Question 5091)
The nurse knows that infectious mononucleosis is caused by which of the following?
A. Cytomegalovirus
B. Beta-hemolytic Streptococcus
C. Epstein-Barr virus
D. Herpes simplex virus I
Answer: C
Explanation: The Epstein-Barr virus is the causative organism for infectious mononucleosis.
Question 5092)
A child who has leukemia is to have a bone marrow biopsy performed. How will the child be positioned for this procedure?
A. On his side with the top knee flexed
B. Prone
C. Modified Trendelenburg position
D. On his back with his head elevated 30 degrees
Answer: A
Explanation: The iliac crest is the site usually used for a bone marrow biopsy.
Question 5093)
A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present?
A. Numerous bruises on the child’s body
B. Ruddy complexion
C. Diarrhea and vomiting
D. Chest pain
Answer: A
Explanation: The child with leukemia has a large number of immature white blood cells and not enough red blood cells and platelets. He is likely to have numerous bruises because of the low platelet count. He is likely to have a pale, not ruddy, complexion because he is deficient in red blood cells. Diarrhea and vomiting are possible if he had an intestinal virus, but bruises are much more common. Chest pain is unlikely.
Question 5094)
An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen?
A. In the morning right after he awakens
B. Immediately after breakfast
C. Two hours after eating
D. Shortly before he retires for the evening
Answer: A
Explanation: The sputum has collected during the night. It is most concentrated early in the morning.
Question 5095)
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse? A. Hemoptysis B. Respirations of 28 C. Pulse of 80 D. Temperature of 99°F Answer: A Explanation: Hemoptysis is the only abnormal finding. All of the others are within normal range for someone who has undergone an invasive procedure. Question 5096) An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M.
B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M.
C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight
D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M.
Answer: A
Explanation: Postural drainage should be scheduled before or between meals and close to bedtime.
Question 5097)
An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
A. Use a sterile tube each time and suction for 30 seconds
B. Use sterile technique and turn the suction off as the catheter is introduced
C. Use clean technique and suction for 10 seconds
D. Discard the catheter at the end of every shift
Answer: B
Explanation: Suctioning should be done under sterile technique for no more than 10 seconds. The suction should be off as the tube is inserted and applied intermittently as it is withdrawn.
Question 5098)
During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
A. Release the suction by opening the vent
B. Continue suctioning to remove the obstruction
C. Increase the pressure
D. Suction deeper
Answer: A
Explanation: Suction should not be applied as the suction tube is inserted, because this will cause the suction tube to appear to attach to the tracheal wall and create a pulling sensation.
Question 5099)
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
A. “Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.”
B. “Lay down and tilt your head backward. Grasp the end of your nose between your fingers.”
C. “Sit up and lean backwards. Put pressure on the side of your nose with your hand.”
D. “Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.”
Answer: A
Explanation: This position will help to stop bleeding without causing aspiration of any blood dripping down the back of the throat.
Question 5100)
A client is admitted with a diagnosis of cancer of the larynx. Which statement made by the client is most likely related to the cause of his illness?
A. “I have always enjoyed hot Mexican-style food.”
B. “I have smoked three packs of cigarettes a day for the last 40 years.”
C. “I used to work in a factory that burned coal.”
D. “I sang in the church choir every Sunday until my voice got hoarse last year.”
Answer: B
Explanation: Cigarette smoking is the greatest risk factor for development of laryngeal cancer.
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