranes to secrete excess mucus, which further narrows the bronchial lumen. Mucosal edema and thickened secretions further block the airways and lungs, inhibiting alveolar ventilation.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Analysis

13. The physician orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to use which of the following oxygen delivery devices?
    • 1   –   Nasal cannula
    • 2   –   Venturi mask
    • 3   –   Partial rebreathing mask
    • 4   –   Nonrebreathing mask

    RATIONALE: A nonrebreathing mask provides the highest possible oxygen concentration – up to 95%. A nasal cannula doesn’t deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client’s respiratory pattern, because the same amount of room air always enters the mask opening. A partial rebreathing mask delivers oxygen concentrations up to 90%.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

14. To evaluate a client for hypoxia, the physician is most likely to order which of the following laboratory tests?
    • 1   –   Red blood cell count
    • 2   –   Sputum culture
    • 3   –   Total hemoglobin
    • 4   –   Arterial blood gas analysis

    RATIONALE: All of these tests help evaluate a client with respiratory problems. However, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs, providing information about the client’s oxygenation status.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

15. Which of the following statements is true about crackles?
    • 1   –   They’re grating sounds.
    • 2   –   They’re high-pitched, musical squeaks.
    • 3   –   They’re low-pitched noises that sound like snoring.
    • 4   –   They may be fine, medium, or coarse.

    RATIONALE: Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They’re classified as fine, medium, or coarse. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, high-pitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

 

Cardiovascular System

1. A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which of the following positions?

   • 1   –   Knee-to-chest
   • 2   –   Fowler’s
   • 3   –   Trendelenburg’s
   • 4   –   Prone

   RATIONALE: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and overriding aorta. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The knee-to-chest position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. During a cyanotic episode, the child with TOF typically assumes this position instinctively. Fowler’s, Trendelenburg’s, and prone positions don’t improve oxygenation.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Knowledge

2. A 55 year-old male requires a 12-lead electrocardiogram. Identify the area where the nurse will place the V2 lead on the chest wall.
   • –

   RATIONALE: The V2 lead is placed at the fourth intercostal space at the left sternal border.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Basic care and comfort
   COGNITIVE LEVEL: Comprehension

3. A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use an intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which of these conditions contraindicates use of the IABP?
   • 1   –   Unstable angina pectoris
   • 2   –   Aortic insufficiency
   • 3   –   Hypertension
   • 4   –   Diabetes mellitus

   RATIONALE: A history of aortic insufficiency contraindicates use of an IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, severe left ventricular dysfunction, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn’t respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren’t contraindications for IABP.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Comprehension

4. A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client’s blood pressure, which is 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What’s the most common cause of malignant hypertension?
   • 1   –   Pyelonephritis
   • 2   –   Dissecting aortic aneurysm
   • 3   –   Pheochromocytoma
   • 4   –   Untreated hypertension

   RATIONALE: Untreated hypertension is the most common cause of malignant hypertension. Pyelonephritis, dissecting aortic aneurysm, and excessive catecholamine release (an effect of pheochromocytoma) are less common causes. Rarely, malignant hypertension results from eclampsia, ingestion of or exposure to drugs or toxic substances, and food and drug interactions (such as monoamine oxidase inhibitors with aged cheeses).
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Knowledge

5. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?
   • 1   –   Deficient knowledge related to interventions used to treat acute illness
   • 2   –   Impaired physical mobility related to complete bed rest
   • 3   –   Social isolation related to restricted visiting hours in the intensive care unit
   • 4   –   Anxiety related to the threat of death

   RATIONALE: Anxiety related to the threat of death is an appropriate nursing diagnosis because the client’s anxiety can adversely affect heart rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death was a real and immediate concern. Unless the nurse deals with anxiety first, the client’s emotional state impedes learning. Client teaching should be limited to clear, concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the knowledge deficit would continue despite attempts at teaching. Impaired physical mobility and social isolation are necessitated by the client’s critical condition; therefore, they aren’t considered problems warranting nursing diagnoses.
   NURSING PROCESS STEP: Analysis
   CLIENT NEEDS CATEGORY: Psychosocial integrity
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Application

6. A client comes to the physician’s office for a complete physical examination required for employment. The physician assesses the client’s arms and legs for evidence of peripheral vascular disease. Which of the following is the most commonly used overall indicator of arm and leg circulation?
   • 1   –   Exercise testing
   • 2   –   Ankle-brachial index
   • 3   –   Limb blood pressure
   • 4   –   Allen’s test

   RATIONALE: The ankle-brachial index is the most commonly used overall indicator of arm and leg circulation. Exercise testing reveals the severity of intermittent claudication and suggests how extensively this condition affects the client’s lifestyle. Limb blood pressure is the single best indicator of arm or leg perfusion, but its significance is limited to the limb being examined; limb blood pressures may vary greatly if peripheral vascular disease is present in one limb but not the other. Allen’s test is used to evaluate blood flow in the arm.
   NURSING PROCESS STEP: Evaluation
   CLIENT NEEDS CATEGORY: Health promotion and maintenance
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Knowledge

7. A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene?
   • 1   –   Administer I.V. fluids, as ordered.
   • 2   –   Administer a vasodilator, as prescribed.
   • 3   –   Insert an indwelling urinary catheter, as ordered.
   • 4   –   Instruct the client to sit up for several minutes before standing.

   RATIONALE: To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly to a standing position. Suggesting that the client sit up for several minutes first is typically helpful. Administering I.V. fluids would be inappropriate (unless the client were dehydrated) because it would counteract the effects of furosemide, possibly leading to fluid imbalance. Administering a vasodilator would reduce the client’s blood pressure further and worsen orthostatic hypotension. Inserting an indwelling urinary catheter would aid the monitoring of urine output but wouldn’t minimize the effects of orthostatic hypotension.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Knowledge

8. A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer:
   • 1   –   an antibiotic.
   • 2   –   an anticoagulant.
   • 3   –   an antihypertensive.
   • 4   –   an anticonvulsant.

   RATIONALE: During PTCA, the client receives an anticoagulant (heparin) as well as calcium agonists, nitrates, or both to reduce coronary artery spasm. An antibiotic isn’t given routinely during PTCA; however, because this procedure is invasive, the client may receive prophylactic antibiotics afterward to reduce the risk of infection. An antihypertensive agent may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn’t indicated because PTCA doesn’t increase the risk of seizures.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Application

9. A client is admitted for treatment of Prinzmetal’s angina. When developing the care plan, the nurse keeps in mind that this type of angina is triggered by:
   • 1   –   activities that increase myocardial oxygen demand.
   • 2   –   an unpredictable amount of activity.
   • 3   –   coronary artery spasm.
   • 4   –   the same type of activity that caused previous angina episodes.

   RATIONALE: Prinzmetal’s angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; however, anginal pain is increasingly severe.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Knowledge

10. A client is admitted to an acute care facility with pneumonia. When auscultating heart sounds, the nurse notes a fixed split of the second heart sound (S2) –a pathologic split that doesn’t vary with respirations. A fixed S2 split signals which of the following conditions?
    • 1   –   Right bundle-branch block
    • 2   –   Left bundle-branch block
    • 3   –   Atrial septal defect
    • 4   –   Aortic stenosis

    RATIONALE: A fixed split of S2 is the hallmark of atrial septal defect. This split, which is continuous and doesn’t vary with respirations, results from prolonged emptying of the right ventricle. A right bundle-branch block causes a wide S2 split that is louder on inspiration than expiration; this split results from delayed depolarization of the right ventricle and late pulmonic valve closure. Left bundle-branch block, aortic stenosis, and patent ductus arteriosus cause a paradoxical S2 split. Heard only on expiration, a paradoxical S2split results from delayed aortic valve closure.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

11. A client is admitted to the coronary care unit with a suspected diagnosis of acute MI. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the creatine kinase isoenzyme CK-MB, found only in cardiac muscle, can be detected how soon after the onset of chest pain?
    • 1   –   30 minutes to 1 hour
    • 2   –   2 to 3 hours
    • 3   –   4 to 6 hours
    • 4   –   12 to 18 hours

    RATIONALE: Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak in 12 to 18 hours and return to normal in 3 to 4 days.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

12. A client is admitted to the coronary care unit with substernal chest pain that radiates to the jaw. The client subsequently develops hypotension and suffers cardiac arrest. Which of the following calcium preparations is injected into the ventricle during a cardiac arrest?
    • 1   –   Calcium carbonate (BioCal)
    • 2   –   Calcium chloride (Calciject)
    • 3   –   Calcium glubionate (Neo-Calglucon)
    • 4   –   Calcium lactate (Ridactate)

    RATIONALE: Calcium chloride is the only calcium preparation that should be injected into the ventricle during a cardiac arrest, if appropriate.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

13. A client is admitted to the critical care unit after being stabilized in the emergency department. Laboratory results show that the client’s creatine kinase isoenzyme CK-MB level is elevated. Based on this information, the nurse would develop a care plan based on which of the following conditions?
    • 1   –   Generalized tonic-clonic seizure
    • 2   –   Perforated duodenal ulcer
    • 3   –   Kidney stone
    • 4   –   Myocardial infarction

    RATIONALE: Creatine and CK-MB are released into the bloodstream by dying myocardial tissue. The higher the CK-MB level, the greater the damage to the myocardium. Seizures, duodenal ulcers, and kidney stones don’t affect CK-MB levels.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

14. A client is admitted to the health care facility for treatment of an aneurysm. When planning this client’s care, the nurse formulates interventions with which of the following goals in mind?
    • 1   –   Decreasing blood pressure and increasing mobility
    • 2   –   Increasing blood pressure and reducing mobility
    • 3   –   Stabilizing the heart rate and blood pressure and easing anxiety
    • 4   –   Increasing blood pressure and monitoring fluid intake and output

    RATIONALE: For a client with an aneurysm, nursing interventions focus on stabilizing the heart rate and blood pressure to avoid aneurysm rupture. Easing anxiety is also important because anxiety and increased stimulation may speed the heart rate and boost blood pressure, precipitating aneurysm rupture. Typically, the client with an aneurysm is hypertensive, so the nurse should take measures to lower blood pressure such as administering antihypertensive agents, as prescribed, to prevent aneurysm rupture. To sustain major organ perfusion, a mean arterial pressure of at least 60 mm Hg should be maintained. Although mobility must be assessed individually, most clients need bed rest initially until their condition stabilizes.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

15. A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which of the following abnormal heart sounds?
    • 1   –   Opening snap
    • 2   –   Graham Steell’s murmur
    • 3   –   Ejection click
    • 4   –   Pericardial friction rub

    RATIONALE: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week after an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell’s murmur is a high-pitched, blowing murmur with a decrescendo pattern. Heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

16. A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that, for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common, spontaneously resolving symptom?

    • 1   –   Depression
    • 2   –   Ankle edema
    • 3   –   Memory lapses
    • 4   –   Dizziness

    RATIONALE: For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves on its own and doesn’t require medical intervention. Ankle edema rarely follows CABG surgery and may indicate right-sided heart failure; because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic dysfunction, rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, a condition that is abnormal after CABG surgery and should be reported immediately to the physician.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

17. A client is recovering from open-heart surgery for a mitral valve replacement. The recovery is uneventful, and the client actively participates in discharge teaching. If the nurse’s discharge teaching is effective, how would the client respond to a family member’s question about medications?
    • 1   –   “I don’t have any new prescriptions.”
    • 2   –   “I will need to take Coumadin because of the type of surgery I had.”
    • 3   –   “I will need to pick up a prescription for a drug to lower my blood pressure.”
    • 4   –   “I will need to take one aspirin a day.

    RATIONALE: Clients undergoing valve replacement must take Coumadin (an anticoagulant) to prevent any subsequent clot formation. The client will have a new prescription for an anticoagulant, not an antihypertensive, and the client shouldn’t take aspirin because of its anticoagulant effect.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

18. A client is recovering from surgical repair of a dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurring dissection. These signs include:
    • 1   –   hematuria and decreased urine output.
    • 2   –   hypotension and tachycardia.
    • 3   –   increased urine output and bradycardia.
    • 4   –   hypotension and bradycardia.

    RATIONALE: When caring for a client recovering from surgical repair of a dissecting aortic aneurysm, the nurse must monitor for hypotension with reflex tachycardia, decreased urine output, and unequal or absent peripheral pulses – all potential signs of bleeding or recurring dissection. Hematuria, increased urine output, and bradycardia aren’t signs of bleeding from aneurysm repair or recurring dissection.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

19. A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling that is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. When exploring the chief complaint, the nurse should look for other common cardiovascular symptoms, including:

    • 1   –   shortness of breath.
    • 2   –   insomnia.
    • 3   –   irritability.
    • 4   –   lower substernal abdominal pain.

    RATIONALE: Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, dyspnea, palpitations, fainting, fatigue, and peripheral edema. Insomnia rarely indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

20. A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub –; a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?
    • 1   –   Semi-Fowler’s
    • 2   –   Leaning forward while sitting
    • 3   –   Supine
    • 4   –   Prone

    RATIONALE: When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler’s, supine, and prone positions don’t cause this pulling-away action and therefore don’t relieve chest pain associated with pericarditis.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

21. A client who’s 30 weeks’ pregnant has a corrected atrial septal defect and minor functional limitations. Which of the following pregnancy-related physiologic changes places her at greatest risk for more severe cardiac problems?
    • 1   –   Decreased heart rate
    • 2   –   Increased plasma volume
    • 3   –   Decreased cardiac output
    • 4   –   Increased blood pressure

    RATIONALE: Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease by 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

22. A client with angina pectoris must learn how to manage acute angina episodes and reduce risk factors that exacerbate this condition. When developing the client’s care plan, the nurse should include which expected outcome?
    • 1   –   “Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours.”
    • 2   –   “Client will verbalize the intention to avoid exercise.”
    • 3   –   “Client will verbalize the intention to stop smoking.”
    • 4   –   “Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol.”

    RATIONALE: The client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart’s oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn’t subside after three nitroglycerin doses taken 10 to 15 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

23. A client with chest pain receives nitroglycerin en route to the hospital. Based on an electrocardiogram obtained on admission, the physician suspects a myocardial infarction (MI) and prescribes I.V. morphine to relieve continuing pain. A primary goal of nursing care for this client is to recognize life-threatening complications of an MI. The major cause of death after an MI is:
    • 1   –   cardiogenic shock.
    • 2   –   cardiac arrhythmia.
    • 3   –   heart failure.
    • 4   –   pulmonary embolism.

    RATIONALE: Cardiac arrhythmias cause roughly 40% to 50% of deaths after MI. Cardiogenic shock accounts for 9% and heart failure for 33% of post-MI deaths. Pulmonary embolism, another potential complication of an MI, is less common.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

24. A client with essential hypertension is started on furosemide (Lasix). The client asks the nurse how a diuretic would help lower the elevated blood pressure. The nurse’s best answer would be:
    • 1   –   “Because Lasix interferes with renin angiotensin conversion, blood pressure is lowered.”
    • 2   –   “Lasix blocks the action of the sympathetic nervous system, which makes blood vessels contract, thus lowering blood pressure.”
    • 3   –   “Lasix dilates small blood vessels, which decreases blood pressure.”
    • 4   –   “Lasix decreases circulating blood volume, thereby reducing the heart’s workload and blood pressure.”

    RATIONALE: Lasix is a loop diuretic that acts to reduce circulating blood volume by increasing urine output. It doesn’t function as stated in the other options.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

25. A client with heart failure must be monitored closely after starting diuretic therapy. What is the most accurate indicator of this client’s status?
    • 2   –   Urine specific gravity
    • 3   –   Vital signs
    • 4   –   Weight

    RATIONALE: Heart failure typically causes fluid overload, which results in weight gain. Therefore, weight is the most accurate indicator of this client’s status. Gain or loss of 1 lb (0.5 kg) is equivalent to 500 ml of fluid. Fluid intake and output is a less accurate indicator than is weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration; although helpful, it isn’t the most accurate indicator because it can be influenced by numerous factors, as can vital signs.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

26. A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue or dizziness, especially on rising. When developing a client teaching plan to minimize postural hypotension, the nurse should include which of the following instructions?
    • 1   –   “Avoid drinking alcohol and straining at stool, and eat a low-protein snack at night.”
    • 2   –   “Wear elastic stockings, change positions quickly, and hold onto a stationary object when rising.”
    • 3   –   “Flex your calf muscles, avoid alcohol, and change positions slowly.”
    • 4   –   “Rest between demanding activities, eat plenty of fruits and vegetables, and drink 6 to 8 cups of fluid daily.”

    RATIONALE: Measures that minimize postural hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, eating a high-protein snack at night, wearing elastic stockings, changing positions slowly, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don’t directly relieve postural hypotension.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

27. A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesias, and a mottled, cyanotic, cold left calf. While the physician determines the appropriate therapy, the nurse should:
    • 1   –   place a heating pad around the affected calf.
    • 2   –   elevate the affected leg as high as possible.
    • 3   –   keep the affected leg level or slightly dependent.
    • 4   –   shave the affected leg in anticipation of surgery.

    RATIONALE: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keep the affected leg level or slightly dependent (to aid circulation), and protect the affected leg from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would compromise tissue perfusion further and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

28. A client with venous insufficiency develops varicose veins in both legs. Which of the following statements about varicose veins is accurate?
    • 1   –   Varicose veins are more common in men than in women.
    • 2   –   Primary varicose veins are caused by deep-vein thrombosis and inflammation.
    • 3   –   Sclerotherapy is used to cure varicose veins.
    • 4   –   The severity of discomfort isn’t related to the size of varicosities.

    RATIONALE: Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, deep-vein thrombosis, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat the signs and symptoms of varicose veins; it doesn’t cure them.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

29. A client, age 59, complains of leg pain brought on by walking several blocks – a symptom that first occurred several weeks ago. The client’s history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental), 400 mg three times daily with meals. Which of the following instructions for long-term care should the nurse provide?

    • 1   –   “Practice meticulous foot care.”
    • 2   –   “Consider cutting down on your smoking.”
    • 3   –   “Reduce your level of exercise.”
    • 4   –   “See the physician if complications occur.”

    RATIONALE: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe the feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications unless the physician approves them. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. The client must see the physician regularly to evaluate the effectiveness of the therapeutic regimen, not just when complications occur.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

30. A nurse is caring for a client with tachycardia. The nurse is aware that tachycardia can result from which of the following factors?
    • 1   –   Vagal stimulation
    • 2   –   Vomiting, anger, or suctioning
    • 3   –   Fear, pain, or anger
    • 4   –   Stress, pain, or vomiting

    RATIONALE: Increased heart rate (tachycardia) may stem from fear, pain, or anger. Decreased heart rate (bradycardia) can stem from vomiting, suctioning (which causes vagal nerve stimulation), and certain medications. Stress can also increase the heart rate, but vomiting causes bradycardia (decreased heart rate). Bradycardia is also the result of vagal stimulation that occurs, for example, with suctioning and with certain medications.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

31. A nurse is performing a cardiac assessment on a client with hypertension. Identify the area where the nurse should place the stethoscope to best auscultate the pulmonic valve.
    • –

    RATIONALE: The pulmonic valve is usually best heard at the second intercostal space, at the left sternal border.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

32. A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:
    • 1   –   “Has your child recently been exposed to other children with rheumatic fever?”
    • 2   –   “Has your child had strep throat recently?”
    • 3   –   “Does your child have a congenital heart defect?”
    • 4   –   “Is your child’s Haemophilus influenzae vaccine up-to-date?”

    RATIONALE: Group A streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn’t infectious and can’t be transmitted from one person to another. Congenital heart defects play no role in the development of rheumatic fever. Haemophilus influenzaevaccine doesn’t prevent streptococcal infection or rheumatic fever.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

33. A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?
    • 1   –   Race
    • 2   –   Age
    • 3   –   History of diabetes mellitus
    • 4   –   History of aortic valve replacement

    RATIONALE: A heart valve prosthesis, such as an aortic valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren’t major risk factors for infective endocarditis.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

34. After a motorcycle accident, a 19-year-old is admitted to the hospital. The physician orders an I.V. colloidal solution to be administered while typing and cross-matching are completed. Which of the following fluids would fit the classification to treat hypovolemic shock?
    • 1   –   Lactated Ringer’s solution
    • 2   –   Dextrose and normal saline solution
    • 3   –   Normal saline
    • 4   –   5% albumin

    RATIONALE: Albumin is a plasma protein and expands intravascular volume. The other solutions are crystalloid, rather than colloid, solutions.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

35. After abdominal surgery, which of the following factors would predispose a client to deep-vein thrombosis?
    • 1   –   The client is 5‘ 5“ (1.7 m) tall and weighs 128 lb (58 kg).
    • 2   –   The client has been pregnant four times.
    • 3   –   The client usually walks 3 miles (5 km) per day.
    • 4   –   The client will be immobile after surgery.

    RATIONALE: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don’t apply to this client. Exercise isn’t a risk factor or preventive measure for deep vein thrombosis.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

36. An intra-aortic balloon pump (IABC) was inserted into a client with cardiogenic shock. Which of the following items would the nurse question if found on the client’s care plan?

    • 1   –   Perform active range of motion (ROM) exercises with all extremities.
    • 2   –   Elevate the head of bed (HOB) to 30 degrees.
    • 3   –   Check femoral, popliteal, and dorsalis pedis pulses.
    • 4   –   Keep affected leg extended.

    RATIONALE: ROM (active or passive) exercises include flexion of the extremities. The HOB should be elevated 30 to 45 degrees and pulses should be checked. The client must keep his affected leg straight or extended to avoid pump malfunction.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

37. An obese, white, male client, age 49, is diagnosed with hypercholesterolemia. The physician prescribes a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client’s well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for:

    • 1   –   a history of diabetes mellitus.
    • 2   –   an elevated high-density lipoprotein (HDL) levels.
    • 3   –   a history of ischemic heart disease.
    • 4   –   alcoholism.

    RATIONALE: Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. Elevated HDL levels aren’t a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn’t been identified as a major risk factor for CAD.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

38. At 32 weeks’ gestation, a client is admitted to the hospital with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal which of the following signs?

    • 1   –   Edema
    • 2   –   Fever
    • 3   –   Glycosuria
    • 4   –   Vomiting

    RATIONALE: Classic signs of PIH include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with any number of disorders and is a common symptom of pregnancy.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

39. Documentation notes that aA 75-year-old client has been admitted with peripheral vascular problems. Which of the following nursing diagnoses would the nurse see on this client’s nursing care plan?
    • 1   –   Chronic low self-esteem related to altered body image
    • 2   –   Risk for impaired skin integrity related to compromised circulation
    • 3   –   Imbalanced nutrition: Less than body requirements, related to GI dysfunction
    • 4   –   Decreased cardiac output related to renal insufficiency

    RATIONALE: Compromised circulation to the legs and feet pose a risk for trauma and infection. The other nursing diagnoses wouldn’t be appropriate because documentation doesn’t note that the client’s appearance is altered or that the client exhibits GI or renal symptoms.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

40. During a prenatal visit, a pregnant client with cardiac disease and slight functional limitation reports increased fatigue. To help combat this problem, the nurse should advise her to:
    • 1   –   Eat three large meals a day.
    • 2   –   Exercise 1 hour before each meal.
    • 3   –   Take a vitamin and mineral supplement.
    • 4   –   Divide daily food intake into five or six meals.

    RATIONALE: To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day. This minimizes the energy expenditure associated with consuming three large meals. Exercising before meals would increase fatigue, interfering with the client’s nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on improving the client’s level of energy and decreasing fatigue.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

41. For a client with cardiomyopathy, the most important nursing diagnosis is:

    • 1   –   Decreased cardiac output related to reduced myocardial contractility.
    • 2   –   Excess fluid volume related to fluid retention and altered compensatory mechanisms.
    • 3   –   Ineffective coping related to fear of debilitating illness.
    • 4   –   Anxiety related to actual threat to health status.

    RATIONALE: Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although options 2, 3, and 4 are important nursing diagnoses, they can be addressed after cardiac output and myocardial contractility have been restored.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

42. On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he has stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?

    • 1   –   Taking daily walks
    • 2   –   Engaging in anaerobic exercise
    • 3   –   Reducing daily fat intake to less than 45% of total calories
    • 4   –   Avoiding foods that increase levels of high-density lipoproteins (HDLs)

    RATIONALE: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

43. The nurse applies compressions to the lower sternum at what depth when performing cardiopulmonary resuscitation on an adult client?
    • 1   –   r“ to 1“
    • 2   –   1“ to 3“
    • 3   –   1“ to 2“
    • 4   –   2“ to 4“

    RATIONALE: The recommended depth of chest compressions in an adult is 1“ to 2“. The other options aren’t within the recommended depth according to standards established by the American Heart Association.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

44. The nurse caring for a client with right-sided heart failure realizes this condition occurs in phases. Place the phases of right-sided heart failure in the order in which they occur. (Use all options.)
    • 1   –   Ineffective right ventricular contractility
    • 2   –   Poor right ventricular pumping
    • 3   –   Weight gain, peripheral and organ edema
    • 4   –   Decreased cardiac output to the lungs
    • 5   –   Blood backup into peripheral circulation

    RATIONALE: Right-sided heart failure results from ineffective right ventricular contractile function. Consequently, blood isn’t pumped effectively through the right ventricle to the lungs, causing blood to back up into the right atrium and the peripheral circulation. The client then gains weight and develops peripheral edema and engorgement of the kidneys and other organs.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

45. The nurse is assigned to a client with a cardiac disorder. When taking the client’s temperature, which route should the nurse avoid?

    • 1   –   Rectal
    • 2   –   Oral
    • 3   –   Axillary
    • 4   –   Tympanic

    RATIONALE: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take his temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. Options 2, 3, and 4 are appropriate routes for measuring the temperature of a client with a cardiac disorder.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

46. The nurse is calculating a nitroprusside infusion rate for a 110-lb cardiac client in her care. The physician orders the client to receive nitroprusside 3 mcg/kg/minute. The nitroprusside dosage is 200 mcg/ml. Use the following chart to determine the infusion rate (ml/hr) for the nitroprusside drip.
    • 1   –   5 ml/hr
    • 2   –   10 ml/hr
    • 3   –   45 ml/hr
    • 4   –   4.99 ml/hr

    RATIONALE: First locate the client’s weight on the chart. Next, find the dose prescribed, in the left hand column. Follow the two lines to the point of intersection, to determine the correct infusion rate of 45 ml/hr.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

47. The nurse is interpreting a rhythm strip. Identify the T wave on this electrocardiogram complex.
    • –

    RATIONALE: The T wave represents repolarization of the ventricles and follows the peaking QRS complex.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Analysis

48. The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which of these findings significant?
    • 1   –   Croup
    • 2   –   Rheumatic fever
    • 3   –   Severe staphylococcal infection
    • 4   –   Medullary sponge kidney

    RATIONALE: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup – a severe upper airway inflammation and obstruction typically striking children ages 3 months to 3 years – may cause latent complications, such as ear infection and pneumonia. However, it doesn’t affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn’t damage heart structures.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

49. The nurse is preparing to administer digoxin 0.25 mg I.V. The pharmacy has dispensed digoxin in a vial containing 0.125 mg/1ml. Calculate the number of milliliters the nurse will administer to the client.
    • –

    RATIONALE: The nurse should calculate the client’s dose using this method:
    (0.125 mg 9 1ml) = (0.25 mg 9 X)
    0.125X = 0.25
    X = 2 ml
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

50. The physician has ordered the client to receive digoxin twice a day until a therapeutic level is attained. When the nurse takes the client’s apical pulse on the third day, the pulse is 58, and the client complains of nausea. What should the nurse do next?
    • 1   –   Administer the medication and leave a note on the chart for the physician.
    • 2   –   Order a serum digoxin level drawn.
    • 3   –   Administer the medication and medicate the client for nausea.
    • 4   –   Withhold the medication and notify the physician.

    RATIONALE: Withholding the medication and notifying the physician is the first step in treating what very well may be digoxin toxicity. Continuing to administer digoxin may result in heart block, and obtaining a serum level doesn’t treat the problem.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

51. The physician orders dopamine hydrochloride (Intropin) for a client in shock to improve the client’s hemodynamic status. When the family asks why the client is taking this medication, the best response by the nurse would be:
    • 1   –   “This drug helps decrease blood pressure, which would decrease the workload of the heart.”
    • 2   –   “This drug helps decrease the circulating blood volume.”
    • 3   –   “This drug decreases the oxygen demand of the heart.”
    • 4   –   “This drug increases cardiac output and stroke volume.”

    RATIONALE: Intropin acts to increase cardiac output and stroke volume, resulting in corrective hypotension and increasing circulating volume and oxygenation. It doesn’t decrease blood pressure, circulating blood volume, or oxygen demand of the heart.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

52. When a client suddenly loses consciousness, which of the following should the nurse do first?
    • 1   –   Call for assistance.
    • 2   –   Assess the client for responsiveness.
    • 3   –   Palpate for a carotid pulse.
    • 4   –   Assess for pupillary response.

    RATIONALE: The nurse should always assess for responsiveness first to prevent injuries to a client who isn’t in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client’s airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is not an appropriate initial assessment in an emergency situation.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

53. When assessing a client with left-sided heart failure, the nurse expects to note which of the following?
    • 1   –   Ascites
    • 2   –   Jugular vein distention
    • 3   –   Air hunger
    • 4   –   Pitting edema of the legs

    RATIONALE: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

54. When caring for a client with rheumatic fever, the nurse formulates a nursing diagnosis of Activity intolerance related to reduced cardiac reserve and enforced bed rest. Before the nurse can eliminate this nursing diagnosis, the client must meet which outcome measurement criterion?

    • 1   –   “Erythrocyte sedimentation rate returns to normal.”
    • 2   –   “Pulse does not rise above 150 beats/minute with activity.”
    • 3   –   “Temperature remains normal with salicylate administration.”
    • 4   –   “Pericardial friction rub is diminishing in intensity.”

    RATIONALE: Bed rest must continue until the client’s erythrocyte sedimentation rate returns to normal, indicating resolution of rheumatic fever. On the other hand, the resting pulse must be under 100 beats/minute; the client must maintain a normal temperature without salicylates; and pericardial friction rub must disappear completely. If the client needs salicylates to maintain a normal temperature, inflammation is still present and activity may cause serious myocardial damage. Resuming activity before a pericardial friction rub disappears completely may impair cardiac function.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

55. When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are found in the carotid sinus and aorta. Which other area should the nurse mention as the site of arterial baroreceptors?
    • 1   –   Brachial artery
    • 2   –   Radial artery
    • 3   –   Left ventricular wall
    • 4   –   Right ventricular wall

    RATIONALE: Arterial baroreceptors are found in the left ventricular wall as well as in the carotid sinus and aorta. No baroreceptors exist in the brachial artery, radial artery, or right ventricular wall.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

56. Which of the following would be the next step in the conduction pathway of the heart: sinoatrial (SA) node, atrioventricular (AV) node, Bundle of His, and:
    • 1   –   depolarization of the cell membrane.
    • 2   –   contraction of cardiac muscle.
    • 3   –   chordae tendineae.
    • 4   –   Purkinje fibers.

    RATIONALE: The next step of the impulse would be the Purkinje fibers. Depolarization occurs at the beginning of the cardiac cycle. The cardiac muscle contracts after receiving the impulse from the Purkinje fibers. The chordae tendineae aren’t prominent in the cardiac cycle.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

 

Neoplasms

1. A 3-year-old child with leukemia has completed the induction phase of chemotherapy. To ascertain if a remission has been achieved, what diagnostic test would be ordered to confirm the absence or presence of leukemic cells?

   • 1   –   Bone marrow aspiration
   • 2   –   Blood culture and smear
   • 3   –   Acid phosphatase
   • 4   –   Alkaline phosphatase

   RATIONALE: Bone marrow aspiration is the definitive diagnostic tool in confirming or ruling out leukemic cells. Blood cultures and acid or alkaline phosphatase wouldn’t supply the needed data.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Knowledge

2. A child has just been operated on for removal of a Wilm’s tumor. The nurse should include which of the following in the care plan?
   • 1   –   Observing for seizures
   • 2   –   Offering a diet low in fat
   • 3   –   Assessing for vision changes
   • 4   –   Taking blood pressure every 15 minutes for the first hour

   RATIONALE: Because kidney removal also removes a source of renin, the client is at risk for a drop in blood pressure. This client isn’t at risk for developing seizures or vision changes and doesn’t require a diet low in fat.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Management of care
   COGNITIVE LEVEL: Application

3. A child is to receive intrathecal methotrexate (Methoblastin) for treatment of acute lymphoblastic leukemia. For which of the following reasons would intrathecal administration be selected?
   • 1   –   The child has very poor veins and isn’t able to receive drugs I.V.
   • 2   –   This drug would be destroyed by gastric acid, so it can’t be given by mouth.
   • 3   –   This drug is poorly transported across the blood-brain barrier, so it’s administered intrathecally.
   • 4   –   Because the drug is rapidly absorbed if given I.M., adverse effects may appear more quickly.

   RATIONALE: Because the I.V. route doesn’t allow chemotherapeutic agents to reach all areas invaded by leukemic cells, this medication is administered intrathecally to ensure that the entire body receives treatment. If the child had poor I.V. access, a long-term access device or a similar port would be inserted. This medication may be given by mouth, I.M., or I.V., but none of these routes would be appropriate in this situation.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Application

4. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is:

   • 1   –   to prevent metabolic breakdown of xanthine to uric acid.
   • 2   –   to prevent uric acid from precipitating in the ureters.
   • 3   –   to enhance the production of uric acid to ensure adequate excretion of urine.
   • 4   –   to ensure that the chemotherapy doesn’t affect the bone marrow adversely.

   RATIONALE: The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk. Allopurinol doesn’t have any of the other actions listed.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Knowledge

5. A client asks why malignant melanoma is considered so serious. The nurse would respond with which of the following reasons?
   • 1   –   It usually metastasizes only to the kidneys.
   • 2   –   It can spread via the lymphatic system and the bloodstream.
   • 3   –   It usually develops where the client can’t see it: the legs in males and the back in females.
   • 4   –   It’s the most common skin cancer.

   RATIONALE: Malignant melanoma may indeed spread through the lymphatic system and the blood stream. This disorder can spread to every organ in the body. Men usually have an affected area on the back, whereas women typically have affected areas on their lower legs. The most common skin cancer is basal cell carcinoma.
   NURSING PROCESS STEP: Analysis
   CLIENT NEEDS CATEGORY: Health promotion and maintenance
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Analysis

6. A client is being treated for lung cancer and has been losing weight. The nurse is calculating the high biological value protein intake for a client’s lunch. The client ate approximately 6.5 oz of tuna on a roll, a cup of peach yogurt, a banana, half a cup of whole milk, and 6 oz of apple juice. Using the chart shown here, what’s the total high biologic protein value of this meal measured in grams?
   • 1   –   63.5 g
   • 2   –   59 g
   • 3   –   60.5 g
   • 4   –   54.5 g

   RATIONALE: The 6.5 oz of tuna contain 44.5 g of protein, the yogurt contains 10 g of protein, and half a cup of whole milk contains 4.5 g of protein. Thus, the total is 59 g. The roll, banana, and apple juice don’t contain high biological value protein.
   NURSING PROCESS STEP: Analysis
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Basic care and comfort
   COGNITIVE LEVEL: Application

7. A client is scheduled to undergo a left hemicolectomy for colorectal cancer. The physician prescribes phenobarbital (Luminal), 100 mg I.M. 60 minutes before surgery for sedation. Which statement accurately describes administration of phenobarbital sodium?
   • 1   –   The preferred route of administration for this drug is I.M.
   • 2   –   This drug can be mixed and given with other medications.
   • 3   –   This drug should be used within 24 hours after opening it.
   • 4   –   This drug should be injected into a large muscle mass.

   RATIONALE: Phenobarbital should be injected into a large muscle mass. The I.M. route of administration is usually avoided because the alkalinity of the soluble preparations causes pain and necrosis at the injection site. Therefore, if the drug must be given I.M., it should always be administered into a large muscle mass. Barbiturates are involved in many drug interactions, so the drug shouldn’t be mixed and given with other medications. The drug solution should be used within 30 minutes after opening it to minimize deterioration.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Analysis

8. A female client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often?
   • 1   –   Once, to establish a baseline
   • 2   –   Every 5 years
   • 3   –   Every 1 to 2 years
   • 4   –   Twice per year

   RATIONALE: A client ages 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 1 to 2 years. After age 50, the client should have a mammogram every year.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Health promotion and maintenance
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Knowledge

9. AA child with a brain tumor sometimes experiences headaches. The nurse is aware that she should obtain additional information on this child because such tumor-related headaches usually:
   • 1   –   follow a long period of nausea.
   • 2   –   occur after eating.
   • 3   –   occur shortly after retiring for the night.
   • 4   –   occur after waking in the morning.

   RATIONALE: Tumor-related headaches usually begin on awakening and may dissipate during the day. These headaches may be aggravated by sneezing or coughing but don’t follow nausea, aren’t affected by eating, and don’t occur in the evening.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Knowledge

10. An oncology nurse is presenting a program on risk factors related to cancer. Which of the following risk factors are associated with cancer? (Select all that apply.)

    • 1   –   Smoking
    • 2   –   Alcohol consumption
    • 3   –   Ingestion of proteins
    • 4   –   Ultraviolet radiation exposure
    • 5   –   Obesity
    • 6   –   Dehydration

    RATIONALE: Smoking, alcohol consumption, exposure to ultraviolet radiation (sunlight), and obesity are identified risk facts associated with cancer. Dehydration and ingestion of proteins haven’t been linked to cancer.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

11. When teaching about radiation therapy to parents of a 3-year-old boy diagnosed with Wilms’ tumor, the nurse would include which of the following statements?
    • 1   –   “The child may need radiation therapy until age 10.”
    • 2   –   “The head will be the only area radiated.”
    • 3   –   “The length of treatment may be 18 months.”
    • 4   –   “Radiation therapy doesn’t cause adverse effects.”

    RATIONALE: The average length of treatment is 18 months after surgical intervention in addition to chemotherapy. The area to be radiated would be the flank, and radiation may, indeed, cause adverse effects.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

12. While doing a preoperative admission assessment on a client scheduled for a craniotomy, the nurse was asked by the client if a primary brain tumor can spread to other parts of the body. The nurse should tell the client that primary brain tumors:

    • 1   –   rarely go outside the central nervous system (CNS).
    • 2   –   are likely to seed or scatter outside the CNS.
    • 3   –   are always encapsulated.
    • 4   –   are thought to be caused by heredity.

    RATIONALE: Primary brain tumors are typically confined to the CNS, but secondary brain tumors may appear from a variety of other sites, such as the breast, lung, or kidney. This particular type of tumor is not always encapsulated, and it may have multiple causes.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

 

Genetics

1. A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting or eliminating:
   • 1   –   vegetables.
   • 2   –   meats.
   • 3   –   grains.
   • 4   –   sugar.

   RATIONALE: PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulating in the blood causes central nervous system damage and progressive mental retardation. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted because they contain large amounts of phenylalanine. The child may consume measured amounts of vegetables, grains, and sugar, which are low in phenylalanine.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Comprehension

2. A 2-year-old child is admitted with vaso-occlusive crisis of sickle cell anemia. The child exhibits pain in the right ankle and edema in the right foot and ankle. Which of the following statements should the nurse question on the physician’s order sheet?
   • 1   –   “Bed rest until further notice”
   • 2   –   “Administer 1,000 ml D5NSS and 0.9% saline over 10 hours”
   • 3   –   “Oxygen if child has respiratory difficulty”
   • 4   –   “Demerol 12.5 mg I.M. for pain q 3 to 4 hr p.r.n.”

   RATIONALE: Clients with sickle cell disease are at risk for developing seizures when given repeated doses of Demerol. Bed rest, I.V. fluids, and oxygen are appropriate treatments.
   NURSING PROCESS STEP: Analysis
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Analysis

3. A 2-year-old client has just been diagnosed with hemophilia. Both parents are very involved with the child’s care and want to know everything about the disease. The father asks what will happen if the child is injured while playing with friends. The nurse would best answer by saying the main goal for treatment of this disorder is:
   • 1   –   replacing whole red blood cells as soon as possible after the injury.
   • 2   –   replacing the missing clotting factor.
   • 3   –   inserting a long-term access device for I.V. access.
   • 4   –   placing the child on steroids prophylactically.

   RATIONALE: The treatment for this disorder is replacement of the missing clotting factor (factor VIII or factor IX). Several products are available for accomplishing this goal. Whole blood or steroid administration is inappropriate in this situation. A long-term access device may be desirable at a later time.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Comprehension

4. A child has phenylketonuria. When planning the child’s menu with the mother, which of the following dietary points is most important to the nurse?
   • 1   –   Phenylalanine is toxic to these children and must be eliminated from the diet.
   • 2   –   Phenylalanine is essential for proper growth, and its intake must be regulated carefully.
   • 3   –   Phenylalanine intake should be controlled by limiting only meat products.
   • 4   –   Children receiving low phenylalanine formula (Lofenalac) can eat a regular diet.

   RATIONALE: Phenylalanine is an essential amino acid and is needed for proper growth; therefore, therapeutic levels must be carefully maintained. Numerous kinds of foods, such as milk and other natural food proteins, are sources of phenylalanine. The intake of these food products must be regulated.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Health promotion and maintenance
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Comprehension

5. A child hospitalized for sickle cell crisis is being discharged. Which statement by the parents of the client demonstrates effective teaching regarding prevention of future crises?

   • 1   –   The parent verbalizes that the child needs to stay away from individuals with known infections.
   • 2   –   The parents verbalize the appropriate dietary restrictions for their child.
   • 3   –   The parents verbalize the need to restrict the child’s fluid intake.
   • 4   –   The parents verbalize that the child needs to participate in an aerobic exercise program.

   RATIONALE: Preventing infections through proper hand washing and staying away from people with known infections is an important measure in preventing sickle cell crises. Dietary restrictions aren’t significant in preventing these crises. The client should maintain adequate hydration and not restrict fluid intake. He should also avoid strenuous activity such as aerobics.
   NURSING PROCESS STEP: Evaluation
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Safety and infection control
   COGNITIVE LEVEL: Analysis

6. A client is hospitalized in sickle cell crisis. Knowledge of Maslow’s hierarchy of needs can assist the nurse in prioritizing client care. Place the stages of Maslow’s hierarchy of needs in order from basic to most complex. (Use all the options.)
   • 1   –   Safety and security
   • 2   –   Self-esteem
   • 3   –   Physiologic needs
   • 4   –   Love and belonging
   • 5   –   Self-actualization

   RATIONALE: Maslow’s hierarchy of needs progresses from the most basic to the most complex. Maslow’s theory states that physiologic needs are the most basic human needs of all. Only after physiologic needs have been met can safety concerns be addressed, followed by the need for love and belonging. Love and belonging then fosters self-esteem and, finally, self-actualization.
   NURSING PROCESS STEP: Analysis
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Basic care and comfort
   COGNITIVE LEVEL: Analysis

7. A client who’s 24 weeks’ pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which of the following factors as a potential trigger for a sickle cell crisis during pregnancy?
   • 1   –   Sedative use
   • 2   –   Dehydration
   • 3   –   Hypertension
   • 4   –   Tachycardia

   RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren’t known to precipitate a sickle cell crisis.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Health promotion and maintenance
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Knowledge

8. A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What’s the nurse’s highest priority when caring for this child?

   • 1   –   Providing fluids
   • 2   –   Maintaining protective isolation
   • 3   –   Applying cool compresses to affected joints
   • 4   –   Administering antipyretics, as prescribed

   RATIONALE: During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Providing I.V. and oral fluids promotes hemodilution, which aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn’t require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don’t play a crucial role in resolving the crisis.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Application

9. AA nurse is caring for a neonate 12 hours after birth. Which of the following clinical manifestations would be the earliest indication that the neonate may have cystic fibrosis?
   • 1   –   Steatorrhea
   • 2   –   Meconium ileus
   • 3   –   Decreased sodium levels
   • 4   –   Rhinorrhea

   RATIONALE: The small intestine becomes blocked with thick meconium; therefore, meconium ileus is the earliest indication that a neonate has cystic fibrosis. Steatorrhea may be present later and may be used as a guideline for administration of pancreatic enzymes. Infants and children with this disorder have increased sodium levels; rhinorrhea isn’t usually present.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Knowledge

10. After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?
    • 1   –   Removing the Logan bow during feedings
    • 2   –   Holding the infant semi-upright during feedings
    • 3   –   Burping the infant less frequently
    • 4   –   Placing the infant on his abdomen after feedings

    RATIONALE: Holding the infant semi-upright during feedings helps prevent aspiration. The Logan bow must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on the abdomen could lead to disruption of the suture line if the infant rubs his face.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

11. The nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis?

    • 1   –   Muscular hypotonicity
    • 2   –   Muscle spasticity
    • 3   –   Increased mucus viscosity
    • 4   –   Hypothyroidism

    RATIONALE: Several conditions make the child with Down syndrome highly vulnerable to respiratory infections. Hypotonicity of chest muscles leads to diminished respiratory expansion and pooling of secretions; an underdeveloped nasal bone impairs mucus drainage. Down syndrome isn’t associated with muscle spasticity or increased mucus viscosity. Although hypothyroidism is common in children with Down syndrome, it doesn’t increase the risk of infection.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Knowledge

12. The nurse is reviewing a client’s prenatal history. Which of the following findings indicates a genetic risk factor?
    • 1   –   The client is 25 years old.
    • 2   –   The client has a child with cystic fibrosis.
    • 3   –   The client was exposed to rubella at 36 weeks’ gestation.
    • 4   –   The client has a history of preterm labor at 32 weeks’ gestation.

    RATIONALE: Cystic fibrosis is a recessive trait; each offspring has a one-in-four chance of having the trait or the disorder. Maternal age isn’t a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn’t correlate with genetic defects.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

13. The parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse would be most appropriate?

    • 1   –   “Pancreatic enzymes promote absorption of nutrients and fat.”
    • 2   –   “Pancreatic enzymes promote adequate rest.”
    • 3   –   “Pancreatic enzymes prevent intestinal mucus accumulation.”
    • 4   –   “Pancreatic enzymes help prevent meconium ileus.”

    RATIONALE: Pancreatic enzymes are given to a child with cystic fibrosis to aid fat and protein digestion. They don’t promote rest or prevent mucus accumulation or meconium ileus.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

14. The parents of a child with cystic fibrosis, an autosomal recessive disorder, are considering having a second child. Each parent is heterozygous for the cystic fibrosis trait. What’s the chance that their second child will develop the disorder?
    • 1   –   0%
    • 2   –   25%
    • 3   –   50%
    • 4   –   100%

    RATIONALE: To express an autosomal recessive disorder, a child must inherit the trait from both parents. A heterozygous person carries one normal gene and one affected gene and doesn’t express the disorder. A child of two heterozygous parents has a one-in-four (25%) chance of manifesting an autosomal recessive disorder. Outcomes of previous pregnancies don’t predict future incidence of the genetic disorder.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

15. Two middle-aged sisters have been diagnosed with Huntington’s disease. The children of these clients want to know how likely it is that they will develop this genetic disorder. The nurse’s best response would be:
    • 1   –   “Only women become symptomatic.”
    • 2   –   “This disorder is an autosomal dominant disorder, so each child has a 50% chance of inheriting it.”
    • 3   –   “This disorder is an autosomal recessive disorder, so each child has a 25% chance of inheriting it.”
    • 4   –   “Women are symptomatic, and men are carriers of this disorder.”

    RATIONALE: Huntington’s disease is an autosomal dominant disorder; therefore, each male or female child has a 50% chance of inheriting it.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

16. When developing a postoperative care plan for an infant scheduled for cleft lip repair, the nurse should assign the highest priority to which of the following interventions?

    • 1   –   Comforting the child as quickly as possible
    • 2   –   Maintaining the child in a prone position
    • 3   –   Restraining the child’s arms at all times with elbow restraints
    • 4   –   Avoiding the crusts that form on the suture line

    RATIONALE: After surgery to repair a cleft lip, the primary goal of nursing care is to maintain integrity of the operative site. Crying causes tension on the suture line, so comforting the child as quickly as possible is the highest nursing priority. Parents may help by cuddling and comforting the child. The prone position is contraindicated after surgery because rubbing on the sheet may disturb the suture line. Elbow restraints may cause agitation; if used to prevent the child from disturbing the suture line, they must be removed one at a time, every 2 to 4 hours. After the elbow restraints are removed, the child can exercise and the nurse can assess his skin for irritation. Crusts forming on the suture line contribute to scarring and must be cleaned carefully.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

17. When doing discharge teaching with a 50-year-old client diagnosed with retinitis pigmentosa, the nurse should cover which important topic?
    • 1   –   The client may have difficulty interpreting red and green.
    • 2   –   The client may complain of floaters, flashing lights, or both.
    • 3   –   Genetic counseling may be helpful to other family members.
    • 4   –   Loss of peripheral vision may be the first thing that the client notices.

    RATIONALE: Retinitis pigmentosa is a disorder that is hereditary in origin and involves visual field loss and night blindness. A client who has difficulty interpreting red versus green has some degree of color blindness, whereas a client who has floaters and flashing lights may have a retinal detachment. The loss of peripheral vision is usually found in glaucoma.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

18. When performing a physical examination on an infant, the nurse notes abnormally low-set ears. This finding is associated with:
    • 1   –   otogenous tetanus.
    • 2   –   tracheoesophageal fistula.
    • 3   –   congenital heart defects.
    • 4   –   renal anomalies.

    RATIONALE: Normally, the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. Low-set ears don’t accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

 

Integumentary System

1. A client is admitted with multiple decubitus ulcers. When developing the client’s diet plan, the nurse should include:
   • 1   –   Fresh orange slices
   • 2   –   Ground beef patties
   • 3   –   Steamed broccoli
   • 4   –   Ice cream

   RATIONALE: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by decubitus ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Knowledge

2. A client is being treated for a stage 3 vascular ulcer. Based on the information charted on this flow sheet, what is the client’s intake and output status between 7 a.m. and 6 p.m.?

   • 1   –   Intake greater than output
   • 2   –   Intake less than output
   • 3   –   Intake equal to output
   • 4   –   Insufficient information

   RATIONALE: The total intake for this period of time was 1,075 ml and the output was 1,050 ml.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Basic care and comfort
   COGNITIVE LEVEL: Analysis

3. A client who has recovered from second- and third-degree burns is being discharged. Which of the following comments demonstrates the client has understood the discharge teaching?

   • 1   –   “I need to wear the pressure stockings to decrease scarring on my legs.”
   • 2   –   “I need to do physical therapy only once a week.”
   • 3   –   “I can take the pressure garments off for 4 hours a day.”
   • 4   –   “I don’t need to worry about contractures because I would have gotten them by now.”

   RATIONALE: Pressure stockings reduce the redness of the scar, soften the tissue, and decrease the vascularity of the involved tissue, thus improving its appearance. Physical therapy at home or at the hospital or clinic is needed until recovery is complete. This therapy is required daily or several days per week for progress to occur. The pressure garments are kept on as ordered by the physician. Contractures may occur until recovery is complete, up to 1 year after the injury.
   NURSING PROCESS STEP: Evaluation
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Management of care
   COGNITIVE LEVEL: Application

4. Several victims of a motor boat explosion are admitted for treatment of burns. The most effective I.V. solution for fluid resuscitation in a client who’s burned is:
   • 1   –   dextrose 5% in water.
   • 2   –   lactated Ringer’s solution.
   • 3   –   dextrose 5% in normal saline solution.
   • 4   –   dextrose 10% in normal saline solution.

   RATIONALE: A crystalloid solution in combination with a colloid solution appears to provide adequate fluid resuscitation for a client with thermal injuries. The crystalloid fluid of choice is lactated Ringer’s solution because it most resembles the body’s extracellular fluid. Dextrose in water or saline solution wouldn’t accomplish fluid resuscitation as effectively.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Knowledge

5. When a client receives a skin graft from another site on his own body, that graft is known as:
   • 1   –   a heterograft.
   • 2   –   an allograft.
   • 3   –   an autograft.
   • 4   –   a xenograft.

   RATIONALE: An autograft is taken from one site on a client’s body to be transplanted on the affected area of the client’s body. Heterografts and xenografts are taken from another species (such as a pig). Allografts are taken from an individual of the same species.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Management of care
   COGNITIVE LEVEL: Knowledge

6. When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation?
   • 1   –   Cephalhematoma
   • 2   –   Petechiae
   • 3   –   Subdural hematoma
   • 4   –   Caput succedaneum

   RATIONALE: Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture lines and typically clears within a few days after birth. Cephalhematoma is a swelling of the head that results from subcutaneous bleeding caused by pressure exerted on the soft tissues during delivery; it’s characterized by sharply demarcated boundaries that don’t cross the suture lines. Petechiae are minute, circumscribed, hemorrhagic areas of the skin. A subdural hematoma is an accumulation of blood between the dura and the brain tissue.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Health promotion and maintenance
   CLIENT NEEDS SUBCATEGORY: None
   COGNITIVE LEVEL: Knowledge

7. When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which of the following points?

   • 1   –   Fifth disease is transmitted by respiratory secretions.
   • 2   –   Fifth disease has an unknown transmission mode.
   • 3   –   Fifth disease is transmitted by respiratory secretions, stool, and urine.
   • 4   –   Fifth disease is transmitted by stool.

   RATIONALE: Fifth disease is transmitted by respiratory secretions. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasites, such as giardiasis and pinworms, are transmitted by stool.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Safety and infection control
   COGNITIVE LEVEL: Comprehension

 

Fluids and Electrolytes

1. If toxic levels of magnesium sulfate are reached, which of the following is the antidote of choice?
   • 1   –   terbutaline (Brethine)
   • 2   –   calcium gluconate (Kalcinate)
   • 3   –   hydralazine (Apresoline)
   • 4   –   dopamine (Intropin)

   RATIONALE: Calcium gluconate is the antidote for magnesium sulfate toxicity. Terbutaline is a tocolytic used in the treatment of preterm labor. Hydralazine is an antihypertensive used in the treatment of pregnancy-induced hypertension. Dopamine is an adrenergic agonist commonly used to treat hypotension.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Comprehension

2. The nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

   • 1   –   daily weight.
   • 2   –   serum sodium levels.
   • 3   –   measured intake and output.
   • 4   –   blood pressure.

   RATIONALE: Daily weight measurements show trends and can assist medication management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the client with fluid balance problems. However, if a client is dehydrated, some data can show false elevations. Intake and output is extremely important, but matching two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by depletion or excess of fluids in some situations.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Basic care and comfort
   COGNITIVE LEVEL: Knowledge

3. The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
   • 1   –   coma or seizures.
   • 2   –   sunken eyeballs and poor skin turgor.
   • 3   –   increased heart rate with hypotension.
   • 4   –   thirst or confusion.

   RATIONALE: Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and changes in heart rate and blood pressure are all later signs.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Basic care and comfort
   COGNITIVE LEVEL: Analysis

4. The nurse is caring for a client in acute renal failure (ARF). The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
   • 1   –   hypernatremia.
   • 2   –   hypokalemia.
   • 3   –   hyperkalemia.
   • 4   –   hypercalcemia.

   RATIONALE: 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. Hypernatremia, hypokalemia, and hypercalcemia don’t usually occur with ARF and aren’t treated with glucose, insulin, or sodium bicarbonate.
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Analysis

5. The nurse receives a physician’s order to administer 1,000 ml of normal saline solution I.V. over 8 hours. What should the drip rate be, in drops per minute, if the drop factor of the tubing is 15 gtt/ml?
   • –

   RATIONALE: The drip rate is calculated using the following formula:
   (Volume of infusion in ml 9 Time of infusion in minutes) x drop factor (in gtt/ml) = gtt/min
   (1,000 ml 9 480 min) x 15 gtt/ml = 31 gtt/min
   NURSING PROCESS STEP: Implementation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Application