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NEW QUESTION # 77
A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:
- A. "Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin."
- B. "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells."
- C. "No, do not increase your insulin. Exercise will not affect your insulin needs."
- D. "You should ask your doctor about this."
Answer: B
Explanation:
Explanation
(A) A nurse can give this information to a client. (B) Exercise makes insulin more efficient in moving more glucose into the cells. No more insulin is needed. (C) Exercise makes insulin more efficient unless the diabetes is poorly controlled. (D) Exercise makes insulin more efficient in moving more glucose into the cells.
NEW QUESTION # 78
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. 0.06 mL
- B. 0.38 mL
- C. 2.7 mL
- D. Information given insufficient to determine the amount of atropine to be administered
Answer: B
Explanation:
Explanation
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
NEW QUESTION # 79
A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room.
Nursing care would include:
- A. Providing sensory stimulation
- B. Monitoring elimination patterns
- C. Forcing the client to attend all unit activities
- D. Encouraging the client to discuss why he is so sad
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. (B) The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. (C) Depressed persons often have little appetite and poor fluid intake. Constipation is common. (D) A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.
NEW QUESTION # 80
A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as:
- A. Malingering
- B. Agoraphobia
- C. Conversion reaction
- D. Housework phobia
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) A typical phobia does not result in physical symptoms (i.e., paralysis). (B) Malingering is pretending to be ill.
This person has a true paralysis. (C) A conversion reaction is a physical expression of an emotional conflict. It has no organic basis. (D) Agoraphobia is fear of public places.
NEW QUESTION # 81
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child's mother for the home treatment of croup?
- A. Place him near a cool mist vaporizer and encourage crying.
- B. Take him in the bathroom, turn on the hot water, and close the door.
- C. Give him a dose of antihistamine.
- D. Give large amounts of clear liquids if drooling occurs.
Answer: B
Explanation:
(A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child.
NEW QUESTION # 82
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
- A. Decreasing her fluids
- B. Eating a moderate to high-protein diet
- C. Increasing her carbohydrate intake
- D. Decreasing her sodium intake
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. (B) Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. (C) Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. (D) Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension.Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.
NEW QUESTION # 83
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. An asthma attack
- B. Pulmonary embolus
- C. A tension pneumothorax
- D. Pneumonia
Answer: A
Explanation:
Section: Questions Set D
Explanation:
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings:
agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation.
Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus.
(D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
NEW QUESTION # 84
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
- A. Scrotal edema
- B. Clot formation
- C. Prostatic infection
- D. Bladder spasms
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication. (D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication.
NEW QUESTION # 85
A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?
- A. 30 µ g/mL
- B. 25 µ g/mL
- C. 4 µ g/mL
- D. 14 µ g/mL
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The therapeutic blood level range of theophylline is 10-20 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug.
NEW QUESTION # 86
At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:
- A. "You will need to drink 6 to 8 glasses of water to fill your bladder."
- B. "Do not eat any food or drink any liquids before the test is started."
- C. "You will have to remain as still as you possibly can."
- D. "You need to know that an IV is always started before the test."
Answer: C
Explanation:
Explanation
(A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well-being.
This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test.
NEW QUESTION # 87
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
- B. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
- C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
- D. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
NEW QUESTION # 88
In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
- A. Is rapidly fatal
- B. Has unpredictable remissions and exacerbations
- C. Becomes progressively debilitating without remission
- D. Responds quickly to antimicrobial therapy
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. (B) Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. (C) Multiple sclerosis is usually slowly progressive. (D) Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.
NEW QUESTION # 89
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
- A. Cleanse area around the meatus twice a day
- B. Change the catheter tubing and bag every 48 hours
- C. Empty the catheter drainage bag at least daily
- D. Maintain fluid intake of 1200-1500 mL every day
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000-2500 mL range if possible to help irrigate the bladder and prevent infection.
NEW QUESTION # 90
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Loss of peripheral pulses
- B. Hypovolemia
- C. Renal damage
- D. Ventricular arrhythmias
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential injury. (B) Renal damage is typically seen because of prolonged hypovolemia or myoglobinuria. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Full-thickness circumferential burns are nonelastic and result in an internal tourniquet effect that compromises distal blood flow when the area involved is an extremity.Circumferential full-thickness torso burns compromise respiratory motion and, when extreme, cardiac return.
NEW QUESTION # 91
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
- A. Has sustained an internal injury in addition to the head injury
- B. Is having intracranial bleeding
- C. Is beginning to experience a dangerously high level of anxiety
- D. Has a sudden and severe increase in intracranial pressure
Answer: A
Explanation:
(A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.
NEW QUESTION # 92
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
- A. After the first trimester
- B. At 28 weeks' gestation
- C. Within 72 hours postpartum
- D. In the immediate postpartum period
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.
NEW QUESTION # 93
Before giving methergine postpartum, the nurse should assess the client for:
- A. Elevated blood pressure
- B. Flushing
- C. Decreased amount of lochial flow
- D. Afterpains
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
NEW QUESTION # 94
Which of the following ECG changes would be seen as a positive myocardial stress test response?
- A. ST-segment depression
- B. Pathological Q wave
- C. Hyperacute T wave
- D. Prolongation of the PR interval
Answer: A
Explanation:
Explanation
(A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI.
NEW QUESTION # 95
During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?
- A. Tinnitus and nausea
- B. Chills and an elevation of temperature
- C. Unconsciousness and acetone odor of the breath
- D. Dermatitis and blurred vision
Answer: A
Explanation:
(A) These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate.
NEW QUESTION # 96
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Ability to focus and concentrate thoughts
- B. Abstract thinking
- C. Judgment
- D. Memory
Answer: A
Explanation:
(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is
correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.
NEW QUESTION # 97
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