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QUESTIONS and Answers Latest 202 5
the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria - A. Nasal congestion why? removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal congestion further interferes with the airway. A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis - B. Hypokalemia why? Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. taking the vital signs B. obtaining the permit C. explaining the procedure D. Checking the lab work - A. taking the vital signs why? the primary responisblity of the nurse is to take the vital signs before any surgery. answers B,C and D are the responsibility of the doctor. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive priority? A. starting an IV? B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain - B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so applying oxygen is priority. the next action should be to start an IV and medicate for pain. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client A. rest in bed after taking the medication for at least 30 mins B. Avoid rapid movements after taking the medication
A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight. A client is admitted with a Ewing's sacroma. which symptoms would be expected due to this tumor's location? A. Hemiplegia B. Aphasia C. Nausea D. Bone Pain - D. Bone Pain why? Sacroma is a type of bone cancer, therefor, bone pain would be expected The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which labatory value might be a indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematoccrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter - C. WBC 2,000 per cubic millimeter why? Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
A. "tell me about the pain" B."what does his vomit look like?" C." Describe his usual diet." D. " have you noticed changes in his adominal size?" - C." Describe his usual diet." why? The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and thus, are incorrect The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be avoided? A. Bran B. Fresh Peaches C. Cucumber salad D. Yeast Rolls - C. Cucumber salad why? the client with diverticulitis should avoid foods with seeds. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage - D. Facilitating perineal wound drainage why?
why? After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups - C. Diarrhea why? Diarrhea is not common in clients with mouth and throat cancer A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage - A. A closed chest drainage why? The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheoostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage.
Six hours after birth, the infant is found to have an areas of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum - A. A cephalohematoma why? The swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it's outside the cranium but beneath the periosteum. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. "You cannot eat food prepared in a microwave." B. "You should avoid moving the should on the side of the pacemaker site for 6 weeks." C. "You should use your cellphone on your right side." D. "You will not be able to fly on a commercial airliner with the defibrillator in place." - C. "You should use your cellphone on your right side." why? The client with an internal defibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting.
A. "You will be sitting for the examination procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area." D. "you will not be able to drink fluids for 24 hours before the study." - B. "Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue. D. A hemoglobin level of 12.0 gm/dL - C. A red, beefy tongue why? A red, beefy tongue is characteristic of a client with pernicious anemia. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction D. An abduction pillow - C. Bucks traction
why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain. A client with caner is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure. B. Ask the client to void immediately before the study. C. Hold medication that affects the central nervous system for 12 hours pre- and post- test. D. Cover the client's reproductive organs with an x-ray shield. - B. Ask the client to void immediately before the study. why? The client having an intravenous pyelogram will have orders for laxatives of enemas so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney, ureters, and urethra. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant mestastasis - B. That is in situ. why?
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician's progress notes to see if understanding has been documented. D. Check with the client's family to see if they understand the procedure fully - A. Call the surgeon and ask him or her to see the client to clarify the information why? It is the responsibility of the physician to explain and clarify the procedure to the client. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client's food intake - A. A history of radiation treatment in the neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation.
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis - B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior. The nurse is obtaining a history of an 80 year old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. "My skin is always so dry." B. "I often use laxatives for constipation." C. "I have always liked to drink ice tea." D. "I sometimes have a problem with dribbling urine." - B. "I often use laxatives for constipation." why? Frequent use of laxatives can lead to diarrhea and electrolyte loss. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime."
D. Suggest a hot water rinse after bathing. - B. Add baby oil to the client's bath water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring D. Dressing changes 2x per day - B. Insertion of a levine tube why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration B. The client will require frequent dressing changes C. The straps provide support for drains that are inserted into the incision D. No sutures or clips are used to secure the incision. - B. The client will require frequent dressing changes
why? Montgomery straps are used to secure dressing that require frequent dressing changes because the client with a cholescystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. The physician has order that the client's medication be administered intrathecally. The nurse is aware that the medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid - D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Which client can be best assigned to the newely licensed to the Practical Nurse? A. The client receiving chemotherapy B. The client post-coronary bypass C. The client with a TURP D. The client with diverticulitis - D. The client with diverticulitis why?
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot - C. A client with a laryngeal cancer with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first. The nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation D. Decrease caloric intake - A. Increase the infant's fluid intake why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater
B. Maintain the client's urinary output greater than 300 cc/hr C. Maintain the client's body temp of greater than 33 F rectal D. Maintain the client's hematocrit less than 30% - A. Maintain the client's systolic blood pressure at 70 mm/Hg or greater why? When the cadaver client is being prepared to donate and organ, the systolic blood pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the donor organ. Which action by the novice nurse indicates need for further teaching? A. A nurse fails to wear gloves to remove a dressing B. The nurse applies the oxygen saturation monitor to the earlobe C. The nurse elevates the head of the bed to check blood pressure D. The nurse places the extremity to a dependent position to acquire a peripheral blood sample - A. A nurse fails to wear gloves to remove a dressing why? The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams
