Transcript MCQs for Nursing students 10

MCQ for Nursing Students 10
1. A nurse is administering IV furosemide to a patient admitted with congestive heart failure.
After the infusion, which of the following symptoms is NOT expected?
A. Increased urinary output.
B. Decreased edema.
C. Decreased pain.
D. Decreased blood pressure.
1. Answer: C.
Decreased pain.
Furosemide, a loop diuretic, does not alter pain. Furosemide acts on the kidneys to increase
urinary output. Fluid may move from the periphery, decreasing edema. Fluid load is
reduced, lowering blood pressure.
2. There are a number of risk factors associated with coronary artery disease. Which of the
following is a modifiable risk factor?
A. Obesity.
B. Heredity.
C. Gender.
D. Age.
2. Answer: A.
Obesity.
Obesity is an important risk factor for coronary artery disease that can be modified by
improved diet and weight loss. Family history of coronary artery disease, male gender,
and advancing age increase risk but cannot be modified.
3. Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the
emergency department following onset of symptoms of myocardial infarction. Which of the
following is a contraindication for treatment with t-PA?
A. Worsening chest pain that began earlier in the evening.
B. History of cerebral hemorrhage.
C. History of prior myocardial infarction.
D. Hypertension.
3. Answer: B.
History of cerebral hemorrhage.
A history of cerebral hemorrhage is a contraindication to tPA because it may increase the
risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works
best when administered within 6 hours of onset of symptoms. Prior MI is not a
contraindication to tPA. Patients receiving tPA should be observed for changes in blood
pressure, as tPA may cause hypotension.
4. Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg
exercises and ambulate in the hallway as directed by his physician. Which of the following
choices reflects the purpose of exercise for this patient?
A. Increases fitness and prevents future heart attacks.
B. Prevents bedsores.
C. Prevents DVT (deep vein thrombosis).
D. Prevent constipations.
4. Answer: C.
Prevents DVT (deep vein thrombosis).
Exercise is important for all hospitalized patients to prevent deep vein thrombosis.
Muscular contraction promotes venous return and prevents hemostasis in the lower
extremities. This exercise is not sufficiently vigorous to increase physical fitness, nor is it
intended to prevent bedsores or constipation.
5. A patient arrives in the emergency department with symptoms ofmyocardial infarction,
progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the
patient to exhibit with cardiogenic shock?
A. Hypertension.
B. Bradycardia.
C. Bounding pulse.
D. Confusion.
5. Answer: D.
Confusion.
Cardiogenic shock severely impairs the pumping function of the heart muscle, causing
diminished blood flow to the organs of the body. This results in diminished brain
function and confusion, as well as hypotension, tachycardia, and weak pulse.
Cardiogenic shock is a serious complication of myocardial infarction with a high
mortality rate.
6. A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea.
Which of the following actions is the first the nurse should perform?
A. Ask the patient to lie down on the exam table.
B. Draw blood for chemistry panel and arterial blood gas (ABG).
C. Send the patient for a chest x-ray.
D. Check blood pressure.
6. Answer: D.
Check blood pressure.
A patient with congestive heart failure and dyspnea may have pulmonary edema, which
can cause severe hypertension. Therefore, taking the patient’s blood pressure should be
the first action. Lying flat on the exam table would likely worsen the dyspnea, and the
patient may not tolerate it. Blood draws for chemistry and ABG will be required, but not
prior to the blood pressure assessment.
7. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the
nurse complaining of frequent headaches. Which of the following responses to the patient is
correct?
A. “Stop taking the nitroglycerin and see if the headaches improve.”
B. “Go to the emergency department to be checked because nitroglycerin can cause
bleeding in the brain.”
C. “Headaches are a frequent side effect of nitroglycerine because it causes
vasodilation.”
D. “The headaches are unlikely to be related to the nitroglycerin, so you should see
your doctor for further investigation.”
7. Answer: C. “Headaches are a frequent side effect of nitroglycerine because it causes
vasodilation.”
Nitroglycerin is a potent vasodilator and often produces unwanted effects such as
headache, dizziness, and hypotension. Patients should be counseled, and the dose
titrated, to minimize these effects. In spite of the side effects, nitroglycerin is effective at
reducing myocardial oxygen consumption and increasing blood flow. The patient
should not stop the medication. Nitroglycerine does not cause bleeding in the brain.
8. A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously,
and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and
difficulty with concentration at her weekly bridge games. Which of the following explanations could
account for her symptoms?
A. The symptoms may be the result of anemia caused by chemotherapy.
B. The patient may be immunosuppressed.
C. The patient may be depressed.
D. The patient may be dehydrated.
8. Answer: A.
The symptoms may be the result of anemia caused by chemotherapy.
Three months after surgery and chemotherapy the patient is likely to be feeling the aftereffects, which often includes anemia because of bone-marrow suppression. There is no
evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of
immunosuppression. The information given does not indicate that depression or
dehydration is a cause of her symptoms.
9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict
vegetarian diet. Which of the follow nutritional advice is appropriate?
A. The diet is providing adequate sources of iron and requires no changes.
B. The patient should add meat to her diet; a vegetarian diet is not advised.
C. The patient should use iron cookware to prepare foods, such as dark green, leafy
vegetables and legumes, which are high in iron.
D. A cup of coffee or tea should be added to every meal.
9. Answer: C. The patient should use iron cookware to prepare foods, such as dark
green, leafy vegetables and legumes, which are high in iron.
Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic.
When food is prepared in iron cookware its iron content is increased. In addition, dark
green leafy vegetables, such as spinach and kale, and legumes are high in iron. Mild
anemia does not require that animal sources of iron be added to the diet. Many nonanimal sources are available. Coffee and tea increase gastrointestinal activity and inhibit
absorption of iron.
10. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of
severe anemia. Which of the following is the most accurate statement?
A. Transfusion reaction is most likely immediately after the infusion is completed.
B. PRBCs are best infused slowly through a 20g. IV catheter.
C. PRBCs should be flushed with a 5% dextrose solution.
D. A nurse should remain in the room during the first 15 minutes of infusion.
10. Answer: D.
infusion.
A nurse should remain in the room during the first 15 minutes of
Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse
should be present during this period. PRBCs should be infused through a 19g or larger
IV catheter to avoid slow flow, which can cause clotting. PRBCs must be flushed with
0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.
11. A patient who has received chemotherapy for cancer treatment is given an injection of
Epoetin. Which of the following should reflect the findings in a complete blood count (CBC)
drawn several days later?
A. An increase in neutrophil count.
B. An increase in hematocrit.
C. An increase in platelet count.
D. An increase in serum iron.
11. Answer: B.
An increase in hematocrit.
Epoetin is a form of erythropoietin, which stimulates the production of red blood cells,
causing an increase in hematocrit. Epoetin is given to patients who are anemic, often as
a result of chemotherapy treatment. Epoetin has no effect on neutrophils, platelets, or
serum iron.
12. A patient is admitted to the hospital with suspected polycythemia vera. Which of the
following symptoms is consistent with the diagnosis? Select all that applies.
A. Weight loss.
B. Increased clotting time.
C. Hypertension.
D. Headaches.
12. Answers: B, C, and D.
Polycythemia vera is a condition in which the bone marrow produces too many red blood
cells. This causes an increase in hematocrit and viscosity of the blood. Patients can
experience headaches, dizziness, and visual disturbances. Cardiovascular effects
include increased blood pressure and delayed clotting time. Weight loss is not a
manifestation of polycythemia vera.
13. A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the
following is an important intervention?
A. Observe for evidence of spontaneous bleeding.
B. Limit visitors to family only.
C. Give aspirin in case of headaches.
D. Impose immune precautions.
13. Answer: A.
Observe for evidence of spontaneous bleeding.
Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising,
particularly in the extremities. When the count falls below 15,000, spontaneous bleeding
into the brain and internal organs may occur. Headaches may be a sign and should be
watched for. Aspirin disables platelets and should never be used in the presence of
thrombocytopenia. Thrombocytopenia does not compromise immunity, and there is no
reason to limit visitors as long as any physical trauma is prevented.
14. A nurse in the emergency department assesses a patient who has been taking long-term
corticosteroids to treat renal disease. Which of the following is a typical side effect of
corticosteroid treatment? Note: More than one answer may be correct.
A. Hypertension.
B. Cushingoid features.
C. Hyponatremia.
D. Low serum albumin.
14. Answers: A, B, and D.
Side effects of corticosteroids include weight gain, fluid retention with hypertension,
Cushingoid features, a low serum albumin, and suppressed inflammatory response.
Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low in
sodium. Corticosteroids cause hypernatremia and not hyponatremia.
15. A nurse is caring for patients in the oncology unit. Which of the following is the most
important nursing action when caring for a neutropenic patient?
A. Change the disposable mask immediately after use.
B. Change gloves immediately after use.
C. Minimize patient contact.
D. Minimize conversation with the patient.
15. Answer: B.
Change gloves immediately after use.
The neutropenic patient is at risk of infection. Changing gloves immediately after use
protects patients from contamination with organisms picked up on hospital surfaces.
This contamination can have serious consequences for an immunocompromised patient.
Changing the respiratory mask is desirable, but not nearly as urgent as changing gloves.
Minimizing contact and conversation are not necessary and may cause nursing staff to
miss changes in the patient’s symptoms or condition.
16. A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches
family members about infectious precautions. Which of the following statements by family
members indicates that the family needs more education?
A. We will bring in books and magazines for entertainment.
B. We will bring in personal care items for comfort.
C. We will bring in fresh flowers to brighten the room.
D. We will bring in family pictures and get well cards
16. Answer: C.
We will bring in fresh flowers to brighten the room.
During induction chemotherapy, the leukemia patient is severely immunocompromised
and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and
should be avoided. Books, pictures, and other personal items can be cleaned with
antimicrobials before being brought into the room to minimize the risk of
contamination.
17. A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the
following is the most likely age range of the patient?
A. 3-10 years.
B. 25-35 years.
C. 45-55 years.
D. over 60 years.
17. Answer: A.
3-10 years.
The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen
years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The
peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of
cases of chronic lymphocytic leukemia (CLL) occur after 60 years.
18. A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease.
Which of the following symptoms is typical of Hodgkin’s disease?
A. Painful cervical lymph nodes.
B. Night sweats and fatigue.
C. Nausea and vomiting.
D. Weight gain.
18. Answer: B.
Night sweats and fatigue.
Symptoms of Hodgkin’s disease include night sweats, fatigue, weakness, and tachycardia.
The disease is characterized by painless, enlarged cervical lymph nodes. Weight loss
occurs early in the disease. Nausea and vomiting are not typically symptoms of
Hodgkin’s disease.
19. The Hodgkin’s disease patient described in the question above undergoes a lymph node
biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the
following cells would the pathologist expect to find?
A. Reed-Sternberg cells.
B. Lymphoblastic cells.
C. Gaucher’s cells.
D. Rieder’s cells
19. Answer: A.
Reed-Sternberg cells.
A definitive diagnosis of Hodgkin’s disease is made if Reed-Sternberg cells are found on
pathologic examination of the excised lymph node. Lymphoblasts are immature cells
found in the bone marrow of patients with acute lymphoblastic leukemia. Gaucher’s
cells are large storage cells found in patients with Gaucher’s disease. Rieder’s cells are
myeloblasts found in patients with acute myelogenous leukemia.
20. A patient is about to undergo bone marrow aspiration and biopsy and expresses fear
and anxiety about the procedure. Which of the following is the most effective nursing response?
A. Warn the patient to stay very still because the smallest movement will increase her
pain.
B. Encourage the family to stay in the room for the procedure.
C. Stay with the patient and focus on slow, deep breathing for relaxation.
D. Delay the procedure to allow the patient to deal with her feelings.
20. Answer: C.
Stay with the patient and focus on slow, deep breathing for relaxation.
Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces
the level of carbon dioxide in the brain to increase calm and relaxation. Warning the
patient to remain still will likely increase her anxiety. Encouraging family members to
stay with the patient may make her worry about their anxiety as well as her own.
Delaying the procedure is unlikely to allay her fears.
21. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to
assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria
would the nurse use?
A. Body temperature of 99°F or less
B. Toes moved in active range of motion
C. Sensation reported when soles of feet are touched
D. Capillary refill of < 3 seconds
21. Answer: D.
Capillary refill of < 3 seconds
It is important to assess the extremities for blood vessel occlusion in the client with sickle
cell anemia because a change in capillary refill would indicate a change in circulation.
Body temperature, motion, and sensation would not give information regarding
peripheral circulation; therefore, answers A, B, and C are incorrect.
22. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis.
What is the best position for this client?
A. Side-lying with knees flexed
B. Knee-chest
C. High Fowler’s with knees flexed
D. Semi-Fowler’s with legs extended on the bed
22. Answer: D.
Semi-Fowler’s with legs extended on the bed
Placing the client in semi-Fowler’s position provides the best oxygenation for this client.
Flexion of the hips and knees, which includes the knee-chest position, impedes
circulation and is not correct positioning for this client. Therefore, answers A, B, and C
are incorrect.
23. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions
would be of highest priority for this client?
A. Taking hourly blood pressures with mechanical cuff
B. Encouraging fluid intake of at least 200mL per hour
C. Position in high Fowler’s with knee gatch raised
D. Administering Tylenol as ordered
23. Answer: B.
Encouraging fluid intake of at least 200mL per hour
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of
the blood. Answer A is incorrect because a mechanical cuff places too much pressure on
the arm. Answer C is incorrect because raising the knee gatch impedes circulation.
Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.
24. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
A. Peaches
B. Cottage cheese
C. Popsicle
D. Lima beans
24. Answer: C.
Popsicle
Hydration is important in the client with sickle cell disease to prevent thrombus formation.
Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A,
B, and D do not aid in hydration and are, therefore, incorrect.
25. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the
client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the
following interventions would be implemented first? Assume that there are orders for each intervention.
A. Adjust the room temperature
B. Give a bolus of IV fluids
C. Start O2
D. Administer meperidine (Demerol) 75 mg IV push
25. Answer: C.
Start O2
The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse
oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over
pain relief. Answer A is incorrect because although a warm environment reduces pain
and minimizes sickling, it would not be a priority. Answer B is incorrect because
although hydration is important, it would not require a bolus. Answer D is incorrect
because Demerol is acidifying to the blood and increases sickling.
26. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal
plans would the nurse expect the client to select?
A. Roast beef, gelatin salad, green beans, and peach pie
B. Chicken salad sandwich, coleslaw, French fries, ice cream
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
D. Pork chop, creamed potatoes, corn, and coconut cake
26. Answer: C.
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron,
which is an important mineral for this client. Roast beef, cabbage, and pork chops are
also high in iron, but the side dishes accompanying these choices are not; therefore,
answers A, B, and D are incorrect.
27. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and
hypoxemia. Which of the following activities would the nurse recommend?
A. A family vacation in the Rocky Mountains
B. Chaperoning the local boys club on a snow-skiing trip
C. Traveling by airplane for business trips
D. A bus trip to the Museum of Natural History
27. Answer: D.
A bus trip to the Museum of Natural History
Taking a trip to the museum is the only answer that does not pose a threat. A family
vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane
travel can cause sickling episodes and should be avoided; therefore, answers A, B, and
C are incorrect.
28. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency.
Which of the following would the nurse include in the physical assessment?
A. Palpate the spleen
B. Take the blood pressure
C. Examine the feet for petechiae
D. Examine the tongue
28. Answer: D.
Examine the tongue
The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining
the tongue should be included in the physical assessment. Bleeding, splenomegaly, and
blood pressure changes do not occur, making answers A, B, and C incorrect.
29. An African American female comes to the outpatient clinic. The physician suspects vitamin
B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia,
what body part would be the best indicator?
A. Conjunctiva of the eye
B. Soles of the feet
C. Roof of the mouth
D. Shins
29. Answer: C.
Roof of the mouth
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in
dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a
yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are
calloused, making answer B incorrect; the shins would be an area of darker pigment, so
answer D is incorrect.
30. The nurse is conducting a physical assessment on a client with anemia. Which of the
following clinical manifestations would be most indicative of the anemia?
A. BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in 6 months
D. Pink complexion
30. Answer: B.
Respirations 28 shallow
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore,
the client is often short of breath, as indicated in answer B. The client with anemia is
often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are
within normal and, therefore, are incorrect.
31. The nurse is teaching the client with polycythemia vera about prevention of complications of
the disease. Which of the following statements by the client indicates a need for further teaching?
A. “I will drink 500mL of fluid or less each day.”
B. “I will wear support hose when I am up.”
C. “I will use an electric razor for shaving.”
D. “I will eat foods low in iron.”
31. Answer: A.
“I will drink 500mL of fluid or less each day.”
The client with polycythemia vera is at risk for thrombus formation. Hydrating the client
with at least 3L of fluid per day is important in preventing clot formation, so the
statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect
because they all contribute to the prevention of complications. Support hose promotes
venous return, the electric razor prevents bleeding due to injury, and a diet low in iron
is essential to preventing further red cell formation.
32. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following
would the nurse inquire about as a part of the assessment?
A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
D. The client’s brother had leukemia as a child.
32. Answer: C.
teenager.
The client had radiation for treatment of Hodgkin’s disease as a
Radiation treatment for other types of cancer can result in leukemia. Some hobbies and
occupations involving chemicals are linked to leukemia, but not the ones in these
answers; therefore, answers A and B are incorrect. Answer D is incorrect because the
incidence of leukemia is higher in twins than in siblings.
33. An African American client is admitted with acute leukemia. The nurse is assessing for signs
and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
A. The abdomen
B. The thorax
C. The earlobes
D. The soles of the feet
33. Answer: D.
The soles of the feet
Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the
hand provide a lighter surface for assessing the client for petechiae. Answers A, B, and
C are incorrect because the skin might be too dark to make an assessment.
34. A client with acute leukemia is admitted to the oncology unit. Which of the following would
be most important for the nurse to inquire?
A. “Have you noticed a change in sleeping habits recently?”
B. “Have you had a respiratory infection in the last 6 months?”
C. “Have you lost weight recently?”
D. “Have you noticed changes in your alertness?”
34. Answer: B.
“Have you had a respiratory infection in the last 6 months?”
The client with leukemia is at risk for infection and has often had recurrent respiratory
infections during the previous 6 months. Insomnolence, weight loss, and a decrease in
alertness also occur in leukemia, but bleeding tendencies and infections are the primary
clinical manifestations; therefore, answers A, C, and D are incorrect.
35. Which of the following would be the priority nursing diagnosis for the adult client with acute
leukemia?
A. Oral mucous membrane, altered related to chemotherapy
B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member
35. Answer: B.
Risk for injury related to thrombocytopenia
The client with acute leukemia has bleeding tendencies due to decreased platelet counts,
and any injury would exacerbate the problem. The client would require close
monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A,
C, and D, which are incorrect.
36. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged
to be married and is to begin a new job upon graduation. Which of the following diagnoses
would be a priority for this client?
A. Sexual dysfunction related to radiation therapy
B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
D. Fatigue related to chemotherapy
36. Answer: A.
Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would be of primary
importance to this client. The psychosocial needs of the client are important to address
in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis
when diagnosed early. Answers B, C, and D are incorrect because they are of lesser
priority.
37. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to
treatment, the nurse would monitor:
A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)
37. Answer: A.
Platelet count
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts,
making answer A the correct answer. White cell counts, potassium levels, and PTT are
not affected in ATP; thus, answers B, C, and D are incorrect.
38. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP).
The client’s platelet count currently is 80, It will be most important to teach the client and family
about:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
38. Answer: A.
Bleeding precautions
The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The
priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but
platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in
this instance.
39. A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the
following interventions would be appropriate for this client?
A. Place the client in Trendelenburg position for postural drainage
B. Encourage coughing and deep breathing every 2 hours
C. Elevate the head of the bed 30°
D. Encourage the Valsalva maneuver for bowel movements
39. Answer: C.
Elevate the head of the bed 30°
Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates
headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva
maneuver, and coughing all increase the intracranial pressure.
40. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and
mental confusion. The priority intervention for this client is:
A. Measure the urinary output
B. Check the vital signs
C. Encourage increased fluid intake
D. Weigh the client
40. Answer: B.
Check the vital signs
The large amount of fluid loss can cause fluid and electrolyte imbalance that should be
corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the
urinary output is important, but the stem already says that the client has polyuria, so
answer A is incorrect. Encouraging fluid intake will not correct the problem, making
answer C incorrect. Answer D is incorrect because weighing the client is not necessary
at this time.
41. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control
the bleeding?
A. Place the client in a sitting position with the head hyperextended
B. Pack the nares tightly with gauze to apply pressure to the source of bleeding
C. Pinch the soft lower part of the nose for a minimum of 5 minutes
D. Apply ice packs to the forehead and back of the neck
41. Answer: C.
Pinch the soft lower part of the nose for a minimum of 5 minutes
The client should be positioned upright and leaning forward, to prevent aspiration of
blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the
bleeding, and ice packs should be applied directly to the nose as well. If a pack is
necessary, the nares are loosely packed.
42. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the
most important measurement in the immediate postoperative period for the nurse to take is:
A. Blood pressure
B. Temperature
C. Output
D. Specific gravity
42. Answer: A.
Blood pressure
Blood pressure is the best indicator of cardiovascular collapse in the client who has had an
adrenal gland removed. The remaining gland might have been suppressed due to the
tumor activity. Temperature would be an indicator of infection, decreased output would
be a clinical manifestation but would take longer to occur than blood pressure changes,
and specific gravity changes occur with other disorders; therefore, answers B, C, and D
are incorrect.
43. A client with Addison’s disease has been admitted with a history of nausea and vomiting for
the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following
interventions would the nurse implement?
A. Glucometer readings as ordered
B. Intake/output measurements
C. Sodium and potassium levels monitored
D. Daily weights
43. Answer: A.
Glucometer readings as ordered
IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer
B is not necessary at this time, sodium and potassium levels would be monitored when
the client is receiving mineralocorticoids, and daily weights is unnecessary; therefore,
answers B, C, and D are incorrect.
44. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the
mouth and in the fingers and toes. What would the nurse’s next action be?
A. Obtain a crash cart
B. Check the calcium level
C. Assess the dressing for drainage
D. Assess the blood pressure for hypertension
44. Answer: B.
Check the calcium level
The parathyroid glands are responsible for calcium production and can be damaged
during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would
be needed in respiratory distress but would not be the next action to take; thus, answer
A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in
hemorrhage, so answers C and D are incorrect.
45. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of
30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with
hypothyroidism. Which of the following nursing diagnoses is of highest priority?
A. Impaired physical mobility related to decreased endurance
B. Hypothermia r/t decreased metabolic rate
C. Disturbed thought processes r/t interstitial edema
D. Decreased cardiac output r/t bradycardia
45. Answer: D.
Decreased cardiac output r/t bradycardia
The decrease in pulse can affect the cardiac output and lead to shock, which would take
precedence over the other choices; therefore, answers A, B, and C are incorrect.
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