Question 5181)
The client asks how he contracted hepatitis A. He reports all of the following. Which one is most likely related to hepatitis A?
A. He ate home-canned corn.
B. He ate oysters his roommate brought home from a fishing trip.
C. He stepped on a nail two weeks ago.
D. He donated blood two weeks before he got sick
Answer: B
Explanation: Hepatitis A is viral hepatitis and is spread via the fecal-oral route. Shellfish that grow in contaminated waters may have the virus. Homecanned corn might cause food poisoning if it is not properly done. Stepping on a nail might cause tetanus. Donating blood will not cause hepatitis. Receiving blood might cause hepatitis B.
Question 5182)
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
A. To immobilize the diaphragm
B. To facilitate full chest expansion
C. To minimize the danger of aspiration
D. To reduce the likelihood of bleeding
Answer: D
Explanation: The liver is a very vascular organ. It is located on the right side. Lying on the right side will put pressure on it and provide hemostasis and reduce the chance of bleeding. There is no reason to immobilize the diaphragm. Lying on the right side does not immobilize the diaphragm or facilitate chest expansion. Aspiration is not a problem following a liver biopsy.
Question 5183)
A client with cirrhosis is about to have a paracentesis for relief of ascites. Which activity is essential prior to the procedure?
A. Administer thorough mouth care.
B. Ask the client to empty his bladder
C. Be sure his bowels have moved recently.
D. Have the client bathe with betadine.
Answer: B
Explanation: Emptying the bladder is essential prior to a paracentesis so that the bladder will not be punctured during the procedure. Mouth care is not related to a paracentesis. It is not necessary to empty the bowels before a paracentesis. Bathing with betadine is not necessary before a paracentesis.
Question 5184)
The client has severe liver disease. Which of the following observations is most indicative of serious problems?
A. The client has generalized urticaria.
B. The client is “confused” and can no longer write his name legibly.
C. The client is jaundiced
D. The client has ecchymotic areas on his arms.
Answer: B
Explanation: This indicates that the client is going into hepatic coma. He will have urticaria from the jaundice, but this is not the most serious problem. He will have ecchymotic areas on his body due to the decrease in prothrombin, which is made in the liver, but this is also not the most serious problem.
Question 5185)
An adult has a nasogastric tube in place. Which nursing action will relieve discomfort in the nostril with the NG tube?
A. Remove any tape and loosely pin the NG tube to his gown.
B. Lubricate the NG tube with viscous lidocaine.
C. Loop the NG tube to avoid pressure on the nares.
D. Replace the NG tube with a smaller diameter tube.
Answer: C
Explanation: Looping the NG tube will prevent pressure on the nares that can cause pain and eventual necrosis. Pinning the tube to the client’s gown would cause irritation of the nares each time he moved and might cause dislocation of the tube. Prior to insertion of an NG tube, it is proper to lubricate the tip with viscous Xylocaine, but this is not applied to the nostril. A smaller tube might not be large enough to drain the stomach contents; it would still irritate the nose, and it may not be changed without a doctor’s order.
Question 5186)
An adult is being treated for a peptic ulcer. The physician has prescribed cimetidine (Tagamet) for which reason?
A. It blocks the secretion of gastric hydrochloric acid.
B. It coats the gastric mucosa with a protective membrane.
C. It increases the sensitivity of histamine (H2) receptors. D. It neutralizes acid in the stomach
Answer: A
Explanation: Cimetidine (Tagamet) is a histamine (H2) antagonist that blocks the secretion of hydrochloric acid. Sucralfate (Carafate) coats the gastric mucosa. Cimetidine is an H2 receptor antagonist; it does not increase the sensitivity, it blocks it. Antacids neutralize acid in the stomach and raise the pH.
Question 5187) The nurse is assessing a client who may have a hiatal hernia. What symptom is the client most likely to report?
A. Projectile vomiting
B. Crampy lower abdominal pain
C. Burning substernal pain D. Bloody diarrhea
Answer: C
Explanation: Heartburn, which is a burning substernal pain, is the most common sign of hiatal hernia in clients who have symptoms. Projectile vomiting is more likely to be associated with pyloric obstruction due to scarring from chronic peptic ulcer disease. Crampy pain in the lower abdomen is commonly associated with lactose intolerance. Bloody diarrhea is more likely to be associated with diverticulitis or ulcerative colitis.
Question 5188)
When an elderly client is receiving cimetidine (Tagamet), it is important that the nurse monitor for which side effect?
A. Chest pain
B. Confusion
C. Dyspnea
D. Urinary retention
Answer: B
Explanation: Drowsiness, confusion, or mood swings may be side effects of cimetidine. Confusion is particularly common in the elderly. Chest pain is more likely to reflect heartburn, which is a symptom that cimetidine is given to relieve. Dyspnea is a sign of an anaphylactic, allergic reaction to any drug. Allergic reactions to cimetidine are very rare. Urinary retention is associated with anticholinergic drugs. Cimetidine is not anticholinergic
Question 5189)
Choose the most therapeutic response to Mr . Sham ‘s question ,”am I going to die’?
A. We all are going to die one day.”
B. what has your doctor told you?”
C. You really don’t want to talk about death , do you?”
D. “would you like to talk about your condition and prognosis.”
Answer: D
Explanation: The response ,would you like to talk about your condition and prognosis? Make the patient to ventilate his/ her feelings thereby it leads clarification why the patient thinking out that ‘ he is going to die’ (therapeutic technique used here is mental ventilation).other responses are antitherapeutic communication techniques.
Question 5190)
Which of the following would not promote trust in the nurse-patient relationship?
A. Examining a wound without providing privacy.
B. Fulfilling promises
C. Returning at the stated time
D. Maintaining confidentiality
Answer: A
Explanation: The client may experience the exploitation of privacy if wound examination is done without providing privacy . This feeling may result in lack of trust in the nurse-patient relationship .other given actions are the measures to promote trust in nurse-patient relationship.
Question 5191)
The nurse is performing a urethral catheterization on a female. After separating the labia, where would the nurse observe the urethral meatus?
A. Between the vaginal orifice and the anus
B. Between the clitoris and the vaginal orifice
C. Just above the clitoris
D. Within the vaginal canal
Answer: B
Explanation: The urethral meatus is located between the clitoris and the vaginal orifice.
Question 5192)
An adult had an indwelling catheter removed. After she voids for the first time, the nurse catheterizes her as ordered and obtains 200 mL of urine. What is the best interpretation of this finding? The client:
A. is voiding normally.
B. has urinary retention.
C. has developed renal failure
D. needs an indwelling catheter.
Answer: B
Explanation: After the client has voided, catheterization for retention should yield 50 mL or less; 200 mL indicates a retention of urine.
Question 5193)
The nurse is preparing to insert an indwelling catheter. What type of technique should the nurse use to perform this procedure?
A. Clean technique
B. Medical asepsis
C. Isolation protocol
D. Sterile technique
Answer: D
Explanation: Catheterization is performed by using the sterile technique. Medical asepsis is the clean technique.
Question 5194)
After inserting the indwelling catheter, how should the nurse position the drainage container?
A. With the drainage tubing taut to maintain maximum suction on the urinary bladder
B. Lower than the bladder to maintain a constant downward flow of urine from the bladder
C. At the head of the bed for easy and accurate measurement of urine
D. Beside the client in his bed to avoid embarrassment
Answer: B
Explanation: The drainage bag is positioned below the bladder with tubing angled so that there is a constant downward flow of urine from the bladder. This position helps to prevent ascending infection.
Question 5195)
The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?
A. Remove the catheter and reinsert it with the client positioned differently
B. Try a straight catheter instead
C. Try a smaller catheter
D. Discontinue the procedure and notify the physician
Answer: D
Explanation: Difficulty passing a catheter suggests an obstruction of some nature. The nurse should discontinue the procedure and notify the physician.
Question 5196)
A client has just had a needle biopsy of the kidney. What should the nurse do immediately following the procedure?
A. Keep him NPO; take his blood pressure every 5 minutes for 1 hour and then every 15 minutes
B. Keep him flat for 24 hours; take his blood pressure every 5 minutes for 1 hour, then every 15 minutes
C. Check his blood pressure every 30 minutes for 2 hours; monitor intake and output; position in the Sims’ position
D. Check intake and output; send all urine to lab for analysis; ambulate after 8 hours; position in high-Fowler’s position.
Answer: B
Explanation: He should be flat to prevent bleeding from the kidney, a very vascular organ. Blood pressure needs frequent monitoring to determine if the client is bleeding. Bleeding is the most common complication following needle biopsy of the kidney.
Question 5197)
A 5-year-old has been wetting his bed since coming into the hospital. The best approach for the nurse to use to help him regain his voluntary bladder control is to do which of the following?
A. Put diapers on him until he promises to stay dry
B. Leave him in his wet bed so he will learn he should not wet his bed
C. Promise him a lollipop if he will call when he needs to void
D. Assist him to the bathroom at regular intervals
Answer: D
Explanation: Taking him to the bathroom at regular intervals will help him regain control. Regression is common in children who are hospitalized. Putting diapers on him and leaving him in his wet bed are punitive, which is not therapeutic. Promising him a lollipop is bribing, which is not therapeutic.
Question 5198)
An adult client has returned to his room following a cystoscopy. When he voids, his urine is pinktinged. What is the most appropriate action for the nurse to take?
A. Continue to observe him
B. Report it immediately to the physician
C. Irrigate the catheter with normal saline
D. Take his blood pressure every 15 minutes
Answer: A
Explanation: Pink-tinged urine is normal following a cystoscopy. Bright-red bleeding would need to be reported.
Question 5199)
An 18-year-old female is seen in the clinic for a bladder infection. Which of the following signs and symptoms would the nurse expect her to manifest?
A. Burning upon urination
B. Flank pain
C. Nausea and vomiting
D. Elevated potassium
Answer: A
Explanation:
Burning upon urination is usually seen in clients with a bladder infection. Flank pain and nausea and vomiting are seen more frequently in persons with kidney infection or stones. Elevated potassium is seen in renal failure.
Question 5200)
The nurse instructs a woman in the proper procedure for obtaining a clean-catch urine specimen. What should the nurse tell her to do?
A. Clean the perineal area with soap and water and then void into the collection container.
B. Clean around the urethral opening using antibacterial cleaning pads, wiping from front to back. Urinate and let some of the urine go into the toilet; then collect urine in the sterile container.
C. Wash the area around the urethra and vagina. Insert the end of the sterile catheter into your urethra and collect the urine that is drained.
D. Use the special cotton balls and clean your perineal area, wiping in circles from the outer labia inward. Collect the urine in a sterile container.
Answer: B
Explanation: This describes the correct technique for a clean catch midstream urine collection. Antiseptic wipes, not soap and water, are used. The container must be sterile for urine for culture. A midstream collection is necessary. The initial urine voided may contain organisms from near the urethral opening. The object of the urine culture is to culture urine in the bladder.
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