Question 5221)
A woman is being seen in the walk-in clinic for recurrent cystitis. The nurse is
teaching her about measures to prevent future episodes of cystitis. What should the nurse include
in the teaching?
A. Drink 1000 mL of fluid each day, including a serving of cranberry juice at bedtime.
B. Take a daily bath, and avoid the use of bath oils and soaps.
C. Take all the medication prescribed, even if you feel better.
D. Go to the bathroom and void soon after sexual intercourse.
Answer: D
Explanation: Bacteria may enter the urethra during intercourse. Voiding soon after intercourse helps flush
organisms from the urinary tract. Daily fluid intake should be at least 2500 to 3000 mL to prevent recurring
cystitis. Showers, not baths, are recommended. Sitting in a tub may cause a reflux of bacteria into the bladder.
Finishing all medication is an appropriate response to a current infection but does not prevent recurring infections.
Question 5222)
A 64-year-old client with late-stage chronic renal failure is admitted. What should
the nurse expect in the nursing care plan for this client?
A. Insert a urinary catheter to promote bladder drainage.
B. Elevate the client’s feet when out of bed to promote venous return
C. Assess the client’s lung sounds each shift to monitor fluid status.
D. Supplement the client’s diet with protein powder shakes to provide essential amino acids to promote healing.
Answer: C
Explanation: Lung sounds should be assessed to monitor for pulmonary edema, which is a complication of chronic
renal failure. Inserting a catheter does not increase kidney function. The client will be oliguric in late-stage chronic
renal failure. Elevating the feet increases fluid flow to the heart, making the heart work harder. This should not be
done because congestive heart failure is associated with chronic renal failure. Protein intake is restricted in
chronic renal failure.
Question 5223)
The nurse is teaching testicular self-examination to a group of young men on a
college campus. Which information should be included in the discussion?
A. Perform the examination immediately following sexual intercourse.
B. See your physician for an examination yearly.
C. A testicular self-exam should be done monthly.
D. Daily examination of the testicles is recommended.
Answer: C
Explanation: All males past the age of puberty should perform testicular self-examination every month. The man
should do this on the same day every month, such as the first or the fifteenth. The exam should be done in the
shower, followed by a visual inspection looking in the mirror. There is no relation to sexual intercourse. Testicular
selfexamination is performed by the man himself. A physician will examine the testicles when a physical is done.
This may not be yearly for young men. Testicular cancer is primarily a disease of young men.
Question 5224)
The nurse is caring for an adult who recently received a kidney transplant. Which
statement, if made by the client, indicates a lack of understanding of his long-term management?
A. “I plan to go back to work as soon as I feel strong enough.”
B. “We have started using gloves whenever we are scrubbing things.”
C. “My spouse has helped me work out a schedule for taking all these medications.”
D. “If my face gets puffy or my feet swell, I will stop taking the new medications.”
Answer: D
Explanation: A puffy face (moon face) and swollen feet may be side effects of steroid medications. A person who
has had an organ transplant will receive immunosuppressant drugs, including a steroid, for the rest of his/her life.
A person who has had a kidney transplant should be able to return to work once strength has been regained. If the
client’s work involved excessive exposure to infectious agents, the client might have to change jobs. Wearing
gloves is an excellent way to reduce the chance of contracting an infection. The client will be taking a number of
antirejection drugs for life.
Question 5225)
An adult is scheduled for an intravenous pyelogram. Which comment by the client
is of greatest concern to the nurse?
A. “I am afraid of needles.”
B. “I get short of breath when I eat crab meat.”
C. “When I had an arteriogram, I felt nauseated when they injected the dye.”
D. “I am allergic to tetanus shots.”
Answer: B
Explanation: Shortness of breath when eating crab meat suggests an allergy to iodine. Iodine dye is used to visualize
the kidney during an intravenous pyelogram. This should be reported immediately to the physician. The client will
have an intravenous needle, but fear of needles is not the greatest concern. Feeling nauseated and a feeling of
warmth along the vein are normal sensations when receiving iodine dye. Tetanus allergy does not indicate an
allergy to iodine.
Question 5226)
A cast has just been applied to a client’s left forearm, and he has 10 lbs of
Russell’s traction on his left leg. Which of the following nursing concerns takes priority in the care
of this client?
A. The casted extremity may swell, and the cast will become a tourniquet.
B. Heat conduction from the wet cast can cause burning to the skin below.
C. Muscle atrophy of the areas involved can lead to decreased muscle tone.
D. Skin irritation from the cast edges can cause abrasions.
Answer: A
Explanation: The nurse must elevate the extremity to prevent swelling, which could cut off circulation. The wet
cast gives a sensation of heat to the client but will not burn the skin. There will be muscle atrophy to both the arm
and the leg; however, this is a longterm problem and will best be addressed after the cast and traction are
removed. Abrasions are a cause for concern after the cast has dried but not at this time.
Question 5227)
The nurse is caring for a client with a newly applied plaster cast. How should the
nurse touch and move the wet cast?
A. Use the palms of the hands
B. Use the fingertips only
C. Use a towel sling
D. Touch the cast only on the petals at the edges
Answer: A
Explanation: The nurse should touch the cast using only the palms of the hands to prevent making indentations in a
wet cast. Indentations could cause irritation of the skin. Fingertips would cause indentations in the wet cast. A
towel sling is not appropriate. The cast is not petalled until it has dried. It would be impossible to move the casted
extremity just by touching the petalled area at the edge of the cast.
Question 5228)
The nurse is caring for a client who has just had a cast applied. Which statement
best describes the expected client outcome relative to the circulatory system for a client with a
cast?
A. There will be no increase in pain in the extremity.
B. The client will have no circulatory impairment.
C. The integrity of the cast will be maintained.
D. The client will report any feelings of skin irritation.
Answer: B
Explanation: The cast should not be so tight as to cause circulatory impairment, which would be evidenced by
swelling and changes in color or temperature. Pain is usually evidence of neurological impairment. The integrity of
the cast should be maintained, but that does not describe an outcome relative to the circulatory system. Skin
irritation is not an indicator of circulatory impairment
Question 5229)
The nurse gently elevates the client’s newly casted arm on a pillow and explains
that this is necessary for the first 24 to 48 hours after casting. What is the chief purpose of this
action?
A. It helps a damp cast to dry more evenly.
B. It reduces the amount of pain medication needed.
C. Venous return is enhanced, and edema is decreased.
D. It is more comfortable than keeping the arm dependent.
Answer: C
Explanation: Elevation of the extremity increases venous return and reduces swelling. Elevation does not help a
damp cast to dry more evenly. Changing the position of the pillow beneath the cast and not covering the cast will
help it dry more evenly. Elevating a casted extremity does not directly reduce the amount of pain medication
needed. A casted extremity that is elevated usually is more comfortable than one that is dependent; the chief
purpose of elevation is to prevent edema formation. The prevention of edema is what makes the extremity more
comfortable.
Question 5230)
An adolescent male was in an accident and is hospitalized with multiple fractures.
The nurse enters the room and observes that he has his back to the door and is staring at the wall
with a sad expression on his face. What is the best response for the nurse to make at this time?
A. “You seem sad.”
B. “Don’t be too down on yourself.”
C. “I know it is hard to be out of school.”
D. “Do you miss your family and friends?”
Answer: A
Explanation: The nurse should open communication. The nurse is sharing with the client the nurse’s perception of
the client’s behavior. This is therapeutic and should open communication. Answer 2 tells him what not to do and
will probably block communication. Answers 3 and 4 assume that the nurse knows what is causing his sadness and
do not allow him to discuss his feelings.
Question 5231)
The client is in Russell’s traction. Which statement best describes how Russell’s
traction works?
A. The legs are suspended vertically with the hip flexed at 90 degrees and knees extended.
B. A straight pull on the affected leg is assured
C. A belt is applied just above and surrounding the iliac crests. The belt is then attached to a pulley system
D. Vertical traction is used at the knee while, at the same time, a horizontal force is exerted on the tibia and fibula.
Answer: D
Explanation: This best describes Russell’s traction. Answer 1 describes Bryant’s traction. Answer 2 is Buck’s
extension traction. Answer 3 is pelvic traction.
Question 5232)
The nurse is assessing the leg of a client in Russell’s traction. Which area is it
essential to assess?
A. Pedal area
B. Femoral area
C. Popliteal area
D. Inner aspect of the thigh
Answer: C
Explanation: The popliteal area should be assessed for adequacy of circulation. In Russell’s traction, there is a
vertical pull at the popliteal area that could obstruct circulation. There is no problem site in the pedal or femoral
areas or the inner aspect of the thigh.
Question 5233)
It is necessary to pull the client, who is in Russell’s traction, up in bed. Which
action should the nurse take?
A. Leave the weights in place
B. Remove the weights completely
C. Reduce the weight of the traction by one half.
D. Have one nurse lift the weights while the others pull the client.
Answer: A
Explanation: The weights should remain in place at all times. They should not be removed or reduced or lifted up
while the client is moved.
Question 5234)
The client has been flat in bed in traction for two weeks, and she is to be allowed
out of bed for the first time today. What must the nurse be particularly alert for when getting the
client out of bed?
A. Renal complications
B. Depression
C. Orthostatic hypotension
D. Skin breakdown
Answer: C
Explanation: The client has been flat for two weeks. Orthostatic hypotension is likely. The nurse should let the
client dangle on the side of the bed before ambulating. Although the client would have an increased possibility of
kidney stones after being immobilized, this is not related to getting the client out of bed. Depression and skin
breakdown can also occur in clients who have been immobilized. However, they are not apt to cause problems
when the client gets out of bed for the first time
Question 5235)
The client is a 73-year-old woman who fell in her home and suffered a right hip
fracture. She tells the nurse that she was walking across the kitchen and felt something “snap” in
her hip and this made her fall. What type of fracture is the client most likely to have?
A. Comminuted fracture
B. Greenstick fracture
C. Open fracture
D. Pathological fracture
Answer: D
Explanation: The description fits that of a pathological fracture in which the bone fractured first and then she fell.
This is usually related to a decrease of calcium in the bone. With a comminuted fracture, the bone is broken into
several pieces. A greenstick fracture occurs in children. One side of the bone is broken, and the other side is
splintered, like breaking a green stick. An open or compound fracture is one in which a wound through the soft
tissue communicates with the site of the break.
Question 5236)
The nurse knows that elderly women have a high incidence of hip fracture for
which reason?
A. Decreased progesterone secretion
B. Decreased mobility due to arthritic conditions
C. Increased calcium absorption
D. Osteoporosis in the skeletal structure
Answer: D
Explanation: Osteoporosis or the loss of calcium is caused by a number of factors and is often related to the
decrease in estrogen following menopause. Osteoporosis is thought to be related to decreased estrogen after
menopause, not decreased progesterone. Elderly women do not all have decreased mobility due to arthritis. The
cause is usually related to decreased calcium absorption rather than increased calcium absorption.
Question 5237)
The nurse is caring for a client prior to surgery to repair a broken right hip. Which
nursing care measure is essential?
A. Get the client out of bed twice a day to maintain mobility
B. Use pillows to maintain the right hip in a state of abduction
C. Elevate the foot of the bed to 25 degrees
D. Feed the client to conserve her energy
Answer: B
Explanation: The hip should be maintained in abduction to keep the hip in the best alignment. She cannot get out
of bed. The foot is not elevated. There are no data indicating a need to feed the client.
Question 5238)
A femoral head replacement was performed on an elderly client. Postoperatively,
the nurse positions the client with an abductor pillow between the client’s legs. What is the
primary reason for this?
A. This position will promote greater comfort.
B. Abduction promotes greater circulation to the hip joint.
C. Abduction will prevent the prosthesis from snapping out of the socket
D. This position will help to prevent pressure on the sciatic nerve.
Answer: C
Explanation: Abduction is necessary to keep the hip from coming out of the socket. This position may or may not be
most comfortable. Comfort, while important, is not of highest priority. Abduction does not necessarily promote
greater circulation to the hip joint. Abduction does not prevent pressure on the sciatic nerve.
Question 5239)
The client with rheumatoid arthritis has been taking 15 to 20 extra-strength
aspirin a day. Which additional statement that the client makes would be of greatest concern to
the nurse?
A. “I sometimes have ringing in my ears.”
B. “I have a rash under my arms.”
C. “My fingers are swollen sometimes.”
D. “I don’t have very much energy.”
Answer: A
Explanation: Tinnitus is a sign of aspirin toxicity. Swollen fingers and decrease in energy are typical of rheumatoid
arthritis. A rash under the arms is not likely to be related to aspirin ingestion.
Question 5240)
The physician orders prednisone for a client with rheumatoid arthritis for painful
wrists and joints. Which instruction is it essential for the nurse to give the client?
A. “Take the pills with milk or food.”
B. “Be sure to take the medication between meals.”
C. “Stop the pills at once if your face begins to get puffy.”
D. “Your urine may turn pinkish while taking this.”
Answer: A
Explanation: Corticosteroids are very irritating to the stomach and are taken with food or milk to reduce the chance
of ulcer development. The client will develop a puffy face from the steroid. This is not an indication to discontinue
the drug. Steroids should not be stopped abruptly. They should always be tapered. Answer 4 is not true; the urine
does not turn pinkish. Dilantin, an ant seizure drug, may turn the urine pinkish.
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