99 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5371) 

Which nursing action has the highest priority for a client in the second stage of labor? 

A. Help the mother push effectively 

B. Prepare the mother to breastfeed on the delivery table 

C. Check the fetal position 

D. Administer medication for pain 

Answer: A 

Explanation: The second stage of labor is the pushing stage. The nurse should help the mother push effectively. Answer 2 is not correct. The mother cannot breastfeed the infant until it is born. Breastfeeding on the delivery table might be an appropriate action in the third stage of labor. Answer 3 is not correct. Checking the fetal position is not the highest priority action during second stage labor. Answer 4 is not correct. Pain medication should not be administered in the second stage because it will cause a sleepy baby. 

Question 5372) 

A woman, gravida 5, para 4, is unable to get to the hospital because labor has progressed very rapidly. A nurse, who lives upstairs, comes down to assist her with the emergency home delivery. The nurse examines the woman and assesses that the perineum is bulging. What is the priority nursing measure at this time? 

A. Encourage the woman to push during the contraction 

B. Place a clean sheet under the perineal area 

C. Accurately time the contractions 

D. Contact the physician by phone for instructions 

Answer: B 

Explanation: The woman is a gravida 5, para 4, and the perineum is bulging. Delivery is imminent. Contamination will be minimized by catching the infant on a clean surface. Answer 1 is not correct. The woman will not need to be encouraged to push; she will be doing it on her own. Secondly, it will be more appropriate to have her pant so that the delivery can be controlled. Answer 3 is not correct. Delivery is imminent. There is no time or need to time the contractions. Answer 4 is not correct. Delivery is imminent. There is no time to contact the physician for instructions. The nurse should be able to handle this emergency delivery. 

Question 5373) 

During an emergency home delivery, the head is beginning to crown. What is the most appropriate action for the nurse to take at this time? 

A. Instruct the mother to push down vigorously. 

B. Press down on the fundus to expel the baby 

C. Apply gentle perineal pressure to prevent rapid expulsion of the head. 

D. Direct the mother to take prolonged deep breaths to improve fetal oxygenation. 

Answer: C 

Explanation: Applying gentle counter pressure to the perineum prevents too rapid expulsion of the head, which can lead to increased intracranial pressure in the infant and laceration in the mother. Answer 1 is not correct. The mother will be encouraged to pant so that the delivery can be controlled. Answer 2 is not correct. The nurse does not press down on the fundus to expel the baby. Answer 4 is not correct. There is no need to tell the mother to take prolonged deep breaths. Applying gentle perineal pressure is by far the most appropriate action for the nurse at this time. 

Question 5374) 

What is the most common complication associated with too rapid delivery in precipitate labor? 

A. Pitting edema of the baby’s scalp 

B. Dural or subdural tears in fetal brain tissue

C. Premature separation of the placenta 

D. Prolonged retention of the placenta 

Answer: B 

Explanation: The sudden change of pressure tends to tear away dural linings. The mother can also get perineal tears. Answer 1 is not correct. Edema of the scalp is not a complication with precipitate labor. Sometimes prolonged labor can cause caput succedaneum, where the baby has bleeding under the scalp. Answers 3 and 4 are not correct. Rapid delivery is not particularly associated with placental problems. 

Question 5375) 

The nurse has just completed emergency delivery of a term infant. What is the priority nursing concern at this time? 

A. Controlling hemorrhage in the mother 

B. Removing the afterbirth 

C. Keeping the infant warm 

D. Cutting the umbilical cord Answer: C Explanation: Newborns have immature temperature regulating mechanisms. The nurse should dry the infant and place the infant in a blanket or towel on the mother’s abdomen. Answer 1 is not correct. The first concern is clearing the infant’s airway and keeping the infant warm. The mother is not likely to hemorrhage at this time. Maternal hemorrhage would be more likely after delivery of the placenta. Answer 2 is not correct. The afterbirth or placenta should separate and deliver itself within 5 to 15 minutes after the baby is born. The nurse should care for the baby until this happens. Answer 4 is not correct. There is no hurry to cut the cord. The cord should never be cut with anything that is not sterile because the baby could develop a fatal infection. 

Question 5376) 

What should the nurse do to stimulate the separation of the placenta after home delivery of a baby? 

A. Ask the mother to push down vigorously 

B. Push the fundus down vigorously 

C. Encourage the baby to breastfeed 

D. Place gentle tension on the umbilical cord 

Answer: C 

Explanation: Breastfeeding stimulates uterine contractions, which will help the placenta to separate. Answer 1 is not correct. Having the mother push down vigorously will not stimulate the placenta to separate. Answer 2 is not correct. The nurse should not push down on the fundus. This is not necessary for the placenta to separate. Answer 4 is not correct. The nurse should never pull on the cord. This could cause inversion of the uterus. 

Question 5377) 

A woman delivered a baby in the car on the way to the hospital. In the emergency room, the physician examined the mother. What is the priority action for the nurse at this time? 

A. Gently tug on the cord and massage the uterus to see if the placenta is ready to be delivered

B. Clamp and cut the cord with sterile scissors 

C. Note and record the Apgar score 

D. Clear the mucus from the baby’s mouth and nose 

Answer: D 

Explanation: A clear airway for the infant is first priority. Answer 1 is not correct. Tugging on the cord before the placenta is expelled could cause inversion of the uterus. Answer 2 is not correct. The cord does not need to be cut immediately. Clearing the infant’s airway is a much higher priority. Answer 3 is not correct. The nurse may assess the infant and get an Apgar score. However, the airway is a much higher priority than the Apgar. 

Question 5378) 

A woman who is giving birth at home wonders if her baby will need drops in the eyes because she knows that neither she nor her husband has gonorrhea. The best answer for the nurse to give should include which of the following? 

A. It is desirable for the baby to receive the eye drops, but it is not essential. 

B. If you do not want your baby to have the eye drops, you must sign a waiver stating that you refuse them. 

C. The baby needs the drops but does not have to receive them for up to two hours after birth. 

D. The drops are needed to prevent the eye condition known as retrolental fibroplasia. 

Answer: C 

Explanation: Antibiotic eye drops have to be instilled into the neonate’s conjunctival sacs to prevent infection, not just from gonorrhea and chlamydia but also from pathogens in the birth canal such as pneumococcus and Streptococcus. It is safe to wait up to two hours to instill the drops. This allows time for maternal-child eye contact and interaction, which facilitates attachment. Answers 1 and 2 are not correct. There is a legal requirement to give the baby eye prophylaxis. Answer 4 is not correct. Retrolental fibroplasia results from too much oxygen concentration in immature retinal vessels during oxygen therapy for the compromised neonate. 

Question 5379) 

The nurse is caring for a laboring woman who has a history of rheumatic heart disease. How should the nurse position her during labor? 

A. Supine 

B. Semi-recumbent 

C. Side-lying 

D. Sitting 

Answer: B 

Explanation: Semi-recumbent or semi-Fowler’s position would be the most appropriate position to reduce the cardiac work load and ease breathing. The laboring woman who has a history of rheumatic heart disease is at risk for congestive heart failure. The supine and side-lying positions would increase the cardiac work load. Sitting upright is not the best choice. 

Question 5380) 

The nurse is caring for a laboring woman who has a history of rheumatic heart disease. Which instruction should the nurse give to her during the second stage of labor? 

A. Avoid prolonged bearing down. 

B. Breathe shallowly and rapidly 

C. Sit on the side of the bed 

D. Sleep between contractions. 

Answer: A 

Explanation: The woman with cardiac disease should not bear down excessively. She will likely be given an epidural anesthesia, and outlet forceps may be indicated to shorten the second stage of labor. Answer 2 is not correct. Breathing shallowly and rapidly will cause respiratory alkalosis. Answer 3 is not correct. Sitting on the side of the bed is not an appropriate action during second stage labor. Second stage labor is the expulsion stage. Answer 4 is not correct. Sometimes mothers do doze between contractions in second stage. However, answer 1 is the priority instruction that the nurse should give this mother.

94 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5321)

A woman is to have a routine gynecological examination tomorrow. What instructions should the nurse give this client? 

A. “Bring a urine sample with you.” 

B. “Be sure to drink plenty of fluids in the morning before you come so that your bladder will be full.” 

C. “Be sure not to douche today or tomorrow.” 

D. “Don’t eat breakfast. You will be able to eat right after the exam.” 

Answer: C 

Explanation: There is no special preparation for a gynecological exam. The client should not douche, however. There is no need to bring a urine specimen. The client may be asked to give a specimen prior to the examination. Drinking plenty of fluids would be appropriate prior to a pelvic ultrasound examination. There is no need to fast before a gynecological exam. 

Question 5322) 

A 46-year-old woman visits her gynecologist because she has been spotting. She is to be evaluated for carcinoma of the cervix. If she has cancer of the cervix, she is most likely to report that vaginal spotting occurred at what time? 

A. On arising 

B. While sitting 

C. After intercourse 

D. On stair climbing 

Answer: C 

Explanation: Postcoital (after intercourse) spotting is often seen with cancer of the cervix. The other responses are not correct. 

Question 5323) 

The nurse is discussing breast self-examination with a group of women in a clinic. One woman asks, “When should I do this examination?” What is the best response for the nurse? 

A. “You should perform breast self-examination early in the morning for most accurate results.” 

B. “Breast self-examination should be done a few days after your period begins every month.” 

C. “Breast self-examination should be done by women after the age of 40 on the first of every month.” 

D. “Breast self-examination is best done just before you expect your menstrual period.” 

Answer: B 

Explanation: The best time to perform breast self-examination is a few days after the menstrual period begins because the breasts are least tender at this time. It should be done every month. Answer 1 is incorrect. It does not matter what time of day the exam is performed. Breast self-examination should be done monthly, starting right after puberty. The incidence of breast cancer does increase with age, but it can occur in teenagers. The breasts are most tender just before the period starts; this is the least desirable time to do a breast self-examination. 

Question 5324) 

The physician prescribes clomiphene (Clomid) for a woman who has been having difficulty getting pregnant. When discussing this drug with the woman, the nurse should know that which of the following is known to be a side effect of clomiphene? 

A. Infertility 

B. Multiple births 

C. Vaginal bleeding 

D. Painful intercourse 

Answer: B 

Explanation: One of the major side effects of fertility drugs, such as clomiphene, which increases ovulation, is multiple births. Clomiphene is used to treat infertility; it does not cause infertility. Clomiphene does not cause vaginal bleeding or painful intercourse. 

Question 5325) 

A young couple asks the nurse which method of contraception is the best and the one that they should use. Which response is most helpful to the couple? 

A. “The pill is the best because it is 100% effective with few side effects.” 

B. “The best method is the one that you both agree upon and will use consistently.”

C. “The condom is the best method because it prevents diseases as well as pregnancy.” 

D. “No method is completely effective; you should practice abstinence until you are ready to have children.” 

Answer: B 

Explanation: The best method for any couple is one they will use consistently. The only 100% effective method is abstinence, which is not a realistic choice for most couples. To be effective, contraception must be used consistently and correctly. Answer 1 is not correct. If the pill is not taken exactly as directed, pregnancies can and do occur. The pill has several side effects, including nausea, weight gain, and enlarged breasts. Answer 3 contains correct information in that the condom does help to prevent disease transmission. However, with a married couple, this is not likely to be an issue. Answer 4 is an unrealistic answer for a married couple and therefore is not very helpful. 

Question 5326) 

A woman is being treated for Trichomonas vaginalis with metronidazole (Flagyl). Which statement the woman makes indicates a need for further teaching? 

A. My husband is also taking medicines 

B. “I will take Flagyl with meals.” 

C. The doctor said I might get a metallic taste in my mouth while I am taking Flagyl.” 

D. “I will drink only one glass of wine per meal while I am taking Flagyl.” 

Answer: D 

Explanation: Alcohol taken with Flagyl causes an Antabuselike reaction, nausea, and vomiting. The client should drink no alcoholic beverages. The husband (partner) should also be treated, even if he has no symptoms, to prevent reinfection. Flagyl, unless it is extended release, should be taken with food to decrease gastrointestinal side effects. People commonly get a metallic taste when taking Flagyl. 

Question 5327) 

A client who is being treated for syphilis says to the nurse, “Why does the doctor want to know who I have had sex with?” What should the nurse include when responding to this question? 

A. It really is not any of the physician’s concern. 

B. The physician wants to help you make better decisions about your lifestyle. 

C. Reporting of sexual contacts is mandatory so that the contacts can receive testing and treatment. 

D. Studies need to be done on sexual activities to learn how to reduce the spread of the disease. 

Answer: C 

Explanation: Sexual contacts must be reported so that they can be contacted, tested, and treated to avoid the serious complications of untreated syphilis. Answer 1 is not correct. It is possible that there might be some truth to answer 2. However, the information regarding contacts is usually obtained in a nonjudgmental manner for the reasons described above. Answer 4 is not correct. 

Question 5328) 

During the early period following a right modified radical mastectomy, which nursing action would be appropriate to include in the client’s plan of care? 

A. Position the client in the right lateral position 

B. Encourage a high fluid intake 

C. Ambulate as soon as sensation and motion have returned 

D. Elevate the right arm on pillows

Answer: D 

Explanation: The arm on the affected side should be elevated on pillows to help prevent the development of lymphedema. The client should not be positioned on the affected side. Once the client is awake following anesthesia, the head of the bed will be elevated. The client may have liquids following surgery, but there is no particular need to encourage a high fluid intake. The client will begin to ambulate fairly quickly. However, the client will not have had an epidural anesthetic for a mastectomy, so the return of sensation and motion is not an issue. A mastectomy is too high for an epidural. Epidurals are not given for surgery above the waist. 

Question 5329) 

The nurse is caring for a client who has had a right modified radical mastectomy this morning. Which exercise should the nurse encourage the client to perform this evening? 

A. Hair combing exercises with the right arm 

B. Wall climbing exercises with the right arm 

C. Movement of the fingers and wrists of the right arm 

D. Exercises of the left arm only 

Answer: C 

Explanation: On the day of surgery, the client should be encouraged to move the fingers and wrists of the affected arm. Hair combing and wall climbing exercises will be performed later, not on the day of surgery. The client should be encouraged to exercise the fingers and wrists of the affected extremity on the day of surgery as well as exercising the unaffected arm. 

Question 5330) 

The client is being discharged following a left simple mastectomy. Which statement the client makes indicates an understanding of discharge teaching? 

A. “I won’t let anyone take blood pressures on my left arm.” 

B. “I understand that I should not have sexual relations for at least three months.” 

C. “I won’t move my arm any more than necessary.” 

D. “I will not lift my arm above my head for the next two weeks.” 

Answer: A 

Explanation: The client who has had a mastectomy should not have blood drawn or blood pressures taken on that arm. There is no reason why she should not have sexual relations for three months. As soon as she feels well enough, sexual relations can resume. She should use a position that does not put pressure on her left side. Answers 3 and 4 are incorrect. A woman who has had a mastectomy will need to perform arm exercises regularly. These will include lifting the arm above the head in exercises like hair combing and wall climbing. 

91 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5291) 

A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now? 

A. Tetanus toxoid booster 

B. Tetanus antitoxin 

C. Hyperimmune human tetanus globulin 

D. DPT booster 

Answer: A 

Explanation: Tetanus toxoid given to when the client has had prior tetanus inoculations. Hyperimmune tetanus globulin is given when the person has not had prior tetanus immunization. DTP is not given past the age of 6 years. Tetanus antitoxin is given when a person has not been immunized and considerable time has elapsed from the time of the injury. Tetanus antitoxin helps to fight a tetanus infection that is developing. Tetanus toxoid and immune globulin help to prevent tetanus infection from developing. 

Question 5292) 

A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client? 

A. A semi-private room with a noninfectious client

B. A room with a postoperative client 

C. An isolation room 

D. A private room with a private bath 

Answer: C 

Explanation: Burn victims should be placed in isolation because they are very susceptible to infection 

Question 5293) 

The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn? 

A. Hourly blood pressure 

B. Assessment of skin color and capillary refill 

C. Hourly urine measurement 

D. Frequent assessment for pain 

Answer: C 

Explanation: Fluid replacement is based on hourly measurement of urine output. The other observations are important and should be done, but they are not the highest priority 

Question 5294) 

Cimetidine (Tagamet) is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client? 

A. To prevent infection 

B. To restore electrolyte balance 

C. To promote renal function 

D. To prevent Curling’s ulcers 

Answer: D

Explanation: Curling’s (stress) ulcers occur frequently in burn victims. Tagamet is a histamine blocker that reduces gastric acid and helps to prevent the development of ulcers. 

Question 5295) 

A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason? 

A. A longer period of time is too tiring 

B. Eschar becomes difficult to remove with longer soaking. 

C. Prolonged soaking causes electrolyte dilution. 

D. The water becomes too cool and may cause chilling. 

Answer: C 

Explanation: The water in the Hubbard tank is hypotonic, and sodium loss occurs through the open wounds. The bath may be painful and fatiguing for the client. The primary reason is the physiological problem of sodium loss. 

Question 5296) 

Silver nitrate dressings are applied to burns on an adult. What should be included in the nursing care plan? 

A. Change the dressings every two hours 

B. Keep the dressings wet. 

C. Carefully monitor fluid intake 

D. Observe for black discoloration 

Answer: B 

Explanation: Silver nitrate dressings must always be kept wet, or the silver nitrate is not effective. Silver nitrate does cause black discoloration, but this is incidental and not a major nursing consideration. 

Question 5297) 

The nurse is caring for a client who is having silver nitrate dressings. Which lab values should the nurse monitor? 

A. Blood urea nitrogen (BUN) 

B. Blood gases 

C. Complete blood count (CBC) 

D. Serum electrolytes 

Answer: D 

Explanation: Silver nitrate can cause depletion of potassium, sodium, and chloride; therefore, serum electrolytes are essential. 

Question 5298) 

A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication? 

A. With a sterile, gloved hand 

B. With a sterile applicator 

C. With sterile 4 × 4’s 

D. By aerosol spray 

Answer: A 

Explanation: A sterile, gloved hand is the preferred way to apply topical antimicrobials. 

Question 5299) 

An electrician was wearing a glove that had a hole in it when he grabbed a “hot” wire. His coworkers came to him immediately and called the rescue squad. When the industrial nurse reached him, the electric current had been shut off. What action should the nurse take initially? 

A. Dress the entrance and exit wounds 

B. Check respirations and pulse rate 

C. Remove clothing from the burned area 

D. Roll him in a blanket 

Answer: B 

Explanation: Electric burns cause cardiac arrhythmias. Checking respirations and the pulse rate is the highest priority. There is no need to remove clothing or roll a victim of an electric burn in a blanket because there are no flames. Dressing wounds is of lesser priority than assessing cardiac and respiratory functioning. 

Question 5300) 

A client who has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this question? 

A. Showering daily with antiseptic soap should be sufficient. 

B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is necessary 

C. Psoriasis is not contagious, so no special precautions are necessary. 

D. Psoriasis is transmitted primarily by direct contact with the skin. 

Answer: C 

Explanation: Psoriasis is not contagious 

90 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5281) 

A client is admitted to the hospital with recently diagnosed Type I diabetes mellitus and is to have fasting blood work drawn this morning. At 7:00 A.M., the lab has not arrived to draw the blood. The client’s dose of regular insulin is scheduled for 7:30 A.M. What is the best action for the nurse to take? 

A. Give the insulin as ordered 

B. Withhold the insulin until the lab comes and the client will be eating within 15 to 30 minutes 

C. Withhold the insulin until the blood has been drawn and the client has eaten 

D. Do not administer insulin until the blood work has been drawn and the results have been called back to the unit 

Answer: B 

Explanation: The onset of regular insulin is within 30 minutes. It should not be given until the client can eat within 15 to 30 minutes so that he will not develop hypoglycemia 

Question 5282) 

An adolescent with newly diagnosed Type I diabetes mellitus asks the nurse if he can continue to play football. What is the best answer for the nurse to give? 

A. “Now that you have diabetes, you should not play football because you may get a cut that will not heal.” 

B. “If you work with your physician to regulate the insulin dosage and your diet, you should be able to play football.” 

C. “It would be better for you to work as equipment manager so you will not be under as much stress.” 

D. “You can probably continue to play football if you can regulate it so that you have the same amount of exercise each day.” 

Answer: B 

Explanation: Diabetes is not a contraindication for sports. Changes in activity level will alter the utilization of glucose, so he will need to work closely with his physician to regulate exercise, insulin, and diet control. 

Question 5283) 

The client is a 62-year-old woman who is 30 pounds overweight. She comes to the doctor’s office complaining of headaches, frequent hunger, excessive thirst, and urination. The presenting complaints suggest that the nurse should assess for other signs of which condition? 

A. Hypothyroidism 

B. Acute pyelonephritis 

C. Addison’s disease 

D. Diabetes mellitus 

Answer: D 

Explanation: The symptoms are the cardinal symptoms of diabetes mellitus: polydipsia, polyphagia, and polyuria. The client with hypothyroidism would have fatigue and weight gain and would complain of being cold all the time. The person with acute pyelonephritis would probably complain of frequent urination and flank pain and might have a fever. The person with Addison’s disease would have polyuria and low blood sugar and might go into hypovolemic shock. 

Question 5284) 

An elderly client with Type 2 diabetes mellitus develops an ingrown toenail. What is the best action for the nurse to take? 

A. Put cotton under the nail and clip the nail straight across 

B. Elevate the foot immediately 

C. Apply warm, moist soaks 

D. Notify the physician 

Answer: D 

Explanation: An ingrown toenail may cause infection, which can be very serious for the diabetic client. The physician should be notified. It is not appropriate for the practical nurse to initiate treatment 

Question 5285) A woman with hypothyroidism asks the nurse why the doctor told her she cannot have a sedative. The nurse’s response is based on which of the following facts? 

A. Sedatives potentiate thyroid replacement medication. 

B. Clients with hypothyroidism have increased susceptibility to all sedative drugs. 

C. Sedatives will have a paradoxical effect on clients with hypothyroidism. 

D. Sedatives would cause fluid retention and hypernatremia 

Answer: B 

Explanation: In hypothyroidism, the metabolic rate is decreased. This causes an increased susceptibility to sedative drugs. 

Question 5286)

The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications? 

A. Lower torso 

B. Upper part of the body 

C. Hands and feet 

D. Perineum 

Answer: B 

Explanation: Persons with burns of the upper part of the body frequently have respiratory involvement. Airway problems increase the mortality rate. 

Question 5287) 

The nurse is caring for several clients who have burns. Which of the following persons with burns has the poorest prognosis? 

A. A 20-year-old with second- and third-degree burns over 60% of the body 

B. An 80-year-old with second- and third-degree burns over 50% of the body 

C. A 35-year-old with second- and third-degree burns over 60% of the body 

D. A 2-year-old with second- and third-degree burns over 30% of the body 

Answer: B 

Explanation: The very old and the very young are at the highest risk and have the highest mortality rate. The very old are half-dehydrated before the burn occurred and have greater difficulty with the fluid shifts. The very young have a greater percentage of their body weight that is supposed to be water. They have more difficulty with the fluid shifts that occur following a burn. 

Question 5288) 

Which of the following clients should have his clothing removed immediately? 

A. A 32-year-old man who was burned while working on high-tension wires 

B. A 14-year-old boy who suffered severe smoke inhalation during a fire at school 

C. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking 

D. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school 

Answer: D 

Explanation: Clothing should be removed from persons with chemical burns so that they will not be further contaminated. A flame burn should be smothered, and if necessary, the area should be soaked with water, but the clothing should not be removed until the person is in the emergency room. A person who suffered from smoke inhalation does not have an immediate need to remove clothing. A person who received an electrical burn does not have an immediate need to remove clothing 

Question 5289) 

A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO? 

A. To prevent the deadly complication of aspiration 

B. To make the client more comfortable 

C. To help prevent paralytic ileus 

D. To help prevent excessive fluid loss 

Answer: C 

Explanation: Burn victims are very prone to paralytic ileus. The client will remain NPO until bowel sounds have returned. 

Question 5290) 

The nurse is ordered to insert an indwelling catheter in a severely burned client for which reason? 

A. To prevent contamination of burned areas 

B. To measure hourly urine output 

C. To prevent urinary tract infection 

D. To detect internal injuries quickly Answer: B Explanation: Measurement of urine output is a high priority. Fluid replacement is based on output. The goal is to prevent the client from going into shock by maintaining a urine output of 50 to 100 mL/hr. 

89 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5271) 

A client is diagnosed as having insulin-dependent diabetes mellitus (IDDM). She received regular insulin at 7:30 A.M. When is she most apt to develop a hypoglycemic reaction? 

A. Mid-morning 

B. Mid-afternoon 

C. Early evening 

D. During the night 

Answer: A 

Explanation: Hypoglycemic reactions occur at peak action time. Peak action time for regular insulin is two to four hours after injection, which would be midmorning. 

Question 5272) 

The nurse is teaching a client to self-administer insulin. The instructions should include teaching the client to: 

A. inject the needle at a 90-degree angle into the muscle. 

B. vigorously massage the area after injecting the insulin. 

C. rotate injection sites. 

D. keep the open bottle of insulin in the refrigerator. 

Answer: C 

Explanation: Injection sites should be rotated to prevent tissue damage. Insulin is injected at a 90-degree angle into the deep subcutaneous tissue, not the muscle. Insulin does not need to be refrigerated. The open vial should be kept in the box to protect it from light. Insulin should not be kept at temperature extremes, such as the glove compartment of the car on a hot day. 

Question 5273) 

An adolescent with IDDM is learning about a diabetic diet. He asks the nurse if he will ever be able to go out to eat with his friends again. What is the most appropriate answer for the nurse to give? 

A. “You can go out with them, but you should take your own snack with you.” 

B. “Yes. You will learn what foods are allowed so you can eat with your friends.” 

C. “When you get food out in a restaurant, be sure to order diet soft drinks.” 

D. “Eating out will not be possible on a diabetic diet. Why don’t you plan to invite your friends to your house?” 

Answer: B 

Explanation: Eating out with friends is very important to an adolescent. Snacks will be allowed on his diet. He should be taught how to use the exchange lists in managing his diet. 

Question 5274) 

At 10 A.M., a client with Type 1 diabetes becomes very irritable and starts to yell at the nurse. Which initial nursing assessment should take priority? 

A. Blood pressure and pulse 

B. Color and temperature of skin 

C. Reflexes and muscle tone 

D. Serum electrolytes and glucose 

Answer: B 

Explanation: The nurse should immediately assess the skin. Behavior change and irritability suggest hypoglycemia. The nurse could also do a finger stick and check the glucose level. If the client is hypoglycemic, the client will have pale, cold, clammy skin and will need treatment (ingestion of a rapid-acting carbohydrate) at once. 

Question 5275) 

An elderly woman has been recently diagnosed as having Type 2 diabetes. Which of the following complaints that she has is most likely to be related to the diagnosis of diabetes mellitus? 

A. Pruritus vulvae 

B. Cough 

C. Eructation 

D. Singultus 

Answer: A 

Explanation: Pruritus vulvae (itching of the vulva) frequently accompanies diabetes. Monilial infections are common due to the change in pH. Eructation is belching or burping, and singultus is hiccups. Neither of these is particularly related to diabetes. 

Question 5276) 

A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position? 

A. To promote respiratory effort 

B. To reduce pressure on the sella turcica 

C. To prevent acidosis 

D. To promote oxygenation 

Answer: B 

Explanation: Slight head elevation will reduce pressure on the sella turcica, where the pituitary gland is located, and edema formation in the area. This position may help promote respiratory effort; however, that is not the primary reason in this client. This position does not prevent acidosis or promote oxygenation. 

Question 5277) 

The nurse is discussing discharge plans with a client who had a transsphenoidal hypophysectomy. Which statement made by the client indicates a need for more teaching? 

A. “I won’t brush my teeth until the doctor removes the stitches.” 

B. “I will wear loafers instead of tie shoes.” 

C. “Where can I get a Medic-Alert bracelet?” 

D. “I will take all these new medicines until I feel better.” 

Answer: D 

Explanation: Because the pituitary or master gland was removed, the client will need to take life-long medications, not just until the client feels better. All of the other actions are appropriate. The client should not bend over to tie shoes because this increases intracranial pressure. Answer 1 is correct. Remember, the client had a transsphenoidal procedure in which the incision is in the mouth above the gum line. The client must take medications daily for the rest of his/her life, so a Medic-Alert bracelet is appropriate. 

Question 5278) 

A woman with a tumor of the adrenal cortex says to the nurse, “Will I always look this ugly? I hate having a beard.” What is the best response for the nurse to make? 

A. “After surgery, you will not develop any more symptoms, but the changes you have now will linger.” 

B. “That varies from person to person. You should ask your physician.” 

C. “After surgery, your appearance should gradually return to normal.” 

D. “Electrolysis and plastic surgery should make your appearance normal.” 

Answer: C Explanation: Gradual return to normal will occur after adrenalectomy when there are no longer abnormal amounts of steroids being produced. 

Question 5279) 

A client develops hypoparathyroidism after a total thyroidectomy. What treatment should the nurse anticipate? 

A. Emergency tracheostomy 

B. Administration of calcium 

C. Oxygen administration 

D. Administration of potassium 

Answer: B 

Explanation: Hypoparathyroidism causes a decrease in calcium, which is manifested by tetany. 

Question 5280) 

A woman with newly diagnosed Type I diabetes mellitus says she wants to have children. She asks if she will be able to have children and if they will be normal, What will be best answer from Nurse? 

A. “Women with diabetes should not get pregnant because it is very difficult to control diabetes during pregnancy.” 

B. “Babies born to diabetic mothers are very apt to have severe and noncorrectable birth defects.” 

C. “You should be able to safely have a baby if you go to your doctor regularly during pregnancy.” 

D. “You should consult carefully with a geneticist before getting pregnant to determine how to prevent your baby from developing diabetes.” 

Answer: C 

Explanation: Most diabetic women can safely have babies if they receive good medical supervision during pregnancy. There is a slightly higher incidence of fetal loss and malformations in babies of diabetic mothers but not enough to preclude the chance of a normal baby. There is no way to prevent the child from later developing diabetes. Diabetes is an inherited condition. 

88 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5261) 

What is the nursing priority when administering care to a client with severe hyperthyroidism? 

A. Assess for recent emotional trauma 

B. Provide a calm, nonstimulating environment. 

C. Provide diversionary activity. 

D. Encourage range-of-motion exercises. 

Answer: B 

Explanation: A calm environment is important to reduce activity. Hyperthyroidism makes a person hyperactive and easily distractible. There is no reason to assess for emotional trauma. The hyperthyroid client is usually hyperactive, so there would be no need for range-of-motion exercises. 

Question 5262) 

Which problem is most likely to develop if hyperthyroidism remains untreated? 

A. Pulmonary embolism 

B. Respiratory acidosis 

C. Cerebro vascular accident 

D. Heart failure 

Answer: D 

Explanation: Hyperthyroidism causes tachycardia, which can be severe enough to cause heart failure. Pulse rates can be 100 to 150 per minute. 

Question 5263) 

Which nursing care measure is essential because a client has exophthalmos? 

A. Administer artificial tears 

B. Encourage the client to wear her glasses. 

C. Promote bed rest. 

D. Monitor her pulse rate every four hours. 

Answer: A 

Explanation: Exophthalmos (protrusion of the eyes) may be so severe that the eyelids cannot close. Artificial tears will keep the eyes moist so that abrasions do not occur. The client who has exophthalmos may or may not have glasses. Bed rest and monitoring pulse rate may be appropriate for a client who has exophthalmos because exophthalmos occurs in persons who are hyperthyroid. However, the question asks what nursing care is essential because the client has exophthalmos. 

Question 5264) 

A client who has just had a thyroidectomy returns to the unit in stable condition. What equipment is it essential for the nurse to have readily available? 

A. Tracheostomy set 

B. Thoracotomy tray 

C. Dressing set 

D. Ice collar 

Answer: A 

Explanation: Swelling in the operative site could cause airway obstruction. The nurse should have a tracheostomy set and oxygen readily available for 48 hours after thyroidectomy. A thoracotomy tray is not indicated. This client is not likely to need intervention in the thoracic cavity. A dressing set is unlikely to be needed in the immediate postoperative period. An ice collar might be indicated but is not critical to have at the bedside. 

Question 5265) 

What is the best way to assess for hemorrhage in a client who has had a thyroidectomy? 

A. Check the pulse and blood pressure hourly. 

B. Roll the client to the side and check for evidence of bleeding. 

C. Ask the client if he/she feels blood trickling down the back of the throat. 

D. Place a hand under the client’s neck and shoulders to feel bed linens. 

Answer: D 

Explanation: Following a thyroidectomy, the client is in semi-sitting position so drainage would go to the back of the neck. Because of the neck incision, the client should not be rolled to the side. The bleeding is unlikely to be inside the throat. Blood trickling down the throat might be seen in a client who has had a tonsillectomy. 

Question 5266) 

Which finding would be the greatest cause for concern to the nurse during the early postoperative period following a thyroidectomy? 

A. Temperature of 100°F 

B. A sore throat 

C. Carpal spasm when the blood pressure is taken 

D. Complaints of pain in the area of the surgical incision 

Answer: C 

Explanation: Carpal spasm is a sign of tetany and is known as Chvostek’s sign. Tetany may occur if the parathyroids have been inadvertently removed or damaged. The parathyroids regulate calcium phosphorus balance. Hypocalcemia causes tetany. Most clients who have been intubated during surgery have a sore throat. Pain in the incision area is normal in the immediate postoperative period. 

Question 5267) 

An adult is admitted to the hospital with a diagnosis of hypothyroidism. Which findings would the nurse most likely elicit during the nursing assessment? 

A. Elevated blood pressure and temperature 

B. Tachycardia and weight gain 

C. Hypothermia and constipation 

D. Moist skin and coarse hair 

Answer: C 

Explanation: Hypothyroidism causes decreased metabolic rate, which will cause lowered body temperature and pulse and decreased digestion of food. The skin is dry, and the hair thins. 

Question 5268) 

Which diet does the nurse expect will be ordered for the client with hypothyroidism? 

A. High protein, high calorie 

B. Restricted fluids, low protein 

C. High roughage, low calorie 

D. High carbohydrate, low roughage 

Answer: C 

Explanation: Hypothyroidism causes constipation and obesity. A diet high in roughage and low in calories is appropriate. The client should not be given a high-calorie diet. There is no need for fluid restriction or alteration in protein. 

Question 5269) 

An adult with myxedema is started on thyroid replacement therapy and is discharged. The client returns to the doctor’s office one week later. Which statement that the client makes is most indicative of an adverse reaction to the medication?  

A. “My chest hurt when I was sweeping the floor this morning

B. “I had severe cramps last night.” 

C. I am losing weight.” 

D. “My pulse rate has been more rapid lately.” 

Answer: A

Explanation: Chest pain on exertion suggests angina. In addition to a slow heart rate, the client with hypothyroidism frequently has atherosclerosis. Thyroxine will increase the heart rate, and the heart will require more oxygen. Angina is a likely and serious complication that can occur. She will also probably lose weight and have an increased pulse. These are expected when taking thyroxine. Cramps are not likely to be related to taking thyroxine. 

Question 5270) 

The nurse’s next door neighbor calls. He says he cannot awaken his 21-year-old wife. The nurse notes that the client is unconscious and is having deep respirations. Her breath has a fruity smell to it. The husband says that his wife has been eating and drinking a lot recently and that last night she vomited before lying down. What is the most appropriate action for the nurse to take? 

A. Start cardiopulmonary resuscitation 

B. Get her to a hospital immediately 

C. Try to rouse her by giving her coffee 

D. Give her sweetened orange juice 

Answer: B 

Explanation: Her symptoms suggest ketoacidosis. She must receive medical treatment at once. Coffee will not help her and is contraindicated because she is unresponsive. Sweetened orange juice is not indicated for ketoacidosis. It would be appropriate for hypoglycemia if the client is conscious. There is no indication for cardiopulmonary resuscitation. 

85 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5201) 

A urinalysis reveals white cells and bacteria in the urine of a female client suspected of having a bladder infection. The client is instructed to take the prescribed antiinfective. What else should the nurse include when teaching the client? 

A. Limit fluid intake until the pain subsides 

B. Wipe from back to front after voiding 

C. Empty her bladder immediately after having sexual relations

D. Take the medication until she is pain free for 48 hours 

Answer: C 

Explanation: Failure to empty the bladder after sexual relations is thought to be a cause of bladder infections. Fluids should be encouraged, not restricted. She should wipe from front to back to prevent rectal organisms from entering the bladder, also thought to be a cause of bladder infections. All of the medication should be taken to adequately treat the infection and to prevent the development of resistant organisms. 

Question 5202) 

An adult male is admitted with severe right flank pain, nausea, and vomiting of four hours in duration. The admitting diagnosis is a kidney stone. Orders include to encourage fluids to 1000 cc per shift. What is the primary reason for encouraging fluids in this client? 

A. To prevent renal failure 

B. To help the stone pass 

C. To prevent infection 

D. To relieve his dehydration 

Answer: B 

Explanation: Encouraging fluids will often help the stone to pass. The client in this question has a kidney stone; there is no mention of impending renal failure. High fluid intake is advised for clients who have bladder infections. However, that is not the diagnosis for this client. Increasing fluid intake may be indicated for a client who is dehydrated; however, that is not the diagnosis for this client. 

Question 5203) 

The nurse is straining the urine of a client admitted with possible renal calculi. A small stone is discovered. What should the nurse do? 

A. Send the stone to the laboratory for analysis 

B. Immediately test for guaiac 

C. Test the stone for glucose 

D. Administer pain medication 

Answer: A 

Explanation: The stone should be sent to the laboratory for analysis to determine the type of stone. This will help to determine the diet he should follow. Stones do not usually contain blood or glucose. The laboratory needs to do the analysis. Passing the stone may be painful, but the pain is usually relieved after the stone is passed. 

Question 5204) 

A client who has kidney stones complains of pain. The nurse finds him pacing the hall. What is the most appropriate action for the nurse to take? 

A. Tell him to get back in bed where he will be more comfortable 

B. Encourage him to walk if it helps to relieve the pain 

C. Remind him to walk only when he has someone with him 

D. Put him back in bed immediately and position him in semi-sitting position 

Answer: B 

Explanation: Walking often helps to relieve the pain and will help the stone to pass. The nurse would instruct the client to have assistance with walking only if he is sedated from pain medication. 

Question 5205) 

The nurse is caring for a client who has acute renal failure. His potassium rises to 7.3 mEq/L. A Kayexalate enema is ordered. What is the primary purpose of the Kayexalate enema? 

A. To remove fluid from the extracellular spaces 

B. To exchange potassium ions for sodium ions 

C. To reduce abdominal pressure 

D. To introduce potassium into the bowel 

Answer: B 

Explanation: The client’s potassium is dangerously high. The normal range is 3.5 to 5.0 mEq/L. Kayexalate is a sodium-potassium exchange resin. It removes potassium from the bloodstream. Although it will not correct the underlying problem, it will lower the serum potassium to safer levels and perhaps prevent serious or even fatal cardiac dysrhythmias. Kayexalate does not remove fluid or reduce abdominal pressure. Kayexalate does not introduce potassium into the bowel. A client who has hyperkalemia does not need additional potassium. 

Question 5206) 

The nurse is caring for a client who is in acute renal failure. Which of the following selections would be best to give for a snack? 

A. A slice of watermelon 

B. Orange juice 

C. A turkey sandwich 

D. A dish of applesauce 

Answer: D 

Explanation: A client in acute renal failure is on a lowsodium, low-protein, low-potassium, highcarbohydrate diet. Applesauce is all of these. Watermelon and orange juice are high in potassium. Turkey contains protein, and the bread contains sodium. 

Question 5207) 

A 67-year-old man is admitted with dysuria that has gotten worse over the past six months. Rectal examination revealed an enlarged prostate. Following urination, he was catheterized and found to have 250 cc of thick, foul-smelling, residual urine. He is admitted with a diagnosis of benign prostatic hypertrophy. Which symptom is least likely to be present in this client? 

A. Urinary frequency 

B. Pus in the urine

C. Dribbling 

D. Decreased force of urinary stream 

Answer: B 

Explanation: BPH causes retention, urinary frequency, dribbling, and decreased force of the urinary stream. It does not cause pus in the urine. If pyuria (pus in the urine) is present, this indicates a secondary infection. 

Question 5208) 

The client who has urinary retention has had an indwelling catheter inserted. Which action is not appropriate for the nurse to take? 

A. Limit the client’s fluid intake 

B. Monitor blood pressure frequently 

C. Weigh the client daily 

D. Assess renal function 

Answer: A 

Explanation: Fluid intake should be encouraged to help prevent the development of a urinary tract infection. It is not appropriate to limit fluid intake. Following the removal of urine from a distended bladder, there is a risk of shock. The nurse should monitor the blood pressure. The nurse should weigh the client daily to assess for fluid retention. The nurse would assess renal function by monitoring intake and output. 

Question 5209) 

The nurse has inserted an indwelling catheter into an adult male. The nurse tapes the urinary drainage tube laterally to the thigh for which of the following reasons? 

A. To ensure client comfort 

B. To prevent reflux of urine 

C. To maintain tension on the balloon of the Foley 

D. To prevent compression at the penoscrotal junction 

Answer: D 

Explanation: Compression at the penoscrotal junction will cause obstruction of urine flow. Taping the catheter to the thigh straightens out the urethra and prevents compression of the penoscrotal junction. Leaving the penis in a dependent position increases pressure at the penoscrotal junction. Taping the catheter to the thigh does not prevent the reflux of urine. Keeping the tubing gently sloping in a downward direction will help to prevent reflux. There is no need to maintain tension on the balloon of the indwelling catheter. If the balloon is inflated and positioned properly, it will stay in position. The client may or may not be more comfortable with the catheter in this position. However, comfort is not the reason for taping the catheter to the thigh. 

Question 5210) 

A client who had a transurethral prostatectomy is returned to the unit with continuous bladder irrigation. The nurse understands that the primary purpose of continuous bladder irrigation for this client is to: 

A. prevent a urinary tract infection. 

B. maintain bladder tone. 

C. prevent clots in the bladder 

D. prevent urethral stricture 

Answer: C 

Explanation: Continuous bathing of the bladder with the irrigating solution will prevent formation of clots in the bladder. The primary purpose of continuous bladder irrigation (CBI) is not to prevent urinary tract infection. CBI does not maintain bladder tone. When a client has CBI, the client has an indwelling catheter. CBI does not prevent urethral stricture formation. 

Question 5211) 

A 35-year-old man asks the nurse about a vasectomy. In discussing a vasectomy with this man, which information is most important to provide? 

A. A vasectomy involves tubal ligation done by surgery 

B. This is a permanent method of contraception 

C. The surgery takes approximately one hour 

D. A vasectomy may cause intermittent impotence. 

Answer: B 

Explanation: A vasectomy is considered a permanent method of contraception even though it is occasionally possible to reverse. A vasectomy is essentially a ligation of the tube (vas deferens) and is done by surgery, so answer 1 is a true statement. However, the information in answer 2, that this is a permanent method of sterilization, is much more essential. A vasectomy causes sterility but not impotence (inability to maintain an erection); it does not interfere with sexual functioning. The procedure does not take an hour; it takes only a few minutes. 

Question 5212) 

A client asks the nurse if he can get his wife pregnant after a vasectomy. What is the best response for the nurse to make? 

A. “No. The procedure works immediately and is permanent.” 

B. “The first few ejaculations after a vasectomy contain active sperm.” 

C. “Yes. You should continue to practice birth control for six months.” 

D. “No. The doctor will flush the sperm out after the procedure is completed.” 

Answer: B 

Explanation: The first few ejaculations contain sperm that are already in the tubes. Before he is considered sterile, he should have two ejaculates a month apart that test sperm free. It is usually at least six to eight weeks before a man is considered sterile following a vasectomy. The surgeon does not flush the sperm from the man’s tubes. 

Question 5213) 

A client asks the nurse if he will be able to ejaculate after the vasectomy is done. What is the best response for the nurse to make? 

A. “Yes. This procedure does not affect the ejaculate.” 

B. “No. The purpose of a vasectomy is to prevent ejaculation.” 

C. “Are you concerned about your sexual identity?”

D. “My husband had a vasectomy and it doesn’t bother us 

Answer: A 

Explanation: A vasectomy does not prevent ejaculation. The ejaculate does not contain sperm. The man’s sexual functioning is not affected. The client asks for information. The most appropriate response is to give the information. There is no evidence in the question that the man is concerned about his sexual identity. The nurse should answer the client’s question, not interject her own experience in answering this question 

Question 5214) 

An Adult was on bed rest for several weeks. A nursing care goal is to prevent the formation of renal calculi. Which of the following liquids is it especially important to include in the client’s diet? 

A. Tomato juice 

B. Coffee 

C. Cranberry juice 

D. Milk Answer: C 

Explanation: Most urinary calculi that form as a result of prolonged immobility are alkaline. Cranberry juice leaves an acid ash, which keeps the urine acidic. The other liquids leave an alkaline ash, which could lead to the development of calculi. 

Question 5215) 

The physician has prescribed a diuretic for an adult client. Which nursing intervention is most important in relation to diuretic therapy? 

A. Test the urine for sugar and acetone 

B. Measure daily weights 

C. Maintain accurate intake and output 

D. Assess for pedal edema 

Answer: B 

Explanation: A diuretic causes increased urine output. Monitoring daily weights is the best way to assess changes in hydration status. Testing urine for sugar and acetone is not indicated for this client. There are no data stating that the client is a diabetic. Intake and output may be indicated, but daily weights will give a more reliable indication of actual fluid loss. It is not wrong to assess for pedal edema, but daily weights will give a better indicator of fluid loss. Edema can be in places other than the feet 

Question 5216) 

The nurse is caring for an adult who has an indwelling urinary catheter with a continuous bladder irrigation infusing. How should the nurse calculate the urine output when the drainage bag is emptied? 

A. Subtract the total drainage from the amount of irrigation solution used 

B. Measure the amount of drainage and subtract the amount of solution infused C. Record both the total drainage and the amount of irrigant used on the intake and output record D. Calculate the total fluid intake and subtract this amount from the total drainage 

Answer: B 

Explanation: The irrigating solution goes in through the catheter, bathes the bladder, and flows out through the tubing into the collection bag. The nurse should measure the total amount of drainage and subtract the amount of irrigating solution infused because this is not urine output. Answer 1 makes no sense because the drainage is larger than the amount of irrigating solution used. The question asked how the nurse calculates total urine output. Answer 3 does not address the issue of calculating the total urine output. Recording total fluid intake will most likely be done for this client, but subtracting it from the drainage does not tell us the client’s urine output. 

Question 5217) 

The nurse calculates intake and output for an adult client. His intake for the shift is 1000 mL. The total amount of drainage emptied from the drainage bag is 2550 mL. During the shift, 1825 mL of genitourinary irrigant has infused. What is the client’s eight-hour urine output? 

A. 725 mL 

B. 650 mL

C. 825 mL 

D. 750 mL 

Answer: A 

Explanation: Total drainage from the bag is 2550 mL. The amount of irrigant infused is 1825 mL. Subtract 1825 mL from 2250 mL, and the answer is 725 mL of urine. 

Question 5218) 

The nurse is caring for a client admitted for treatment of acute glomerulonephritis. Which question should the nurse ask when obtaining information about the present illness? 

A. “Have you had a sore throat recently?” 

B. “Has anyone in your family had chickenpox recently?” 

C. “Have you had a bladder infection in the last six weeks?” 

D. “Does anyone in your family have a history of kidney disease?” 

Answer: A 

Explanation: When obtaining a history of the present illness, the nurse questions the client about precipitating factors. Acute glomerulonephritis (AGN) usually occurs 10 to 14 days after a streptococcal (strep) infection. Strep throat or strep-related otitis media is the most common precipitating event. Chickenpox is caused by herpes zoster virus and is not usually associated with AGN. A bladder infection is not usually associated with AGN. AGN follows a strep infection and is not specifically an inherited condition. 

Question 5219) 

A 78-year-old man is scheduled for a transurethral resection of the prostate (TURP) tomorrow morning for treatment of benign prostatic hypertrophy. What instruction should the nurse give him about the initial postoperative period? 

A. “Void every two hours whether or not you feel the urge to do so.” 

B. “Get up and walk to decrease discomfort from bladder spasms.” 

C. “Cough and deep breathe every two hours to prevent clot formation 

D. “Expect cherry-red urine that will gradually turn pink.” 

Answer: D 

Explanation: It is important to tell the client that his urine will be red during the postsurgical period so that he is not frightened. The client will have an indwelling urinary catheter after surgery. He may even have a continuous, normal saline irrigation. There is no need to give instructions regarding voiding until after the catheter has been removed. Walking does not usually relieve bladder spasms. Coughing and deep breathing are important postoperative interventions, but they do not prevent clot formation. 

Question 5220) 

A 35-year-old man is admitted with severe renal colic. The nurse should monitor this man for possible complications. Which of the following is a complication of renal colic? 

A. Anemia 

B. Polyuria 

C. Hypertension 

D. Oliguria 

Answer: D 

Explanation: Renal colic is severe pain associated with ureteral spasms when the ureter is irritated by a stone. A stone may occlude the ureter and block urine flow from the kidney. This can also result in hydronephrosis, a complication that can lead to kidney necrosis. Anemia and hypertension are complications of renal failure. Polyuria is not associated with renal colic