1. After obtaining 3 L of fluid from a client via parecentesis, the nurse would be alert for which complication? a.

Respiratory distress b. Bleeding from the site c. Encephalopathy d. Vascular collapse Rationale: The removal of large amount of fluid, such as 2-3 L, via paracentesis may lead to acute fluid shifting and hypotension, subsequently leading to vascular collapse. 2. Open glove method is preferred to use except: a. In the emergency department when donning sterile gloves for suturing lacerations b. Intravenous cutdown or administering of spinal anesthesia c. Changing a glove during an operation d. When donning gloves for procedures requiring gown Rationale: Open glove technique is used when only sterile gloves are worn, as far intravenous cutdown or administering of spinal anesthesia, or in the emergency department when donning sterile gloves for suturing lacerations. It is also for changing a glove during an operation and for procedures not requiring gown. 3. Correction of a drooping upper eyelid: a. Excision of chalazion b. Blepharaptosis repair c. Correction of entropion d. Canthotomy Rationale: Blepharaptosis repair is the Correction of a drooping upper eyelid. Correction of Entropion is the correction of an eversion and drooping of the lower eyelid. Canthotomy is the incision of the canthus. Exicision of the chalazion is the incision and curettage if a granulomatous swelling of the meibomian glands. 4. 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. Temporary atony may result from surgical manipulation in the area b. The bladder is removed along with the uterus c. Infection from surgery interferes with the clients ability to void d. Surgically induced menopause impairs the client urinary function Rationale: With a hysterectomy, the area around the bladder typically undergoes surgical manipulation. This causes edema and nerve trauma, possibly leading to temporary atony. Therefore if the client cannot void within 8 hours, urinary catheterization is performed to prevent urinary retention. 5. A client arrives at the clinic for a routine physical examination. During the examination, the nurse performs as otoscopic examination. Which finding would nurse expect as normal? a. Pale optic disk b. Pearly gray tympanic membrane c. Tactile fremitus d. Positive red reflex Rationale: An otoscopic examination uses an otoscope to inspect the external canal and middle ear, specifically the tympanic membrane and its landmarks. Normally, the tympanic membrane appears pearly gray ad intact. A pale optic disk is an abnormal fining during an ophthalmoscopic examination of the eyes. A positive red reflex is a normal finding with an ophthalmoscopic examination, not an otoscopic examination.

Tactile frmitus is an abnormal finding when the chest is palpated. 6. Following a bee sting a client who develops shortness of breath and hives on his face and neck receives an epinephrine injection. Which assessment data would indicate that the epinephrine is effective? a. Increased itching b. Drowsiness c. Easier breathing d. Reduced pain at the sting site Rationale: The client is exhibiting allergi reaction to the beesting. Epinephrine acts as a bronchodilator to ease the clients breathing. It has no effect on pain and will not cause drowsiness or increase itching. 7. 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. Leukocytosis b. Hyperkalemia c. Hypernatremia d. Thrombocytopenia Rationale: The clients serum potassium level is above the normal range of 3.5 to 5.5 mEq/L. indicating hyperkalemia. 8. It is the resection of the half of the colon and a segment of the terminal ileum and their mesenteries. a. Ileostomy b. Hemicolectomy c. Transverse colectomy d. Colostomy Rationale: Hemicolectomy is the resection of the half of the colon and a segment of the terminal ileum and their mesenteries. Colostomy is the formation of a permanent or temporary opening into the colon brought out onto the abdominal wall as a stoma. Transverse colectomy is the resection of a segment of the transverse colon with an end-toend anastomosis to reestablish continuity of the colon. 9. Which instruction is most important to provide when discharging a client from the emergency department following penetrating foot injury? a. Call the health care provider at the first signs of any red streaks appearing on the foot or leg b. Watch for signs and symptoms of anaphylaxis from the tetanus toxoid c. Avoid smoking until the entire wound is no longer open to the air d. Refrain from crossing the legs at the knee or ankle Rationale: The appearance of red streaks indicates lymphadenitis and evidence of spreading infection. The client should call the health care provider because further treatment is necessary. Not crossing the legs will aid in venous return but foot edema is not a serious threat to health as a spreading infection. Avoiding smoking is always an important health consideration. However, their effect is not an immediate as those of the spreading infection. Signs and symptoms of anaphylactic shock would most likely occur immediately after the administration of tetanus toxoid while the client is still in the health care facility. 10. Following a thyroidectomy, the client experiences hemorrhage. The nurse would prepare for which emergency intervention? a. I.V administration of thyroid hormone

b. Creation of a tracheostomy c. Insertion of an oral airway d.I.V administration of calcium Rationale: Following a thyroidectomy, postoperative hemorrhage may cause compression of the trachea, necessitating an emergency tracheostomy to maintain airway patency. Calcium and thyroid hormones may be administered postoperatively, but these agents are unrelated to hemorrhage. Insertion of an oral airway would be ineffective in maintaining airway patency because the compression from the hemorrhage is below the airway insertion site. 11. Which intervention must be implemented first during the initial assessment of a client with major burn injury? a. Inserting a nasogastric tube b. Treating for burn shock c. Ensuring a patent airway d. Eliminating the source of the burn Rationale: Before any other action can be taken, the source of the burn injury must be eliminated. The airway patency is ensured, any associated injuries are assessed, and then burn shock is treated. 12. Prior the operation the nurse checks the client receiving warfarin sodium, an anticoagulant, has a prothrombin time of 22 and a partial thromboplastin time of 39. The control values are PT 12.9; and PTT 37. The International Normalized Ratio (INR) is 2.8. Which nursing intervention would be most appropriate? a. Notifying the health care provider immediately b. Administering the medication as ordered c. Holding the medication and assessing for bleeding d. Preparing to administer protamine sulfate Rationale: When a client is receiving warfarin, the PT value should be 1.5 to 2 times the control value. The INR should be between 2 to 3. The clients INR value is therapeutic, so the medication should be administered as ordered. 13. 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. Notifying the health care provider that the stoma is pink c. Assessing the abdominal incision d. Assessing the clients blood pressure and pulse e. Medicating the client as ordered Rationale: The nurse should rule out surgical complications, such as hemorrhage, by assessing the clients blood pressure and pulse. The nurse also should medicate the client immediately because the client is only 4 hours postoperative. The client will not have an abdominal incision with the surgery (rectal dressing). The nurse would be concerned if the stoma is purple not pink. The clients need medication not distraction at 4 hours postoperative. Sitting on the side of the bed will not help the clients pain. 14. Which intervention should the nurse implement first when beginning preoperative teaching? a. Assessing the clients knowledge base related to the surgical procedure b.Describing the possible risks of the surgical procedure c. Having the client read the printed instructional booklet

d. Using a standardized preoperative teaching plan for consistency Rationale: Before beginning any teaching program; the nurse must first assess the clients knowledge base. Doing so allows the nurse to identify the clients teaching needs, avoid repetition of areas the client is already familiar with, and identify or correct in misconceptions or misinformation that the client might have. 15. Which topic would be most important to include in the postoperative teaching for the client scheduled for a vaginal hysterectomy? a. Lower-extremity exercises and deep breathing b. Pelvic muscle strengthening exercises c. Use of a bedpan and call light d. Availability of support persons Rationale: Use of lithotomy position for a vaginal hysterectomy predisposes the client to DVT. Additionally, atelectasis from surgery may also occur. Thus, the client needs instructions on lower extremity exercises to minimize the risk of DVT. She also needs deep breathing exercises to prevent atelectasis.