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A. Hematuria
B. Dysuria
C. Polyuria
D. Dribbling
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the
client most likely experience?
A. Visual hallucinations.
B. Receptive aphasia.
C. Hemiparesis.
D. Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that
decreased blood pressure of the client with Addison’s disease involves a disturbance in the
production of:
A. Androgens
B. Glucocorticoids
C. Mineralocorticoids
D. Estrogen
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would
base the teaching on the understanding that:
A. Inspired air will move from the lung into the pleural space.
B. There is greater negative pressure within the chest cavity.
C. The heart and great vessels shift to the affected side.
D. The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an increased risk for developing
cancer of the tongue. Which of the following health history will be a concern?
A. Compact bone is stronger than cancellous bone because of its greater size.
B. Compact bone is stronger than cancellous bone because of its greater weight.
C. Compact bone is stronger than cancellous bone because of its greater volume.
D. Compact bone is stronger than cancellous bone because of its greater density.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC
count, the nurse understands that the higher the red blood cell count, the :
A. Catecholamines released at the site of the infarction causes intermittent localized pain.
B. Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
C. Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
D. Inflammation in the myocardium causes a rise in the systemic body temperature.
14. Following an amputation of a lower limb to a male client, the nurse provides an instruction
on how to prevent a hip flexion contracture. The nurse should instruct the client to:.
A. Advise the client to refrain from vigorous brushing of teeth and hair.
B. Instruct the client to avoid driving for 2 weeks.
C. Encourage eye exercises to strengthen the ocular musculature.
D. Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department.
The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood
gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;
A. “You sound concerned; You’ll probably remember more as you wake up.”
B. “Tell me what you think happened.”
C. “You were in a car accident this morning.”
D. “An amputation of your right leg was necessary because of an accident.”
19. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a
Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is
something wrong with the medication and nursing care. The nurse recognizes this behavior is
probably a manifestation of the client’s:
A. “I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
B. “I’m going to have a figure like a model in about a year.”
C. “I need to eat more high-protein foods.”
D. “I will be going to be out of bed and sitting in a chair the first day after surgery.”.
22. The client who had transverse colostomy asks the nurse about the possible effect of the
surgery on future sexual relationship. What would be the best nursing response?
A. Furosemide (Lasix)
B. Hydrochlorothiazide (HydroDIURIL)
C. Metolazone (Zaroxolyn)
D. Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the
administration of the medication the nurse should monitor the client for:
A. Palpitation
B. Visual disturbance
C. Decreased pulse rate
D. Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan
aimed at reducing the side effects of this medication?
A. Take the drug with an antacid.
B. Lie down after meals.
C. Avoid dairy products in diet.
D. Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective
when there is decrease in:
A. The triglycerides
B. The INR
C. Chest pain
D. Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
A. Muscle strength
B. Symptoms
C. Blood pressure
D. Consciousness
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of
trigeminal neuralgia by monitoring the client’s:
A. Seizure activity
B. Liver function
C. Cardiac output
D. Pain relief
37. Administration of potassium iodide solution is ordered to the client who will undergo a
subtotal thyroidectomy. The nurse understands that this medication is given to:
A. Arterial blood pH
B. Pulse rate
C. Serum glucose
D. Intake and output
40. A client with recurrent urinary tract infections is to be discharged. The client will be taking
nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge
instructions to the client. Which of the following instructions will be correct?
A. Strain urine for crystals and stones
B. Increase fluid intake.
C. Stop the drug if the urinary output increases
D. Maintain the exact time schedule for drug taking.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic
therapy for the client. The nurse understands that chemotherapy destroys rapidly growing
leukocytes in the:
A. Bone marrow
B. Liver
C. Lymph nodes
D. Blood
42. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to
continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The
nurse explains to the client that the purpose of gradual dosage reduction is to allow:
A. Potassium
B. Sodium
C. Chloride
D. Calcium
45. Which of the following client has a high risk for developing hyperkalemia?
A. Crohn’s disease
B. End-Stage renal disease
C. Cushing’s syndrome
D. Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level
is 5.8 mEq/L. Which of the following is the initial nursing action?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answers and Rationales
1. A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort
with distention, and overflow with a large residual. This leads to urinary stasis and infection.
High fluid intake limits urinary stasis and infection by diluting the urine and increasing
urinary output.
2. D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and
cardiac workload.
3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
4. A. The occipital lobe is involve with visual interpretation.
5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus
causes hypotension.
6. B. As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.
7. A. Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
8. D. The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced
to haversian canals.
9. A. Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of
red cells suspended in plasma.
10. C. Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.
11. D. Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.
12. C. The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the
anus in females also increases this incidence.
13. D. Temperature may increase within the first 24 hours and persist as long as a week.
14. C. The hips are in extension when the client is prone; this keeps the hips from flexing.
15. C. Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
16. A. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.
17. C. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical
evaluation.
18. C. This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.
19. D. Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.
20. C. There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.
21. B. Clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after weight
stabilizes, which may require a panniculectomy. Body image disturbance often occurs in
response to incorrectly estimating one’s size; it is not uncommon for the client to still feel
fat no matter how much weight is lost.
22. D. Surgery on the bowel has no direct anatomic or physiologic effect on sexual
performance. However, the nurse should encourage verbalization.
23. C. Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture and
the risk in men is estimated between 13% and 25%; a bone mineral density measurement
assesses the mass of bone per unit volume or how tightly the bone is packed.
24. A. Around-the-clock administration of analgesics is recommended for acute pain in the
older adult population; this help to maintain a therapeutic blood level of pain medication.
25. C. Generally, female voices have a higher pitch than male voices; older adults with
presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-
pitched sounds.
26. D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
27. A. Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause
tachycardia and palpitation.
28. D. Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29. A. Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and
cholesterol.
30. C. Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight
container.
31. A. Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32. B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.
33. B. Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because
it may indicate toxic levels of the drug.
34. B. Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by
limiting vasoconstriction, which may result in orthostatic hypotension.
35. A. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia
gravis in client who have the disease and is therefore an effective diagnostic aid.
36. D. Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission
of nerve impulses in clients with trigeminal neuralgia.
37. C. Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.
38. C. Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in
metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it
enables the body to adapt to stress.
39. D. DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of
normal urine output and thirst.
40. B. To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.
41. A. Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help counter
infections that the body can no longer handle easily.
42. A. Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.
43. B. Dehydration is most readily and accurately measured by serial assessment of body
weight; 1 L of fluid weighs 2.2 pounds.
44. A. The concentration of potassium is greater inside the cell and is important in establishing
a membrane potential, a critical factor in the cell’s ability to function.
45. B. The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.
46. C. Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac
dysrhythmias.
47. A. Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is
generally supplied.
48. C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.
49. A. Because IV solutions enter the body’s internal environment, all solutions and
medications utilizing this route must be sterile to prevent the introduction of microbes.
50. A. A low pH and bicarbonate level are consistent with metabolic acidosis.