1. Answer: A
Sclerotherapy is the injection of a sclerosing agent into a varicosity. The
agent damaged the vessel and causes aseptic thrombosis, which results in vein
closure. With no blood flow through the vessel, there is no distention. The
surgical procedure for varicose veins is vein ligation and stripping. This
procedure involves tying off the varicose vein and large tributaries and then
removal of the vein with the use of hook and wires via multiple small incisions
in the leg.
2. Answer: C
3: In rheumatic fever, the joints especially the knees, ankles, elbows, and
wrists are painful, swollen, red, and hot to the touch. Limiting movement of
the affected joints typically minimizes pain. 1: Massaging the joints likely
will not aid in pain relief because the pain is due to the disease process and
subsequent inflammation in the joint. 2: Applying ice to the affected joints
likely will not aid in pain relief because of the inflammation, edema, and
effusion in the joint tissue. 4: Exercise should be avoided because of the
increased workload placed on the heart muscle. This is in contrast to usual
recommendations for clients with other forms of arthritis. Despite joint
involvement in rheumatic fever, permanent deformities do not occur.
3. Answer: D
If 6 hours or fewer have passed since the onset of symptoms related to MI,
thrombolytic therapy is indicated. (The client's chest pain began 4 hours
before diagnosis.) The preferred choice is tPA, which is more specific for
cardiac tissue than streptokinase. Stress testing shouldn't be performed during
an MI. The client doesn't exhibit symptoms that indicate the use of lidocaine.
4. Answer: A
Prinzmetal's or variant angina is triggered by coronary artery spasm. An
unpredictable amount of activity may trigger unstable angina. Activities that
increase myocardial oxygen demand may trigger predictable stable angina.
5. Answer: D
The nursing diagnosis of Acute pain takes highest priority because pain
increases the client's pulse and blood pressure. During an acute phase of an
MI, low-grade fever is an expected result of the body's response to the
myocardial tissue necrosis. This makes Risk for imbalanced body temperature
an incorrect answer. The client's blood pressure and heart rate don't suggest a
nursing diagnosis of Decreased cardiac output. Anxiety could be
an appropriate nursing diagnosis but it may be corrected by addressing the
priority concern
6. Answer: C
Standard management for the client with deep vein thrombosis includes bed rest
for 5 to 7 days, limb elevation, relief of discomfort with warm moist heat, and
analgesics as needed. Ambulation is contraindicated because activity such as
ambulation can cause the thrombus to dislodge and travel to the lungs. Narcotic
analgesics are not required to relieve pain, and pain normally is relieved by
acetaminophen (Tylenol).
7. Answer: D
The client exhibits signs of myocardial infarction (MI), and the most accurate
serum determinant of MI is troponin level. The other tests can show evidence of
muscle injury but they're less specific indicators of myocardial damage than
troponin.
8. Answer: B
2: Common laboratory findings in the client who has suffered a MI include
elevated CPK level. CPK is also released during muscle injury and brain injury.
The CPK isoenzyme CPK-MB elevates only in response to myocardial damage. 1:
Elevated serum cholesterol level is a risk factor for coronary artery disease
(CAD). It is not a diagnostic tool for MI. 3: The erythrocyte sedimentation
rate may be elevated with an MI but it is not diagnostic. 4: The white blood
cell count is typically elevated but not diagnostic for MI.
9. Answer: A
The client with uncontrolled atrial fibrillation with a ventricular rate more
than 100 beats per minute is at risk for low cardiac output because of loss of
atrial kick. The nurse assesses the client for palpitations, chest pain or
discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope,
shortness of breath, and distended neck veins.
10. Answer: A
Initial treatment consists of avoiding cold, avoiding mechanical or chemical
injury, and quitting smoking. Vasodilator drug therapy is generally reserved
for severe cases. Hands are affected bilaterally, and amputation isn't usually
done. Blood clots don't cause Raynaud's disease.
11. Answer: D
The client should alert any health care provider of a history of infective
endocarditis before any procedure that involves instrumentation. The provider
should place the client on prophylactic antibiotics. The client should take
antibiotics for the full course of therapy. The client should notify the
physician if chest pain worsens or if dyspnea or other symptoms occur. The
client should use a soft toothbrush and floss carefully to avoid any bleeding
of the gums, which would provide a portal of entry for bacterial infection.
12. Answer: D
D","The paralysis is not progressive and the prognosis is usually
excellent. ","This is unnecessary; passive range of motion and
intermittent splinting performed by a family member is all that is necessary;
recovery usually occurs in 3 months. ","Intermittent splinting and
passive range of motion are all that is required; only in rare instances when
avulsion of the nerves results in permanent damage is orthopedic or surgical
intervention necessary. ","The nerves that have been stretched
normally take about 3 months to recover from the trauma sustained during
delivery. "
13. Answer: C
(3) For a confused patient with memory failure, supervision of medication
administration is essential. In order for a patient to self-medicate, the
patient needs to understand and comprehend drug information. The patient with
cognitive changes has difficulty remembering, especially when multiple
medications are given. (1) Not all medications are to be administered with
meals. Some medications are better absorbed on an empty stomach. (2) A confused
patient does not understand the implications of refusing medications, and
therefore the nurse needs to instruct the family how to handle medications for
the patient who refuses them. (4) Self-medication, even though it gives the
patient control and independence, is not recommend¬ed in a confused patient for
safety reasons.
14. Answer: D
4: Nitroglycerin can cause hypotension. A priority nursing assessment after the
administration of nitroglycerin is the client’s blood pressure. 1: This is
not a priority nursing assessment after the administration of nitroglycerin. 2:
This is not a priority nursing assessment after the administration of
nitroglycerin. 3: This is not a priority nursing assessment after the
administration of nitroglycerin.
15. Answer: B
The cardiac cycle consists of contraction and relaxation of the heart muscle.
The heart normally sends out about 5 L of blood every minute to the body.
16. Answer: A
Sickle cell anemia is an autosomal recessive trait found most commonly in
African-American individuals. The treatment for this condition is heat,
hydration, oxygenation, and pain relief. (SR 5381)
17. Answer: A
Correct procedure for cardiopulmonary resuscitation with two rescuers includes
a compression to ventilation ratio of 5 to 1. With adults, compressions are
performed at a depth of 1 ½ to 2 inches. The 5:1 ratio yields an effective rate
of 12 respirations per minute. With effective compressions, carotid pulsations
should be present. At its best, cardiopulmonary resuscitation produces only 30
% of the normal cardiac output, so correct technique is vital.
18. Answer: D
Clients undergoing PTCA receive abciximab because it inhibits platelet
aggregation, thereby reducing cardiac ischemic complications. Before abciximab
is administered, the client should have an up-to-date APTT result available.
The drug isn't contraindicated in clients with a seizure history. Abciximab
isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone
doesn't need to be at the bedside. Any client with refractory angina should be
on continuous ECG monitoring; however, monitoring isn't a requirement for
administering abciximab.
19. Answer: C
Triamterene is a potassium-sparing diuretic, and the client should avoid foods
high in potassium. Fruits that are naturally higher in potassium include
avocado, bananas, fresh oranges, mangoes, nectarines, papayas, and dried
prunes.
20. Answer: C
1: Telling the mother that she didn't bring the child in for 2 weeks implies
that the mother was at fault, possibly causing the mother to become defensive.
2: With congenital hypothyroidism, failure of normal development occurs during
the embryonic period or when an inborn error of metabolism prevents the normal
synthesis of thyroxine. Although the condition is present at birth, maternal
thyroxine can pass through the placenta to the fetus, supplying the fetus and
neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are
commonly masked at birth. 3: With congenital hypothyroidism, failure of normal
development occurs during the embryonic period or when an inborn error of
metabolism prevents the normal synthesis of thyroxine. Although the condition
is present at birth, maternal thyroxine can pass through the placenta to the
fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates,
the signs of hypothyroidism are commonly masked at birth. 4: Telling the mother
that she couldn't be reached is not therapeutic and may cause the mother to
become defensive, implying that she was at fault.
21. Answer: D
Acetazolamide is a carbonic unhydrase inhibitor that has sulfonamide
properties. Before administration of this medication, the nurse should assess the
client for an allergy to sulfonamides because the medication is contraindicated
if an allergy exists. The nurse also should monitor the client during therapy
for an allergic reaction and for photosensitivity.
22. Answer: B
Elastic stockings are used to promote venous return. The nurse needs to remove
them once per day to observe the condition of the skin underneath the
stockings. Applying the stockings increases blood flow to the heart. When the
stockings are in place, the leg muscles can still stretch and relax, and the
veins can fill with blood.
23. Answer: A
An anterior MI causes left ventricular dysfunction and can lead to
manifestations of heart failure, which include pulmonary crackles and dyspnea.
The other types of MI aren't usually associated with heart failure.
24. Answer: D
Procainamide is an antidysrhythmic that may be used to treat ventricular
dysrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac
glycoside; metoprolol is a β-adrenergic blocking agent; and verapamil is a
calcium channel blocking agent.
25. Answer: B
B","Thickened formula is given to an infant with reflux problems,
such as vomiting after each feeding. ","Because of the cleft
(opening) in the lip, the infant tends to suck in more air than usual; burping
will prevent frequent regurgitation of formula. ","The infant's
bottle should never be propped; the infant can aspirate. ","The baby
should be held while being fed. "
26. Answer: C
The client should wear loose, comfortable clothing for the procedure.
Electrocardiogram lead placement is enhanced if the client wears a shirt that
buttons in front. The client should wear rubber-soled, supportive shoes such as
sneakers. The client is NPO after bedtime or for a minimum of 2 hours before
the test. The client should avoid smoking, alcohol, caffeine on the day of the
test. Inadequate or incorrect preparation can interfere with the test and
possibly yield false-positive findings.
27. Answer: B
Toxic shock syndrome is caused by infection and often is associated with tampon
use. Disseminated intravascular coagulation is a complication of toxic shock
syndrome. Options A, C, and D are unrelated to the cause of toxic shock syndrome.
28. Answer: C
The normal activated partial thromboplastin time (aPPT) varies between 20 and
36 seconds, depending on the type of activator used in testing. The therapeutic
dose of heparin for treatment of deep vein thrombosis is to keep the aPPT
between, 1.5 and 2.5 times normal. Thus the client’s aPPT is within the
therapeutic range, and the dose should remain unchanged.
29. Answer: C
The client undergoing pericardiocentesis is positioned supine with the head of
bed raised to a 45- to 60- degree angle. This places the heart in close
proximity to the chest wall for easier insertion of the needle into the
pericardial sac. Options A, B, and D are incorrect positions.
30. Answer: D
Applying pressure to both carotid arteries at the same time is contraindicated.
Excess pressure to the baroreceptors in the carotid vessels could cause the
heart rate and blood pressure to drop reflexively. In addition, the manual
pressure could interfere with the flow of blood to the brain, causing possible dizziness
and syncope.
31. Answer: B
The aortic valve separates the aorta from the left ventricle. Options A, C, and
D describe the mitral, tricuspid, and pulmonic valves, respectively.
32. Answer: A
1: Based on the mother's description, the child most likely is exhibiting
signs and symptoms of laryngotracheal bronchitis. The mother should try to
decrease the inflammation in the upper airway by exposing her child to a warm,
steamy environment. The safest method is to steam up the bathroom and stay with
the child. 2: Steam vaporizers work by boiling water. Their use is to be
avoided because they can cause severe burns if the child comes in close contact
with the steam or if the vaporizer spills. 3: A decongestant may assist in
decreasing the rhinorrhea (runny nose) but it will not decrease the
inflammation in the upper airway. 4: Laryngotracheal bronchitis is caused by a
virus. Aspirin is contraindicated in children with viral infection because this
combination is implicated in Reye's syndrome.
33. Answer: B
The advanced cardiac life support nurse would place one gel pad to the right of
the sternum just below the clavicle and the other gel pad to the left of the
precordium. The nurse then would place the electrode paddles over the pads. Options
A, C, and D identify incorrect positions.
34. Answer: A
Following pericardiocentesis, a rise in blood pressure and fall in central
venous pressure are expected. The client usually expresses immediate relief.
Heart sounds are no longer muffled or distant.
35. Answer: D
QUESTION: Should you give the medication? STRATEGY: Determine the outcome of
each answer choice. NEEDED INFO: Digoxin: loading dose 0.5 - 1 mg, maintenance
dose 0.125 - .25 mg. S/S of toxicity: N + V, visual disturbances, bradycardia.
Aldactone: potassium sparing diuretic that antagonizes aldosterone in distal
tubules. Side effect: hyperkalemia. CORRECT ANSWER: (4) loading dose (1)
inappropriate (2) not necessary (3) never change dose
36. Answer: A
Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60
to 100 beats per minute. The PR and QRS measurements are normal, measuring 0.12
to 0.20 second and 0.04 to 0.10 second, respectively.
37. Answer: D
Typical discharge activity instructions for the first 6 weeks include
instructing the client to lift nothing heavier than 5 lb, not to drive, and to
avoid any activities that cause straining. The nurse teaches the client to use
the arms for balance, but not weight support, to avoid the effects of
straining. These limitations are to allow for sternal healing, which takes
about 6 weeks.
38. Answer: D
Usually CVP ranges from 4 to 10 cm H20 or 3 to 7 mm Hg. The other
options are outside this range.
39. Answer: C
COPD causes pulmonary hypertension, leading to right ventricular failure or cor
pulmonale. The resultant venous congestion causes dependent edema. A weight
gain may further stress the respiratory system and worsen the client's
condition. He should eat a low-sodium diet to avoid fluid retention and should
engage in moderate exercise to avoid muscle atrophy.
40. Answer: D
(4)The basic physiological defect caused by anemia is a decrease in the
oxygen-carrying capacity of the blood and, consequently, a reduction in the
amount of oxygen available to the cell! When the anemia develops slowly, the
child usually adapts to the declining hemoglobin l~ in his/her body and can
function quite well. When the hemoglobin level falls sufficiently low to
produce clinical manifestations, the symptoms that result are due to tissue
hypoxia. Manifestations include pallor and muscle weakness, and the child
becomes fatigued easily. Central nervous system manifestations include
headache, light-headedness, dizziness, irritability, slowed thought processes,
decreased attention span, apathy and depression. (1)Abdominal pain and vomiting
are not manifestations associated with iron deficiency anemia in a chil (2)Poor
posture and unclear speech are not characteristic of a child with iron
deficiency anemia. (3)Bradycardia is not seen in a child with a low hemoglobin
level. Usually the child is tachycardic and has an increased cardiac output to
compensate for the low hemoglobin level. Dyspnea on exertion is possible
because of the decreased oxygen-carrying capacity of the blood.
41. Answer: C
3: Rheumatic fever is an inflammatory collagen disease that typically follows
an infection by group A beta-hemolytic streptococci, ordinarily occurring in
the throat. Rheumatic fever generally follows infection with streptococci
within about 2 weeks. It is believed that the disease involves an autoimmune or
allergic response to the organism. 1: Rheumatic fever typically follows an
infection by group A beta-hemolytic streptococci, ordinarily occurring in the
throat. Infection with measles, a virus, does not predispose the child to
develop rheumatic fever. 2: Rheumatic fever typically follows an infection by
group A beta-hemolytic streptococci, ordinarily occurring in the throat.
Infection with mumps, a virus, does not predispose the child to develop
rheumatic fever. 4: Rheumatic fever typically follows an infection by group A
beta-hemolytic streptococci, ordinarily occurring in the throat. Infection with
influenza virus does not predispose the child to develop rheumatic fever.
42. Answer: D
D","This is not essential to the accomplishment of the procedure.
","The child should have had the local anesthetic applied before the
procedure. ","This will not guarantee that the child will keep still
during the procedure. ","Movement by the child will impede the procedure
and may cause additional injuries to the surrounding structures. "
43. Answer: B
The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL
for females. A critical value is one that is less than 100 mg/dL. With
disseminated intravascular coagulation the fibrinogen level drops because
fibrinogen is used up in the clotting process. Option 2 is the only option that
identifies a normal level for a female client.
44. Answer: D
4: The characteristic of anginal pain that helps differentiate it from the pain
of a heart attack is that anginal pain is transient and usually alleviated by
resting or lying down. In unstable angina, however, there is increasing
frequency, intensity, or duration of pain. 1: Anginal pain is not always less
severe than that of an MI. 2: Anginal pain may radiate down the arm or into the
jaw. 3: Anginal pain may be relieved with rest, while the pain related to an MI
is not.
45. Answer: B
Foods that are lower in sodium include fruits and vegetables (option B),
because they do not contain physiological saline. Highly processed or refined
foods (option A and C) are higher in sodium unless their food labels
specifically state “low sodium.” Saltwater fish and shellfish are high in
sodium.
46. Answer: A
The client with uncontrolled atrial fibrillation and a ventricular rate of more
than 100 beats per minute is at risk for low cardiac output because of loss of
atrial kick. The nurse assesses the client for palpitations, chest pain or
discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope,
shortness of breath, and distended neck veins.
47. Answer: D
4: Coldness is the assessment finding most consistent with complete arterial
obstruction. Other expected findings would include paralysis and pallor. 1:
Aching pain, an earlier sign of tissue hypoxia and ischemia, is associated with
incomplete obstruction. 2: Burning sensations are earlier signs of tissue
hypoxia and ischemia and are associated with incomplete obstruction. 3:
Numbness and tingling, which are earlier signs of tissue hypoxia and ischemia,
are associated with incomplete obstruction.
48. Answer: A
Iron is necessary for hemoglobin (HB) synthesis. HB is responsible for oxygen
transport in the body. Iron deficiency anemia causes subnormal HB levels, which
impair tissue oxygenation and bring about a nursing diagnosis of Impaired
gas exchange. Iron deficiency anemia doesn't cause fluid volume deficit and
is less directly related to ineffective airway clearance and impaired breathing
pattern than it is to ineffective gas exchange.
49. Answer: A
The normal left atrial pressure is 1 to 10 mm Hg. Because the left atrium does
not generate significant pressure during atrial contraction, the atrial
pressure as an average (mean) pressure rather than as a systolic or diastolic
pressure. Options 2, 3, and 4 are incorrect.
50. Answer: B
The client commonly is fatigued following the cardiac catheterization
procedure. Other preprocedure teaching points include that the procedure is
done in a darkened cardiac catheterization room. A local anesthetic is used so
there is little to no pain with catheter insertion. General anesthesia is not
used. The x-ray table is hard and may be tilted periodically, and the procedure
may take 1 to 2 hours. The client may feel various sensations with the
catheterization.
51. Answer: A
The symptoms of hyperkalemia relate to its effect on the myocardial muscle.
These include changes noted on the electrocardiogram, such as tall, peaked T
waves; prolonged PR interval; and widening of the QRS complex. Other cardiac
symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST
segment depression is noted in hyperkalemia.
52. Answer: C
3: Feeding methods should produce the least tension possible on the sutures to
promote effective healing of the cleft lip repair. Therefore, a rubber-tipped
medicine dropper has been found to be a satisfactory method for feeding an
infant who has had surgical repair of a cleft lip. 1: Ordinarily, gastric
gavage is not used unless the infant develops respiratory problems. 2:
Intravenous fluids do not supply complete nutrition for the infant; therefore,
they would not be used as a feeding method. 4: A lamb's nipple may be
successful for feeding a child with a cleft palate once the lip is healed;
however, the action of making a seal around the nipple would put tension on the
suture line.
53. Answer: D
4: People with heart failure are taught to maintain a target weight and to
weigh themselves daily to monitor increasing fluid retention. Fluid retention
can lead to decompensation and hospitalization. 1: Monitoring daily urine
output is not required of these clients. 2: A week of bed rest is not indicated
for most people with heart failure. 3: Clients on potassium-wasting diuretics
will be taught to include dietary sources of potassium or to take a potassium
supplement. However, all clients with heart failure should weigh themselves
daily to monitor fluid status.
54. Answer: C
The therapeutic range for prothrombin time is 1.5 to 2 times control for
clients at high risk for thrombus. Based on the client’s control value, the
therapeutic range for this individual would be 16.5 to 22 seconds. Therefore
the result is within the therapeutic range.
55. Answer: B
Giving acetaminophen is helpful but will not ease difficult breathing. | For
the child with croup who is coughing and having difficulty breathing, the child
should be taken into the shower where hot water is running to make the bathroom
steamy. Steam helps to loosen secretion and relieve some of the respiratory
distress. | Giving over-the-counter cough syrup is inappropriate because the
underlying problem is airway inflammation and subsequent mucus accumulation and
bronchoconstriction. | Getting the child to take as much fluid as possible is
important but it will not be effective in easing difficult breathing.
56. Answer: B
When given to treat acute MI, morphine sulfate eliminates pain, reduces venous
return to the heart, reduces vascular resistance, reduces myocardial workload,
and reduces the oxygen demand of the heart. Morphine sulfate doesn't increase
myocardial contractility, raise blood pressure, or increase venous return.
57. Answer: A
1: Based on the report of the child’s signs and symptoms, the nurse would
suspect otitis media. On assessment, the tympanic membrane would appear bulging
and bright red (because of increased middle ear pressure), typically indicative
of otitis media. Other characteristic findings include rhinorrhea, fever,
cough, irritability, pulling at the ears, earache, vomiting, and diarrhea. A
reddened, nonbulging tympanic membrane may indicate otitis media if the
membrane has ruptured. 2: A clear, inverted membrane may indicate a blockage of
the eustachian tubes. 3: A pearly gray tympanic membrane is normal. 4: A
scarred tympanic membrane indicates that the membrane has burst due to
pressure, but this condition would have occurred earlier if scar tissue has
formed.
58. Answer: A
Preload is the volume in the left ventricle at the end of diastole. It's also
referred to as end-diastolic volume. Preload is reduced by any condition that
reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis.
Hemorrhage reduces circulating volume by loss of volume from the intravascular
space. Sepsis and anaphylaxis reduce circulating volume by increased capillary
permeability. Diuresis, vasodilation, and third spacing also reduce preload.
Preload would increase with fluid overload and heart failure.
59. Answer: A
As a response to shock, the renin-angiotensin-aldosterone system alters renal
function by decreasing urine output and increasing reabsorption of sodium and
water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone
system in an effort to conserve circulating volume.
60. Answer: A
1: PTCA is best described as insertion of a balloon-tipped catheter into the
coronary artery to compress a plaque, thereby opening a stenosed or blocked
artery. 2: This is a description of an atherectomy. 3: This only describes a
cardiac catheterization. 4: Inserting grafts to divert blood from blocked
arteries describes coronary artery bypass graft surgery.
61. Answer: D
4: Propranolol hydrochloride is a β-adrenergic blocking agent used to treat
hypertension. In addition to lowering blood pressure by blocking sympathetic
nervous system stimulation, the drug lowers the heart rate. Therefore, the
client should be assessed for bradycardia and other dysrhythmias. 1: The client
needs to be instructed not to discontinue medication because sudden
withdrawal of propranolol hydrochloride may cause rebound hypertension. 2:
Propranolol dosage is not typically adjusted based on weekly blood pressure
readings. 3: Measurement of partial thromboplastin time values is not a factor
in treatment of hypertension.
62. Answer: B
B","This does not occur in celiac disease. ","Celiac
disease is a primary defect in which the intestinal mucosal transport system is
impaired; the inability to digest gliadin results in an accumulation of
glutamine, which is toxic to mucosal cells and causes atrophy of the villi.
","This does not occur in celiac disease. ","The pancreatic
acini degenerate in cystic fibrosis. "
63. Answer: B
Nitroglycerin dilates arteries and veins, causing peripheral blood pooling and
thus reducing preload, after load and myocardial work. The dilation also
accounts for the primary side effect of nitroglycerin, which is hypotension. In
the absence of continuous direct arterial pressure (intraarterial) monitoring,
the nurse should use an automatic noninvasive blood pressure monitor. Options
A, C, and D are not associated specifically with the administration of nitroglycerin
intravenously.
64. Answer: C
3: A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age.
Increased heart rate is an early indication of ensuing septic shock. 1:
Although the temperature is slightly elevated, it is not an indication of
shock. A low axillary temperature may indicate the peripheral blood supply
shutdown that occurs early in shock. 2: A blood pressure of 45/25 mm Hg is
normal for a neonate. 4: The neonate's respiratory rate is within normal limits
for age.
65. Answer: B
The client should be instructed to avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn, cause skin irritation and
breakdown. Both cotton and cornstarch absorb perspiration. The client should be
instructed to cut toenails straight across with nail clippers.
66. Answer: C
The infant does not have a physiologic or psychological advantage related to
surgery when compared with older children. | Infants, like any other child or
adult, experience stress and fear when having surgery. | Inguinal hernia repair
is ordinarily done promptly after diagnosis in healthy infants and children.
Delaying surgery may result in a possible partial obstruction due to a loop of
bowel protruding into the inguinal canal. Serious progression with complete
obstruction and perhaps strangulation of the bowel requires emergency surgery
to prevent gangrene, which could be fatal. | Although performing surgery around
the genitals before the preschool years is recommended, the best reason for
performing this surgery now would be to avoid having to perform emergency surgery
later.
67. Answer: A
The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to
11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2 times greater
than the client’s control level. Because the value of 30 seconds is high (and
perhaps near the critical range), the nurse should anticipate that the client
would not receive further doses at this time.
68. Answer: B
Morphine sulfate is a narcotic analgesic that may be administered to relieve
pain in a client with myocardial infarction. Although monitoring mental status
is a component of the nurse’s assessment, it is not the priority following
administration of morphine sulfate. The nurse would monitor the client’s
respirations and blood pressure. Signs of morphine toxicity include respiratory
depression and hypotension. Apical pulse rate is unrelated to the
administration of this medication. Monitoring the temperature also is not
associated with the use of this medication.
69. Answer: C
Fruits and vegetables tend to be lower in fat because they do not come from
animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat
food.
70. Answer: D
In the client with a venous disorder, the legs are elevated above the level of
the heart assist with the return of venous blood to the heart. Option B
provides an infrequent time period and is not the priority. Alcohol is
irritating and drying to tissues and should not be used in areas of skin
breakdown.
71. Answer: C
QUESTION: How would you know a patient with CHF was improving after receiving a
diuretic? STRATEGY: Think about the answer choices and how they relate to CHF.
CORRECT ANSWER: (3) reason for diuretics; crackles/rales: movement of air over
fluid; diuretic reduces edema and pulmonary venous pressure (1) should decrease,
no change in CHF (2) could be due to other causes (4) will increase but may not
change CHF
72. Answer: A
Medication-specific teaching points for quinidine sulfate include to take the
medication exactly as prescribed; not to chew the sustained-release tablets; to
take with food if stomach is upset occurs; to wear a Medic Alert bracelet or
tag; and to have periodic checks of heart rhythm and blood counts. The client
should not stop taking a prescribed medication unless specifically ordered by
the physician.
73. Answer: D
The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.4
ng/mL exceeds the therapeutic range and could be toxic to the client. The most
important action is notify the physician, who may give further orders about
holding further doses of digoxin. Option A is incorrect because the value is
not normal. The next dose should not be administered because the serum digoxin
level exceeds the therapeutic range. Checking the client’s last pulse rate is
not incorrect but may have limited value in this situation. Depending on the time
that has elapsed since the last assessment, a current assessment of the
client’s status may be more useful.
74. Answer: C
Chest pain that is unrelieved by rest and three doses of nitroglycerin
administered 5 minutes apart may not be typical anginal pain but may signal
myocardial infarction. Because the risk of sudden cardiac death is greater in
the first 24 hours after myocardial infarction, it is imperative that the
client receive emergency cardiac care. A physician’s office is not equipped to
treat myocardial infarction. Communication with the family or home care agency
delays client treatment, which is needed immediately.
75. Answer: D
D","Alcohol sponge baths are never used with children; the temperature
may be decreased too quickly and this may shock the child; in addition, a fever
of 101 degree F is not high enough for sponge bathing. ","There is no
inoculation against Reye's syndrome. ","The child's metabolism is
increased during illness; the child should have a high-caloric intake.
","Reye's syndrome is associated with viral infections, such as
influenza or varicella, and commonly follows the ingestion of aspirin during
the prodromal stage of these diseases. "
76. Answer: A
Overflow incontinence with constant dribbling is common in neonates with
myelomeningocele. Applying gentle pressure to the suprapubic area helps empty
the neonate's bladder, thus preventing urinary tract infections. | Intermittent
clean catheterization is an appropriate technique for management of urinary
retention in older infants or when a urine specimen is urgently needed. |
Inserting an indwelling urinary catheter is done most frequently when the
neonate is unable to void. | Collecting a urine specimen provides urine for
analysis but will do nothing to aid in relieving overflow incontinence.
77. Answer: B
No evidence is presented to indicate that altered nutrition is the problem. In
fact the mother reports that the child is taking the prescribed amounts of
formula. The weight gain is due to the fluid overload. | The child is
exhibiting characteristics of fluid volume excess related to congestive heart
failure. These include decreased output, diaphoresis, weight gain, and
crackles. The congestive heart failure is related to left to right shunting
that occurs when the child has a large ventral septal defect. | The child’s
digoxin level is within normal limits. Additionally, there is no evidence to
suggest any risk for injury. | Although the child’s output is decreased, the
weight gain is related to fluid overload systemically, not urinary retention.
78. Answer: C
3: The goal is to decrease the bleeding. This can be aided by decreasing
circulation to the area. Elevating the part and applying cold decreases
circulation to the area. The child will also receive cryoprecipitate. 1:
Aspirin is contraindicated for clients who have bleeding disorders because it
increases capillary fragility. 2: The dependent position will increase bleeding
and swelling. 4: Lack of clotting factors, not lack of platelets, is the
problem in children with hemophilia.
79. Answer: D
Raising the infant's head would not ease the respiratory effort. The mouth
needs to be opened. | Turning the infant onto the abdomen would not ease the
respiratory effort. The mouth needs to be opened. | Oxygen is not necessary if
opening the airway is successful. In any case, using a mask over the child's
face may aggravate the problem and could potentially damage the suture line. |
After the repair of a cleft lip, the infant must become accustomed to nasal
breathing. If the infant is having difficulty breathing, it would be best to
open the mouth by exerting downward pressure on the chin. In some instances, an
airway is used postoperatively; when there is no airway in place, it is best to
try pressure on the chin first.
80. Answer: B
B","A positive, not a negative, C-reactive protein would be present;
this is indicative of an inflammatory process. ","A positive
antistreptolysin titer is present with rheumatic fever because of previous
infection with streptococci. ","This is usually related to a decrease
in mature RBCs caused by hemorrhage or other blood diseases; it is unrelated to
an infectious or inflammatory process. ","The ESR would be elevated,
not decreased, indicating the presence of an inflammatory process. "
81. Answer: A
1: Infants who have failure to thrive often are fussy during feedings. This
fussiness maybe related to the caretaker not recognizing cues about what the
infant needs or wants. 2: Typically infants with failure to thrive are unafraid
of strangers. This lack of fear would be abnormal for a 5-month-old. 3:
Although they protest being put down, infants with failure to thrive often are
not content while being held because they are not used to it. 4: Infants with
failure to thrive often have difficulty sleeping for any length of time. They
often awaken owing to hunger.
82. Answer: D
The left coronary artery divides into the anterior descending and the
circumflex artery providing blood for the left atrium and left ventricle. The
right coronary artery supplies the right atrium and right ventricle. Options A,
B, and C are correct.
83. Answer: C
(3) Pulmonary edema is common in patients with patent ductus arteriosus (PDA).
Both pul¬monary edema and cardiomegaly are seen on x-ray due to shunting of
blood across the PDA. Patent ductus arteriosus is common in preterm infants.
(1) Mitral valve prolapse is an uncommon finding in the newborn. (2)
Inflammation of the pericardium is usually caused by infection and is not
related to fetal circulation. (4) Bacterial endocarditis is an associated
complication of valve replacement surgery in children with congenital heart
defects (i.e., tetralogy of Fallot).
84. Answer: B
Motion artifacts, or “noise”, can be caused by frequent client movement,
electrode placement on limbs, and insufficient adhesion to the skin, such as
placing electrodes over hairy areas of the skin. Electrode placement over bony
prominences also should be avoided. Signal interference also can occur with
electrode removal and cable disconnection.
85. Answer: B
Digoxin exerts a positive inotropic effect on the heart while slowing the overall
rate through a variety of mechanisms. Digoxin is the medication of choice to
treat heart failure. Diltiazem (calcium channel blockage) and propranolol and
metoprolol (β-adrenergic blockers) have a negative inotropic effect and would
worsen the failing heart.
86. Answer: A
1: The blood sample for routine screening for phenylketonuria, done after the
neonate has been eating for 48 hours, is obtained from a heel stick. The
lateral heel is the best site because it prevents damage to the posterior
tibial nerve and artery, plantar artery, and the important longitudinally
oriented fat pad of the heel. 2: The radial artery is an inappropriate site to
obtain the blood sample because of the risk for severe trauma. 3: The scalp
vein is used for intravenous infusions, not to obtain a blood sample for PKU.
4: The brachial artery is not an appropriate site for obtaining a PKU blood
sample because the artery is too small and severe trauma may result.
87. Answer: A
A","This is done because any attempt by the infant to maintain
temperature further compromises physical status by increasing metabolic
activity and O2 demands. ","Increased activity will increase oxygen
demands. ","This is not accurate; the O2 percentage will vary with
PO2 values of the infant. ","Increased activity will increase oxygen
demands. "
88. Answer: A
1: Before administering the medication, the nurse needs to evaluate the
possibility of digitalis toxicity. A sign of digitalis toxicity is atrial
fibrillation, sometimes with a heart rate of more than 100 bpm. The appropriate
action by the nurse is to evaluate the cardiac rhythm of the client. 2:
Tachycardia can be a sign of digitalis toxicity. The nurse should evaluate
further before administering digoxin. 3: The nurse needs to further evaluate
the client's cardiac rhythm before determining any intervention. 4: The
cardiac rhythm is a higher assessment priority than the client's respiratory
rate.
89. Answer: A
When a client has congestive heart failure, the goal is to reduce fluid
accumulation. One way to accomplish this is sodium reduction. Ham, cheese (and
most cold cuts), and potato chips are high in sodium. Daily weight measurement
is an appropriate intervention to help the client monitor fluid overload. Most
fresh fruits and vegetables are low in sodium.
90. Answer: D
Fluid surrounding the heart such as in cardiac tamponade, suppresses the
amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and
amplitude increase aren't expected on the ECG of an individual with cardiac
tamponade.
91. Answer: C
3: Hypokalemia is suspected when the T wave on an ECG tracing is depressed or
flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia.
1: This would have no significance in diagnosing a potassium deficit. 2: This
would have no significance in diagnosing a potassium deficit. 4: This would
have no significance in diagnosing a potassium deficit.
92. Answer: C
Stable angina is induced by exercise and relieved by rest or nitroglycerin
tablets. Unstable angina occurs at lower and lower levels of activity or at
rest, is less predictable, and is often a precursor of myocardial infarction.
Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at
the same time each day, most often in the morning.
93. Answer: D
D","This would be difficult to determine accurately; it is far more
important to assess the infant for signs of dehydration and metabolic
alkalosis. ","These are not indicators of immediate needs; assessment
for signs of dehydration and metabolic alkalosis are more important.
","Although this might help to confirm the diagnosis, the most
important concern at this time is to assess for dehydration and metabolic
alkalosis. ","When a baby has scanty dark urine, poor skin turgor,
and increased depth of respirations, it is likely that dehydration and
metabolic alkalosis are present; these occur because of the fluid and
hydrochloric acid loss and the potassium depletion; immediate intervention is
necessary. "
94. Answer: C
Furosemide is a non-potassium-sparing diuretic, and insufficient replacement of
potassium may lead to hypokalemia. Although the glucose, sodium, and magnesium
levels may be monitored, these laboratory values are not specific to
administering furosemide.
95. Answer: C
The client with thrombophlebitis, also known as deep vein thrombosis, exhibits
redness and warmth of the affected leg, tenderness at the site, possible
dilated veins (if superficial), low-grade fever, edema distal to the
obstruction, positive Homans’ sign, and increased calf circumference in the
affected extremity. Pedal pulses are unchanged from baseline because this is a
venous, not arterial, problem. Often clients silently develop thrombophlebitis;
that is, they do not have any signs and symptoms unless they experience
pulmonary embolism as a complication.
96. Answer: B
Ventricular tachycardia is characterized by the absence of P waves, wide QRS
complexes (usually greater than 0.14 second), and a rate between 100 and 250
impulses per minute. The rhythm is usually regular.
97. Answer: C
Fast-line treatment of ventricular tachycardia in a client who is
hemodynamically stable is the use of an antidysrhythmic such as amiodarone
(Cordarone), lidocaine (Xylocaine), and Procainamide (Pronestyl). Cardioversion
also may be needed to correct the rhythm (cardioversion is recommended for
stable ventricular tachycardia). Defibrillation is used with pulseless
ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle
and is contraindicated.
98. Answer: A
In the postoperative period, intake and output are carefully monitored to
prevent fluid overload that could lead to increased intracranial pressure. |
Feedings will be started when the infant is fully awake. | The infant will need
to be disturbed to check vital signs and be repositioned. | Age-appropriate
activities are important but not until the infant is awake and less fussy.
99. Answer: D
Each of the options indicates a positive outcome on the part of the client.
However, option A most likely would indicate progress if the client had a
nursing diagnosis of Imbalanced Nutrition. Option B would be a satisfactory
outcome for Disturbed Sleep Pattern. Options C and D relate to the nursing
diagnosis of Activity Intolerance. However, the question asks about progress.
Option D is more action oriented and is therefore the better choice.
100. Answer: C
Preoperative and postoperative pictures of babies with cleft palates and
lips provide clear and concrete images of what to expect after corrective
surgery. Providing these pictures is specific to the parents' behavior because
the parents reflect societal values that emphasize an infant's facial appearance
and responsive expressiveness.
A: Encouraging the parents to visit more often may make them believe they are currently not visiting enough and could cause unwarranted guilt. There is no evidence they will not visit frequently.
B: Although reassuring the parents that the defect can be corrected may be helpful, showing the parents pictures of infants before and after surgical correction provides them with objective evidence of what to expect.
D: Allowing the completion of the grieving process before another interaction between the infant and parents could result in a separation for months.
For practice test please click the link below:
http://ilovenurselouie.blogspot.com/2014/08/practice-test-questions.html
A: Encouraging the parents to visit more often may make them believe they are currently not visiting enough and could cause unwarranted guilt. There is no evidence they will not visit frequently.
B: Although reassuring the parents that the defect can be corrected may be helpful, showing the parents pictures of infants before and after surgical correction provides them with objective evidence of what to expect.
D: Allowing the completion of the grieving process before another interaction between the infant and parents could result in a separation for months.
For practice test please click the link below:
http://ilovenurselouie.blogspot.com/2014/08/practice-test-questions.html
