1.

Which statement best explains the scientific rationale for performing urinary catheterization on a client following an abdominal hysterectomy if she is unable to void within 8 hours? A The bladder is removed along with the uterus B Infection from surgery interferes with the clients ability to void C Surgically induced menopause impairs the client urinary function D Temporary atony may result from surgical manipulation in the area 2. A client is 4 hours postoperative abdomino-peritoneal resection with sigmoid colostomy. He is complaining of rectal pain that ranks 8 on a scale of 1 to 10. Which interventions should he nurse implement? (select all that apply) A Assisting the client with distraction to help the pain B Assessing the abdominal incision C Assessing the clients blood pressure and pulse D Notifying the health care provider that the stoma is pink E Medicating the client as ordered 3. An adult client has the following laboratory results: white blood cells 6,300/ mm3; platelets 250,000 mm3; serum sodium 140 mEq/L; serum potassium 6 mEq/L. which condition is present? A Hypernatremia B Leukocytosis C Hyperkalemia D Thrombocytopenia Situation: Bobby, a 13 year old is being seen in the emergency room for possible appendicitis. 4. An important nursing action to perform when preparing Bobby for an appendectomy is to: a) administer saline enemas to cleanse the bowels b) apply heat to reduce pain c) measure abdominal girth d) continuously monitor pain 5. Which of the following would indicate that Bobby's appendix has ruptured?

a) diaphoresis b) anorexia c) pain at Mc Burney's point d) relief from pain 6. A nurse is making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6 F. The nurse should intervene by: a) administering Tylenol (acetaminophen) for the elevated temperature b) advising the client to increase oral fluids c) asking the client when she last had a bowel movement d) notifying the physician 7. A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a. yellow sclerae. b. light amber urine. c. circumoral pallor. d. black, tarry stools.
Answer A. Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools dont occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

8. During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia? a. vitamin A b. vitamin D c. vitamin E d. vitamin K
Answer D. Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Therefore,

antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria dont synthesize vitamins A, D, or E.

9. A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially? a. Lying on the right side with legs straight b. Lying on the left side with knees bent c. Prone with the torso elevated d. Bent over with hands touching the floor
Answer B. For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldnt allow proper visualization of the large intestine.

10. The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a. Dyspnea and fatigue b. Ascites and orthopnea c. Purpura and petechiae d. Gynecomastia and testicular atrophy
Answer C. A hepatic disorder, such as cirrhosis, may disrupt the livers normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

11. When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

12. To prevent gastroesophageal reflux in a male client with hiatal hernia, the nurse should provide which discharge instruction? a. Lie down after meals to promote digestion. b. Avoid coffee and alcoholic beverages. c. Take antacids with meals. d. Limit fluid intake with meals.
Answer B. To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids arent gastric irritants.

13. Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: a. a sedentary lifestyle and smoking. b. a history of hemorrhoids and smoking. c. alcohol abuse and a history of acute renal failure. d. alcohol abuse and smoking.
Answer D. Risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids arent risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

14. While palpating a female clients right upper quadrant (RUQ), the nurse would expect to find which of the following structures? a. Sigmoid colon b. Appendix c. Spleen d. Liver
Answer D. The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

15. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately? 1. 2. 3. 4. Notify the physician. Apply ice to the affected eye. Irrigate the eye with cool water. Accompany the client to the emergency department.
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Answer:

Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.

16. A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect: a. b. c. d. hair loss. stomatitis. fatigue. vomiting.

Answer C. Radiation therapy may cause fatigue, skin toxicities, and anorexia regardless of the treatment site. Hair loss, stomatitis, and vomiting are sitespecific, not generalized, adverse effects of radiation therapy.

17. Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by: a. b. c. d. breast self-examination. mammography. fine needle aspiration. chest X-ray.

Answer C. Fine needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the most reliable method for detecting breast lumps early. Mammography is used to detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib metastasis.

18. A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy? a. b. c. d. Urine output of 400 ml in 8 hours Serum potassium level of 3.6 mEq/L Blood pressure of 120/64 to 130/72 mm Hg Dry oral mucous membranes and cracked lips

Answer D. Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include dry oral mucous membranes, cracked lips, decreased urine output (less than 40 ml/hour), abnormally low blood pressure, and a serum potassium level below 3.5 mEq/L.

19. Nurse Amy is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: a. b. c. d. perform breast self-examination annually. have a mammogram annually. have a hormonal receptor assay annually. have a physician conduct a clinical examination every 2 years.

Answer B. The American Cancer Society guidelines state, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually [not every 2 years]; all women should perform breast self-examination monthly [not annually]." The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

20. A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that he unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. (Letter A is the first and letter F is the last action.) a) hang the bag of blood b) obtain the unit of blood from the bank c) ensure that an informed consent has been signed d) verify the physician's order for the blood transfusion e) insert an 18 or 19-gauge IV catheter into the client f) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity. 21. Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood: a) b) c) d) Hanging for a longer four hours creates an increased risk of sepsis May clot in the bag May evaporate May not clot in the recipient after this time period

22. The results of an arterial blood gas are as follows: pH: 7.5, PaCO 2: 50, PaO2: 88, HCO3: 28; Base excess: +5. Evaluate the acid-base imbalance. 23. What is the correct universal precaution? (A) Gloves, gown, goggles, and surgical cap surgical caps offer protection to hair but arent required. (B) Sterile gloves, mask, plastic bags, and gown plastic bags provide no direct protection and arent part of universal precautions

(C) Gloves, gown, mask, and goggles CORRECT: must use universal precautions on ALL patients; prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated (D) Double gloves, goggles, mask, and surgical cap surgical cap not required; unnecessary to double glove 24. The client who has a history of gout also is diagnosed with urolithisis and the stones are determined to be of uric acid type. The nurse gives the client instructions in which foods to limit, including: a) milk b) liver c) apples d) carrots 25. The client arrives at the emergency department with complaints of low abdominal pain and hematuria. Theclient is afebrile. The nurse next assesses the client to determine a history of: a) pyelonephritis b) glomerulonephritis c) trauma to the bladder or abdomen d) renal cancer in the client's family