NCLEX-RN Exam 2024/2023 75 Questions & Answers Updated 2024 graded A+, Exams of Nursing

Download NCLEX-RN Exam 2024/2023 75 Questions & Answers Updated 2024 graded A+ and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam 2024/2023 75 Questions & Answers Updated 2024 1. Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation? o A. Altered level of consciousness o B. Exertional Dyspnea o C. Increase creatine phosphokinase concentration o D. Chest pain o o o 2. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is of renal origin, the nurse should assess whether the client has discomfort or pain in the: o A. Urinary meatus o B. Pain in the labium o C. Suprapubic area o D. Right or left costovertebral angle Correct Answer: D. Right or left costovertebral angle Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side. Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present. Discomfort varies from absent to severe. This finding is usually not subtle and may be elicited with mild or moderately firm palpation. o Option A: Pain or discomfort in the urinary meatus can also be indicative of urethritis or acute urinary tract infection. In both men and women, common causes of urethral pain include sexually transmitted diseases (STDs) such as chlamydia, local irritation from soaps or spermicides, and urinary tract infections (UTIs). In men, prostatitis isn’t an uncommon cause, whereas in women, vaginal dryness due to menopause can be an issue. o Option B: Pain in the labium can be due to a swollen labia or vulva. Chronic yeast infections and bacterial infections can both cause pain that ranges from mild discomfort and itching to severe burning or throbbing. Viral and bacterial infections, such as bacterial may also endorse symptoms associated with myocardial ischemia, such as chest pain radiating to the neck, jaw, shoulders, or upper extremities, nausea, and diaphoresis. 5. Smoking cessation is a critical strategy for the client with Buerger’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication? o A. Paracetamol o B. Ibuprofen o C. Nitroglycerin o D. Nicotine (Nicotrol) happen during sleep. After the seizure, the client may feel tired or confused. o Option B: An absence seizure causes the client to blank out or stare into space for a few seconds. They are also called petit mal seizures. Absence seizures are most common in children and typically don’t cause any long-term problems. o Option D: Clonic seizures are characterized by repeated jerking movements of the arms and legs on one or both sides of the body, sometimes with numbness or tingling. If it is a focal (partial) seizure, the client may be aware of what’s happening. During a generalized seizure, the client may be unconscious. Correct Answer: D. Nicotine (Nicotrol) Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome. Nicotine replacement therapy (NRT) is for those who want to quit smoking, as abruptly quitting can cause withdrawals and cravings. Nicotine withdrawal occurs after smoking cigarettes discontinued suddenly. Using NRT helps one to reduce the motivation of smoking cigarettes because the body still gets nicotine from another safer method. o Option A: Paracetamol (acetaminophen) is a pain reliever and a fever reducer. Acetaminophen (APAP) is considered a non-opioid analgesic and antipyretic agent used to treat pain and fever. Clinicians can use it for their patients as a single agent for mild to 6. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by: o A. Episodic vasospastic disorder of capillaries o B. Episodic vasospastic disorder of small veins o C. Episodic vasospastic disorder of the aorta o D. Episodic vasospastic disorder of the small arteries moderate pain and in combination with an opioid analgesic for severe pain. o Option B: Ibuprofen is a nonsteroidal anti- inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. Ibuprofen is used to reduce fever and treat pain or inflammation caused by many conditions such as headache, toothache, back pain, arthritis, menstrual cramps, or minor injury. o Option C: Nitroglycerin belongs to a class of drugs called vasodilators. It works by relaxing the smooth muscle and blood vessels in the body. This increases the amount of blood and oxygen that reaches the heart. In turn, the heart doesn’t work as hard. This reduces chest pain. Correct Answer: D. Episodic vasospastic disorder of the small arteries Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involve fingers and toes. In Raynaud phenomenon, blood-flow restriction occurs during cold temperatures and emotional stress. Specifically, in Raynaud phenomenon, there is vasoconstriction of the digital arteries and cutaneous arterioles. o Option A: Only the arteries are affected in Raynaud’s disease. With cold temperatures, the sympathetic nervous system causes the release of vasoconstricting 7. Nurse Jamie should explain to a male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because: o A. More accurate o B. Can be done by the client o C. It is easy to perform o D. It is not influenced by drugs neuropeptides and norepinephrine leading to vasoconstriction of arteriole smooth muscle and decreased blood flood to the skin. Of note, in secondary Raynaud phenomenon, endothelin-1 is released by endothelial cells which causes vasoconstriction. o Option B: The veins are unaffected by the vasospasm occurring with Raynaud’s disease. In the primary Raynaud phenomenon, an increase in alpha-2 adrenergic sensitivity in the digital and cutaneous vessels results in the vasoconstrictive response to cold temperatures and emotional stress. Alpha-2 adrenergic receptors are present on the distal arterial smooth muscles of the digits and affected by the sympathetic nervous system. o Option C: The aorta is a major blood vessel unaffected by Raynaud’s disease. In the secondary Raynaud phenomenon, the underlying disease is the factor that disrupts normal vessel reactivity to cold temperatures. Usually, the endothelial function of the digital and cutaneous vessels is compromised leading to eventual vasoconstriction with resulting tissue ischemia. Correct Answer: A. More accurate Urine testing provides an indirect measure that may be influenced by kidney function while blood glucose testing is a more direct and accurate measure. Accurate measurement of o B. Diffusion o C. Active transport o D. Filtration Correct Answer: A. Osmosis Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration. In physiology, osmosis (Greek for push) is the net movement of water across a semipermeable membrane. Across this membrane, water will tend to move from an area of high concentration to an area of low concentration. It is important to emphasize that ideal osmosis requires only the movement of pure water across the membrane without any movement of solute particles across the semipermeable membrane. o Option B: Diffusion is the movement of a substance from an area of high concentration to an area of low concentration. Passive transport, most commonly by diffusion, occurs along a concentration gradient from high to low concentration. No energy is necessary for this mode of transport. Examples will include diffusion of gases across alveolar membranes and diffusion of neurotransmitters such as acetylcholine across the synapse or neuromuscular junction. o Option C: Active transport is the process of transferring substances into, out of, and between cells, using energy. Active transport is an energy-driven process where membrane proteins transport molecules across cells, mainly classified as either primary or secondary, based on how energy is coupled to fuel these mechanisms. o Option D: Filtration is a process used to separate solids from liquids or gases using a filter medium that allows the fluid to pass through but not solid. The term “filtration” applies whether the filter is mechanical, biological, or physical. The fluid that passes through the filter is called the filtrate. The filter medium may be a surface filter, which is a solid that traps solid particles, or a depth filter, which is a bed of material that traps the solid. 10. Myrna, a 52-year-old client with a fractured left tibia, has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking? o A. Left leg discomfort o B. Weak biceps brachii o C. Triceps muscle spasm o D. Forearm weakness Correct Answer: D. Forearm weakness Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae. Crutch palsy is observable in axilla crutch users who rest their weight on the shoulder rest. The pressure on the brachial plexus can result in palsy to the radial and ulnar nerves. Extra padding on the shoulder rest can aid in preventing crutch palsy. o Option A: The left leg would be at rest since the fracture is at the left tibia. Crutches are vital in the short-term and long-term management of orthopedic and neurologic injuries. Through offloading body weight to the injured extremity optimal conditions are provided to allow healing of acute injuries. o Option B: All the strength spent in crutch walking falls on the forearms, not the biceps brachii. Crutches provide ambulatory support and mobility options to those with neurologic injuries or chronic orthopedic injuries enabling the individual to stay mobile and active. Crutches are a vital adjunct for those with acute and chronic injuries to maintain mobility and independence. o Option C: The triceps would not be as affected than the forearms after crutch walking The user’s strength and coordination should undergo evaluation before issuing them a set of crutches. The use of the wrong 11. Which of the following statements should the nurse teach the neutropenic client and his family to avoid? o A. Performing oral hygiene after every meal o B. Using suppositories or enemas o C. Performing perineal hygiene after each bowel movement o D. Using a filter mask Correct Answer: B. Using suppositories or enemas Neutropenic clients are at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract. An ly administered enema can damage tissue in your rectum/colon, cause bowel perforation and, if the device is not sterile, infections. o Option A: Performing oral hygiene consistently after meals could help prevent infection of the oral mucous membranes. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes. Hard-bristled toothbrushes can compromise the integrity of the mucous membrane and provide a port of entry for pathogens. o Option C: Proper perineal hygiene helps prevent urinary tract infections. Wash hands or perform hand hygiene before having contact with the patient. Also impart these duties to the patient and their significant others. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. o Option D: Wearing a mask, especially in a crowded place, would help prevent contagious respiratory infections. Provide surgical masks to visitors who are coughing and provide rationale to enforce usage. crutches can lead to injury. Most injuries are a direct result of falling. 14. George, who has undergone thoracic surgery has a chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in the water-seal chamber, the nurse should: o A. “Strip” the chest tube catheter o B. Check the system for air leaks o C. Recognize the system is functioning correctly o D. Decrease the amount of suction pressure o Option B: Assessing hypoventilation through the lungs would provide inadequate results. Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions. o Option D: Oxygen may be maintained after surgery but this might be inadequate. The key is that the client receives oxygenation support at all times until mechanical ventilation is no longer required. 15. A client who has been diagnosed with hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that: o A. I can eat celery sticks and carrots o B. I can eat broiled scallops o C. I can eat shredded wheat cereal o D. I can eat spaghetti on rye bread pressure, which can be injurious (invagination of tissue into catheter eyelets, collapse of tissues around the catheter, and bleeding from rupture of small blood vessels). o Option C: The presence of excessive bubbling is not a normal finding. Observe for abnormal and continuous water-seal chamber bubbling. With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (system- centered). o Option D: Decreasing the amount of suction pressure without any appropriate orders may cause the system to be ineffective. Check suction control chamber for a correct amount of suction (determined by water level, wall or table regulator at correct setting. Water in a sealed chamber serves as a barrier that prevents atmospheric air from entering the pleural space should the suction source be disconnected and aids in evaluating whether the chest drainage system is functioning appropriately. Correct Answer: C. I can eat shredded wheat cereal Wheat cereal has a low sodium content. Sodium controls fluid balance in the body and maintains blood volume and blood pressure. Eating too much sodium may raise blood pressure and cause fluid retention, which could lead to swelling of the legs and feet or other health issues. 16. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulting from ascites. The nurse should be aware that the ascites is most likely the result of increased: o A. Pressure in the portal vein o B. Production of serum albumin o C. Secretion of bile salts o D. Interstitial osmotic pressure o Option A: Celery and carrots are both high in sodium content. With 50 milligrams of sodium in both a large stock of celery and a large carrot, these vegetables provide that familiar savory flavor in soups and stews, without several pinches of salt. o Option B: Seafoods are rich in sodium. According to the American Heart Association, 1,500 mg of sodium per day is the recommended intake. Three ounces of scallops can give about 325 mg of sodium-20% of the recommendation. While most fish runs relatively low on the sodium scale, its ocean brethren can top the natural sodium charts. Shrimp, lobster, crab, and scallops (to name a few) can all contain hundreds of milligrams of sodium per 3-ounce serving o Option D: Rye bread has a high sodium content. Actions of industry in reducing the sodium in the processed food supply are important in the public health effort to lower the sodium of what we eat. Gorton7 gives insight into the dialogue of industrial bakers in lowering the sodium in their products. Salt plays an important role in gluten modification, yeast control, and microbial inhibition in baked products. Correct Answer: A. Pressure in the portal vein Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting in ascites. Portal pressure increases above a critical threshold and circulating nitric o C. Respiratory rate of 4 breath/min o D. Pulse rate less than 60 bpm Correct Answer: A. Systolic blood pressure less than 90mm Hg Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg. The first changes in vital signs seen in hypovolemic shock include an increase in diastolic blood pressure with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. As a result, oxygen delivery to vital organs is unable to meet oxygen demand. o Option B: Unequally dilated pupils refer to anisocoria. Acute onset should be considered an emergency because it may be due to brain mass lesions which cause oculomotor nerve palsy. Anisocoria is a condition characterized by unequal pupil size. The etiology of anisocoria is complex, ranging from benign to potentially life-threatening causes. There are many pathways involved in pupil size. Some potential etiologies of anisocoria include systemic drug use, topical ophthalmic drug use, headaches, and autonomic ganglion pathology. o Option C: This indicates a very low respiratory rate or bradypnea. Tachypnea is seen in clients with class II hemorrhage (loss of 15-30%). Similar to examining pulse pressure variation, measuring respiratory variation in inferior vena cava diameter as a measure of volume responsiveness has only been validated in patients without spontaneous breaths or arrhythmias. o Option D: The cardiovascular system initially responds to hypovolemic shock by increasing the heart rate, increasing myocardial contractility, and constricting peripheral blood vessels. Patients with volume depletion may complain of thirst, muscle cramps, and/or orthostatic hypotension. Severe hypovolemic shock can result in mesenteric and coronary ischemia that can cause abdominal or chest pain. Agitation, lethargy, or confusion may result from brain malperfusion. 19. Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included? o A. Results of the surgery will be immediately noticeable postoperatively o B. Normal saline nose drops will need to be administered preoperatively o C. After surgery, nasal packing will be in place 8 to 10 days o D. Aspirin-containing medications should not be taken 14 days before surgery Correct Answer: D. Aspirin-containing medications should not be taken 14 days before surgery Aspirin-containing medications should not be taken 14 days before surgery to decrease the risk of bleeding. Impaired coagulation may cause postoperative complications. Patients should be asked about a history of excessive bruising or bleeding, consumption of drugs, supplements, or vitamins that alter coagulation cascade or history of thrombotic events in the past. Any drug, vitamins, or supplement that impairs coagulation might have to be suspended preoperatively. o Option A: Results would not be seen immediately, as swelling on the postoperative part will be prominent after surgery. Preoperative photos have to be taken for previous analysis and planning and for medico-legal purposes. Frontal, both profiles, and a basal view are the minimum requirements. They should be taken using a dark background with good lighting settings. o Option B: There is no indication for normal saline nose drops after surgery. Closed rhinoplasty can be performed either with general anesthesia or local anesthesia and sedation, both with similar results in experienced hands.The patient is placed in the supine 20. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem? o A. Regular insulin o B. Potassium o C. Sodium bicarbonate o D. Calcium gluconate position, with a slight reverse Trendelenburg, to minimize bleeding. o Option C: Internal dressings or nasal packings remain in place for 1 to 7 days after the surgery. After mucosal incisions are closed with resorbable sutures, Silastic splints are placed and sutured to each side of the septum in order to provide septal support and enhance mucosal healing. Several strips of paper tape are distributed over the dorsum and a cast over it, which is removed 7 days postoperatively. 23. After gastroscopy, an adaptation that indicates major complication would be: o A. Nausea and vomiting o B. Abdominal distention o C. Increased GI motility o D. Difficulty in swallowing o o o Correct Answer: B. Abdominal distention Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis. Bowel perforation occurs in less than 0.3 % of cases, and infection is rarely reported. Complications typically are identified in the first 24 hours after the procedure. Perforation is identified due to fever, tachycardia, abdominal pain or discomfort. 24. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that: o A. “Most people need to eat a high protein diet for 12 months after surgery” o B. “I should not eat those foods that upset me before the surgery” o C. “I should avoid fatty foods as long as I live” o D. “Most people can tolerate regular diet after this type of surgery” o Option A: It is normal to feel nauseous a day or two after surgery. Complications following esophagogastroduodenoscopy (EGD) are rare, occurring in less than 2% of patients. These could be related to sedation, endoscopy, and complications related to diagnostic or therapeutic maneuvers. o Option C: An increase in GI motility is not a cause for concern. The risk of bleeding following EGD with biopsy is 0.3%. Post mucosal biopsy bleeding can occur as intraluminal hemorrhage or intraluminal hematoma. A duodenal hematoma is a rare complication of EGD with an unknown incidence and seems to occur more often in children than adults. o Option D: There would be difficulty in swallowing after the surgery until the local anesthesia fades. Adverse events from over sedation include hypoxemia, hypoventilation, hypotension, airway obstruction, arrhythmias, and aspiration. The complications following diagnostic EGD include infection, bleeding, duodenal hematoma, and bowel perforation. Correct Answer: D. “Most people can tolerate regular diet after this type of surgery” It may take 4 to 6 months to eat anything, but most people can eat anything they want. Start with clear liquids after the surgery to prevent nausea, vomiting, and constipation, (soup, Jell-O, juices, popsicles, and carbonated beverages.) then advance to a regular low-fat diet. Eat smaller meals more often instead of fewer larger meals. o Option A: A high protein diet is unnecessary. A healthy meal should include small amounts of lean protein. If the patient has diarrhea, he should try avoiding spicy foods, dairy products, fatty foods, and alcohol. If diarrhea continues for more than 2 weeks, he should talk to his doctor. o Option B: High-fat foods should be avoided not only before the surgery, but it should be restricted a week after surgery as well. The patient can eat a normal diet, but avoid eating fatty foods for about one (1) month. Fatty foods include hamburgers, whole milk, cheese, and many snack foods. If the stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt o Option C: Fatty foods, fried and greasy foods, and sauces should be avoided for at least a week after surgery. Eat lots of whole grains, fruits, and green leafy vegetables. Avoid foods that cause constipation such as dairy products, red meat, processed foods such as pizza, frozen dinners, pasta, and sugar products such as cakes, pies, pastries, doughnuts, and drinks containing caffeine. 25. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is: o A. Restlessness o B. Yellow urine o C. Nausea 27. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following: o A. Genetic defect in gastric mucosa o B. Stress o C. Diet high in fat o D. Helicobacter pylori infection Correct Answer: D. Helicobacter pylori infection Most peptic ulcers are caused by Helicobacter pylori which is a gram-negative bacterium. H. pylorus is a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers. H. pylori infection is more prevalent among those with lower socioeconomic status and is commonly acquired during childhood. The organism has a wide spectrum of virulence factors allowing it to adhere to and inflame the gastric mucosa. This results in hypochlorhydria or achlorhydria, leading to gastric ulceration. o Option A: Peptic ulcers are not genetic in nature. They occur when acid in the digestive mucosa eats away at the inner surface of the stomach or small intestine. Peptic ulcer disease (PUD) has various causes; however, Helicobacter pylori-associated PUD and NSAID-associated PUD account for the majority of the disease etiology. o Option B: Stress is not a cause of peptic ulcers. Nonsteroidal anti-inflammatory drugs use is the second most common cause of PUD after H. pylori infection. The secretion of prostaglandin normally protects the gastric mucosa. NSAIDs block prostaglandin synthesis by inhibiting COX-1 enzyme resulting in a decrease in gastric mucus and bicarbonate production and a decrease in mucosal blood flow. o Option C: Common causes of peptic ulcer include a bacteria (H. pylori), regular use of certain pain 28. Ryan has undergone a subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? o A. Bile green o B. Bright red o C. Cloudy white o D. Dark brown relievers, and use of certain medications along with NSAIDs. Apart from NSAIDs, corticosteroids, bisphosphonates, potassium chloride, steroids, and fluorouracil have been implicated in the etiology of PUD. Smoking also appears to play a role in duodenal ulcers, but the correlation is not linear. Alcohol can irritate the gastric mucosa and induce acidity. o o 29. Nurse Joan is assigned to come for a client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the postoperative period. Which of the following is best recommended for the client? o A. Watching circus o B. Bending over o C. Watching TV o D. Lifting objects o Option C: Cloudy white drainage is not expected during the first 12 to 24 hours. Gastric aspirates were most frequently cloudy and green, tan or off-white, or bloody or brown. Intestinal fluids were primarily clear and yellow to bile-colored. In the absence of blood, pleural fluid was usually pale yellow and serous, and tracheobronchial secretions were usually tan or off- white mucus. 32. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptoms? o A. Absence of drainage from the ileostomy for 6 or more hours o B. Passage of liquid stool in the stoma o C. Occasional presence of undigested food o D. A temperature of 37.6 °C o o o Correct Answer: A. Absence of drainage from the ileostomy for 6 or more hours Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed. Sometimes the ileostomy does not function for short periods of time after surgery. This is not usually a problem, but if the stoma is not active for more than 6 hours and the patient experiences cramps or nausea, he may have an obstruction. o Option B: Passage of a moderate amount of stool in the stoma is expected during the first few days after surgery. With no large intestine to absorb as much water from it, stool becomes thinner. Stools may thicken up as the body adapts and the small intestine starts to absorb more water, but this is something that happens long-term. At first, the stool will be thin and output may be high. o Option C: As the body gets used to the stoma and ileostomy, the presence of undigested food every now and then can be normal. However, this piece of food might obstruct the stoma and cause abdominal pain and swelling. Avoid solid foods for the time being and drink plenty of water. o Option D: 37.6ºC is more than the normal range of temperature. Nursing interventions such as a tepid sponge bath may be done to decrease the temperature to the normal range. Pouchitis is when an internal pouch becomes inflamed. It’s a common complication in people with an ileo-anal pouch. 33. Jerry has been diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications? o A. Intestinal obstruction o B. Peritonitis o C. Bowel ischemia o D. Deficient fluid volume Correct Answer: B. Peritonitis Complications of acute appendicitis are peritonitis, perforation and abscess development. Diffuse peritonitis and sepsis can also develop, which may progress to significant morbidity and possible death. Postoperative abscesses, hematomas, and wound complications are all complications that can be seen after appendectomies. If the wound does get infected, one may grow Bacteroides. “Recurrent” appendicitis can occur if too much of the appendiceal stump is left after an appendectomy. o Option A: Signs of intestinal obstruction include crampy abdominal pain, loss of appetite, constipation, vomiting, inability to have a bowel movement or pass gas, and swelling of the abdomen. Complications of appendicitis and appendectomy include surgical site infections, intra-abdominal abscess formation (3% to 4% in open appendectomy and 9% to 24% in laparoscopic appendectomy), prolonged ileus, enterocutaneous fistula, and small bowel obstruction. o Option C: Symptoms of bowel ischemia include sudden abdominal pain, an urgent need to have a bowel movement, frequent, forceful bowel movements, abdominal distention or swelling, bloody stool, and mental confusion in older adults. o Option D: Deficient fluid volume may be characterized by hypotension, concentrated urine, decreased skin turgor, decreased urine output, and dry mucous membranes. If diagnosed and treated early, within 24 to 48 hours, the recovery and prognosis should be very good. Cases that present with advanced abscesses, sepsis, and peritonitis may have a more prolonged and complicated course, possibly requiring additional surgery or other interventions. 34. Which of the following complications should the nurse carefully monitor a client with acute pancreatitis? o A. Myocardial Infarction o B. Cirrhosis o C. Peptic ulcer o C. Steroids o D. Anticonvulsants Correct Answer: C. Steroids Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema. Corticosteroids produce their effect through multiple pathways. In general, they produce anti-inflammatory and immunosuppressive effects, protein and carbohydrate metabolic effects, water and electrolyte effects, central nervous system effects, and blood cell effects. o Option A: Diuretics help rid the body of salt (sodium) and water. Most of them help the kidneys release more sodium into the urine. The sodium takes with it water from the blood, decreasing the amount of fluid flowing in the veins and arteries, thereby reducing blood pressure. Diuretics are a medication used in the management and treatment of edematous and other non-edematous disease conditions. Diuretics are a class of drugs. o Option B: Antihypertensive drugs comprise several classes of compound with the therapeutic intention of preventing, controlling, or treating hypertension. The classes of antihypertensive drugs differ both structurally and functionally. They are important in anaesthetic practice because they are commonly prescribed to the general population, with the overall prevalence of hypertension being 31% in the UK [defined by the National Institute for Health and Care Excellence (NICE) as a measurement of 140/90 mm Hg or higher in clinic, with subsequent ambulatory or home measurement of 135/85 mm Hg or higher]. o Option D: Anticonvulsants suppress the excessive rapid firing of neurons during seizures. Anticonvulsants, or antiepileptics, are an ever-growing class of medications that act through multiple different mechanisms to control seizures — antiepileptic toxicity commonly presents with a triad of symptoms, which includes central nervous system (CNS) depression, ataxia, and nystagmus. 36. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should: o A. Increase the flow of normal saline o B. Assess the pain further o C. Notify the blood bank o D. Obtain vital signs. Correct Answer: A. Increase the flow of normal saline The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume. Treatment is to stop the transfusion, leave the IV in place, intravenous fluids with normal saline, keeping urine output greater than 100 mL/hour, diuretics may also be needed and cardiorespiratory support as appropriate. A hemolytic workup should also be performed which includes sending the donor blood and tubing as well as post-transfusion labs (see below for list) from the recipient to the blood bank. o Option B: Assessing the pain further could delay any interventions that are needed to be done. Fatal hemolysis is extremely rare, occurring only in 1 out of nearly 2 million transfusions. It is the result of ABO incompatibility, and the recipient’s antibodies recognize and induce hemolysis in donor’s transfused cells. Patients will develop an acute onset of fevers and chills, low back pain, flushing, dyspnea as well as becoming tachycardic and going into shock. o Option C: The blood bank can be notified after stopping the infusion first. According to the American Association of Blood Banks (AABB), febrile reactions are the most common, followed by transfusion- associated circulatory overload, allergic reaction, TRALI, hepatitis C viral infection, hepatitis B viral infection, human immunodeficiency virus (HIV) infection, and fatal hemolysis which is extremely rare, 37. Nurse Maureen knows that the positive diagnosis of HIV infection is made based on which of the following: o A. A history of high-risk sexual behaviors. o B. Positive ELISA and western blot tests o C. Identification of an associated opportunistic infection o D. Evidence of extreme weight loss and high fever only occurring almost 1 in 2 million transfused units of RBC. o Option D: Vital signs could be obtained after stopping the infusion and infusing normal saline. There are multiple complications of blood transfusions, including infections, hemolytic reactions, allergic reactions, transfusion-related lung injury (TRALI), transfusion- associated circulatory overload, and electrolyte imbalance. Asterixis is a disorder of motor control characterized by an inability to actively maintain a position and consequent irregular myoclonic lapses of posture affecting various parts of the body independently. o Option B: Hematocrit levels in uremic syndrome are usually very low, which leads to a higher risk of starting dialysis. Anemia-induced fatigue is thought to be one of the major contributors to the uremic syndrome. Erythropoietin (EPO), a hormone necessary for red blood cell production in bone marrow, is produced by peritubular cells in the kidney in response to hypoxia. o Option C: Life-threatening complications, such as hypertension, occur in clients with uremic syndrome. Cardiac arrest may occur from severe underlying electrolyte abnormalities, such as hyperkalemia, metabolic acidosis, or hypocalcemia. Renal dysfunction may contribute to associated fluid retention, which may lead to uncontrolled hypertension and congestive heart failure. o Option D: Several underlying electrolyte abnormalities such as hyperkalemia and hypocalcemia leads to cardiac arrest. Hyperkalemia (potassium >6.5 mEq/L) may be an acute or chronic manifestation of renal failure, but regardless of the etiology, a potassium level of greater than 6.5 mEq/L is a clinical emergency. As renal function declines, the nephron is unable to excrete a normal potassium load, which can lead to hyperkalemia if dietary intake remains constant. 40. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be: o A. Flank pain radiating in the groin o B. Distention of the lower abdomen o C. Perineal edema o D. Urethral discharge Correct Answer: B. Distention of the lower abdomen This indicates that the bladder is distended with urine, therefore palpable. In the elective setting, the examination should include abdominal examination (looking for a palpable bladder/loin pain) and examination of external genitalia (meatal stenosis or phimosis). Benign prostatic hyperplasia (BPH) refers to the nonmalignant growth or hyperplasia of prostate tissue and is a common cause of lower urinary tract symptoms in men. o Option A: Flank pain is a vague symptom associated with urinary system infections. Lower urinary tract symptoms can be divided into storage (frequency, nocturia, urgency) and voiding symptoms (stream, straining, hesitancy, prolonged micturition) and can help establish other causes of urinary symptoms such as urinary tract infections/overactive bladder, in addition to determining the site affected (bladder vs. prostate). o Option C: BPH only occurs in older men. Disease prevalence has been shown to increase with advancing age. Indeed the histological prevalence of BPH at autopsy is as high as 50% to 60% for males in their 60’s, increasing to 80% to 90% of those over 70 years of age. o Option D: Urethral discharge is not a manifestation of BPH. Men with BPH are likely to report predominant symptoms of nocturia, poor stream, hesitancy, or prolonged micturition. The examination should then conclude with a digital rectal examination making a note in particular of the size, shape (how many lobes), and consistency (smooth/hard/nodular) of the prostate (BPH is characterized by a smooth enlarged prostate). 41. A client has undergone a penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should: o A. Assist the client with sitz bath o B. Apply warm soaks in the scrotum o C. Elevate the scrotum using a soft support o D. Prepare for a possible incision and drainage Correct Answer: C. Elevate the scrotum using a soft support Elevation increases lymphatic drainage, reducing edema and pain. The penis should then be placed upward on the lower abdomen, to limit any downward curvature of this penis postoperatively. Scrotal support or tight mesh underwear may be used after the sterile dressing is removed. o Option A: Several warm baths per day, beginning on the third day after the procedure, would reduce the swelling. Most patients will stay in the hospital overnight following prosthesis placement. This allows for proper guidance on post-operative instructions, as well as the ability to remove the foley catheter without an additional visit to the outpatient clinic. o Option B: Warm baths, instead of soaks, are recommended after three days post surgery. After the penile implant procedure, it is common for bruises and swelling of the scrotum to occur. With several warm baths per day, beginning on the third day after the penile procedure, swelling slowly disappears over a 7 to 14 day period. As healing occurs and swelling disappears, the pain will gradually subside. o Option D: Edema and pain are normal manifestations 24 hours after the surgery. A short course of narcotic pain medication may be warranted. The patient is instructed to avoid any heavy lifting until the follow-up visit in 7-14 days. A drain may be placed if the patient is scheduled to stay in the hospital overnight. The drain may be removed on postoperative day number one at the same time as foley catheter removal. 42. Nurse Hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 44. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be: o A. Ineffective health maintenance o B. Impaired skin integrity o C. Deficient fluid volume o D. Pain o Option B: Superior vena cava (SVC) syndrome is a collection of clinical signs and symptoms resulting from either partial or complete obstruction of blood flow through the SVC. This obstruction is most commonly a result of thrombus formation or tumor infiltration of the vessel wall. The most common signs and symptoms include face or neck swelling, upper extremity swelling, dyspnea, cough, and dilated chest vein collaterals. o Option C: Aortic regurgitation is a condition in which the aortic valve does not close properly, allowing blood to leak from the aorta back into the heart’s left ventricle. This leakage increases the left ventricle’s volume load, causing it to dilate and eventually fail – leading to pulmonary (lung) congestion. Correct Answer: A. Ineffective health maintenance Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat. Monitor and record BP. Measure both arms and thighs three times, 3–5 min apart while the patient is at rest, then sitting, then standing for initial evaluation. Use correct cuff size and accurate technique. o Option B: Impaired skin integrity is an inappropriate nursing diagnosis because there is no alteration in the skin in hypertension. Comparison of pressures provides a more complete picture of vascular 45. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including: o A. High blood pressure o B. Stomach cramps o C. Headache o D. Shortness of breath involvement or scope of problem. Severe hypertension is classified in the adult as a diastolic pressure elevation to 110 mmHg; progressive diastolic readings above 120 mmHg are considered first accelerated, then malignant (very severe). Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated. o Option C: The client with hypertension experiences no fluid deficit. Note presence, quality of central and peripheral pulses. Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion. o Option D: There is no pain experienced in hypertension. Auscultate heart tones and breath sounds. S4 heart sound is common in severely hypertensive patients because of the presence of atrial hypertrophy (increased atrial volume and pressure). Development of S3 indicates ventricular hypertrophy and impaired functioning. Presence of crackles, wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure. Correct Answer: C. Headache Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension, and dizziness. Headaches can be severe, throbbing, and persistent and may occur immediately after use. Vasodilation and venous pooling can increase the amount of blood in the cranial space, resulting in increased intracranial pressures; this can cause persistent, throbbing headaches, along with confusion, fever, vertigo, nausea, vomiting, and visual disturbances. o Option A: Nitroglycerin produces hypotension instead of hypertension due to its vasodilating effects. Many of these adverse effects are secondary to the hypotensive effects of nitroglycerin. Patients may report symptoms of orthostatic hypotension which manifest as dizziness, weakness, palpitations, and vertigo. Profound hypotension may occur in patients with preload-dependent conditions. o Option B: Stomach cramps are not a side effect of nitroglycerin. Some patients can be more sensitive to the hypotension caused by nitrates, which can result in nausea, vomiting, diaphoresis, pallor, and collapse even at therapeutic doses. Nitroglycerin is both a protein-bound drug, and it undergoes hepatic metabolism. Therefore it has numerous drug interactions. Before prescribing, providers should determine if the patient is taking any medications that may interact with nitroglycerin. o Option D: Difficulty of breathing is one of the side effects of nitroglycerin. In the event of overdose, monitoring of vital signs may be necessary to monitor the hemodynamic effects of nitroglycerin. Continuous monitoring of blood pressure, heart rate, respiratory rate, and oxygen saturation is recommended. As intracranial pressure increases, symptoms will progress to dyspnea secondary to a reduced respiratory effort, heart block, bradycardia, paralysis, seizures, coma, and, eventually, death. 46. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD? o A. High levels of low-density lipid (LDL) cholesterol 48. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12? o A. Dairy products o B. Vegetables o C. Grains o D. Broccoli no GI complications associated with this surgery. The nurse should also auscultate for bowel sounds and convey the results to the interprofessional team so that feeding can be initiated. Prior to discharge, the pharmacist and nurse should educate the patient on the importance of medication compliance, the need to control blood pressure, and avoiding tobacco. o o 49. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions? o A. Bowel function o B. Peripheral sensation o C. Bleeding tendencies o D. Intake and output o Option D: Broccoli is rich in fiber, vitamin C, potassium, vitamin B6, and vitamin A. Broccoli is also packed with phytochemicals and antioxidants. Phytochemicals are chemicals in plants that are responsible for color, smell and flavor. Research shows that they have numerous healthful benefits, according to the American Institute for Cancer Research. Phytochemicals in broccoli are good for the immune system. They include glucobrassicin; carotenoids, such as zeaxanthin and beta-carotene; and kaempferol, a flavonoid. 50. Lydia is scheduled for elective splenectomy. Before the client goes to surgery, the nurse in charge final assessment would be: o A. Signed consent o B. Vital signs o C. Name band o D. Empty bladder o Option B: Peripheral sensation among clients with aplastic anemia are unaffected. Splenomegaly is not seen, and its presence suggests an alternative diagnosis. Labs will demonstrate macrocytic normochromic anemia with reticulopodia, neutropenia, and thrombocytopenia. There must be no cytologic abnormalities as this would suggest an underlying hematologic process. o Option D: Intake and output may be disturbed, especially if the client is undergoing chemotherapy, but it can be managed. The most common complications of aplastic anemia include bleeding, infections, or transformation to lymphoproliferative disorders. These are managed by surveillance and symptomatic treatment including antibiotics, chemotherapy, and/or transfusions. 53. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client? a. A. Administering Heparin b. B. Administering Coumadin c. C. Treating the underlying cause d. D. Replacing depleted blood products washing, washing of fruits and vegetables and maintaining good personal hygiene. o Option B: Chemotherapy side effects include nausea, vomiting, and hair loss. Treatment options include prochlorperazine, haloperidol, metoclopramide, lorazepam, dexamethasone, ondansetron, granisetron, dolasetron, palonosetron, dronabinol, aprepitant, fosaprepitant, netupitant. palonosetron has a longer half-life, better efficacy, and higher binding affinity than granisetron. o Option C: Clients may experience headaches and vomiting due to meningeal irritation. Meningitis can have a varied clinical presentation depending on age and immune status of the host. Symptoms typically include fever, neck pain/stiffness, and photophobia. More non-specific symptoms include headache, dizziness, confusion, delirium, irritability, and nausea/vomiting. Correct Answer: B. Administering Coumadin Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin. Warfarin is contraindicated in patients with hemorrhagic tendencies (e.g., active GI ulceration, patients bleeding from the GI, respiratory, or GU tract; a cerebral aneurysm; central nervous system (CNS) hemorrhage; dissecting aortic aneurysm; spinal puncture and other diagnostic or therapeutic procedures with the potential for significant bleeding). i. Option A: Heparin, an anticoagulant, is widely used during DIC treatment and in the prevention of thrombotic diseases. Heparin may also become necessary if a patient has extensive clotting as this medication may prevent further activation of the clotting cascade. Patients with DIC who are not actively bleeding should receive prophylactic anticoagulation with heparin or low molecular weight heparin (LMWH). ii. Option C: The DIC component will resolve on its own once the underlying disorder is addressed. The treatment for DIC centers on addressing the underlying disorder, which ultimately led to this condition. Consequently, therapies such as antibiotics for severe sepsis, possible delivery for placental abruption, and possible exploratory surgical intervention for trauma represent the mainstays of treatment for DIC. iii. Option D: Platelet and factor replacement should be directed not at simply correcting laboratory abnormalities but at addressing clinically relevant bleeding or meeting procedural needs. Platelet and plasma transfusions should only be considered in patients with active bleeding or a high risk of bleeding or those patients requiring an invasive procedure. A common threshold utilized for platelet transfusions in this patient population is less than 50 x 10^9 platelets per liter for actively hemorrhaging patients and 10-20 x 10^9 platelets per liter for those not actively bleeding but at high risk of future bleeding. 54. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate? a. A. Urine output greater than 30ml/hr b. B. Respiratory rate of 21 breaths/minute c. C. Diastolic blood pressure greater than 90 mmHg d. D. Systolic blood pressure greater than 110 mmHg Correct Answer: A. Urine output greater than 30ml/hr Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr. Renal losses of salt and fluid can lead to hypovolemic shock. The kidneys usually excrete sodium and water in a manner that matches intake. Diuretic therapy and osmotic diuresis from hyperglycemia can lead to excessive renal sodium and volume loss. In addition, there are several tubular and interstitial diseases beyond the scope of this article that cause severe salt-wasting nephropathy. i. Option B: Respiratory rate is not an indicator of adequate fluid replacement. Patients with volume depletion may complain of thirst, muscle cramps, and/or orthostatic hypotension. Severe hypovolemic shock can result in mesenteric and coronary ischemia that can cause abdominal or chest pain. Agitation, lethargy, or confusion may result from brain malperfusion. ii. Option C: Diastolic blood pressure is a less reliable indicator of adequate fluid replacement. Although relatively nonsensitive and nonspecific, physical exams can be helpful in determining the presence of hypovolemic shock. Physical findings suggestive of volume depletion include dry mucous membranes, decreased skin turgor, and low jugular venous distention. Tachycardia and hypotension can be seen along with decreased urinary output. iii. Option D: Systolic blood pressure is not a reliable indicator of fluid volume replacement. For hypovolemic shock due to fluid losses, history and physical should attempt to identify possible GI, renal, skin, or third-spacing as a cause of extracellular fluid loss. Symptoms of hypovolemic shock can be related to volume depletion, electrolyte imbalances, or acid- base disorders that accompany hypovolemic shock. 57. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is: a. A. Vital signs q4h b. B. Weighing daily c. C. Urine output hourly d. D. Level of consciousness q4h Cyclophosphamide acts by covalent alkylation, together with chlorambucil, exert an immunomodulatory effect. They inhibit strand separation of DNA during replication. o Option B: The production of acetylcholine is unaffected during immunosuppressive therapy. Methotrexate is an analog of folic acid and blocks pathways essential for DNA synthesis. Azathioprine is a drug that can convert to 6-mercaptopurine, and its effect is incorporation into DNA as a fraudulent base. o Option D: Pyridostigmine is an anticholinesterase inhibitor that works at the neuromuscular junction and prevents the breakdown of acetylcholine. The use of cytokines to successfully treat certain malignancies is a reality, for example, the use of IL-2 in combination with interferon-gamma for renal carcinoma; use of interferon-alpha and beta for hairy leukemia; and TNF- alpha used in various tumors caused a notable reduction of the mass. These cytokines upregulated the immune system through stimulation of T cell and NK cell activation and increased MHC class I expression. Correct Answer: C. Urine output hourly The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney. Urine output also requires monitoring; failure for urine output to increase after administration of mannitol should prompt cessation of mannitol and evaluation for possible renal or genitourinary issues. i. Option A: Vital signs monitoring is a must for every shift, not just for mannitol administration. It is essential to monitor cardiac function as the fluid shifts can precipitate heart failure. Additional electrolytes, including sodium, potassium, and osmolality, require monitoring by the nurses and physicians. Abnormalities in these laboratory values necessitate prompt communication to all members of the team. ii. Option B: The patient’s weight is a less reliable indicator especially for safe administration of mannitol. The nursing staff should pay particular attention to urine output and monitor it carefully, reporting any concerns to the treating clinician. The pharmacist can verify dosing and perform medication reconciliation and alert the team if any interactions are present. iii. Option D: It would be more appropriate to monitor the patient’s neurological status if she has an increase in intracranial pressure. When giving mannitol, it is essential to monitor cardiac function as the fluid shifts can precipitate heart failure. Additional electrolytes, including sodium, potassium, and osmolality, all require monitoring. The clinician should stop mannitol if significant electrolyte abnormalities develop or the osmolality reaches 320 mOsm or higher. 58. Patricia, a 20-year-old college student with diabetes mellitus, requests additional information about the advantages of using a pen-like insulin delivery device. The nurse explains that the advantages of these devices over syringes include: a. A. Accurate dose delivery b. B. Shorter injection time c. C. Lower cost with reusable insulin cartridges d. D. Use of a smaller gauge needle. Correct Answer: A. Accurate dose delivery These devices are more accurate because they are easy to use and have improved adherence to insulin regimens by young people because the medication can be administered discreetly. Once in use, most insulin analog vials, cartridges, and prefilled pens must be discarded after 28 days. This means that many patients who use a 10-ml vial end up either wasting insulin or using insulin beyond its recommended discard date. This is rarely a problem for patients using either a 3-ml prefilled pen or a reusable pen containing a 3-ml insulin cartridge. i. Option B: Injection time of insulin pens and the traditional insulin syringes have no significant difference. Patients must therefore keep the device in place with the button pressed in for 5– 10 seconds. If the patient is using more than 50 units of insulin per dose, a good rule of thumb might be to instruct them to count to 10 regardless of the pen they are using to ensure complete absorption of the insulin. ii. Option C: An additional issue is the greater prescription cost of insulin cartridges and prefilled insulin pens compared with insulin vials, although the cost to the patient may be the same depending on their coverage; in fact, if they have one copay per box of pens, the cost to the patient may actually be less per unit of insulin. It should be noted, however, that despite the higher unit cost of insulin in pen devices versus vials, several studies have found that overall diabetes-related treatment costs are lower with pen devices than with vial and syringe. iii. Option D: For all insulin pen devices, a separate prescription for pen needles is required, with gauges ranging from 29 to 32 and in lengths from 5 to 12.7 mm, much like the traditional insulin syringes used. More recent developments have resulted in the introduction of safety needles with protective shields that not only reduce needle-stick injuries but may also allay patient anxieties about needle use. 59. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood 61. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the: a. A. Buttocks b. B. Ears c. C. Face d. D. Abdomen Correct Answer: B. Ears Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears. Tophi, which are subcutaneous depositions of urate that form nodules, can also be found in patients with persistent hyperuricemia. Tophi typically occur in the joints, ears, finger pads, tendons, and bursae. i. Option A: The buttocks are incredibly vascular areas making it a rare location for the growth of tophi. In a patient who is having a gout flare- up, the symptoms are often apparent. The most commonly involved joint is the first metatarsophalangeal joint. The talar, subtalar, ankle, and knee can also be involved in some cases. ii. Option C: Tophi rarely grow on the face; they are found most commonly on the fingers, toes, wrists, and ears. Although affliction of the joints mentioned above is common in gout, the physician should pay attention to other joints, specifically those joints with underlying osteoarthritis. Besides joints, other periarticular structures such as tendons and bursa may also be affected. iii. Option D: The abdomen is not a location for tophi growth because it occurs most commonly in least cast, physical therapy may be beneficial to help the client to return to normal everyday activities, work, or even sports activities. 62. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the: a. A. Palms of the hands and axillary regions b. B. Palms of the hand c. C. Axillary regions d. D. Feet, which are set apart vascular areas or in joints. The physical exam findings align with the patient history. The affected joint is typically red, swollen, warm, and tender. In patients with chronic gout, the flare-up may involve multiple joints. With the involvement of many joints, it can cause a systemic inflammatory response syndrome that may masquerade as sepsis. 63. Mang Jose with rheumatoid arthritis states, “The only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage: a. A. Active joint flexion and extension b. B. Continued immobility until pain subsides c. C. Range of motion exercises twice daily d. D. Flexion exercises three times daily o Option C: The axillary area should never bear the client’s weight because the nerves might be damaged. The user’s strength and coordination should undergo evaluation before issuing them a set of crutches. The use of the wrong crutches can lead to injury. Most injuries are a direct result of falling. o Option D: Placing the weight on both feet would not allow the client to lift the crutches properly. Through offloading body weight to the injured extremity optimal conditions are provided to allow healing of acute injuries. Crutches provide ambulatory support and mobility options to those with neurologic injuries or chronic orthopedic injuries enabling the individual to stay mobile and active. d. D. Hyperkalemia Correct Answer: A. Hypovolemia In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced. The diuretic stage usually lasts for 1-2 weeks but can persist longer. In this stage, an increase in urine output is noted and uremia begins to resolve as the kidney continues to heal. i. Option B: The client is already experiencing renal failure. In the initiating stage, which begins when the kidney is injured and lasts from hours to days, signs of renal impairment are present such as altered BUN and creatinine levels and decreased urine output. During this phase, the cause of acute renal failure is sought and treatment is initiated. ii. Option C: Metabolic acidosis is caused by a build-up of too many acids in the blood. Differentiating between pre-renal azotemia and ATN can be difficult. In prerenal azotemia, urine output is diminished. In ATN, urine output may or may not be diminished. In pre-renal assaults, the urinalysis will show normal urinary sediment with hyaline or granular casts, high specific gravity, high osmolality, low urinary sodium and urea, and normal urine creatinine. iii. Option D: People with chronic kidney disease have a high risk for hyperkalemia, due in part to the effects of kidney dysfunction on potassium homeostasis. Other complications can include cardiac arrest from hyperkalemia due to the decrease in urine output, elevated phosphorus levels due to impaired renal regulation of calcium and phosphates, metabolic acidosis due to decreases in excretion hydrogen ions, GI bleeding, and decreased nutritional status. In treating hyperkalemia, all sources of dietary potassium should be stopped and a low potassium diet prescribed. 66. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)? a. A. Protein b. B. Specific gravity c. C. Glucose d. D. Microorganism Correct Answer: C. Glucose The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose. A true normal range cannot be given for CSF glucose. As a general rule, CSF glucose is about two thirds of the serum glucose measured during the preceding two to four hours in a normal adult. This ratio decreases with increasing serum glucose levels. CSF glucose levels generally do not go above 300 mg per dL (16.7 mmol per L) regardless of serum levels. i. Option A: Testing for protein would not differentiate mucus from CSF because CSF does not contain protein. CSF protein concentration is one of the most sensitive indicators of pathology within the CNS. Newborn patients have up to 150 mg per dL (1.5 g per L) of protein. The adult range of 18 to 58 mg per dL (0.18 to 0.58 g per L) is reached between six and 12 months of age. ii. Option B: The specific gravity of CSF at normal body temperature remains between 1.004 and 1.003. Cerebrospinal fluid is alleged to have markedly varied readings: extravagant differences are quoted-1.004 to 1.012, and even greater diversities. If such estimates were arrived at by some form of small hydrometer, or there was delay in testing, or no account was taken of the temperature of the fluid at the moment, then such computed answers were inevitable. iii. Option D: If microorganisms are found in CSF, this might suggest an infection. Normal CSF may contain 67. A 22-year-old client suffered from his first tonic-clonic seizure. Upon awakening, the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic-clonic seizures in adults more than 20 years? a. A. Electrolyte imbalance b. B. Head trauma c. C. Epilepsy d. D. Congenital defect up to 5 WBCs per mm3 in adults and 20 WBCs per mm3 in newborns. Eighty-seven percent of patients with bacterial meningitis will have a WBC count higher than 1,000 per mm,3 while 99 percent will have more than 100 per mm3. Having less than 100 WBCs per mm3 is more common in patients with viral meningitis. Multiple Sclerosis Society. Can help the patient to stay motivated to remain active within the limits of the disability or condition. Group activities need to be selected carefully to meet the patient’s needs and prevent discouragement or anxiety. i. Option A: Individuals with MS may experience loss of balance, muscle spasms, problems in moving arms or legs, double vision, or loss of vision. Mechanical aids may come in handy once these symptoms occur, but the client should be taught not to depend on these devices. Mobility aids can decrease fatigue, enhancing independence and comfort, as well as safety. However, individuals may display poor judgment about the ability to safely engage in an activity. ii. Option B: Multiple sclerosis is a disorder that is chronic and has no cure. However, following good health habits would benefit the client. Anticipate hygienic needs and calmly assist as necessary with the care of nails, skin, and hair; mouth care; shaving. Caregiver’s example can set a matter-of-fact tone for acceptance of handling mundane needs that may be embarrassing to the patient and repugnant to SO. iii. Option D: Most people with MS continue to function normally for 20 years after diagnosis or more. Keeping active would be very beneficial to the client’s health and in maintaining a high quality of life. Plan care consistent rest periods between activities. Encourage afternoon naps. Reduces fatigue, aggravation of muscle weakness. 70. The nurse is aware the early indicator of hypoxia in the unconscious client is: a. A. Cyanosis b. B. Increased respirations c. C. Hypertension d. D. Restlessness Correct Answer: D. Restlessness Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in an unconscious client who suddenly becomes restless. When oxygen delivery is severely compromised, organ function will start to deteriorate. Neurologic manifestations include restlessness, headache, and confusion with moderate hypoxia. In severe cases, altered mentation and coma can occur, and if not corrected quickly may lead to death. i. Option A: Cyanosis is the bluish discoloration of the tissues that results from increased concentration of reduced hemoglobin. This may be a late indication of hypoxia. Sufficiently severe hypoxia can result in tachycardia to provide sufficient oxygen to the tissues. Some of the signs are very evident on physical exam; stridor can be heard once the patient arrives in cases of upper airway obstruction. Skin can be cyanotic, which might indicate severe hypoxia. ii. Option B: Hypoxia induces a breathing pattern of rapid and shallow breaths with a relatively higher increase in respiratory rate than tidal volume. This is more noticeable in conscious patients. The chronic presentation is usually less dramatic, with dyspnea on exertion as the most common complaint. Symptoms of the underlying condition that induced the hypoxia can help in narrowing the differential diagnosis. iii. Option C: Pulmonary hypoxic hypertension is associated with high pressure in the blood vessels of the lungs, caused by a shortage of oxygen in the body. This is a late sign of hypoxia. The 6-minutes walk test is frequently used in the preoperative pulmonary evaluation, pulmonary hypertension treatment and assessment of supplemental oxygen need with exercise. 71. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following? a. A. Normal b. B. Atonic c. C. Spastic d. D. Uncontrolled Correct Answer: B. Atonic In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized. The full spinal examination should include motor, sensory reflexes including bulbocavernosus reflex and anal wink reflex. Motor activity and strength decrease not only in the skeletal muscles but the motor activity of internal organs like bowel and bladder. This decrease leads to constipation and urinary retention. i. Option A: The bladder would not be on its normal function during spinal shock. Often it is observed that the patient starts losing neurologic function above the level of injury, which brings anxiety to an inexperienced provider prompting more imaging of the patient’s spinal cord. Loss of function that happens several days post-injury above the level of the injury is mostly due to spinal cord pathways rearrangement. ii. Option C: Spastic or neurogenic bladder is caused by neurologic damage, and not by spinal shock. In clinical practice, patients usually have a mixture of symptoms that involve both pathways. Patients with sacral or intracranial lesions often complain of alterations in erectile function. Reflexogenic erections, like bladder and external sphincter contractility, rely on the somatic function of the pudendal nerve and the autonomic function of the pelvic nerve. These pathways may become disrupted in patients with intracranial or CONUS lesions, but 95% of patients with suprasacral lesions have reflexogenic erections. iii. Option D: An uncontrolled bladder can be caused by pregnancy, changes in age, menopause, enlarged prostate, prostate cancer, or an obstruction. Stress urinary incontinence is the involuntary leakage of urine that occurs with increases in intra abdominal pressure (e.g., with exertion, effort, sneezing, or coughing) due to urethral sphincter and/or pelvic floor weakness. Young women active in sports may experience this type of incontinence. In addition, 74. A 65 year old female is experiencing a flare-up of pruritus. Which of the client’s actions could aggravate the cause of flare-ups? a. A. Sleeping in cool and humidified environment b. B. Daily baths with fragrant soap c. C. Using clothes made from 100% cotton d. D. Increasing fluid intake pain. Determining how the patient alleviates pain may also assess for healthy coping behaviors. o Option B: Various stimuli may exacerbate pain, and determining these factors can aid in establishing the pathophysiologic mechanisms of pain. The history of pain or “pain history” is the physician’s initial tool to assess a patient in pain. A detailed history and physical examination is essential, not only to narrow the diagnoses but also to guide further diagnostic studies, if appropriate. o Option C: Causing factors are not a part of the components in assessing pain. Different disease processes may present with similar pain characteristics. Vascular and neurogenic claudication symptoms are a classic example. However, patients with similar pathology may describe different types of pain or may have no pain at all (eg, spinal cord lesions, diabetic neuropathy). Correct Answer: B. Daily baths with fragrant soap The use of fragrant soap is very drying to the skin hence causing pruritus. Avoid factors that may contribute to skin dryness such as overheating, hot baths, and soaps, shower and bath products. Use emollients for dry skin, including for washing, bathing, and showering. o Option A: A cool and humidified environment could help moisten the skin. Dry skin could be very itchy. Lay a cool flannel that has been soaked in an emollient cream on the skin or apply a cooled emollient that has been kept in the refrigerator. Option C: Cotton is non-irritating and soft for the skin. Patting the skin instead of scratching and keeping nails short. Other interventions may include the use of behavior modification including habit reversal training, phototherapy, the use of systemic medications, which include antidepressants such as tricyclic and SSRIs, and anticonvulsants such as gabapentin and pregabalin. Option D: Increasing fluid intake could make the skin supple and moist. Using anti-itch creams containing a moisturizer and additional ingredients such as crotamiton, lauromacrogols, menthol, and doxepin is possible. However, their use should be based on the classification as recent evidence does not support using these products for all types of pruritus.