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The correct answer is C:

Force fluids and reassess blood pressurePostur al hypotension, a decrease in

systolic blood pressure of morethan 15 mm Hg and an increase in heart rate of more than 15

percentusually accompanied by dizziness indicates volume depletion,inad equate

vasoconstricto r mechanisms, and autonomic insufficiency.2 8. A client has a Swan-Ganz catheter in

place. The nurse understandstha t this is intended to measureA)

Right heart function B) Left heart function C) Renal tubule

functionD) Carotid artery functionThe correct answer is B: Left heart function The Swan-

Ganz catheter isplaced in the pulmonary artery to obtain information about the

leftside of the heart. The pressure readings are inferred from pressuremeasu rements

obtained on the right side of the circulation. Right-sided heart function is assessed

through the evaluation of the centralvenous pressures (CVP).29. A nurse enters a

client's room to discover that the client has nopulse or respirations. After calling for help, the

first action the nurseshould take isA) Start a peripheral IVB) Initiate closed-chest massage

C) Establish an airway D) Obtain the crash cartThe correct answer is C: Establish an airway

Establishing an airway isalways the primary objective in a cardiopulmona ry arrest.30. A

client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The healthcare provider has

written a new order to give metoprolol (Lopressor)25 mg. B.I.D. In assessing the client prior to

administering themedication s, which of the following should the nurse reportimmedia

tely to the health care provider? A) Blood pressure 94/60

B) Heart rate 76C) Urine output 50 ml/hourD) Respiratory rate 16The correct answer

is A: Blood pressure 94/60 Both medicationsde crease the heart rate. Metoprolol

affects blood pressure. Therefore,the heart rate and blood pressure must be within normal range

(HR60-100; systolic B/P over 100) in order to safely administer both

medications.3 1. While assessing a 1 month-old infant, which finding should thenurse

report immediately? A) Abdominal respirationsB) Irregular breathing rate

C) Inspiratory grunt D) Increased heart rate with cryingThe correct answer

is C: Inspiratory grunt Inspiratory grunting isabnormal and may be a

sign of respiratory distress in this infant.32. The nurse practicing in a maternity

setting recognizes that thepost mature fetus is at risk due toA) Excessive

fetal weightB) Low blood sugar levelsC) Depletion of subcutaneous fat

D) Progressive placental insufficienc y The correct answer is D:

Progressive placental insufficiency Theplacenta functions less efficiently as pregnancy

continues beyond 42weeks. Immediate and long term effects may be related to

hypoxia.33. The nurse is caring for a client who had a total hip replacement 4days ago.

Which assessment requires the nurses immediate attention?A) I have bad

muscle spasms in my lower leg of the affectedextrem ity. B) "I just can't 'catch

my breath' over the past few minutes andI think I am in grave danger."

C) "I have to use the bedpan to pass my water at least every 1 to 2hours." D) "It seems that the

pain medication is not working as welltoday."Th e correct answer is B: "I just can''t

''catch my breath'' over the pastfew minutes and I think I am in grave danger." The nurse

would beconcerned about all of these comments. However the most

lifethreatening is option B. Clients who have had hip or knee surgery areat greatest risk

for development of post operative pulmonaryem bolism. Sudden

dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle

spasms do not require immediateatte ntion. Option C may indicate a urinary tract

infection. And option Drequires further investigation and is not life threatening.34.

A client has been taking furosemide (Lasix) for the past week. Thenurse recognizes

which finding may indicate the client is experiencinga negative side effect from the medication?

A) Weight gain of 5 poundsB) Edema of the anklesC) Gastric irritability

D) Decreased appetite The correct answer is D: Decreased appetite Lasix

causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemi

a include anorexia, fatigue, nausea, decreased GI motility,muscl e weakness,

dysrhythmias. 35. A client who is pregnant comes to the clinic for a first visit.

Thenurse gathers data about her obstetric history, which includes 3 year-old twins

at home and a miscarriage 10 years ago at 12 weeksgestatio n. How would the nurse

accurately document this information? A) Gravida 4 para 2B) Gravida 2 para 1

C) Gravida 3 para 1 D) Gravida 3 para 2The correct answer is C: Gravida 3 para 1

Gravida is the number of pregnancies and Parity is the number of pregnancies that

reachviability (not the number of fetuses). Thus, for this woman, she is nowpregnant,

had 2 prior pregnancies, and 1 viable birth (twins).36. The nurse is caring for a

client with a venous stasis ulcer. Whichnursing intervention would be most effective in

promoting healing?A) Apply dressing using sterile technique

B) Improve the client's nutrition status C) Initiate limb compression

therapyD) Begin proteolytic debridementT he correct answer is B: Improve the

client''s nutrition status The goalof clinical management in a client with venous stasis

ulcers is topromote healing. This only can be accomplished with proper nutrition.The

other answers are correct, but without proper nutrition, the otherinterventi ons would be

of little help.37. A nurse is to administer meperidine hydrochloride (Demerol)

100mg, atropine sulfate (Atropisol) 0.4 mg, and promethizineh ydrochloride

(Phenergan) 50 mg IM to a pre-operative client. Whichaction should the nurse take

first?A) Raise the side rails on the bedB) Place the call bell within reachC) Instruct the

client to remain in bed D) Have the client empty bladder

The correct answer is D: Have the client empty bladder The first stepin the process is to

have the client void prior to administering the preoperative medication. The other

actions follow this initial step in thissequence: 4 3 1 238. Which of these

statements best describes the characteristic of aneffective reward-

feedback system? A) Specific feedback is given as close to the

event as possible B) Staff are given feedback in equal amounts over timeC)

Positive statements are to precede a negative statementD) Performance goals should

be higher than what is attainableThe correct answer is A: Specific feedback is given as close

to theevent as possible Feedback is most useful when given immediately.P ositive

behavior is strengthened through immediate feedback, and itis easier to modify

problem behaviors if the standards are clearlyunderst ood.39. A client with

multiple sclerosis plans to begin an exercise program.In addition to discussing the

benefits of regular exercise, the nurseshould caution the client to avoid activities

whichA) Increase the heart rate B) Lead to dehydration C) Are considered

aerobicD) May be competitiveTh e correct answer is B: Lead to dehydration

The client must take inadequate fluids before and during exercise periods.40.

During the evaluation of the quality of home care for a client withAlzheimer 's disease, the

priority for the nurse is to reinforce whichstatemen t by a family member?A) At least 2 full

meals a day is eaten.B) We go to a group discussion every week at our

community center. C) We have safety bars installed in the bathroom

and have 24hour alarms on the doors. D) The medication is not a problem

to have it taken 3 times a day.The correct answer is C: We have safety bars installed in the

bathroomand have 24 hour alarms on the doors. Ensuring safety of the clientwith

increasing memory loss is a priority of home care. Note all optionsare correct

statements. However, safety is most important toreinforce.

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