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PN Comprehensive Review CD Questions 801-900 {COMP: Question 812 is a multiple-response question} 801. A male client is admitted to the emergency department with a diagnosis of druginduced anxiety related to overingestion of his prescribed antipsychotic medication. The most important piece of information the nurse should obtain initially is the: 1. Name and phone number of the nearest relative 2. Reason for the suicide attempt and if he will attempt it again 3. Length of time on the medication and symptom control information 4. Name of the ingested medication and the amount ingested Answer: 4 Rationale: The relatives and the reason for the suicide attempt are not the most important initial data. The length of time on the medication and symptom control are also not the priority in this situation. In an emergency, lifesaving facts are obtained first. The name and the amount of medication ingested are of utmost importance in treating this potentially life-threatening situation. Test-Taking Strategy: Use the process of elimination and note the key word initially. Lifesaving treatment cannot begin until the medication and amount are identified. Review emergency care of a client with an overingestion of a medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostrom, C. (2003). Psychiatric nursing (4th ed.). St. Louis: Mosby, pp. 361-362. 802. A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. During the administration of this medication, the nurse should specifically monitor which of the following? 1. Deep tendon reflexes 2. Apical heart rate 3. Degree of edema 4. Presence of pitting peripheral edema Answer: 1 Rationale: Loss of reflexes is often the first sign of developing toxicity. The nurse should assess knee jerk (patellar tendon reflex) for evidence of diminished or absent reflexes. Although options 2, 3, and 4 may be components of the assessment, these are not specifically associated with this medication. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar. From the remaining options, recall that option 1 is specific to the administration of this medication. Review this medication and the nursing responsibilities associated with its administration if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 661. 803. A nurse is assigned to care for a client who has returned to the nursing unit following a left nephrectomy. The nurse places the highest priority on monitoring which of the following? 1. Tolerance for sips of clear liquids 2. Oxygen saturation levels 3. Hourly urine output 4. Ability to turn side to side Answer: 3 Rationale: Following a nephrectomy, it is imperative to measure the urine output hourly. This is done to monitor the function of the remaining kidney and to detect renal failure early if it should occur. The client may also experience significant pain after this surgery, which could affect the client’s ability to reposition, cough, and deep breathe. Therefore the next most important measurements are vital signs (including oxygen saturation), pain level, and bed mobility. Clear liquids are not given until the client has bowel sounds, which are not referred to in this question. Test-Taking Strategy: Use the process of elimination. Note the key words highest priority, which tells you that more than one or all of the options is partially or totally correct. Options 1 and 4 are helpful, but are also not of the highest priority and therefore are eliminated first. Oxygen saturation levels are an important indicator of tissue perfusion, but urine output is the most valuable indicator in the client who has undergone surgery of the kidney. Therefore select option 3 over option 2 as the answer to the question. Review care to the client following nephrectomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 446. 804. A nurse is caring for a client experiencing thyroid storm. Which of the following would be a priority nursing diagnosis for this client? 1. Risk for decreased cardiac output 2. Disturbed body image 3. High Risk for sexual dysfunction 4. Ineffective coping Answer: 1 Rationale: Clients in thyroid storm are experiencing a life-threatening event, which is associated with uncontrolled hyperthyroidism. It is characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. The signs and symptoms of

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the disorder develop quickly, and therefore emergency measures must be taken to prevent death. These measures include maintaining hemodynamic status and patency of the airway and providing adequate ventilation. Options 2, 3, and 4 are not a priority in the care of the client in thyroid storm. Test-Taking Strategy: Use the process of elimination noting the key words priority nursing diagnosis. Use the ABCs—airway, breathing, and circulation—to direct you to option 1. Also using Maslow’s Hierarchy of Needs theory will direct you to the correct option. Options 2, 3, and 4 relate to psychosocial problems, and although they may exist for the client in thyroid storm, they are not a priority. Review the pathophysiology associated with thyroid storm if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 12001202. 805. A client with cancer is receiving cisplatin (Platinol). Which finding indicates that the client is having an adverse effect of the medication? 1. Excessive urination 2. Tinnitus 3. Increased appetite 4. Yellow halos in front of the eyes Answer: 2 Rationale: An adverse effect related to the administration of cisplatin, an antineoplastic medication, is ototoxicity with hearing loss. The nurse should monitor for this adverse effect when administering this medication. Options 1, 3, and 4 are not adverse effects of this medication. Test-Taking Strategy: Focus on the name of the medication noting that it is an antineoplastic medication. Remember that ototoxicity is associated with this medication. Review the effects of this medication and the nursing responsibilities during its administration if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 233. 806. A nurse is caring for a client with a psychomotor retarded depression. Based on this condition, the nurse would expect to note which behavior in the client? 1. Standing without moving, as if a statue, for long periods 2. Slowed walking and talking 3. Verbalization of increasingly angry feelings 4. Rapid pacing back and forth

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Answer: 2 Rationale: Slowed walking and talking is characteristic behavior of a psychomotor retarded depression. The physical symptoms may be explained by the person’s pessimistic view of the future, leading to the psychomotor inhibition and/or vegetative signs typically seen with depressed clients. Options 3 and 4 may occur in any agitated state. Option 1 is behavior more likely seen in schizophrenia. Test-Taking Strategy: Use the process of elimination. The key words psychomotor retarded depression should assist in eliminating options 3 and 4. From the remaining options, recalling that option 1 is most likely seen in the client with schizophrenia will assist in directing you to the correct option. Review the characteristics of this disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed.). St. Louis: Mosby, p. 208. 807. A nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority item? 1. Bladder distention 2. Homans’ sign 3. Extremity shortening 4. Heel breakdown Answer: 2 Rationale: Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Checking for the presence of Homans’ sign will detect this complication. Although bladder distention may occur postoperatively, option 1 is incorrect because it is not specific to the information in the question. Extremity lengthening or shortening may occur as a result of knee replacement, but is not the highest priority. Additionally, heel breakdown is not the highest priority. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Checking for deep vein thrombosis involves circulation. Review postoperative care following total knee replacement if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1688. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1537. 808. A nurse is collecting data on a client with hyperparathyroidism. Which of the following questions would elicit the most accurate information about this condition from the client?

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1. “Have you had problems with diarrhea lately?” 2. “Do you have tremors in your hands?” 3. “Are you experiencing pain in your joints?” 4. “Do you notice swelling in your legs at night?” Answer: 3 Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they provide information about hypoparathyroidism. From the remaining options, recalling the pathophysiology related to hyperparathyroidism will direct you to option 3. Review the manifestations associated with hyperparathyroidism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 469. 809. An 18-year-old client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain. The nurse further collects data on the client to see if these episodes occur with: 1. Exposure to heat 2. Being in a relaxed environment 3. Prolonged episodes of inactivity 4. Ingestion of coffee or chocolate Answer: 4 Rationale: Raynaud’s disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Test-Taking Strategy: Focus on the data in the question. The symptoms that the client describes occur with vasoconstriction, so you can use your knowledge of events that precipitate vasoconstriction to answer this question. Thus you can eliminate options 1, 2, and 3 because these events are unlikely to cause vasoconstriction. Review the manifestations and precipitating factors of Raynaud’s disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular

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Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1533. 810. A client is admitted to the hospital with pericarditis. The nurse reviews the client’s record for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1. Chest pain that worsens on expiration 2. Pericardial friction rub 3. Anterior chest pain 4. Weakness and irritability Answer: 2 Rationale: A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders. Test-Taking Strategy: Use the process of elimination. The key word is differentiates. This tells you that the correct option will be one that is unique to this health problem. This key word should assist in easily eliminating options 3 and 4. From the remaining options, option 2 is the one that is specific to pericarditis. Also note the relation of the client’s diagnosis and option 2. Review the characteristics associated with pericarditis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 325. 811. A nurse is beginning to ambulate a client with bacterial endocarditis who has a nursing diagnosis of Activity Intolerance documented in the nursing care plan. The nurse determines that the client is best tolerating the exercise if which parameter is noted? 1. Pulse rate that increases from 68 to 94 beats/min 2. Blood pressure that increases from 114/82 to 118/86 mm Hg 3. Minimal chest pain rated 1 on a 1- to 10-pain scale 4. Mild dyspnea after walking 10 feet Answer: 2 Rationale: General indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats/min, and a blood pressure change of less than 10 mm Hg. Test-Taking Strategy: Note the key words best tolerating the exercise in the question. Begin to answer this question by eliminating options 3 and 4 first because they represent abnormal data. From the remaining options, select option 2 noting that option 2 reflects the least physiological change as a result of the exercise. Review the indicators of exercise tolerance if you had difficulty with this question.

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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular References: Gulanick, M., Myers, J., Klopp, A., Galanes, S., Gradishar, D., & Puzas, M. (2003). Nursing care plans: Nursing diagnosis and intervention (5th ed.). St. Louis: Mosby, p. 7 Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 565. 812. A nurse is caring for a client with a multilumen catheter and is monitoring for signs of an air embolism. Select all clinical manifestations that would be noted in this complication. ___ Hypertension ___Chest pain ___A churning “windmill” sound heard over the right ventricle on auscultation ___Rales heard in the lung bases on auscultation ___Coughing Answer: Chest pain A churning “windmill” sound heard over the right ventricle on auscultation Coughing Rationale: All clients with IV lines are at risk for an air embolism. Because an air embolism can be life threatening, it is essential that the nurse monitor for the presence of chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning “windmill” sound. Test-Taking Strategy: Focus on the issue, air embolism. Recalling the pathophysiology associated with this complication will assist in determining the clinical manifestations. Review the manifestations of air embolism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 703. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 263. 813. A client is admitted to the hospital with pleurisy. The nurse checks the client for which characteristic symptom of this disorder? 1. Early morning fatigue 2. Dyspnea that is relieved by lying flat 3. Pain that worsens when the breath is held 4. Knifelike pain that worsens on inspiration Answer: 4

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Rationale: A typical symptom with pleurisy is a knifelike pain that worsens on inspiration. This is due to the friction caused by the rubbing together of inflamed pleural surfaces. This pain usually disappears when the breath is held because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat. Test-Taking Strategy: Use the process of elimination. Option 2 is eliminated first because dyspnea is not relieved by lying flat. Option 1 is eliminated next because fatigue, if it were to occur, would not be present in the morning when the client is most rested. From the remaining options, keep in mind that pleurisy results from inflammation of the pleura. Because the visceral and parietal lung pleura glide over one another with respiration, it is expected that chest movement precipitates or intensifies the pain. With this in mind, eliminate option 3. Review the clinical manifestations of pleurisy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 382. 814. A client seeks treatment for a complaint of hoarseness that has lasted for 6 weeks. Based on this symptom, the nurse interprets that the client is at risk of having: 1. Laryngeal cancer 2. Acute laryngitis 3. Bronchogenic cancer 4. Thyroid cancer Answer: 1 Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of bronchogenic or thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute problem, such as laryngitis. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating option 2 because an acute problem does not generally last for 6 weeks. From the remaining options, knowing that the vocal cords are in the larynx makes option 1 preferable to any of the others. Review the signs of laryngeal cancer if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 365. 815. A client is admitted to the nursing unit following lobectomy. The nurse assisting in caring for the client notes that in the first hour after admission the chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets that:

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1. The lung has fully re-expanded 2. This is normal 3. The client needs to cough and deep breathe 4. The tube may be occluded Answer: 4 Rationale: Chest tube drainage in the first 24 hours following thoracic surgery may total 500 to 1000 mL. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further evaluation. Options 1, 2, and 3 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Noting that the chest tube drainage has dropped from 75 mL to 5 mL will direct you to option 4. Review the concepts related to chest tube drainage systems if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1862. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 383-385. 816. A nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub, which was auscultated the previous day. The nurse interprets that this is most likely due to: 1. Decreased inflammatory reaction at the site 2. The deep breaths that the client is taking 3. Accumulation of pleural fluid in the inflamed area 4. Effectiveness of medication therapy Answer: 3 Rationale: Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 4 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, which would intensify the pain. Options 1 and 4 are similar, and because the question states that the problem is new in onset, these should be eliminated next. This leaves option 3, which is correct. Fluid accumulation in the area provides a buffer between the lung and chest wall surfaces, which eliminates the friction rub. Review the manifestations that occur with pleurisy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing

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(3rd ed.). Philadelphia: W.B. Saunders, p. 484. 817. A nurse is monitoring a client following a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion when the client exhibits: 1. Shortness of breath and tracheal deviation 2. Chest pain and shortness of breath 3. Decreasing oxygen saturation and bradypnea 4. Peripheral cyanosis and hypotension Answer: 1 Rationale: Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit decreasing oxygen saturation, but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal deviation and impedance of venous return to the heart. It may also be the result of other problems, such as a failing heart. Test-Taking Strategy: Use the process of elimination. Recalling that tracheal deviation is a manifestation that indicates a tension pneumothorax will direct you to option 1. Review the signs associated with tension pneumothorax and the conditions that require closed chest drainage if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2492. 818. A client has a serum sodium level of 129 mEq/L as a result of hypervolemia. The nurse anticipates that which of the following measures will be prescribed? 1. Providing a 2-g sodium diet 2. Providing a 4-g sodium diet 3. Restricting fluid intake 4. Administering intravenous hypertonic saline Answer: 3 Rationale: Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is due to hemodilution. Intravenous hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L. A 4-g sodium diet is a no-added-salt diet; a 2-g sodium diet does not raise the serum sodium level. Test-Taking Strategy: To answer this question accurately, it is necessary to know that the serum sodium level is low. With this in mind, you can eliminate option 1. Knowing that

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hypervolemia causes hemodilution of the serum sodium will guide you to choose option 3 over options 2 and 4. Review treatment measures for hyponatremia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 215-216. deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 424. 819. A nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which of the following is most important to include in the plan to ensure accurate monitoring of the client’s oxygenation status? 1. Notify the registered nurse immediately of an O2 saturation less than 90% 2. Instruct the client not to move the sensor 3. Tape the sensor to the client’s finger 4. Place the sensor on a finger below the blood pressure cuff Answer: 2 Rationale: The pulse oximeter passes a beam of light through the tissue, and a sensor attached to the fingertip, toe, or earlobe measures the amount of light absorbed by the oxygen-saturated hemoglobin (Hgb). The oximeter then gives a reading of the percentage of Hgb that is saturated with oxygen (SaO2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood, and because the detector cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client’s finger. If values fall below preset norms (usually 90%), the client should be instructed to deep breathe, if this is appropriate. Test-Taking Strategy: Use the process of elimination. The issue of the question is “to ensure accurate monitoring.” Eliminate option 1 because although reporting a low O2 saturation to the registered nurse is important, it is unrelated to ensuring accurate monitoring with a pulse oximeter. Option 4 is unreasonable; therefore eliminate this option. From the remaining options, recalling that motion at the sensor site changes light absorption will assist in selecting the correct option. Review the principles associated with pulse oximetry if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 496.

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820. A client with acute renal failure (ARF) has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse evaluates this therapy as effective if which of the following values is noted on follow-up laboratory testing? 1. Potassium 4.9 mEq/L 2. Sodium 142 mEq/L 3. Phosphorus 3.9 mg/dl 4. Calcium 9.8 mg/dl Answer: 1 Rationale: Of all the electrolyte imbalances that accompany renal failure, hyperkalemia is the most dangerous because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate may be given to cause excretion of potassium through the gastrointestinal tract. Each of the electrolyte levels noted in the question falls within the normal reference range for that electrolyte. The potassium level is measured following administration of this medication to note the extent of its effectiveness. Test-Taking Strategy: To answer this question correctly, it is necessary to know that the potassium level rises in ARF, and it is treated with the medication noted above. This knowledge allows you to eliminate each of the incorrect options. Also note the relationship of the name of the medication, Kayexalate, and option 1. If this question was difficult, review these concepts and this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Renal References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, pp. 980-981. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 781. 821. A nurse is admitting a client with chronic renal failure (CRF) to the nursing unit. The nurse monitors the client for which most frequent cardiovascular sign that occurs in CRF? 1. Hypertension 2. Hypotension 3. Tachycardia 4. Bradycardia Answer: 1 Rationale: Hypertension is the most common cardiovascular finding in the client with CRF. It is due to a number of mechanisms, including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and absence of prostaglandins. Hypertension may also be the cause of the renal failure. It is an important item to assess because hypertension can lead to heart failure in the CRF client because of increased cardiac workload in conjunction with fluid overload. Test-Taking Strategy: Use the process of elimination. Recalling that the blood pressure is a key item to assess helps you to eliminate options 3 and 4. From the remaining options, recall that hypertension, not hypotension, is associated with CRF. Review the

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manifestations associated with CRF if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 783. 822. When a client progresses from preeclampsia to eclampsia, the nurse’s first action is to: 1. Administer magnesium sulfate 2. Check the blood pressure and fetal heart tones 3. Clear and maintain an open airway 4. Administer oxygen by face mask Answer: 3 Rationale: It is important as a first action to clear and maintain an open airway and prevent injuries to the client. Options 1, 2, and 4 are all procedures that should be done, but are not the first action. Test-Taking Strategy: Note that the question asks for the “first action.” All of the options are correct procedures for this client. However, there is a certain order that ought to be followed for the client’s safety. Use the ABCs—airway, breathing, and circulation—to answer the question. Review care to the client with eclampsia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 223. 823. A nurse is admitting a client who has a history of bipolar disorder to the hospital, and the physician has indicated that the client is currently in the manic phase. When collecting data regarding the client’s rest needs, the nurse knows that the most reliable information may be obtained by: 1. Asking the client how many hours of sleep were obtained last night 2. Observing the facial appearance of the client 3. Asking the significant other about the current sleep patterns 4. Asking the night shift to record hours of sleep tonight Answer: 3 Rationale: Option 3 will provide the most reliable information because the client may not be able to report the sleep accurately. The client may report that sleep has not been a problem when in fact a minimum amount of sleep has been obtained for the past several days. Rest needs are very important because the manic client may be at the point of exhaustion by the time hospitalization occurs. Facial expressions may be an indicator of fatigue, but they are not quantifiable. Asking the night shift for data is not in the best interest of the client because the data collection process would be delayed.

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Test-Taking Strategy: Use the process of elimination and note the key words most reliable information. The option that is likely to give the most quantifiable data is the correct option. In this situation, the significant other is the only one that can give information about the past few days or weeks. Review care to the client with mania if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 215. 824. A nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). The nurse identifies that the priority nursing diagnosis of the acute phase would be: 1. Anxiety 2. Interrupted family process 3. Pain 4. Impaired tissue integrity Answer: 3 Rationale: Pain is the prevailing symptom of acute MI. Relief of pain is a priority. Pain stimulates the autonomic nervous system, increasing myocardial oxygen demand. Although options 1, 2, and 4 are also appropriate nursing diagnoses, the presence of pain affects these additional nursing diagnoses. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory, remembering that physiological needs are the priority. This will assist in eliminating options 1 and 2. From the remaining options, pain is certainly the priority over tissue “integrity.” Additionally, there are no data in the question to indicate that impaired tissue integrity exists. Review the priorities of care in a client with acute MI if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 310, 315. 825. A nurse is planning for a nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test? 1. Indirect and direct bilirubin levels 2. Rh and ABO blood typing 3. Heel stick blood glucose 4. Serum insulin level Answer: 3 Rationale: After birth the most common problem in the LGA infant is hypoglycemia, especially if the mother has diabetes mellitus. At delivery when the umbilical cord is

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clamped and cut, the maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant’s blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the newborn may suffer central nervous system damage caused by inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually ordered after the first 24 hours because jaundice is usually seen at 48 to 72 hours after birth. There is no rationale for ordering an Rh and ABO blood type unless the maternal blood type is O or Rh negative. Serum insulin levels are not helpful because there is no intervention to decrease these levels to prevent hypoglycemia. Test-Taking Strategy: Use the process of elimination and knowledge of the complications associated with the LGA infant. Options 1 and 2 can be eliminated first because these laboratory tests do not require immediate interventions after birth. Option 4 is not helpful; therefore eliminate this option. Review care to the LGA infant if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 259. 826. A client with cancer is receiving daunorubicin (Cerubidine) intravenously. The nurse assigned to assist in caring for the client monitors for which most commonly expected side effect? 1. Hypertension 2. Polycythemia 3. Nausea and vomiting 4. Hypovolemia Answer: 3 Rationale: Daunorubicin is an antineoplastic medication. The major gastrointestinal (GI) side effects include nausea, vomiting, stomatitis, and esophagitis. Cardiovascular side effects include congestive heart failure and dysrhythmias. Other frequently occurring side effects are alopecia and bone marrow depression. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Focusing on the client’s diagnosis will assist in determining that this medication is an antineoplastic. Knowing that antineoplastic medications commonly cause GI side effects, you can eliminate each of the other options. Review the side effects of antineoplastic medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 291. 827. A client’s arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which of the following medications that would be ordered to treat this acid-base disorder?

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1. Sodium bicarbonate 2. Furosemide (Lasix) 3. Acetazolamide (Diamox) 4. Spironolactone (Aldactone) Answer: 3 Rationale: Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide and spironolactone are loop and potassium-sparing diuretics, respectively. These are of no value when there is a need to excrete bicarbonate. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by interpreting the acid-base disorder as metabolic alkalosis. Eliminate option 1 first based on this conclusion. You can choose correctly among the remaining options by knowing which of the three diuretics is used to excrete bicarbonate. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 9. 828. A client is in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares for the administration of which of the following medications as a primary treatment for this problem? 1. Sodium bicarbonate 2. Calcium gluconate 3. Potassium 4. Regular insulin Answer: 4 Rationale: The primary treatment for any acid-base imbalance is treatment of the underlying disorder that caused the problem. In this case the underlying cause of the metabolic acidosis is anaerobic metabolism as a result of the lack of ability to use circulating glucose. Administration of regular insulin corrects this problem. Test-Taking Strategy: Use the process of elimination. The key words in the question are primary and diabetic ketoacidosis. This should assist in directing you to option 4. Review the causes and treatments for various acid-base disorders if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488.

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829. A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists to implement which measure as the most effective means to treat the problem? 1. Administer prescribed antibiotics 2. Administer prescribed PRN antipyretics 3. Have the client breathe into a paper bag 4. Request an order for a partial rebreather oxygen mask Answer: 1 Rationale: The most effective way to treat an acid-base disorder is to treat the underlying disorder. In this case the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis, but do nothing to treat the acid-base disorder. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again these do not treat the primary cause of the imbalance. Test-Taking Strategy: Use the process of elimination and note the key words most effective and sepsis. Recalling that the most effective treatment of acid-base disorders involves treatment of the primary problem and that sepsis is a systemic infection will direct you to option 1. Review treatment measures for sepsis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 257. 830. A nurse is developing goals for a school-aged child with a knowledge deficit related to the use of inhalers and peak flowmeters. The nurse identifies which of the following as an appropriate goal for this child? 1. Expresses feelings of mastery and competence with breathing devices 2. Has regular respirations at a rate of 18 to 22 breaths per minute 3. Denies shortness of breath or difficulty breathing 4. Watches the educational video and reads printed information provided Answer: 1 Rationale: School-aged children strive for mastery and competence to achieve the developmental task of industry and accomplishment. Options 2 and 3 do not relate to the knowledge deficit, which is the issue of the question. Option 4 is an intervention rather than a goal. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 because they are similar. From the remaining options, focus on the issue to direct you to option 1. Option 1 is the age-appropriate outcome that is related directly to the issue of the question. Review growth and development concepts related to a school-aged child if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Child Health

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Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 133-134. 831. A nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates an inaccurate understanding regarding BSE? 1. “I don’t need to do that; I’m too old for that.” 2. “I do BSE 7 days after I get my period.” 3. “I examine my breasts in the shower.” 4. “I lie on my back to examine my breasts.” Answer: 1 Rationale: BSE should be done even after menopause. No one is too old to get breast cancer. The other options reflect an accurate understanding of BSE. Test-Taking Strategy: Use the process of elimination and note the key word inaccurate. This word indicates a false-response question and that you need to select the incorrect client statement. Recalling the importance of this monthly self-examination will direct you to option 1. Review BSE if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 312. 832. A nurse is monitoring a client at risk for abruptio placentae. Which of the following is most indicative of this complication? 1. Severe nausea and vomiting 2. Painless bleeding 3. Tender to rigid abdomen 4. Normal blood pressure Answer: 3 Rationale: Signs of abruptio placentae include a tender, rigid abdomen; pain; cramp-like to severe, dark red vaginal bleeding; and maternal shock (hypotension) and fetal distress. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Focusing on the issue, abruptio placentae, will assist in eliminating options 1 and 4. From the remaining options, it is necessary to know the manifestations of this complication. Review these manifestations if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 876. 833. Abruptio placentae has been diagnosed in a pregnant client. The nurse caring for the client prepares the client for: 1. A cesarean birth

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2. Frequent enemas until clear 3. A stress test 4. Frequent repositioning from the right to the left side Answer: 1 Rationale: Early diagnosis of abruptio placentae is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood work analysis, and either an immediate cesarean birth or vaginal delivery. Options 2, 3, and 4 are not helpful in managing this problem. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 3 first because they are the least likely to be helpful in this situation. Choose correctly between the remaining options, knowing that cesarean birth will deliver the baby quickly and minimize the risk of maternal or fetal compromise. Review the treatment for abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 877. 834. A nurse is told that a prenatal client is at risk for abruptio placentae. The nurse expects to note which risk factor documented in the client’s record? 1. Gestational diabetes 2. Hyperemesis gravidarum 3. Maternal hypertension 4. Oliguria Answer: 3 Rationale: Maternal hypertension is a risk factor associated with abruptio placentae. This factor leads to degenerative changes in the small arteries that supply the intervillous spaces of the placenta. This results in thrombosis, causing retroplacental hematoma and leading to placental separation. Options 1, 2, and 4 are not associated risk factors. Test-Taking Strategy: Focus on the issue, the risk factors for abruptio placentae. Use the ABCs—airway, breathing, and circulation. Option 3 addresses circulation. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 875. 835. A generally healthy 63-year-old man is seen in the physician’s office for a routine examination. Which statement by the client is most important for the nurse to follow-up on? 1. “Everyone in my immediate family has died from gastrointestinal cancer.” 2. “I try to avoid overly hot or spicy foods because they give me heartburn sometimes.”

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3. “I have been following the balanced diet plan that the physician gave me.” 4. “I check my stool yearly for occult blood.” Answer: 1 Rationale: The nurse should follow-up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him, and the nurse should gather further data to understand the client’s situation and to identify additional risk factors. Options 2, 3, and 4 identify appropriate client behaviors regarding the prevention and detection of gastrointestinal cancer. Test-Taking Strategy: Use the process of elimination and note the key words most important. Note that the correct option is an item suggesting the need for further data collection. Options 2, 3, and 4 are similar in that they identify client behaviors regarding the prevention and detection of gastrointestinal cancer. Review these prevention and detection measures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 761. 836. A tentative diagnosis of gastroesophageal reflux was made in a client who is going to undergo ambulatory pH monitoring. The nurse brings which of the following items to the bedside? 1. IV line insertion kit 2. Enema bag 3. Nasogastric (NG) tube 4. Subcutaneous injection syringe Answer: 3 Rationale: Ambulatory pH monitoring requires insertion of a nasogastric tube that has a probe attached. The other items are unnecessary for this test. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis. Note that the NG tube is the only option that is directly correlated with the location of the client’s problem, that is, the esophagus. Review this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 10141015. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1246. Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed). St. Louis: Mosby, p. 484.

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837. A client has just undergone gastroscopy. Which of the following is the most essential postprocedure nursing intervention? 1. Assist the client to gargle with a local anesthetic 2. Keep the client in a prone position 3. Maintain the client on bed rest 4. Check the gag reflex before giving oral foods or fluids Answer: 4 Rationale: The client may not eat or drink after this procedure until protective airway reflexes return to prevent aspiration. The nurse must document that the gag and swallow reflexes have returned. The client would receive a local anesthetic to the throat before the procedure, not after. The client does not require activity or positioning restrictions following the procedure. Test-Taking Strategy: The key words in the question are most essential. Use the ABCs— airway, breathing, and circulation—to direct you to option 4. Review postprocedure care following gastroscopy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 590. 838. A client who has been taking indomethacin (Indocin) for gout has an order for guaiac testing of the stool. The nurse explains to the client that this test is necessary because it detects which of the following that may be caused or affected by this medication? 1. Steatorrhea 2. Occult blood 3. pH of stool 4. Color of stool Answer: 2 Rationale: The stool guaiac test is noninvasive and is widely used as a gross screening for blood in the gastrointestinal tract. It is not used for any of the other reasons listed in options 1, 3, or 4. Test-Taking Strategy: Specific knowledge of this common test or the side effects of indomethacin will help you to identify the correct option. Recalling that guaiac relates to the presence of blood will direct you to option 2. Review the purpose of this test if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 756. Lilley, L., Harrington, S., & Snyder, J. (2005). Pharmacology and the nursing process

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(4th ed.). St. Louis: Mosby, p. 741. 839. A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. The nurse determines that the client has understood discharge instructions if the client states: 1. “I will call if I haven’t had a normal bowel movement in a week.” 2. “I need to take a laxative every night from now on.” 3. “I will continue on a low-residue diet for several days and limit fluids.” 4. “I should take a laxative, and my stool should return to normal color.” Answer: 4 Rationale: Discharge teaching following this procedure includes that the client should take a laxative to enhance passage of remaining barium from the bowel to prevent impaction. Stools change from clay colored back to a normal color once all the barium is eliminated. The information contained in the client’s other statements does not reflect accurate discharge teaching. Test-Taking Strategy: Focus on the issue of the question, which is knowledge of items that should be reviewed as part of discharge teaching following barium enema. Recalling that barium can cause an impaction will direct you to option 4. Review postprocedure instructions following this test if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 219. 840. A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which signs or symptoms? 1. Dizziness after meals 2. Moderate right upper quadrant pain unrelated to eating 3. Difficulty swallowing 4. Left lower quadrant pain 2 hours after eating Answer: 3 Rationale: Although many clients with hiatal hernia are asymptomatic, those with symptoms usually have difficulty swallowing along with heartburn and reflux. Options 1, 2, and 4 are unrelated to this disorder. Test-Taking Strategy: To answer this question correctly, note that this client has an upper gastrointestinal disorder. Recalling that pain is usually in the epigastric area and that it correlates with food intake will assist in eliminating each of the incorrect options. Review the signs or symptoms of hiatal hernia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing

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(3rd ed.). Philadelphia: W.B. Saunders, p. 680. 841. A nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. The nurse makes which statement to the client? 1. “Be sure to sleep with your head elevated in bed.” 2. “This problem requires surgery most of the time.” 3. “Eat foods that are higher in fat to slow down digestion.” 4. “Lie down for at least an hour after eating.” Answer: 1 Rationale: Most clients with hiatal hernia can be managed by conservative measures, which include a low-fat diet, avoiding lying down for an hour after eating, and elevating the head of the bed. Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with hiatal hernia. This will direct you to option 1. Review the treatment for this disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 842. A client will undergo a barium swallow to determine whether the client has a hiatal hernia. The nurse provides preprocedure instructions and tells the client to: 1. Avoid eating or drinking after midnight before the test 2. Have a clear liquid breakfast only, on the morning of the test 3. Take all routine medications on the morning of the test 4. Limit self to two cigarettes only, on the morning of the test Answer: 1 Rationale: The stomach should be empty at the time of a barium swallow because food and medications can interfere with test results. Smoking increases mucus and acid production and can interfere with the tests. For this reason, all foods, liquids, medication, and smoking are avoided before the test. Test-Taking Strategy: Use the process of elimination and focus on the issue, preparation for a barium swallow. Remember that options that are similar are not likely to be correct. Each of the incorrect options involves taking in something on the morning of the examination. Review the preprocedure instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 220. 843. A nurse documents that a client with a hiatal hernia is complying with the

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prescribed treatment if the client reports doing which of the following? 1. Using low-fat or nonfat foods 2. Elevating the foot of the bed during sleep 3. Doing household chores immediately after eating 4. Sleeping with the head of the bed flat and the feet elevated Answer: 1 Rationale: The use of low-fat or nonfat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep and wait at least 1hour after meals to perform chores. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 2 and 4. Choose correctly between the remaining options, knowing that low-fat foods are helpful, and activity following meals can aggravate reflux. Review the treatment measures for hiatal hernia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 844. A client arrives in the emergency department with bleeding esophageal varices, and the physician states that a Sengstaken-Blakemore tube will be used to try to control the gastrointestinal hemorrhage. The nurse prepares for insertion of the tube via which of the following routes? 1. Percutaneous 2. Oral gastric 3. Nasogastric 4. Gastrostomy Answer: 3 Rationale: A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect. Test-Taking Strategy: Focus on the client’s diagnosis, bleeding esophageal varices. Eliminate options 1 and 4 first because they are least likely to be correct. Choose between the remaining options by visualizing the tube and what it is intended to accomplish. Review this type of tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 660-661. 845. A nurse is assisting in caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse plans to:

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1. Have a family member remain with the client 2. Keep scissors at the bedside 3. Give frequent oral and nasal care 4. Provide tracheal suction as necessary Answer: 3 Rationale: Frequent oral care, including oral suctioning, is necessary to prevent ulceration and necrosis of oral and nasal mucosa. A family member’s presence will not prevent this from occurring, nor will the actions taken in options 2 and 4. Keeping scissors at the bedside is an appropriate action, however; they are used to cut the tube if the client begins to have airway maintenance problems. Test-Taking Strategy: Focus on the issue of the question, which is preventing ulceration and necrosis of the oral and nasal mucosa. Eliminate each of the incorrect options because they do not address this problem. Also, note the presence of the words “oral” and “nasal” in both the question and the correct option. Review care to the client with a Sengstaken-Blakemore tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1346. 846. A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless. The client’s heart rate and blood pressure increase and the client has difficulty breathing. The most important nursing action is prepare to: 1. Cut the tube and pull it out immediately 2. Administer oxygen at 3 L/min via nasal cannula 3. Call the attending physician immediately 4. Stay with the client and use the call bell to summon help Answer: 1 Rationale: Sudden rupture of the esophageal balloon can cause airway obstruction, aspiration, and/or asphyxiation. The tube should be cut and removed to prevent airway obstruction and respiratory arrest. Options 3 and 4 can also be done once the nurse takes action to safeguard the client’s airway. Option 2 may be done with a physician’s order, but this is not the most important action at this time. Test-Taking Strategy: The key words in the stem of the question are most important. This tells you that more than one or all actions may be partially or totally correct, but that one is better than the others. Use the ABCs—airway, breathing, and circulation—and knowledge of the risks inherent with the use of this tube to direct you to option 1. Only option 1 definitively assists in maintaining the client’s airway. Review care to the client with a Sengstaken-Blakemore tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal

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References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1346-1347. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1379. 847. A 70-year-old client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which of the following additional supportive data for this diagnosis from the client? 1. Complaints of stress with a history of chronic renal failure 2. Frequent “heartburn” with a sour taste in the mouth 3. Blood group and history of chronic obstructive pulmonary disease with weight gain 4. History of alcohol use, smoking, and weight loss Answer: 4 Rationale: Alcohol use, smoking, and weight loss are most commonly associated with gastric ulcers. The other options do not identify risk factors or symptoms commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease. Test-Taking Strategy: Use the process of elimination and focus on the client’s suspected diagnosis, gastric ulcer. Recalling that alcohol and smoking can lead to gastric ulcer formation and that weight loss is part of the clinical picture will direct you to option 4. Review the causes and manifestations associated with a gastric ulcer if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 685. 848. A client with peptic ulcer disease has been prescribed to take misoprostol (Cytotec) and sucralfate (Carafate). The nurse teaches the client that these two medications will work primarily to: 1. Inhibit histamine action 2. Kill bacteria 3. Decrease stomach acid 4. Protect the gastric mucosa Answer: 4 Rationale: Both of these medications protect the stomach lining. Misoprostol increases the production of protective gastric mucus, and sucralfate coats the ulcer surface. Options 1 and 2 describe histamine antagonists and antibiotics, respectively. Option 3 describes antacids. Test-Taking Strategy: Specific knowledge of the mechanism of action for these medications is necessary to answer this question. Focusing on the names of the medications identified in the question and recalling their actions will direct you to option

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4. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 686. 849. A nurse should include which of the following in a teaching plan for a client who has peptic ulcer disease? 1. Continue to eat the same diet as before diagnosis 2. Smoke only at bedtime 3. Learn to use stress reduction techniques 4. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief Answer: 3 Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client should also limit intake of foods that aggravate pain, quit smoking, and avoid irritants, such as NSAIDs. Antibiotic therapy is often prescribed to treat this disease. Test-Taking Strategy: Use the process of elimination and focus on the issue, the factors that will reduce the symptoms of peptic ulcer disease. Eliminate each of the incorrect options, knowing that only option 3 is consistent with minimizing the disease process. Review the treatment measures for peptic ulcer disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 691. 850. A nurse is providing dietary instructions to a client with peptic ulcer disease (PUD). The nurse tells the client to: 1. Include foods that will increase gastrointestinal (GI) motility 2. Eat at least ten small meals per day 3. Consume a bland diet only 4. Eat anything that does not aggravate or cause pain Answer: 4 Rationale: The client may eat foods as long as they do not aggravate or cause pain. Foods that increase GI motility should be avoided. A bland diet is unnecessary. It is also unnecessary for the client to eat ten meals per day with this disease, although smaller meals are better managed by the client. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis. Note that option 4 is the umbrella (global) option. Review dietary teaching for a client with PUD if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 688. 851. A client has undergone subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item should be included when teaching the client about ongoing self-management? 1. Stress can no longer exacerbate gastrointestinal symptoms 2. The client can resume full activity immediately 3. Follow-up visits with the physician are no longer necessary 4. Smaller, more frequent meals should be eaten Answer: 4 Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation. Test-Taking Strategy: To answer this question accurately, recall that subtotal gastrectomy is often used to manage more severe gastric ulcers. With this in mind, eliminate the options that actually increase gastrointestinal symptoms. This will direct you to option 4. Review client teaching points following a subtotal gastrectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 691. 852. A nurse is providing home care instructions to a client following a gastric resection. The nurse includes which of the following in the instructions? 1. Eat a diet high in vitamin B12 2. Avoid iron supplementation 3. Self-monitor for signs and symptoms of lower gastrointestinal hemorrhage 4. Take actions to prevent dumping syndrome Answer: 4 Rationale: Dumping syndrome can occur in clients after gastric surgery and may occur as an early or late complication. Upper gastrointestinal hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks intrinsic factor needed for absorption of the vitamin. Instead the client requires injections to supplement this vitamin. Iron supplements are necessary to help absorption of parenteral vitamin B12. Test-Taking Strategy: Use the process of elimination and focus on the issue, a gastric resection. Recalling the pathophysiology associated with the upper gastrointestinal tract and the needs of a client following gastric resection will direct you to option 4. Review

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these client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 690. 853. A nurse provides information to a client following a gastrectomy about the signs and symptoms of pernicious anemia. The nurse understands that: 1. Once symptoms of pernicious anemia are evident, it is fatal 2. Regular monthly injections of vitamin B12 are used to treat this disorder 3. Pernicious anemia can occur any time for up to 10 years after surgery 4. Most diets are deficient in all of the B vitamins Answer: 2 Rationale: Vitamin B12 deficiency occurs from lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Replacement therapy is given by the parenteral route to ensure adequate absorption. Symptoms generally occur within 5 years or less following the surgery. Although it is not fatal, pernicious anemia can contribute to many other fatal diseases. Test-Taking Strategy: Knowledge regarding the pathophysiology and treatment measures related to pernicious anemia is necessary to answer this question. Remembering that this disorder is treated with monthly injections of vitamin B12 will direct you to option 2. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 690. 854. A nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. The nurse should focus interventions on which of the following during this time frame? 1. Maintaining a patent nasogastric (NG) tube 2. Providing the client with an oral diet 3. Teaching the client about the symptoms of dumping syndrome 4. Promoting the use of stress reduction techniques Answer: 1 Rationale: An NG tube is inserted during surgery and is left in place for 24 to 48 hours to decompress the gastrointestinal tract, which enhances sealing of the suture line. It is essential that the NG tube does not become occluded because this could disrupt the suture lines if distention occurs. The other options are also appropriate, but not within the first 24 hours following surgery. Test-Taking Strategy: Use the process of elimination and note the key words within the first 24 hours. Focusing on these key words will assist in eliminating options 2, 3, and 4.

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Review care to the client following total gastrectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 690. 855. A nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. The nurse recalls that absorption is best defined as: 1. Transfer of nutrients into the cell by active transport 2. A chemical process involving the breakdown of foods 3. Removal by osmosis of digested food to the cells 4. Transfer of digested food molecules from the GI tract into the bloodstream Answer: 4 Rationale: Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Digestion involves the mechanical and chemical breakdown of foods. Options 1, 2, and 3 are incorrect statements. Test-Taking Strategy: Knowledge regarding the definition of absorption is required to answer this question. Remember that absorption is the transfer of digested food elements into the bloodstream. Review this gastrointestinal process if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 351, 653. 856. A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN assists the client into which of the following positions? 1. Sims position 2. Supine with the head and feet flat 3. Supine with the head raised slightly and the knees slightly flexed 4. Semi-Fowler with the head raised 45 degrees and the knees flat Answer: 3 Rationale: To perform an abdominal assessment, the client is placed in the supine position with the head raised slightly and the knees slightly flexed. This position will relax the abdominal muscles. If the head is raised to 45 degrees, the abdomen cannot be accurately assessed. Sims position is a side-lying position and does not adequately expose the abdomen for examination. Placing the head and feet flat results in the abdominal muscles becoming taut. Test-Taking Strategy: Use the process of elimination. Visualize each of the positions identified and evaluate each of them against their natural ability to keep abdominal

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muscles relaxed. This will direct you to option 3. Review this technique if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 371. 857. A nurse is providing postprocedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately: 1. 1 to 2 days 2. 5 to 7 days 3. 1 week 4. 10 days Answer: 1 Rationale: It takes at least 12 to 24 hours for a substance to pass through the colon. The other time frames listed are excessive. Barium should be eliminated to prevent the risk of impaction from this substance. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar time frames. Next eliminate option 4 because it is excessive in length. Review postprocedure teaching following an upper GI series if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1109. Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 901. 858. A physician asks a nurse to obtain a Salem sump tube for gastric intubation. The nurse selects which of the following tubes from the unit storage area? 1. A Sengstaken-Blakemore tube 2. A Miller-Abbott tube 3. A tube with just a single lumen 4. A tube with a lumen and an air vent Answer: 4 Rationale: A Salem sump is used commonly for gastric intubation and has a large suction lumen and a small air vent. A Sengstaken-Blakemore tube is a tube used for gastroesophageal bleeding and has a balloon that controls bleeding. A Miller-Abbott tube is a long double-lumen tube used to drain and decompress the small intestine. Option 3 describes a Levin tube. A Levin tube does not have an air vent, but is used for the same functions as a Salem sump tube.

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Test-Taking Strategy: Knowledge regarding the characteristics of a Salem sump tube is required to answer this question. Remember that a Salem sump tube has a large suction lumen and a small air vent. Review this type of tube and the tubes identified in the options if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, pp. 476-480. 859. A nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse expects that the physician will prescribe the suction setting at: 1. Low and continuous 2. High and intermittent 3. Low and intermittent 4. High and continuous Answer: 3 Rationale: A Levin tube has no air vent, and the suction must be placed on a low and intermittent setting to prevent trauma to the gastric mucosa. A Salem sump allows for continuous suction because of the presence of an air vent on that tube. Low suction pressure is safer for the stomach than high pressure. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 4 because of the word “high.” To choose between the remaining options, recall that a Levin tube has no air vent. This will direct you to option 3. Review care to the client with a Levin tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 486-487. 860. A nurse is working with a client with anorexia nervosa. The nurse plans care focusing on which of the following as the primary problem? 1. Lack of nutritional knowledge 2. Impaired nutritional status 3. Depression 4. Pain Answer: 2 Rationale: A client with anorexia has a decreased appetite, which can be due to any number of causes. The plan of care primarily focuses on the risk of impaired nutritional status. The other options listed may or may not be associated with this client’s diagnosis. Test-Taking Strategy: Note the key word primary. Use Maslow’s Hierarchy of Needs theory to eliminate options 1 and 3 because these are not physiological problems. From the remaining options, focusing on the client’s diagnosis will direct you to option 2.

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Review the primary problems associated with anorexia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 236. 861. A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which of the following will be prescribed to treat the problem? 1. Vitamin B6 injections 2. Vitamin B12 injections 3. Antibiotic therapy 4. Antacid use Answer: 2 Rationale: Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Vitamin B6 is absorbed when given orally. Vitamin B6, antibiotic therapy, and antacid use do not help to treat lack of intrinsic factor. Test-Taking Strategy: Knowledge regarding the pathophysiology related to chronic gastritis is required to answer this question. Remember that insufficient intrinsic factor results in the inability to absorb vitamin B12. Review this disorder and its associated complications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 690. 862. A nurse is caring for a client in the emergency department who has right lower quadrant pain. After noting a white blood cell count of 16,500/mm3, the nurse should question an order for which of the following? 1. NPO 2. Intravenous fluids at a rate of 100 mL/hr 3. Cold pack to the abdomen 4. Milk of magnesia Answer: 4 Rationale: A client with right lower quadrant pain may have appendicitis. This client should be NPO and given IV fluids for hydration. Cold packs may provide comfort. Laxatives are not ordered; therefore the nurse should question this order. Test-Taking Strategy: Use the process of elimination and note the client’s complaint, right lower quadrant pain. Focusing on the key words question an order and noting that a

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definitive diagnosis has not been determined will direct you to option 4. Review emergency care to a client with right lower abdominal pain if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 672-673. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 698. 863. A nurse receives a telephone call from the mother of a child who has a foreign body in the eye. The mother states that the object is clearly visible and is not imbedded and asks the nurse about the most effective way to get it out. The nurse tells the mother to: 1. Let the object just work its way out 2. Touch the object gently with a cotton swab and lift it out 3. Irrigate the eye with natural tears 4. Irrigate the eye with running tap water Answer: 2 Rationale: The most effective method that causes the least amount of trauma is to lift the foreign body from the eye. It should not be allowed to remain in the eye and work its way out. Irrigating the eye may cause the foreign body to move and cause trauma in another area of the eye. Test-Taking Strategy: Use the process of elimination and knowledge of general principles of eye safety to answer this question. Remember also that options that are similar are not likely to be correct. With this in mind, eliminate options 3 and 4 first. Choose between the remaining options, knowing that the correct option is the one that provides relief to the child without causing further harm. Review care to the client with a foreign body in the eye if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1003. 864. After a routine eye examination, an adult client has been told that there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated by: 1. Eye drops 2. Rigid contact lenses 3. Prescription for corrective lenses 4. Keratoplasty Answer: 3 Rationale: Errors of refraction in vision include astigmatism, presbyopia, myopia, and

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hyperopia. Corrective lenses, or eyeglasses, are the most common method used to correct errors of refraction. Eye drops are used for several eye conditions, most commonly glaucoma. The client may or may not need rigid contact lenses, and this is not the most common treatment. A keratoplasty is a surgical procedure for cataracts. Test-Taking Strategy: Use the process of elimination and focus on the issue, the primary treatment for errors of refraction. With this in mind, you can then eliminate options 1 and 4. Choose option 3 over option 2 because of the word “rigid” in option 2. Rigid lenses may or may not be required. Many clients wear soft contact lenses to correct errors of vision. Review the treatment for refractive errors if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1962-1964. deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 297-298. 865. A nurse has provided discharge instructions to a client about ways to prevent strain on the operative eye following right eye cataract surgery. The nurse determines that the client needs further instruction if the client makes which of the following statements? 1. “I am not to lift more than 5 lb.” 2. “I should take stool softeners to prevent straining.” 3. “I can lie on my right side.” 4. “I cannot rub my eye.” Answer: 3 Rationale: The client should not lie on the operative side to reduce strain on the surgical eye. The information contained in options 1, 2, and 4 is correct and indicates accurate understanding by the client of postoperative instructions. Test-Taking Strategy: Use the process of elimination and note the key words needs further instruction. These words indicate a false-response question and that you need to select the incorrect client statement. Use knowledge of care to the client following eye surgery to eliminate each of the incorrect options. Also, note the relationship of the words “right eye” in the question and option 3. Review postoperative instructions following eye surgery if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1065. 866. A registered nurse (RN) asks a licensed practical nurse (LPN) to obtain a vial of mannitol (Osmitrol) for administration to a client. The LPN notes that the vial contains a few small crystals. Based on this observation, the LPN expects that the RN will:

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1. Discard the vial 2. Shake the vial to dissolve the crystals 3. Send the vial back to the pharmacy for replacement 4. Place the vial in warm water until the crystals dissolve Answer: 4 Rationale: Crystals form in mannitol if the solution is cooled, but quickly dissolve if the container is placed in warm water, then cooled to body temperature before administration. Options 1 and 3 are unnecessary, and option 2 will not dissolve the crystals. Test-Taking Strategy: To answer this question accurately, you must be familiar with this property of mannitol and its corrective action. This allows you to eliminate each of the incorrect options. Remember that this medication can be placed in warm water to dissolve crystals if present in the vial. Review the characteristics of this medication and the procedures related to its administration if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Lilley, L., Harrington, S., & Snyder, J. (2005). Pharmacology and the nursing process (4th ed.). St. Louis: Mosby, pp. 428-429. 867. A client is taking large doses of acetylsalicylic acid (aspirin) for rheumatoid arthritis. The nurse tells the client to report which of the following signs and symptoms of ototoxicity? 1. Tinnitus, hearing loss, dizziness, and ataxia 2. Dizziness, tinnitus, and purpura 3. Gastrointestinal (GI) upset, hematuria, and dizziness 4. GI bleeding, ecchymosis, and tinnitus Answer: 1 Rationale: Ototoxicity is damage to the eighth cranial nerve, which is responsible for hearing and balance. Purpura and ecchymosis are caused by prolonged bleeding, but not ototoxicity. GI bleeding and upset may be caused by acetylsalicylic acid (aspirin) irritation, but are not symptoms of ototoxicity. Test-Taking Strategy: Use the process of elimination and focus on the issue, signs and symptoms of ototoxicity. Remember that for an option to be correct all of its parts must be correct. Look for the option that contains manifestations associated with the ear. This will direct you to option 1. Review the signs and symptoms of ototoxicity if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 88. 868. A nurse is caring for a client with acute otitis media. The nurse plans care, knowing

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that the treatment for this problem is most likely to include: 1. Bed rest 2. Mastoidectomy 3. Diphenhydramine (Benadryl) 4. Myringotomy Answer: 4 Rationale: Myringotomy is a surgical procedure that allows fluid to drain from the middle ear. Bed rest is not required, but activity may be restricted. The mastoid bone is removed or partially removed for chronic otitis media. Diphenhydramine is an antiemetic used to treat nausea and vomiting. Test-Taking Strategy: Use the process of elimination and note the key word acute. This tells you that prompt and definitive treatment is necessary to alleviate the problem. With this in mind, eliminate options 1 and 3 first. Choose between the remaining options, knowing that a myringotomy is indicated for acute otitis media. Review the treatment for acute otitis media if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Ear Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 588. 869. A nurse is assisting in preparing a teaching plan for a client with Meniere’s disease. The nurse places highest priority on teaching the client information related to: 1. Current medications 2. Avoiding tobacco 3. Safety 4. Self-care Answer: 3 Rationale: Attacks of Meniere’s disease come on suddenly and can be dangerous. The client is at risk for falls and requires information about how to prevent injury when symptoms begin. This information is highest in priority to maintain the client’s wellbeing. The information listed in the other options is also necessary, but has lesser priority than preventing falls or injury. Test-Taking Strategy: The key words in the question are highest priority. Use Maslow’s Hierarchy of Needs theory, knowing that maintenance of safety comes before self-care, knowledge about current medications, and avoiding tobacco. Review the priority needs of a client with Meniere’s disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1090-1091. 870. A nurse is assisting in caring for a client in transfer from the postanesthesia care unit

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following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling? 1. Supine 2. Semi-Fowler 3. Sims 4. Prone Answer: 2 Rationale: The nurse should place the client in semi-Fowler position because elevating a body part will reduce swelling. The prone and supine positions do not decrease swelling because the client is lying flat. Sims position, which is side lying, also does not decrease the swelling. Test-Taking Strategy: Use the process of elimination to eliminate options 1 and 4 first because they are similar. From the remaining options, use knowledge of postoperative swelling, concepts of gravity, and client positioning to answer this question. Review measures that will reduce swelling in the postoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1102, 1109. 871. Nasal polyps, asthma, and an acetylsalicylic acid (aspirin) allergy are diagnosed in a client. The nurse provides home care instructions based on the knowledge that the client has: 1. Triad disease 2. Coryza 3. Allergic rhinitis 4. Sinusitis Answer: 1 Rationale: The word “triad” means three. This term encompasses the three health problems identified in the question. Coryza is a nasal discharge. Allergic rhinitis is called hay fever and is an allergic response to an allergen. Sinusitis is inflammation of the sinuses. Test-Taking Strategy: Use the process of elimination. The prefix “tri” means three, hence the three conditions of nasal polyps, asthma, and aspirin allergy. The other options are incorrect because they are terms for other nose and sinus conditions. Review the disorders identified in the options if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1803.

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872. A client comes to the urgent care center with epistaxis, but no obvious facial injury. The nurse should take which action first? 1. Have the client sit down, lean forward, and apply pressure to the nose 2. Place the client in a semi-Fowler position and apply ice packs to the nose 3. Prepare a nasal balloon for insertion 4. Position the client in a sitting position and ask the client to bite on a tongue blade Answer: 1 Rationale: Sitting the client with the head forward and with pressure applied to the nose is the most effective way to initially control bleeding. Treatment is always directed at a conservative measure first. Placing the client in semi-Fowler position causes the client to swallow blood. Preparing a nasal balloon for insertion is invasive and used only when all other efforts fail. Biting on a tongue blade does not cause cessation of nasal bleeding. Test-Taking Strategy: Use the process of elimination and note the key word first. Focusing on the issue, to control the bleeding, will direct you to option 1. Remember that both proper positioning and pressure are most effective in controlling bleeding initially. Review initial care to the client with epistaxis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 194. 873. A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit? 1. Headache 2. Runny nose 3. Epistaxis 4. Nasal obstruction Answer: 4 Rationale: Nasal obstruction is the most common symptom associated with a nasal tumor because the tumor occupies space in the nasal area. Bleeding (epistaxis) may occur, but is not a primary sign. Headache and a runny nose are not compatible with the clinical picture of a client with a nasal tumor. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are not typical manifestations with a nasal tumor. Choose correctly between the remaining options, recalling that a tumor is likely to exert pressure, causing obstruction. Review the manifestations associated with a nasal tumor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1105.

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874. A client who has laryngeal nodules is scheduled for outclient surgery to have them removed. The nurse collects data on the client and expects the client to complain of which typical symptom associated with this condition? 1. Hoarseness 2. Aphonia 3. Sore throat 4. Swollen glands Answer: 1 Rationale: Hoarseness is a typical symptom associated with laryngeal nodules. Aphonia is associated with laryngitis. Sore throat typically occurs with pharyngitis. Swollen glands usually accompany tonsillitis. Test-Taking Strategy: Use the process of elimination. Focusing on the client’s diagnosis, laryngeal nodules, will direct you to option 1. Review the symptoms associated with laryngeal nodules if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1111. 875. A nurse is assisting a client who underwent radical neck surgery to get out of bed. The nurse provides the most support to the client who is afraid to move the head by doing which of the following? 1. Assisting the client to roll to the side of the bed and sit up slowly 2. Placing a hand behind the client’s head 3. Applying a soft cervical collar 4. Raising the head of the bed 90 degrees Answer: 2 Rationale: The nurse provides the most support to the surgical site by placing a hand behind the client’s head. Options 1 and 4 involve little assistance or support by the nurse. Option 3 is unnecessary and could occlude a tracheostomy if one is in place. Test-Taking Strategy: The issue of the question is the best method of assisting the client who is afraid to move the head. Visualizing each of the actions in the options and using knowledge regarding this surgical procedure will direct you to option 2. Review care to the client following radical neck surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 366. 876. A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should do which of the following after obtaining the culture

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if the specimen cannot be delivered to the laboratory for at least an hour? 1. Keep the client NPO for 30 minutes and obtain a second specimen 2. Discard the specimen and make the client wait an hour to get a new one 3. Obtain a second specimen immediately 4. Refrigerate the specimen Answer: 4 Rationale: Refrigeration will stabilize the culture and prevent the growth of additional bacteria. Options 1, 2, and 3 are unnecessary. Test-Taking Strategy: Use the process of elimination. The issue of the question is knowing that the culture should be refrigerated if transport to the laboratory is delayed more than 1 hour. This will direct you to option 4. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1045. 877. A client reports the chronic use of nasal sprays. The nurse provides instructions to this client about which piece of information related to chronic use of nasal sprays? 1. The protective mechanism of the nose may be damaged 2. Fungal infections of the nose may occur because of container contamination 3. Nosebleeds are common 4. It is acceptable to double the dose if one dose is ineffective Answer: 1 Rationale: The protective mechanisms of the nose may be altered with the chronic use of nasal sprays. Fungal infections occur with oral inhalers, but not nasal inhalers. Nosebleeds are uncommon. The client should not double the dose of medications to increase their effect. Test-Taking Strategy: The key words in the question are chronic use. This tells you that the correct option will be an adverse consequence of prolonged use of nasal inhalers. Use medication knowledge and the process of elimination to direct you to option 1. Review the adverse effects of nasal sprays if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Respiratory Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 815. 878. A nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which of the following meals? 1. Broccoli, buttered rice, and grilled chicken 2. Fresh strawberries, steamed vegetables, and baked fish

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3. Hamburger, baked apples, and avocado salad 4. Eggs, cereal, and toast Answer: 2 Rationale: Diets high in saturated fats raise the serum lipid level, which in turn raises the blood cholesterol. Over time high blood cholesterol levels lead to the development of atherosclerosis and diseases, such as CAD. A diet that is low in saturated fats is helpful in reducing the progression of atherosclerosis. Meats and dairy products tend to be higher in fat than other food groups. Test-Taking Strategy: Recall that a diet high in saturated fats contributes significantly to CAD. Therefore choose the food groups with the least amount of saturated fat. Remember that when there are multiple parts to an option all of the parts must be correct for the option to be correct. With this in mind, eliminate option 1 (butter), option 3 (hamburger), and option 4 (eggs). Review the foods high in saturated fats if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Nix, S. (2005). Williams’ basic nutrition & diet therapy (12th ed.). St. Louis: Mosby, pp. 353-354. 879. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action first? 1. Get an order for pain medication 2. Report the complaint to the physician 3. Have the client continue to get out of bed and into a chair 4. Have the client stop the activity and lie back down in bed Answer: 4 Rationale: The pain associated with coronary artery disease is called angina pectoris and occurs because of myocardial tissue ischemia from insufficient blood flow to the heart. The nurse should first have the client stop the activity and lie back down to decrease the workload and oxygen demand on the heart. Options 1 and 2 can be done after ensuring that the client is resting. The pain medication that is likely to be ordered is nitroglycerin, which is a coronary vasodilator. Option 3 is contraindicated and will worsen the pain and possibly lead to myocardial infarction. Test-Taking Strategy: The key word in the question is first. This tells you that more than one or all of the options may be partially or totally correct and that you must prioritize your answer. With this in mind, eliminate option 3 first because it is a contraindicated action. From the remaining options, select option 4 because it focuses on the client and the client’s immediate needs. Review care to the client experiencing chest pain if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed.). St.

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Louis: Mosby, p. 149. 880. A nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which of the following is available at the bedside? 1. Oxygen tubing and flowmeter 2. Rolling shower chair 3. Bedside commode 4. Twelve-lead ECG machine Answer: 1 Rationale: CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. Providing oxygen to the client is important to help decrease pain and prevent its recurrence. A beside commode and ECG machine may be helpful, but are not the priority. A rolling shower chair has no value for this client because the client would be able to walk if pain free, and an activity order allows it. Test-Taking Strategy: Use the process of elimination and note the key words highest priority. This tells you that more than one or all of the options may be partially or totally correct and that you must prioritize your answer. Use the ABCs—airway, breathing, and circulation—to answer this question. Oxygen supports respiration and assists in oxygenation at the cellular level. Review care to the client with CAD if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed.). St. Louis: Mosby, p. 149. 881. A nurse working the 3 to 11 P.M. shift notes that a client with coronary artery disease (CAD) has an order for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results? 1. Early meal tray delivered before the laboratory test 2. Added snack at bedtime 3. NPO for 24 hours 4. Fasting for 12 hours Answer: 4 Rationale: To obtain an accurate cholesterol level, a client must fast 12 hours before the tests. Options 1 and 2 interfere with accurate test results, and option 3 represents an unnecessary wait. Test-Taking Strategy: To answer this question correctly, you must be familiar with the preparation necessary before serum lipid levels are drawn. Recalling that the client needs to fast will assist in eliminating options 1 and 2. From the remaining options, eliminate option 3 because of the unnecessary time noted in this option. Review preparation for this test if you had difficulty with this question.

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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 727. 882. A client with angina pectoris who was given a first dose of newly ordered sublingual nitroglycerin tablet complains of slight dizziness and headache. The nurse takes which action first? 1. Take the client’s blood pressure 2. Tell the client not to worry about it 3. Give the client a dose of acetaminophen (Tylenol) ordered PRN 4. Report the findings to the physician Answer: 1 Rationale: Clients receiving nitroglycerin for the first time are more likely to experience side effects of this coronary vasodilator, which includes a drop in blood pressure and headache. The nurse should take the blood pressure first. The nurse can then give acetaminophen for headache and document or report the side effects. The nurse should not ignore a client’s concerns (option 2). Test-Taking Strategy: Use the process of elimination and knowledge of the side effects of this medication to answer this question. The key word first tells you that more than one option may be a correct nursing action. Use the ABCs—airway, breathing, and circulation. This will direct you to option 1. Review care to the client receiving nitroglycerin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 779. 883. A nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which of the following statements? 1. “It doesn’t matter if my father had high cholesterol.” 2. “My weight has nothing to do with this disease.” 3. “I will walk for one-half hour daily.” 4. “As long as I exercise, I can eat anything I wish.” Answer: 3 Rationale: Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Options 2 and 4 are incorrect because obesity and a diet high in fat can contribute to CAD. Option 1 is incorrect because genetic factors also contribute to CAD. Test-Taking Strategy: Use the process of elimination. Recalling the risk factors for CAD and their management will direct you to option 3. Review these risk factors and the

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measures to manage the disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 308. 884. A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). The nurse determines that the client indicates an initial understanding of lifestyle alterations if the client states an intention to: 1. Take daily medication for life 2. Eat a diet that is low in dietary fat and cholesterol 3. Begin to exercise if diet is not sufficient to achieve weight loss 4. Continue to smoke to keep the metabolic rate high Answer: 2 Rationale: A diet that is low in fat and cholesterol helps slow the progression of CAD. This must be accompanied by regular exercise and cessation of smoking. If these measures are effective, the client may not need daily medication. Test-Taking Strategy: Use the process of elimination and note the key words initial understanding. Recalling the lifestyle alterations needed to prevent the progression of this disease will direct you to option 2. Review these lifestyle alterations if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed.). St. Louis: Mosby, p. 148. 885. A nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Based on this finding, the nurse should: 1. Ask the client to write down a list of stressors to be evaluated at a later time 2. Ask if the client wants to see a psychiatrist 3. Reassure the client that everybody seems stressed these days 4. Explore with the client the sources of stress in life Answer: 4 Rationale: The nurse should encourage the client to explore and verbalize stressors. Later, the nurse can teach the client strategies for coping with stress, such as the basic relaxation techniques of deep breathing, progressive muscle relaxation, and visualization. Option 1 places further data collection of this area on hold. Option 2 could be construed as excessive or insulting and puts the client’s feelings on hold. Option 3 ignores the client’s concerns. Test-Taking Strategy: Use therapeutic communication techniques. Eliminate options 1, 2, and 3 because they are communication blocks. Review therapeutic communication

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techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular References: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed.). St. Louis: Mosby, p. 158. 886. A client with a diagnosis of myocardial infarction has a new activity order allowing the client to have bathroom privileges. As the nurse walks the client into the bathroom, the client begins to complain of chest pain. The nurse should initially take which action? 1. Assist the client to get back into bed 2. Tell the client to stand still and take the client’s blood pressure 3. Give a nitroglycerin tablet and assist the client to the bathroom 4. Report the chest pain episode to the physician Answer: 1 Rationale: The client is assisted back to bed to put the client at rest. The nurse can then measure vital signs and administer nitroglycerin that is ordered for PRN use. The nurse should then report the chest pain episode to the physician. The nurse would not continue to assist the client into the bathroom because it places the client in danger because of continued myocardial oxygen demands. Test-Taking Strategy: Use the process of elimination and note the key word initially. Recalling that the client experiencing chest pain needs to immediately be placed at rest will direct you to option 1. Review care to the client experiencing chest pain if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 583. 887. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which most important action in delivering holistic nursing care to this client? 1. Teaches about the effects of cocaine on the heart and offer referral for further help 2. Reports the client to the police for illegal drug use 3. Tells the client it is imperative to stop before myocardial infarction occurs 4. Explains to the client the damage that cocaine does to the heart Answer: 1 Rationale: To provide the most holistic care, the nurse should teach the client about the effects of cocaine on the heart and also offer referral for further help with this possible addiction. Option 2 is not indicated and breaches the client’s right to confidentiality. Option 3 is incorrect because it “preaches” to the client. Option 4 is partially correct, but does not meet the holistic needs of the client.

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Test-Taking Strategy: Use the process of elimination and note the key word holistic. With this in mind, select the umbrella (global) option that meets the client’s needs. Knowing that cocaine is an addiction guides the nurse to help the client seek treatment for it along with providing for the information needs of the client. Review care to the client who abuses drugs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1568. 888. A client with angina pectoris has just been started on medication therapy with nitroglycerin. In planning care for this client, the nurse places highest priority on measuring: 1. Therapeutic serum drug levels 2. Serum glucose 3. Vital signs 4. Intake and output Answer: 3 Rationale: The nurse places highest priority on measuring vital signs, especially the blood pressure, because of the vasodilator action of the medication. Drug levels are not measured for nitroglycerin, and the medication does not affect serum glucose level. Intake and output may be measured as part of the general plan of care for the client with heart disease, but are not directly related to the administration of this medication. Test-Taking Strategy: Focus on the name of the medication. Recalling that this medication is a vasodilator will direct you to option 3. Also use of the ABCs—airway, breathing, and circulation—will direct you to the correct option. Review the action and effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 318. 889. A nurse who has administered one sublingual nitroglycerin tablet for chest pain has to leave the client’s room to obtain blood pressure–monitoring equipment. The nurse ensures that the client has which most important item within easy reach before leaving the room? 1. Telephone 2. Call bell 3. Tissues 4. Cool cloth for the forehead Answer: 2

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Rationale: The highest priority is to ensure that the client has the call bell, so the client can call for help if the pain does not subside or gets worse before the nurse’s return. A telephone is of no use for this purpose, nor are tissues or a cool cloth. Test-Taking Strategy: Use knowledge of the medication and principles of client safety to answer this question. The client would need to be able to contact the nurse if chest pain (circulation) reoccurred. Review these basic safety principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 270. 890. A nurse is providing instructions to a client with angina pectoris about measures to reduce recurrences of chest pain. The nurse should stress to the client the importance of doing which of the following? 1. Avoiding exposure to either very hot or very cold weather 2. Saving all chores for the end of the day 3. Eating large meals to reduce the work of the gastrointestinal tract 4. Keeping most items stored above shoulder level to encourage exercise Answer: 1 Rationale: The client should avoid extreme hot or cold temperatures to prevent placing undo stress on the heart from a circulatory point of view. The client should space activities throughout the day rather than to save them for the end of the day when the client is more fatigued. The client should eat smaller meals, so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level to prevent straining and increased intrathoracic pressure, which can decrease cardiac output. Test-Taking Strategy: Use the process of elimination. Recalling the pathophysiology of angina pectoris and factors that aggravate it and relieve it will direct you to option 1. Review these factors if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 307. 891. A nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which of the following to most effectively accomplish this goal? 1. Encourage the family to come visit very frequently 2. Encourage the client to call friends and relatives each day 3. Provide a quiet and low-stimulus environment 4. Recommend that the client watch TV as a constant diversion

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Answer: 3 Rationale: Chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain, such as emotional excitement. Each of the incorrect options increases the amount of client stimulation, which increases the risk of an anginal episode. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate each of the three options that provide for increased activity and possible stress for the client. The correct option is the one that is different, which in this case is the quiet, low-stimulus environment. Review care to the client with angina if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 306-307. 892. A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should do which of the following to care for this client in a holistic manner? 1. Instruct the family member to dress the client warmly before going outside 2. Tell the client that this is not allowed 3. Tell the family member not to take the client outdoors 4. Give the client a cup of hot coffee before going outside Answer: 1 Rationale: The nurse should meet both the physiological and psychosocial needs of the client in a holistic manner by asking the family member to be sure that the client is dressed warmly before going outside. Option 1 is correct because dressing the client warmly will decrease the chance of vasoconstriction, which may lead to an angina attack. Options 2 and 3 ignore the psychosocial needs. Option 4 is detrimental to physiological needs because caffeine places an additional burden on the heart in addition to the cold weather. Test-Taking Strategy: Use the process of elimination and note the key word holistic. This tells you that both physiological and psychosocial needs of the client must be considered. Eliminate options 2 and 3 first because they are similar. From the remaining options, note that option 1 meets both the physiological and psychosocial needs of the client. Review care to the client with angina pectoris if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 308. 893. A nurse carries out an order for a stat ECG on a client who has an episode of chest

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pain. The nurse should take which action next? 1. Wait to see if the pain resolves 2. Report the episode of chest pain to the physician 3. Give sublingual nitroglycerin per physician’s orders 4. Do a repeat 12-lead ECG Answer: 3 Rationale: After completing the ordered stat ECG, the nurse should administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. The nurse should not wait to see if pain resolves on its own, but should determine whether the pain is relieved with nitroglycerin. The nurse should do a repeat ECG if it is ordered. Test-Taking Strategy: Note the key word next. This tells you that there is a particular time sequence that should be followed. Use knowledge of the basic care of the client with chest pain and the ABCs—airway, breathing, and circulation—to answer the question. The correct option supports the client’s circulation by dilating coronary vessels and improving cardiac output. Review care to the client experiencing chest pain if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 293, 307. 894. A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain most likely resulted from the chicken-fried steak sandwich that the client had for lunch. The nurse responds to the client, using the knowledge that: 1. The client probably wants to belittle the opinion of the staff 2. The client is not motivated to learn about heart disease at this time 3. Most people love high-fat diets 4. Denial is a common occurrence early after MI Answer: 4 Rationale: An early initial coping response following MI is denial. The nurse uses this knowledge of this common response in planning care for the client. There is no evidence in the question to support options 1 or 2. Option 3 is an opinion and not based on information in the question. Test-Taking Strategy: Focus on the issue, the causative factors and common initial responses following MI. Recalling that denial is a common occurrence after MI will direct you to option 4. Review the psychosocial responses to an MI if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 526.

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895. A nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). The nurse should alter the environment to ensure that it is: 1. Moderate stimulus, low stress 2. No stimulus, low stress 3. Low stimulus, low stress 4. High stimulus, low stress Answer: 3 Rationale: An environment that is low stimulus and low stress is needed to decrease anxiety and metabolic demands for the client after MI. Nursing care is directed at promoting rest and assisting with activities of daily living. Option 2 cannot be provided, and options 1 and 4 are too high in stimulus to be therapeutic. Test-Taking Strategy: Use knowledge of the environment needed by the client following myocardial infarction to answer this question. Recalling that the amount of stimuli and stress should be reduced will direct you to option 3. Review care to the client following an MI if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 314. 896. A male client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time? 1. Explore the specific concerns with the client 2. Tell the client to talk it out with the significant other 3. Tell the client that his fears are not rational 4. Tell the client that his life has not changed Answer: 1 Rationale: The therapeutic action by the nurse is one that gathers more data. This then allows the nurse to formulate the appropriate response. Each of the incorrect options is nontherapeutic because they place the client’s feelings on hold and do not address them. Test-Taking Strategy: Use therapeutic communication techniques and the steps of the nursing process to answer the question. Remember that data collection is the first step of the nursing process and remember to always address the client’s concerns first. This will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 315.

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897. A client complaining of chest pain has a PRN order for sublingual nitroglycerin. Before administering the medication to the client, the nurse should first check the client’s: 1. Cardiac rhythm 2. History of allergy to iodine 3. Blood pressure 4. Respiratory rate Answer: 3 Rationale: Assessing the blood pressure is a priority before administering nitroglycerin to determine the vasodilating effect of the medication and to monitor for a drop in blood pressure. Cardiac rhythm and respiratory rate are also important items that are assessed after checking the blood pressure. Allergies are important, but the allergy to check is to nitrates, not iodine. Test-Taking Strategy: Use the process of elimination and note the key word first. Recalling that nitroglycerin has a vasodilating effect will direct you to option 3. Review the effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 318. 898. A nurse is caring for a postoperative adrenalectomy client. Which of the following does the nurse specifically monitor for in this client? 1. Signs and symptoms of hypocalcemia 2. Peripheral edema 3. Signs and symptoms of hypovolemia 4. Bilateral exophthalmos Answer: 3 Rationale: Following adrenalectomy, the client is at risk for hypovolemia. Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. A deficiency of adrenocortical hormones does not cause the clinical manifestations noted in options 1, 2, and 4. Test-Taking Strategy: Note that the client had an adrenalectomy. Recalling the action of adrenocortical hormones and the effects of adrenal hypofunction will direct you to option 3. If you had difficulty with this question, review postoperative care following an adrenalectomy. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 878. 899. A nurse notes redness, warmth, and a yellowish drainage at the insertion site of a

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central venous catheter in a client receiving total parenteral nutrition (TPN). The nurse immediately reports these findings, knowing that: 1. Infections of a central catheter site can lead to septicemia 2. The client is experiencing an allergy to the TPN solution 3. The TPN solution has infiltrated and must be stopped 4. The client is allergic to the dressing material covering the site Answer: 1 Rationale: Redness, warmth, and purulent drainage are signs of an infection, not an allergic reaction. Infiltration causes the surrounding tissue to become cool and pale. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they both address an allergic reaction. From the remaining options, focus on the data in the question. Recalling that redness, warmth, and drainage indicate infection will direct you to option 1. Review care to the client receiving TPN if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 537. 900. A nurse is assisting in performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be reported to the physician? 1. Concave, midline umbilicus 2. Pulsation between the umbilicus and pubis 3. Bowel sound frequency of 15 sounds per minute 4. Absence of a bruit Answer: 2 Rationale: The umbilicus should be in the midline with a concave appearance. The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported. Bruits are not normally present. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute. Test-Taking Strategy: Use the process of elimination and note the key words should be reported. Recalling the normal findings in an abdominal assessment will direct you to option 2. Remember that the presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm. Review normal and abnormal abdominal assessment findings if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 680. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.).

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Philadelphia: W.B. Saunders, p. 629.

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