NURSING PRACTICE III

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART A

1. An adult client has stapedectomy. Which of the following is most important for the nurse to include in the post-op care plan?

a. Checking the gag reflexb. Encouraging independence

c. Instructing the client not to blow her nosed. Positioning the client on the operative side.

Rationale: Correct answer: C. The client should be taught to avoid blowing her nose because this action could increase the pressure in the eustachian tube and dislodge the surgical graft. A stapedectomy is done under local anesthesia, which will have no affect on the gag reflex. Encouraging independence is not a priority nursing approach at this time. The client should be positioned on the un-operative side.

2. The nurse is explaining cryotherapy to a client who has a detached retina. The nurse should explain that the MAJOR purpose of cryotherapy in the treatment of detached retina is to

a. Create a scar that promotes healingb. Disintegrate debris in the eyec. Freeze small blood vesselsd. Halt secretions of the lacrimal duct

Rationale: Correct Answer: ACryotherapy is used to produce a chorio-retinal adhesion or scar that allows the retina to return to its normal position. It does not involve the freezing of blood vessels or affect material in the vitreous. It will not halt the action and function of the lacrimal duct.

3. An adult who has a detached retina asks the nurse what may have contributed to the development of his detached retina. The nurse explains that the client at greatest risk for development of a retinal tear usually has

a. Hypertension c. Cranial tumorsb. Near-sightedness d. Sinusitis

Rationale: Correct answer: BMyopia or nearsightedness is a predisposing factor in the development of a retinal tear. Hypertension, cranial tumors, and sinusitis are not causes of retinal tears unless they result in eye trauma.

4. A 42 year old male is receiving cryotherapy for repair of a detached retina. When taking a history from him, which symptom should the nurse expect him to have?

a. Diplopia b. Severe eye pain c. Sudden blindness d. Bright flashed of light

Rationale: Correct answer: DMomentary bright flashes of light are a common symptom of retinal detachment. Retinal detachment is usually partial at first; however, if the disorder goes untreated and the entire retina becomes involved, blindness may occur. Diplopia does not accompany retinal detachment. Retinal detachment is a painless process.

5. Which notation on the nursing care plan reflects inappropriate care pf the elderly with a hearing problem?

a. Face the client when speakingb. Examine the ears for cerumen

c. Assess the function of the clients hearing aid dailyd. Shout loudly and clearly when talking to the client

Rationale: Correct answer: DRaising the voice to shout loudly only increases the emission of higher frequency sounds, which the elderly client with presbycusis (a progressive bilateral perceptive loss of hearing in the older individual that occurs with the aging process) will have difficulty hearing. Facing the client when speaking allows the client to read lips as well as listen to the words. It is important to examine the ears for cerumen, which could be obstructing the auditory canal. Assessing the function of the client’s hearing aid is important because the hearing aid batteries could be losing power.

6. To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the a. Finger and toenail b. Eyes c. Perianal area d. External ear canals

Rationale: The correct answer is BKeratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.

7. In reading a client’s plan of care the nurse has identified interventions which relate to the client’s hemiparesis. The nurse would expect to see a. Padded siderails c. Full active and passive range of motionb. Full active range of motions d. The use of picture aids for communication

Rationale: The answer is: C The client with hemiparesis, or weakness on one side of the body will require active range of motion for the side not affected, and passive range of motion for the side affected with hemiparesis.

8. When assessing a client for an increase in intracranial pressure, the nurse would prioritize the assessment in which manner? a. Level of consciousness, respiratory rate, blood pressure, papillary reactionb. Pupillary reaction, level of consciousness, respiratory rate, blood pressurec. Blood pressure, level of consciousness, respiratory rate, papillary reactiond. Respiratory rate, blood pressure level of consciousness, papillary reaction

Rationale: The answer is: DThe client with increasing intracranial pressure must be first assessed for Airway, Breathing and Circulation followed by the first criteria to change-the level of consciousness then papillary reaction.

9. When caring for the client with head trauma, a priority of care would be to prevent transient increases in intracranial pressure. A nursing intervention aimed at preventing this would be to

a. Administer antiemetics as soon as nausea occursb. Maintain the client in a flat position with proper head and neck alignmentc. Encourage television and radio for sound diversiond. Perform only rectal temperatures for accuracy

Rationale: The answer is: A Following head trauma, the client’s head must be elevated at least 30 degrees at all times: the client should not be allowed to be stimulated by the television or the radio, and should not have rectal stimulation. Immediately treat nausea to preventing vomiting.

10. A classic finding associated with an increase in intracranial pressure isa. Tachycardia c. Projectile vomitingb. Hypotension d. A slow deep regular respiratory pattern

Rationale: The answer is: CManifestations of increased intracranial pressure are: hypertension with widened pulse pressure slow deep irregular respiratory pattern, bradycardia, and projectile vomiting.

11. A complication of spinal cord injury, during the rehabilitative stage, is autonomic dysreflexia and manifested by

a. Increased BP, decreased HR, severe headacheb. Decreased BP, increased HR, severe headachec. Increased/Decreased BP, increased HR, decreased level of consciousnessd. Increased/Decreased BP, increased/decreased HR, dry, hot skin

Rationale: The answer is: AManifestations of autonomic dysreflexia are: severe rapid onset of hypertension, badycardia, flushing, profuse sweating, and severe headache.

12. In the client who has undergone cataract surgery, an activity that would be discourage due to the risk of increased intraocular pressure is

a. Reading b. Sewing c. Gardening d. Driving

Rationale: The answer is: CGardening would require upper body straining activities, which are contraindicated in the client at risk for increased intraocular pressure: driving would be contraindicated but not due to the risk of increasing intraocular pressure.

13. Client teaching has been effective if when instilling eye drops the client a. Drops the drop onto closed eyesb. Holds the upper lid open and allows the drop to drop onto the eyec. Pulls down on the lower lid and drops the drop onto the eyed. Pulls down the lower lid and drops the drop into the lower lid

Rationale: The answer is: DCorrect method for a client to use to instill eye drops is to pull down on the lower lid, evrt the lid, and place the drop on the cup formed by the lower lid.

14. A client comes to the ambulatory clinic seeking care with a complaint of “getting something in my eye.” Which of the following actions should the nurse take first? a. Provide copious irrigation with normal salineb. Get a detailed health historyc. Evaluate the client’s visiond. Swab the cornea several times using a cotton tipped applicator

Rationale: The answer is: CThe nurse should evaluate the client’s vision first to provide a baseline, and then treat the injury. Irrigation is often used to remove foreign bodies from the eye, followed by application of an eye patch.

15. A client is being admitted to the post-anesthesia recovery area following lens removal and replacement I the left eye for a cataract. The nurse places the client into which of the following most appropriate positions?a. On the left side with the head of bed elevated 30 degreesb. On the right side with the head of bed elevated 30 degreesc. Supine with the head of bed flatd. Upright with the head and neck turned to the right

Rationale: The answer is: BFollowing eye surgery, the head of the bed should be elevated 30 to 45 degrees and the client should lie on back or unaffected side to reduce intraocular pressure. Small pillows may be used at the sides of the head to immobilize the head when lying on the back.

16. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment?

a. An increase in appetite c. A decrease in lethargyb. A decrease in fluid retention d. A reduction in jaundice

Rationale : CDue to physiological changes in the elderly, as well as conditions such as dehydration, hyperthermia, immobility and liver disease, the metabolism of drugs may decrease. As a result, drugs can accumulate to toxic levels and cause serious adverse reactions.

17. An adult is scheduled to undergo an exploratory laparotomy in one hour. The nurse has just received the order to administer his preoperative medication. What assessment is essential for the nurse before administering the medication?

a. The client’s ability to cough and deep breatheb. Any drug hypersensitivity or allergyc. The client’s understanding of the surgical procedured. Whether the client’s family is present and supportive

Ratio: Correct Answer B

1. His ability to cough and deep breathe should be assessed earlier so that further teaching can take place if needed. Once preoperative medications are administered, the client’s ability to retain information is impaired. 2. A complete drug history on every preoperative client is essential because of potential reactions to drugs. Drug hypersensitivity and allergic reactions must be assessed before preoperative medications are administered. 3. The client’s understanding should be assessed earlier so the nurse can do further teaching if indicated. This should be done before the operative consent is signed. 4. While it is optimal to have the family present, medication should be given as ordered so that the timing of the peak action is most beneficial to the client.

18. A client asks the nurse how she can live without her gallbladder. In order to respond to this client, the nurse must have which understanding of the hepatobiliary system?a. The liver produces about 1000ml. of bile per dayb. The gallbladder produces about 90ml. of bile per dayc. The liver concentrates biles more than 10 timesd. The gallbladder dilutes and release bile

Ratio: Correct answer: AThe liver produces between 700 and 1000 mL of bile per day. The gallbladder stores and concentrates bile and then releases it when stimulated, but is not an essential structure.

19. The client is diagnosed with obstructive jaundice. The nurse should ask the client about which of this manifestation?a. Clear, pale urine c. Lactose intoleranceb. Clay – colored stools d. Ankle edema

Ratio: Correct answer: BClay-colored stools indicate that no bile is reaching the intestine and suggest obstructive jaundice. Option A and C are unrelated to the question. Option D can be present due to cardio vascular disease or as an indirect consequence of portal hypertension with impaired venous return, but there is insufficient information in the question to support the opinion.

20. A client has jaundice. Which of the following comfort measures would be appropriate for the nurse to implement?

a. Offer hot beverages frequentlyb. Encourage taking a hot bath or showerc. Keep the air temperature at approximately 68° to 70° Fd. Suggest the use of alcohol –based skin lotion

Ratio: Correct answer: CJaundice frequently causes pruritis. Comfort measures include keeping the air temperature cool (68° to 70° F) and the humidity at 30 to 40 percent. Tepid baths (not hot) with colloidal agents decrease itching (option b). Use of an emollient lotion is also helpful, but anything drying should be avoided (option D). Hot beverages (option A) are of no benefit as a comfort measure for pruritus due to jaundice.

21. The client has just had a liver biopsy. Which of the following nursing action would be the priority after the biopsy?a. Monitor pulse and blood pressure every 30 minutes until stable then hourly up to 24 hoursb. Ambulate every 4 hours for the first day as long as the client van tolerate thisc. Measure urine specific gravity every 8 hours for the next 48 hoursd. Maintain NPO status for 24 hours post-biopsy

Ratio: Correct answer: AComplications of liver biopsy include hemorrhage or accidental penetration of biliary canniculi. The nurse should assess for for sign of hemorrhage (increased pulse, decreased blood pressure) every 30 minutes for the first few hours and then hourly 24 hours. The client should be monitored for every 4 hours and remain on bed rest for 24 hours.

22. Serum Lactulose (Cephulac) is ordered for the client with cirrhosis. Which of the following

serum laboratory test should the nurse monitor to determine if the drug is having the desired effect?a. Albumin b. Ammonia c. Sodium d. Lactate

Ratio: Correct answer: BLactulose (Cephulac) is a disaccharide laxative used to decrease the absorption of ammonia in the intestines, thereby lowering the serum ammonia and resulting in improvement in hepatic encephalopathy.

23. The client is admitted to the hospital for possible cholelithiasis. While taking the history, the nurse notes that the client has which of the following risk factors for development of gallstones:a. Black race c. Age of 37 yearsb. History of hypertension d. Use of oral contraception

Ratio: Correct answer: DFactors that increase the risk of gallstone formation include female gender, aging, use of oral contraceptives, pregnancy, and rapid weight loss, high cholesterol level, and diseases of the ileum.

24. A client with cirrhosis is admitted to the hospital. Which of the following assessments made by the nurse would indicate the development of portal hypertension?a. Hematemesis b. Asterixis c. Elevated blood pressure d. Confusion

Ratio: Correct answer: AIn cirrhosis, the liver becomes fibrotic, which obstructs the venous blood flow through the liver. This increases the vascular pressure in the portal system, and causes congestion in the spleen and development of variscosities in the esophagus. Bleeding esophageal varices are a complication of portal hypertension and result in vomiting of blood and possible hemorrhage and death.

25. The nurse is doing discharge teaching for a client who has cirrhosis and ascites. Which of the following foods used by the client as snacks should the nurse instruct the client to avoid?a. Whole wheat bread b. Cookies c. Potato chips d. Hard candy

Ratio: Correct answer: CA low-sodium diet is recommended for client that has cirrhosisand ascites. Potato chips are high in sodium. Cookies and hard candy are high in sugar, while bread is high in complex carbohydrates.

26. The client who has disease asks the nurse why the bruises bso easily. Which of the following information should the nurse include in the response?

a.. “Your liver is unable to make the proteins that are neede to making clotting factors.”b. “Your liver can no longer metabolize drugs and render them inactive.”c. “Your liver is breaking down blood cells too rapidly.”d. “Your liver can’t store vitamin C any longer.”

Ratio: Correct answer: A The liver synthesizes clotting factirs I, II, VII, IX and X as well as prothrombin and fibrinogen. These substances are needed for adequate clotting, so their reduction leads to increased risk of

bleeding. The other responses do not address these concerns.

27. A client is seen in the clinic for a routine physical examination and the laboratory test results indicate are elevated HBsAg. In order to plan teaching this lab result to mean:

a. The client has immunity to hepatitis B c. The client has resolving hepatitis Bb. The client has active hepatitis B d. The client has had the hepatitis B vaccine

Ratio: correct answer: BHBsAg is hepatitis surface antigen and is usually present before symptoms manifest. It indicates acute disease. The other options are incorrect conclusions regarding this test results.

28. The client who has esophageal varies is receiving a vasopressin infusion. Which of these findings would indicate a complication of this therapy?a. Chest pain b. Tinnitus c. Flushed skin d. Polyuria

Ratio: correct answer: AVasopressin causes vasoconstriction and may precipitate an acute anginal attack or myocardial infarction, especially in those with known cardiovascular disease. The other options are unrelated to the questions.

29. The client who has cholelithisis is scheduled for extracorporeal shock wave lithotripsy. The nurse should tell the client about which of these symptoms that may occur after this procedure?

a. Colic-type pain b. Headache c. Diarrhea d. Hiccups

Ratio: correct answer: AAfter the extracorporeal shock wave lithotripsy, the nurse should monitor for biliary colic and nausea. The colicky pain is caused by passage of stone fragments through the biliary tree into the small intestine. Headache, diarrhea, and hiccups are unrelated manifestations.

30. The client is admitted to the hospital with acute pancreatitis. The nurse taking a history question the client about which of these risk for developing pancreatitis?

a. Inflammatory bowel disease c. Diabetes mellitusb. Alcoholism d. High fiber diet

Ratio: correct answer: BPancreatitis is associated with alcoholism in men and gallstones in women. This disorders in option A and C are not associated with increased risk of pancreatitis, while option D promtes health.

31. An adult client is receiving radiation therapy. The nurse is teaching the client about signs of radiation-induced thrombocytopenia, which include

a. Fatigue c. elevated temperature b. Shortness of breath d. A tendency to bruise easily

Rationale: DThrombocytopenia is a reduction of thrombocytes (platelet) below normal levels hence the risk of bleeding into tissue (bruising) easily. Clients with decreased platelet counts (thrombocytopenia) have a tendency to bruise easily. Fatigue could indicate anemia. Shortness of breath could be evidence of fluid overload, respiratory disease, or decreased red cells. Elevated temperature could indicate infection due to decreased white cells.

32. The nurse is caring for a client who is receiving radiation therapy. Which activity by the client indicates he does NOT understand the side effects of radiation therapy?

a. Using an electric razor c. Taking his children to see Santa at the mallb. Eating a high-protein diet d. Calling the doctor for a temperature of 101 F (38.3 C)

Rationale: CPeople being treated with radiation therapy should avoid crowds because of the increased risk of infection. Crowds at Christmastime can be very large and children are frequent carriers of infection. Use of an electric razor would be preferable to using a safety razor because of the danger of cutting the skin and causing prolonged bleeding due to thrombocytopenia. The client should eat a high-protein diet. The client should call his doctor for a temperature of 101 F.

33. Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older? a. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments which should occur at no longer than 3 months intervalsb. A glycosylated hemoglobin is to be obtained at least twice a year c. A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment d. A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment

Rationale: CAmerican Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. The goals for persons with diabetes define the target A1c level as less than or equal to 6.5% or less than 7.0%. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that a glycosylated hemoglobin be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. Most would agree, however, that an A1c level greater than 9.0% is poor control for all patient types.

34. A 24 year old is diagnosed with Hodgkin’s disease Stage 1A. He is being treated with radiation therapy. To minimize skin damage from radiation therapy, the nursing care plan should include which of the following?

a. Avoid washing with water c. Cover the area with an airtight dressingb. Apply a heating pad to the site d. Avoid applying creams and powders

Rationale: DCreams and powders, many of which contain heavy metals, will further irritate skin sensitized by radiation therapy and reduce the effectiveness of therapy by blocking radiation. The client may wash with water only, but must take care not to wash off the radiation markings. It would not be desirable to further heat the area. Covering the area is not desirable. The area should be left open to the air as much as possible.35. The nurse is at the scene of a multi-vehicular accident. A young man was injured when his motorcycle was hit by a car. He fell off the bike and then it fell back on his legs. He is

bleeding profusely from a 4-inch gash on his left leg. Which of the following is the best approach for the nurse to take to stop the bleeding?

a. Apply direct pressure to the wound c. Raise the extremityb. Move the motorcycle off his legs d. Wrap a tourniquet above the wound

Rationale: Correct answer: ADirect pressure to the wound will aid in the development of a blood clot, which is the first step in wound healing. The extremity should be elevated while applying direct pressure. A tourniquet would be a last resort if elevation and direct pressure did not stop the bleeding.

36. Bone marrow aspiration is performed on a patient with leukemia to:a. Examine the plateletsb. Determine if the cancer is lymphocytic or myelogenous c. Measure the amount of marrow in the bone d. Cellular biopsy

Rationale : BBone marrow aspiration determines what type of immature white blood cell is involved, which directs the type of treatment.

37. The presence of Reed-Sternberg cells is associated witha. Prostate cancer c. Hodgkin’s diseaseb. Malignant melanoma d. Cervical cancer

Rationale: CReed-Sternberg cells must be present before a diagnosis of Hodgkin’s disease can be made.

38. A client asks the nurse why vitamin B12 is important for the red blood cell formation. The nurse responds with the knowledge that Vitamin B12 deficiency causes which of the following changes in the red blood cell?

a. Decreased mean corpuscular volume (MCV) b. Increased hemoglobin in the red blood cellc. Makes the cell irregular and oval-shapedd. Makes the cell smaller in shape and deficient in hemoglobin

Ratio: Answer: CVitamin B12 deficiency causes the production of abnormally large red blood cells. This deficiency causes the red blood cell to be irregular and oval, rather than the biconcave shape of a normal red blood cell. This shape predisposes the cells to a shorter lifespan. In this type of anemia, there is an increase in the MCV (option A) and a decrease in the hemoglobin (option B). Option D is characteristics of iron deficiency anemia.

39. A nurse is discussing the role of hypoxia in red blood cell (RBC) production. Which of the following statements is accurate?a. Hypoxia stimulates the hemoglobin content of the RBC to increaseb. Hypoxia stimulates the release of erythropoietin in the kidneys.c. Reticulocytes become erythrocytes faster with hypoxiad. RBC destruction is increased with hypoxia therefore stimulating RBC production.

Ratio: Answer: BHypoxia stimulates the release of the hormone erythropoietin from the kidney and increases

bone marrow production of RBCs. The hemoglobin does not increase in size with hypoxia. Reticulocytes mature in 24 to 48 hours, and their maturation is not influenced by hypoxia.

40. A client with a hemolytic blood disorder presents to the primary care center with jaundice is most likely caused by which of the following?a. Increased bilibrubin in plasma c. Hepatitis infectionb. Increased haptoglabin in plasma d. Loss of plasma proteins

Ratio: Answer: ALysis of red blood cells causes retention of iron and other substances including bilibrubin causes jaundice. Although hepatitis infection may also be the reason for jaundice, the hemolytic anemia present most likely caused the jaundice to occur.

41. A nurse is evaluating the response of a patient with anemia to therapy. Which of the following laboratory tests would the nurse look to that best reflects bone marrow production of red blood cells?a. Hematocrit b. Hemoglabin c. Serum ferritin d. Reticulocyte count

Ratio: Answer: DThe reticulocyte (immature RBC) count is an indicator that new red blood cells are being produced by the bone marrow. An increase in the reticulocytecount in an anemic client indicates that the bone marrow is responding to the decrease in RBCs. The hematocrit count measures the percent of directly linked to bone marrow activity. Serum ferritin levels reflect available iron stores.

42. The nurse is teaching a client about measures to increase the absorption of the prescribed oral iron preparation. Which of the following instructions would the nurse give to the client?a. Take the medicine with milk c. Take the iron with mealb. Take the pill with a drink that contains vitamin C d. Take the iron after meal

Ratio: Answer: BAn acidic environment (such as in the presence of Vitamin C) enhances the absorption of iron. Administering the medication with meals binds the iron with food and interferes with its absorption.

43. Which of the following statements made by a client with anemia best indicates that the teaching regarding selection of foods high in iron has been successful?a. Citrus fruits c. Eggs, milk and milk productsb. Green leafy Vegetables d. Liver and muscle meat

Ratio: Answer: DLiver and muscle meats are excellent sources of iron. The other foods are also beneficial for the dietary management for anemia, but option D is specifically an excellent source of iron.

44. A nurse is preparing to administer an intramuscular (IM) dose of iron to a client with anemia. Which of the following precautions should the nurse take?a. Administer the drug utilizing a Z tract technique b. Use a 1-inch, 19-guage needlec. Administer the drug deep in the deltoid muscled. Massage the area vigorously after administering the iron.

Ratio: Answer: AWhen administering an iron preparation intramuscularly, it should be given deep in the muscle. The site should be in the upper outer quadrant of the buttocks utilizing the Z tract technique. No more than 2 mL of the solution should be administered and the length of the needle should be 2 to 3 inches. The area should not be massaged after the injection.

45. A client has an order for a test to determine if pernicious anemia is present. For which of the following tests should the nurse schedule the client?a. Serum folate level c. Serum iron and total iron building capacity (TIBC)b. Schilling test d. Bone marrow aspiration

Ratio: Answer: B Schilling test involves the administration of radioactive vitamin B12 when intrinsic factor is given parentally is indicative of pernicious anemia.

46. A client with myasthenia gravis reports the occurrence of difficulty chewing. The physician prescribes pyridostigmine bromide (Mestinon) to increase muscle strength for this activity. The nurse instructs the client to take the medication at what time, in relation to meals? a. after dinner daily when most fatiguedb. before breakfast dailyc. as soon as arising in the morningd. thirty minutes before each meal

Rationale: DPyridostigmine is a cholinergic medication used to increase muscle strength for the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client’s ability to eat.

47. A client is advised to take senna (Senokot) for the treatment of constipation asks the nurse how this medication works. The nurse responds knowing that it: a. accumulates water in the stool and increases peristalsisb. stimulates the vagus nervec. coats the bowel walld. adds fiber and bulk to the stool

Rationale: ASenna works by changing the transport of water and electrolytes in the large intestine, which causes the accumulation of water in the mass of stool and increased peristalsis.

48. A client is receiving heparin sodium by continuous intravenous infusion. The nurse monitors the client for which adverse effect of this therapy? a. decreased blood pressure c. ecchymosesb. increased pulse rate d. tinnitus

Rationale : CHeparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood.

49. A client is being treated for acute congestive heart failure (CHF) and the client’s vital signs

are as follows: BP 85/50 mm Hg; pulse, 96 bpm; respirations, 26 cpm. The physician prescribes digoxin (Lanoxin). To evaluate a therapeutic effectiveness of this medication, the nurse would expect which of the following changes in the client’s vital signs?a. BP 85/50 mm Hg, pulse 60 bpm, respirations 26 cpmb. BP 98/60 mm Hg, pulse 80 bpm, respirations 24 cpmc. BP 130/70 mm Hg, pulse 104 bpm, respirations 20 cpmd. BP 110/40 mm Hg, 110 bpm, respirations 20 cpm

Rationale: CThe main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with CHF. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well.

50. Diazepam (Valium) is prescribed for a client with anxiety. The nurse instructs the client to expect which side effect? a. inccordination b. cough c. tinnitus d. hypertension

Rationale: CValium, a benzodiazepine, can cause motor incoordination and ataxia and safety precautions should be instituted for clients taking this medication.

51. A client receives oxytocin (Pitocin) to induce labor. During the administration of the oxytocin, it is most important for the nurse to monitor: a. urinary output c. central venous pressure b. fetal heart rate d. maternal blood glucose

Rationale: BPitocin produces uterine contractions. Uterine contractions can cause fetal anoxia. The nurse monitors the fetal heart rate and notifies the physician of any significant changes.

52. A clinic nurse is performing assessment on a client who is being seen in the clinic for the First time. When asking about the client’s medication history, the client tells the nurse that He takes nateglinide (Starlix). The nurse then questions the client about the presence of Which disorder that is treated with this medication? a. hypothyroidism b. insomnia c. type 2 diabetes mellitus d. renal failure

Rationale: CNateglinide (Starlix) is an antidiabetic medication used to treat type 2 diabetes mellitus in clients whose disease cannot be adequately controlled with diet and exercise. It stimulates the release of insulin from beta cells of the pancreas by depolarizing beta cells, leading to an opening of calcium channels. Resulting calcium influx induces insulin secretion.

53. A client who is taking rifampin (Rifadin) as part of the medication regimen for the treatment of tuberculosis calls the clinic nurse and reports that her urine is a red-orange color. The nurse tells the client to: a. come to the clinic to provide a urine sample b. stop the medication until further instructions are given by the physician c. take the medication dose with an antacid to prevent this adverse effect d. expect a red-orange color in urine, feces, sweat, sputum, and tears as a harmless

side effect

Rationale: DRifampin (Rifadin) is an antitubercular medication used in conjunction with at least one other antitubercular agent for initial treatment or retreatment of tuberculosis. Urine, feces, sputum, sweat, and tears may become red-orange in color. The client should also be told that soft contact lenses may become permanently stained as a result of this harmless side effect. There is no useful reason for the client to provide a urine sample. The client is not told to stop a medication. Antacids are not usually taken with a medication because of interactive effects.

54. A nurse is caring for a client with a tracheostomy that has been diagnosed with a respiratory infection. The client is receiving vancomycin hydrochloride (Vancocin) 500 mg intravenously every 12 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse effect of the medication? a. decreased hearing acuity c. hypotension b. photophobia d. bradycardia

Rationale: AVancomycin hydrochloride (Vancocin) is an antibiotic. Adverse and toxic effects include nephrotoxicity characterized by a change in the amount or frequency of urination, anorexia, nausea, vomiting, and increased thirst; ototoxicity characterized by hearing loss due to damage to the auditory branch of the eight cranial nerve; and red-neck syndrome from too rapid injection of the medication characterized by chills, fever, fast heartbeat,nausea, vomiting, itching, rash and redness on the face, neck, arms, and back. When this medication is administered to a client, nursing responsibilities include monitoring renal function laboratory results, intake and output, and hearing acuity.

55. A nurse is caring for a client with a diagnosis of metastatic breast carcinoma who is receiving tamoxifen citrate (Nolvadex) 10 mg orally twice daily. Which of the following would indicate to the nurse that the client is experiencing a side effect related to the medication? a. hypetension b. diarrhea c. nose bleeds d. vaginal bleeding

Rationale: DTamoxifen citrate is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentration of receptors such as the breasts, uterus, and vagina. Frequent side effects include hot flashes, nausea, vomiting, vaginal bleeding or discharge, pruritus, and skin rash. Adverse or toxic effects include retinopathy, corneal opacity, and decreased visual acuity.

56. A client has just been given a prescription for diphenoxylate with atropine (Lomotil). The nurse teaches the client which of the following about the use of this medication? a. drooling may occur while taking this medication b. irritability may occur while taking this medication c. this medication contains a habit-forming ingredient d. take the medication with a laxative of choice

Rationale: DDiphenoxylate with atropine (Lomotil) is an antidiarrheal. The client should not exceed the recommended dose of this medication because it may be habit-forming. Since this medication is an antidiarrheal, it should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness.

57. A nurse is gathering data from client about the client’s medication history and notes that the client is taking tolterodine tartrate (Detrol LA). The nurse determines that the client is taking the medication to treat which disorder? a. glaucoma c. pyloric stenosisb. renal insufficiency d. urinary frequency and urgency

Rationale: DTolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.

58. A client has an order to receive psyllium (Metamucil) daily. The nurse administers this medication with: a. a multivitamin and mineral supplement c. applesauce b. a dose of an antacid d. eight ounces of liquid

Rationale: DMetamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice, and followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect.

59. A nurse is teaching a client taking cyclosporine (Sandimmune) after renal transplant about medication information. The nurse tells the client to be especially alert for: a. signs of infection b. hypotension c. weight loss d. hair loss

Rationale: ACyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication, and report them to the physician if experienced. The client is also taught about other side effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints.

60. A nurse reinforces dietary instruction for the client receiving spironolactone (Aldactone). Which food would the nurse instruct the client to avoid while taking this medication? a. crackers b. shrimp c. apricots d. popcorn

Rationale: CAldactone is a potassium-sparing diuretic and the client needs to avoid foods high in potassium, such as whole grain cereals, legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Option c provides the highest source of potassium and should be avoided.

61. A client begins to have Cheyne-Stokes respirations. This type of breathing pattern is best explained as a. Completely irregular breathing pattern with random deep and shallow respirations b. Prolonged inspirations with inspiratory and/or expiratory pauses c. Rhythmic waxing and waning of both rate and depth of respiration with brief periods of interspersed apnea d. Sustained, regular, rapid respirations of increased depth.

Rationale: CCheyne-Stokes respirations are a pattern of breathing in which phases of hyperpnea regularly alternates with apnea. The pattern waxes (crescendo) and wanes (decrescendo). Ataxic breathing is a completely irregular breathing pattern. Apneustic breathing is a pattern of prolonged inspiration with pauses. Central neurogenic hyperventilation is a sustained, regular, raid respiratory pattern of increased depth.

62. An 87 year old woman has come to the medical clinic for her annual physical examination. The nurse assessing her knows that pulmonary function in elderly clients often shows

a. A reduced vital capacity c. An increase in functional alveolib. A decrease in residual volume d. Blood gases that reflect mild acidosis

Rationale: AResidual volume increases with age, probably related to the loss of elastic forces in the lung. This increased residual value reduces the vital capacity. Arterial pH does not change with age. The functional alveoli decrease in the elderly due to the thinning of alveolar walls, resulting in the loss of alveolar septal tissue. There are also fewer capillaries present.

63. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?a. Obtain a 12-lead EKG c. Lower the oxygen rateb. Place client in high Fowler’s position d. Take baseline vital signs

Rationale: CA low oxygen level acts as a stimulus for respiration. A high concentrationof supplemental oxygen removes the hypoxic drive to breathe, leading toincreased hypoventilation, respiratory decompensation, and the developmentof or worsening of respiratory acidosis. Unless corrected, it can lead tothe client’s death.

64. The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis?a. Respiratory rate c. Pulse oximetryb. Peak air flow volumes d. Skin color

Rationale: BThe peak airflow volume decreases about 24 hours before clinical manifestations.

65. An adult who has general anesthesia for major surgery is in the PACU. One of the signs that May indicate that his artificial airway should be removed is:

a. gagging b. restlessness c. an increase in pain d. clear lungs on auscultation

Rationale: AReturn of the gag reflex often indicates that the client is able to manage his own secretions and maintain a patent airway. Restlessness can indicate cerebral anoxia due to a blockage of the tube. Changes in the perception of pain are unrelated to intubation. It is expected that the client who is intubated will have clear lungs.

66. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?

a. Have the client cough into a tissue and dispose in a separate bagb. Instruct the client to cover the mouth with a tissue when coughingc. Reinforce for all to wash their hands before and after entering the room d. Place client in a negative pressure private room and have all who enter the room use

masks with shields

Rationale: DA client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries (Africa, Asia, South America), transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled.

67. The nurse is assessing a client with chronic obstructive pulmonary disease receiving oxygen for low PaO2 levels. Which assessment is a nursing priority?

a. Evaluating SaO2 levels frequently c. Assessing for clubbing fingersb. Observing skin color changes d. Identifying tactile fremitus

Rationale AThe best method to evaluate a client’s oxygenation is to evaluate the SaO2. This is just as effective as an Arterial Blood Gas to evaluate the oxygenation, and is less traumatic and expensive.

68. A client is admitted to the hospital with the medical diagnosis of traumatic brain injury. From the assessment finding of slow, shallow respirations, the nurse concludes that which area of the brain is affected by injury? a. Anterior pituitary b. Hypothalamus c. Medulla d. Cerebral cortex

Rationale: CThe medulla and pons are the areas of brain tissue that control breathing. Injury to these tissues would produce alterations in the client’s breathing rate and pattern. The other options are incorrect areas of te brain.

69. In the client with right lung pneumonia, the nurse should encourage which position to facilitate optimal oxygenation?

a. Prone positionb. Supine position with head elevated 30 degreesc. Positioned with the right side dependentd. Positioned with the left side dependent

Rationale: DWith unilateral disease, the example to remember is “good ling down.” Since ventilation and perfusion are gravity dependent, enhancing ventilation and perfusion to healthy lung tissue and alveoli with enhance oxygenation. Perfusion refers to the circulation of blood into the tissues and cells. Supine positioning would provide near equal ventilation and perfusion to both lungs. In the diseased lung, excess fluid and fibrosis inhibit gas exchange at the pulmonary capillary membrane, thereby diminishing oxygenation.

70. The nurse is making a home visit to a 70-year-old client with emphysema. Which assessment finding has the most serious implication for this client’s nursing care?

a. Increased anterior-posterior diameter of the chest b. Bilateral crackles throughout the lung fieldsc. Pursed-lip breathingd. Circumoral cyanosis

Rationale: BIncreased anterior-posterior diameter of the chest, pursed-lip breathing, and circumoral cynosis are chronic findings in clients with emphysema. They do not indicate acute changes in the client’s condition. Bilateral crackles throughout the lung fields indicate excessive pulmonary fluid requiring acute intervention. The etiology of the fluid excess in the lungs needs to be explored in-depth. 71. In developing the care plan for a client with pulmonary mycrobacterium tuberculosis, what primary precaution should be located?a. Contact skin precautionsb. Use of special mask to avoid inhaling infected airborne dropletsc. Avoidance of blood contaminationd. Containment of draining wounds

Rationale: BMycobacterium tuberculosis is transmitted via airborne droplets so use of a properly fitted particulate filter mask is indicated to prevent its spread. The other options do not represent methods of preventing airborne transmission.

72. The family of a client with emphysema asks the nurse about the disease process. The nurse explains that the disorder results from a decreased oxygen supply because of:a. Paralysis of respiratory musclesb. Infectious obstructionc. Pleural effusiond. Loss of surface area for gas exchange

Rationale: DEmphysema is a chronic disease with progressive destruction of alveoli and loss of alveolar area available for gas exchange. Paralysis of respiratory muscles, airway obstructions, and pleural effusion would diminish ventilatory capacity that could ultimately lead to decreased oxygen supply.

73. A client comes to the clinic with an acute asthma episode. Which breath sound characteristic does the nurse expect to find auscultation?a. Bilateral crackles c. Diminished breath sounds in upper lobes b. Wheezing d. Rhonchi

Rationale: BExpiratory wheezing is a characteristic finding in acute asthma due to airway constriction. Crackles are indicative of excess pulmonary fluid, which is not typical finding with acute asthma. Ronchi are related to mucus obstruction of large airways and are common finding in chronic obstructive pulmonary disease processes.

74. Which of the following blood gas reports would the nurse expect in a client with progressive chronic obstructive pulmonary disease (COPD)?

a. pH 7.55, PaCO2 30 mmHg, PaCO2 80 mmHg, HCO3 24 mEq/L.b. pH 7.40, PaCO2 40 mmHg, PaCO2 94 mmHg, HCO3 22 mEq/L.c. pH 7.38, PaCO2 45 mmHg, PaCO2 88 mmHg, HCO3 26 mEq/L.d. pH 7.30, PaCO2 60 mmHg, PaCO2 70 mmHg, HCO3 30 mEq/L.

Rationale: DDuring the later stages of COPD, arterial blood gas findings indicate low pH, elevated pCO2 ,

LOW pO2, and elevated HCO3, which indicate the body’s attempt to compensate for chronically low pH. Option A is indicative of respiratory alkalosis; option B and C are variations of normal ABG results.

75. What instruction is most important for the nurse to provide during discharge teaching of a client who underwent a laryngectomy?a. Operation of feeding pumpb. Use of Passy Muir (speaking tracheostomy) valve c. Tracheostomy cared. Wound care

Rationale: C For any client with a tracheostomy, maintenance of the airway is clearly the priority. Clients are taught to perform routine tracheostomy care to prevent airway obstruction. Only those clients discharged with a feeding tube will need instruction about operation of a feeding pump. Wound care and use of a Passy Muir valve for communication are important factors to include discharge teaching, but the airway is the clear priority.

76. A client with chronic lymphocytic leukemia has a central venous access device. She has a tunneled central catheter called a Hickman. The nurse knows that this catheter is inserted surgically and threaded to the subclavian, and then is advanced into the superior vena cava just above the junction with the

a. left atrium b. right atrium c. left ventricle d. right ventricle

Rationale: BThe superior vena cava brings deoxygenated blood to the right atrium. The central venous catheter is threaded into the superior vena cava approximately 2 to 3 cm above the junction with the right atrium.

77. A 2 day old neonate is receiving phototherapy for hyperbilirubinemia. During this therapy, it is essential that the nurse:

a. decrease the unit’s level of light every 2 hoursb. keep the neonate well covered to prevent cold stress c. maintain the neonate’s position for 4 hours at a time d. place an opaque mask over the neonate’s eyes

Rationale: DAn opaque mask is placed over the neonate’s eyes to prevent retinal damage from the lights. The mask should be removed for 2-5 minutes every 8 hours to assess for irritation or redness.

78. In performing CPR, the primary goal of the nurse is to:a. return the heart to normal rhythm c. maintain circulation to vital organs

b. maintain acid base balance d. correct fluid volume deficit

Rationale: CThe goal of CPR is to maintain circulation to vital organs until more advanced forms of life support can be initiated.

79. A client with a peripheral IV line is about to receive a blood transfusion of packed red blood cells due to anemia. The nurse administering the transfusion will:

a. infuse the blood slowly over a period of 5 to 6 hoursb. initially infuse at a rapid rate and check pulse frequentlyc. obtain the client’s vital signs prior to the transfusion d. prime the tubing with a D5W solution prior to infusing blood

Rationale: CThe nurse must obtain baseline vital signs for this client just prior to starting the transfusion. Then the nurse will continue to monitor his vital signs as per protocol to evaluate for signs of a transfusion reaction.

80. The nurse is caring for an adult admitted to the coronary care unit with a myocardial infarction. During the second night in the CCU, the client develops congestive heart failure. A Swan-Ganz catheter is inserted to monitor the client for left ventricular function because:

a. It provides information about pulmonary resistanceb. It measures myocardial oxygen consumption.c. It controls renal blood flow.d. It controls afterload.

Rationale: AThe Swan-Ganz catheter measures pulmonary artery and capillary wedge pressures, which are good indicators of pulmonary pathology. The Swan-Ganz catheter does not measure myocardial oxygen consumption and does not control renal blood flow.

81. Mrs. Barcelo is admitted to the cardiac care unit with a myocardial infarction. The morning after admission she and her husband tell the nurse that she must be home tonight to care for the children when Mr. J. goes to work. The problem identified at this point would be

a. Anxiety related to physical limitations. b. Alteration in cardiac outputc. Inability of client/family to understand disease process. d. Safety needs related to inability to cope.

Rationale: CThe nurse should assess both Mr. and Mrs. J.’s understanding of the disease and rehabilitation processes. They both exhibit the need for information in order to be able to make rational decisions

82. Ms. Concepcion is admitted to the coronary care unit to rule out a myocardial infarction. She tells the nurse she is sure it is just angina and cannot understand what the difference is between angina and infarct pain. Which response is most appropriate for the nurse to make?

a. Anginal pain usually only lasts 3-5 minutes. b. Anginal pain produces clenching of the fists over the chest while acute MI pain does

not.c. Anginal pain requires morphine for reliefd. Anginal pain radiates to the left arm while acute MI pain does not

Rationale: AAnginal pain is of short duration. It is usually relieved by rest. The usual treatment for anginal pain is nitroglycerin. Anginal pain and the pain of an acute MI can both radiate to other locations

83. Which assessment finding in the elderly is caused by decreased vessel elasticity and increased peripheral resistance?

a. Confusion c. An increase in blood pressureb. An erratic pulse rate d. Wide QRS complexes on the ECG

Rationale: CThe blood pressure increases in response to the thickening of vessels and less-distensible arteries and veins. There is also an impedance to blood flow and increased systemic vascular resistance, contributing to hypertension. Confusion could be caused by a decreased oxygenation to the brain or by the interaction of multiple medications. An erratic pulse is not caused by decreased vessel elasticity and increased peripheral vascular resistance. An erratic pulse could be a sign of cardiac disease, a side effect of a prescribed medication, or a sign of the interaction of multiple medications. A wide QRS complex on an ECG is present in arrhythmias arising from the ventricles or in the presence of conduction defects of the ventricles.

84. A nurse is caring for a client during the recovery phase following a myocardial infarction. A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis. Which nursing action following the procedure is unsafe for the client?

a. Placing the client’s bed in the Fowler’s positionb. Encouraging the client to increase fluid intake c. Instructing the client to move the toes when checking circulation d. Resuming prescribed pre-catheterization medications

Rationale: AImmediately following a cardiac catheterization with femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move their toes assess motion, which could be impaired if a hematoma or thrombus were developing. The pre-catheterization medications are needed to treat acute and chronic conditions. [Some facilities may require the MD to reorder all pre-procedural medications. Check your facility policy & procedures.] Keywords for this question are unsafe and femoral artery approach.

85. A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be:

a. Order an EKG c. Start an IVb. Administer morphine sulphate d. Measure vital signs

Rationale: BDecreasing the client’s pain is the most important priority at this time. As long as pain is present

there is danger in extending the infarcted area. Morphine will decrease the oxygen demands of the heart and act as a mild diuretic as well.

86. A client is getting ready to go home after having a myocardial infarction (MI).The client is is asking questions about his medications, and wants to know why metoprenolol (Lopressor) was prescribed. The nurse’s best response would be which of the following?a. “Your heart was bearing too slowly, and Lopressor increase your heart rate.”b. “Lopressor helps to increase the blood supply to the heart by dilating your coronary arteries.”c. “This medication helps make your heart beta stronger to supply more blood to your body.”d. “It slows your heart rate and decreases the amount of work it has to do so it can heal.”

Rationale: DMetropolol (Lopressor) is a beta blocker, and it slows heart rate; the main therapeutic effect after a MI is to reduce cardiac workload. It does not dilate the coronary arteries, and it actually decreases the contractility (strength of the heart beat).

87. A client is taking digoxin (Lanoxin) and furosemide (Lasix) for heart failure. Which of the following would be the best menu choices for this client? a. Chicken with baked potato and cantaloupeb. Eggs and hamc. Grilled cheese sandwhich and French fried potatoesd. Pizza with pepperoni

Rationale: AA prudent diet would be high in potassium because digoxin and furosemide can both deplete potassium. The diet needs to be low in sodium to prevent additional fluid overload with heart failure. Chicken, potato, and cantaloupe are all potassium-rich foods; options 2,3, and 4 are higher in sodium.

88. A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. What response from the client indicates that the client understands this medication?a. “Will the physician give me a year’s supply of nitroglycerine tablets?”b. “I will carry my nitroglycerine tablets in the inside pocket of my jacket, so they are always close.”c. “I usually take three of my nitroglycerine tablets at the same time. I find that they work better that way.”d. “I have a small labeled case for a few nitroglycerine tablets that I carry with me when I go out.”

Rationale: DNitroglycerine loses potency over time when exposed to light and heat. They should be kept cool, dry, and in a dark container. Clients should get a new bottle every 6 months, and store them in a cool place; tablets should be taken 5 minutes apart, taking more that one tablet at a time can actually decrease the effectiveness of the drug and may cause severe hypotension.

89. A client is being evaluated for a possible myocardial infarction. The nurse performs a 12- lead ECG for an episode of new chest pain. The nurse will monitor for which sign of acute

myocardial Injury?a. ST depression b. ST elevations c. New Q wave d. New U wave Rationale: BST elevations indicate immediate myocardial injury; ST depressions indicate myocardial ischemia; a Q wave forms several days after a myocardial infarction; a U wave is a sign of hypokalemia.

90. The nurse is caring for a client with new onset atrial fibrillation. The nurse anticipates that which of the following is a possible treatment for this dysrhythmia when it first develops?a. External pacemaker applicationb. Insertion of automatic internal cardiac defibrillator (AICD)c. Synchronized cardioversiond. Defibrillation

Rationale: CSynchronized cardioversion is most effective with new –onset atrial fibrillation. Pacemakers are indicated for heart block, AICDs are used for ventricular dysrhythmias, and defibrillation is indicated for ventricular fibrillation and pulseless ventricular tachycardia.

SITUATION: Pain is one of the most common reasons why people consult their physicians. It is now regarded as the 5th Vital Sign. This strategy is used to give emphasis on how pain should be managed. You have collaborative as well as independent nursing interventions for pain.

91. The WHO Analgesic ladder provides the health professional with:a. pharmacologic and non-pharmacologic pain management choicesb. general pain management choices based on level of painc. non-pharmacologic interventions based on level of paind. specific pain management choices based on a severity of pain

Rationale: BThe World Health Organization (WHO) recommends a three-step ladder approaches to manage chronic cancer pain. This approaches focuses on the intensity of the pain. Step 1 of the analgesic ladder suggests a non-opioid analgesic and the possibility of an adjuvant analgesic. If the client receives the maximum recommended dose of nonopioids and continues to experience pain, Step 2 recommends adding an opioid. It appears that there is no difference between steps 2 and 3, however, in practice the differences is in the choice of analgesic.Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 220 (Figure 13-1)Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 1153-1154December 2007 NLE Board Examination Question Nursing Practice IV Set B Item No. 91

92. Jacqueline has been on morphine on a regular basis for several weeks. She is now complaining that the usual dose she has been receiving is no longer relieving her pain as effectively. Assuming that nothing has changed in his condition, you would suspect that the client is:

a. becoming psychologically dependentb. needing to have the morphine discontinuedc. developing tolerance to the morphine

d. exaggerating her level of pain

Rationale: CThere is no maximum safe dosage of opioids, nor is there any easily identifiable therapeutic serum level. Tolerance (the need for increasing doses of opiods to achieve the same therapeutic effect) will develop in almost all patients taking opioids over an extended period. Patients requiring opioids over a long term, especially cancer patients, will need increasing doses to relieve pain. Patients who become tolerance to the analgesic effect of large doses of morphine may obtain pain relief by switching to a different opioid.Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 236December 2007 NLE Board Examination Question Nursing Practice IV Set B Item No. 94

93. The nurse is caring for a group of adult patients who require pain management. It is most important for the nurse to remember:

a. to use medication only as a last resort after trying to distract the patientb. that medicating a patient with chronic pain is a lower priority than medicating a patient

with acute pain.c. that medication should be given based on the patient’s perception of pain. d. to wait for 15 minutes after a patient’s request for pain medication to be sure the pain

is real.

Rationale: CThe patient’s ability to tolerate pain, the patient’s pain threshold, stamina, physical and emotional condition, and cultural patterns all influence the patient’s response to pain and expression of pain. Remember that each person’s pain experience is unique and that the client is the best interpreter of the pain experience.Option A – this is not an appropriate action, especially for patients in severe pain.Option B – medicating for chronic pain is not a lower priority than medicating for acute pain.Option D – the nurse should respond to the patient’s request for pain medication immediately. Response to medication is better when it is given before pain becomes severe.Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 226-229Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 1141

SITUATION: Pablo, an adolescent, was diagnosed to have pneumonia. He constantly complains of chest pain and has a standing order of Morphine SO4.

94. Which of the following most appropriately describe pain sensations that has periods of remission and exacerbation?a. Acute b. Intractable c. Chronic d. Neuropathic

Rationale: CChronic pain is a prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning. Periods of remission and exacerbation persists over 6 months and may be longer. Option B – pain that is highly resistant to relief. Example is the pain from an advanced malignancy. When caring for a client experiencing intractable pain, nurses are challenged to use a number of methods, pharmacologic and nonpharmacologic, to provide the client with pain relief.

Option C – acute pain last only through the expected recovery period, whether it has a sudden or slow onset and regardless of the intensity. Acute pain does not persists over 6 months.Option D – is the result of current or past damage to the peripheral or central nervous system and may not have a stimulus such as tissue or nerve damage for the pain. Reference: Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 1133-1134 December 2006 NLE Board Examination Question Nursing Practice I Set B Item No. 36

95. To get accurate information about the quality of pain the patient is experiencing, which of the following statements would be most appropriate?a. “What cause you the pain?”b. “Tell me what your pain feels like”c. “Have you taken something to relieve the pain?”d. “Is it stubbing or radiating pain?”

Rationale: BWhile taking pain histories, the nurse must provide an opportunity for clients to express in their own words how they view the pain and the situation. This will help the nurse understand what the pain means to the client and how the client is coping with it. Remember that each person’s pain experience is unique and that the client is the best interpreter of the pain experience.Reference: Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 1140-1141December 2006 NLE Board Examination Question Nursing Practice I Set B Item No. 38

96. Pablo, who describes his pain as 7 on a scale of 1 to 10, is having:a. Severe pain c. Very severe painb. Mild pain d. Moderate pain

Rationale: AA 10-point pain intensity scale with word modifiers serve as a guideline based on studies. Severe pain ranges from 6-7 scale. On a scale of 0 to 10, a pain rating of 3 or greater signals a need to revise the pain treatment plan (higher dose or different analgesics0. A rating of 6 or more demands immediate attention.Option B – from 2 to 3 pain scaleOption C – from 8 to 9 pain scaleOption D – from 4 to 5 pain scaleReference: Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 1142 (Figure 44-6 and Clinic Alert!)

97. There is an order of Demerol 50 mg IM now and every 6 hours p.r.n. You injected Demerol at 5pm. The next dose of Demerol 50 mg IM is given:a. at 11pm c. when the patient is in severe painb. at 12 pm d. when the client asks for the next dose

Rationale: AA preventive approach to relieving pain by administering analgesic agents is considered the most effective strategy because a therapeutic serum level of medication is maintained. With the preventive approach, analgesic agents are administered at set intervals so that the medication acts before the pain becomes severe and before the serum opioid level falls to a subtherapeutic level. Administering analgesic medication on a time basis, rather than on the basis of the

patient’s report of pain, prevents the serum drug level from falling to subtherapeutic level. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 232June 2007 NLE Board Examination Question Nursing Practice II Set A Item No. 12

98. Maria, a nurse at the PACU discovered that Luisa, 50 kilos who is 3 hours post cholecystectomy was in severe pain. Upon checking the chart, she found out that Luisa had “Demerol 100 mg PRN for pain”. What should Maria do?

a. verify the order from the M.D.b. inject 100 mg. Demerol I.M. to Luisac. report to the nurse supervisor for opiniond. administer the recommended dose which is 50 mg because Luisa weighs 50 kilos

Rationale: AThe doctor’s order is incomplete, the route of administration is not specified. Verify the doctor’s order. Demerol can be given in various routes (IV, IM, SQ, PO). Always remember the different rights in drug administration. Right patient, right route, right drug, right dose, right time, right documentation (6 rights). Additional rights according to (ANSAP) teach patient about the drugs the client is receiving, take a complete patient drug history, find out for any drug allergies, and be aware of potential drug-drug, drug-food interactions.Reference: Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 794, 795, 804ANSAP’s Nursing Standards on Intravenous Practice (2006). 7th Edition. Page 14December 2006 NLE Board Examination Question Nursing Practice III Set B Item No. 8

SITUATION: Nurses’ attitudes toward pain influence the way they perceive and interact with clients in pain.

99. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment and management of pain should address the following concerns and misconceptions, except:a. older patients seldom tend to report pain than the younger onesb. pain is a sign of weaknessc. older patients do not believe in analgesics; they are tolerantd. complaining of pain will lead to being labeled a ‘bad’ patient

Rationale AThe way an older person responds to pain may differ from the way a younger person responds. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass than younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer. (correct statement)Option B, C and D – most common concerns and misconceptions about pain, analgesia and why clients may be reluctant to report pain. Pain threshold does not appear to change with aging, although the effect of analgesics may increase due to physiologic changes related to drug metabolism and excretion.Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 225, 228 (Chart 13-4)Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Edition. Page 1141 (Box 44-2)December 2007 NLE Board Examination Question Nursing Practice III Set B Item No. 16100. Respiratory depression is the most serious adverse effect of opioid analgesic agents. What

is the antidote for this?a. Narcan b. Methadone c. Codeine d. Diazepam

Rationale: AAdminister an opioid antagonist, such as naloxone hydrochloride (Narcan) until respiration return to an acceptable rate. Administer the medication slowly by intravenous route with 10 ml of saline. Monitor the client, and repeat the procedure as required.Option B – this is given for opioid withdrawal among drug abusers.Option C – one of the opioid analgesicsOption D – one of the adjuvant analgesicsReference: Kozier, B., et. al. (2004) Fundamentals of Nursing. Concepts, Process and Practice. 7th Ed.. Page 1151, 1153

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