Lesson 24

Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and
tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure
of the Client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control
her BP. Which potential nursing diagnosis will be a priority for discharge teaching?

Sleep pattern disturbance

Impaired physical mobility

Noncompliance - Your answer was correct

Fluid volume excess

The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression
stockings?

Compression stockings promote venous return - Your answer was correct

Compression stockings divert blood to major vessels

Compression stockings decreases workload on the heart

Compression stockings improve arterial circulation

Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?

Slow, irregular pulse

Dull, abdominal discomfort - Your answer was correct

Urinary frequency

Throbbing headache

The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during
the immediate postoperative period following a thyroidectomy?

Assess extremities for weakness and flaccidity

Support the head and neck during position changes - Your answer was correct

Position the client in high Fowler's

Medicate for restlessness and anxiety

A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He
also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary
for this client?

Sex partner of 3 months ago must be treated

Women with gonorrhea are symptomatic

Use a condom for sexual activity

Sex partner needs to be evaluated - Your answer was correct

The nurse in the nursing care unit is assigned to care to a client who is immunocompromised. The client tells the nurse
that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?

Call the physician

Give a pm pain medication

Clarify if the client is on a new medication

Use gown and gloves while assessing the lesions - Your answer was correct

The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on
the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:

Tripod gait

Two-point gait

Four-point gait

Three-point gait - Your answer was correct

A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to
notify the physician?

Expanding ecchymosis - Your answer was correct

Ascites and serum albumin of 3.2g/dl

Slurred speech

Hematocrit of 37% and hemoglobin of 12g/dl

What would be the recommended diet the nurse will Implement to a client with burns of the head, face, neck and anterior
chest?

Serve a high-protein, high-carbohydrate diet - Your answer was correct

Encourage full liquid diet

Serve a high-fat diet, high-fiber diet

Monitor intake to prevent weight gain

A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client
is complaining of having difficulty in bowel movement. Which of the following would be the most appropriate nursing
intervention?

Administer an enema

Perform range-of-motion exercise to all extremities

Ensure maximum fluid intake (3000ml/day) - Your answer was correct

Put the client on the bedpan every 2 hours

A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care
regarding expectoration of thick sputum. Which nursing action is most effective?

Place the client in a lateral position every 2 hour

Splint the patient's chest with pillows when coughing

Use humified oxygen

Offer fluids at regular intervals - Your answer was correct

A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following
instructions would the nurse include?

Wash the catheter with soap and water after each use - Your answer was correct

Lubricate the catheter with Vaseline

Perform the Valsalva maneuver to promote insertion

Replace the catheter with a new one every 24 hour

Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the
scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review
the client's chart and note the physician's prescription with an order to repeat. What should the nurse do next?

Rub the client's back until relaxed

Prepare a glass of warm milk

Give the second dose of pentobarbital sodium

Explore the client's feelings about surgery - Your answer was correct

The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the
nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?

Eating mainly bland food and milk or dairy products

Reducing intake of high-fiber foods

Eating small, frequent meals and a bedtime snack

Eliminating intake of alcohol and coffee - Your answer was correct

John is diagnosed with Addison's disease and admitted in the hospital. What would be the appropriate nursing care for
John?

Reducing physical and emotional stress - Your answer was correct

Providing a low-sodium diet

Restricting fluids to 1,500 ml/day

Administering insulin-replacement therapy

The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder
infection. Which of the following will the nurse include in the instruction?

Drink 3-4 quarts of fluid every day

Empty the bladder every 2-4 hours while awake - Your answer was correct

Encourage the use of coffee, tea, and colas for their diuretic effect

Teach Kegel exercises to control bladder flow

A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client
includes:

No eye pain is expected postoperatively

Semi-fowler's position will be used to reduce pressure in the eye.

Eye patches may be used postoperatively - Your answer was correct

Return of normal vision is expected following surgery

Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged
immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention
in the prevention of decubitus?

Giving backrubs with alcohol - Your answer was correct

Use of a bed cradle

Frequent assessment of the skin

Encouraging a high-protein diet

The nurse in the morning shift is making rounds in the ward. The nurse enters the client's room and found the client in
discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of
the client, the nurse can encourage the client to:

Sleep with a hot pad

Take to aspirins before arising, and wait 15 minutes before attempting locomotion

Take a hot tub bath or shower in the morning - Your answer was correct

Put joints through passive ROM before trying to move them actively

A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the
priority nursing intervention in the immediate post operative care of this client is:

Elevate the stump on a pillow for the first 24 hours - Your answer was correct

Encourage use of trapeze

Position the client prone periodically

Apply a cone-shaped dressing

The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, "When I will be allowed to eat
three meals a day like the rest of my family?". The appropriate nursing response is:

"You will probably have to eat six meals a day for the rest of your life."

"Eating six meals a day can be a bother, can't it?"

"Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you."

"It varies from client to client, but generally in 6-12 months most clients can return to their previous meal
patterns." - Your answer was correct

A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered
nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the
management of this client?

Speech pattern may be altered

Respiratory isolation is necessary for 24 hours after antibiotics are started - Your answer was correct

Perform skin culture on the macular popular rash

Expect abnormal general muscle contractions

A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following
foods will the nurse give to the client?

Whole grain cereal, orange juice, and apricots - Your answer was correct

Turkey, green bean, and Italian bread

Cottage cheese, cooked broccoli, and roast beef

Fish, green beans and cherry pie

Ms. Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in
the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has
to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent
fatigue?

Avoid extremes in temperature - Your answer was correct

Install safety devices in the home

Attend support group meetings

Avoid physical exercise

Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of
becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will
recommend to:

Allow plenty of time after the insulin injection and before beginning the match

Eat a carbohydrate snack before and during the badminton match - Your answer was correct

Drink plenty of fluids before, during, and after bed time

Take insulin just before starting the badminton match

A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may
have minimal but permanent disability. The family is concerned regarding the client's difficulty accepting the possibility of
long term effects. Which nursing diagnosis is best for this situation?

Nutrition, less than body requirements

Injury, potential for sensory-perceptual alterations

Impaired mobility, related to muscle weakness

Anticipatory grieving, due to the loss of independence - Your answer was correct
Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit.
The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent
contractures. Which of the following is the best position to the client?

Side-lying, alternating left and right sides

Sitting in a reclining chair twice a day

Lying on abdomen several times daily - Your answer was correct

Supine with stump elevated at least 30 degrees

client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site,
the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the
client's blood spills onto the floor. Which action will the nurse take to remove the blood spill?

Promptly clean with a 1:10 solution of household bleach and water - Your answer was correct

Promptly clean up the blood spill with full-strength antimicrobial cleaning solution

Immediately mop the floor with boiling water

Allow the blood to dry before cleaning to decrease the possibility of cross-contamination

Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On the assessment of the
nurse, his temperature is 38.1°C The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and
oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in
preventing infection is:

Using standard precautions and medical asepsis - Your answer was correct

Enforcing a "no visitors" rule

Using moist heat on painful joints

Monitoring a vital signs every 2 hour

Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely
to assist the client?

Placing food in the unaffected side of the mouth - Your answer was correct

Increasing fiber in the diet

Asking the patient to speak slowly

Increasing fluid intake

The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client's room
when a ventilator alarm sounds, what is the first action the nurse should do?

Assess the lung sounds

Suction the client right away

Look at the client - Your answer was correct

Turn and position the client

After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred
from the post anesthesia care unit?

Notify the family to report the client's condition

Immediately administer the narcotic as ordered

Keep client on right side supported by pillows

Encourage coughing and deep breathing every 2 hours - Your answer was correct

Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking
barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What
problem does the client most probably have?

Nephropathy

Macroangiopathy

Carpal tunnel syndrome

Peripheral neuropathy - Your answer was correct

A client is scheduled to have an inguinal herniorrhaphy in the outpatient surgical department. The nurse is providing
health teaching about-post surgical care to the client. Which of the following statement if made by the client would
reflect the need for more teaching?

"I should call the physician if I have a cough or cold before surgery"

"I will be able to drive soon after surgery" - Your answer was correct

"I will not be able to do any heavy lifting for 3-6 weeks after surgery"

"I should support my incision if I have to cough or turn"

What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus
aureus (MRSA)?

Use gloves and handwashing before and after client contact - Your answer was correct

Do nasal cultures on healthcare providers

Place the client on total isolation

Use mask and gown during care of the MRSA client

A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen.
The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which
of the following is the appropriate nursing response?

"How much of a difference have you noticed" - Your answer was correct

"It's part of the swelling your body is experiencing"

"It's probably because you have been less physically active"

"Your liver is not destroying estrogen hormones that all men produce"

The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the
client?

Orange juice.

Whole milk. - Your answer was correct

Ginger ale.

Black coffee.

The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe
pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?

Promote air and pleural drainage

Prevent kinking of the tube

Eliminate the need for a dressing

Eliminate the need for a water-seal drainage - Your answer was correct

A 70-year-o1d client is brought to the emergency department with a caregiver. The client has manifestations of anorexia,
wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?

Talk to the client about the caregiver and support system

Complete a gastrointestinal and neurological assessment - Your answer was correct

Check the lab data for serum albumin, hematocrit and hemoglobin

Complete a police report on elder abuse

The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate.
The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the
best nursing action to minimize the pain felt by the client?

Advising the client not to urinate around catheter - Your answer was correct

Intermittent catheter irrigation with saline

Giving prescribed narcotics every 4 hour

Repositioning catheter to relieve pressure

Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early
indicator of fluid retention in the postoperative period?

Periorbital edema

Increased specific gravity of urine

A urinary output of 50mL/hr

Daily weight gain of 2 lbs. or more - Your answer was correct

The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should
listen for at least:

5 minutes

60 seconds

30 seconds

2 minutes - Your answer was correct

A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?

NPO

Small feedings of bland food - Your answer was correct

A regular diet given frequently in small amounts

Frequent feedings of clear liquids

The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for
patency and capacity and then deflated. Which of the following nursing measure will ease the insertion to the tube?

Positioning the client in Semi-Fowler's position

Administering a sedative to reduce anxiety

Chilling the tube before insertion - Your answer was correct

Warming the tube before insertion

A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening.
What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?

Wash all vegetables before cooking

Wear gloves when gardening - Your answer was correct

Wear a mask when travelling to foreign countries

Avoid contact with cats and birds Mo

The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that
immediately following pneumonectomy; the client should be in what position?

Supine on the unaffected side

Low-Fowler's on the back

Semi-Fowler's on the affected side - Your answer was correct

Semi-Fowler's on the unaffected side

The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium
diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum
potassium has which of the following effects?

Potentiates the action of digoxin

Promotes calcium retention

Promotes sodium excretion

Puts the client at risk for digitalis toxicity - Your answer was correct

A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing
intervention by the nurse?

Monitor the client's vital signs

Keep the client on bed rest - Your answer was correct

Keep the patient on bed rest

Give a stat dose of Sucralfate (Carafate)

The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following
will alert the nurse?

Decreased pain in the fetal position

Urine output of 35mL/hr

CVP of l2mmHg - Your answer was correct

Cardiac output of 5L/min

A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of
the following assessment findings would the nurse report to the physician?

CVP of 5mmHa

Glasgow Coma Scale score of 13

Polyuria and dilute urinary output - Your answer was correct

Insomnia