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. 

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Question 5311) 

A 39-year-old woman is seen in the gynecology clinic and asks the nurse about menopause. What is the best explanation for the nurse to give her? 

A. “It usually occurs around the age of 40. You can expect severe hot flashes.” 

B. “It usually occurs after the age of 45 and frequently marks the end of a woman’s sex life.” 

C. “You can expect to have symptoms for about three years while your body adjusts to additional hormones.” 

D. “No more ovarian hormones are produced, so you will stop menstruating.” 

Answer: D 

Explanation: Menopause is the cessation of production of ovarian hormones. Amenorrhea will occur. Not all women have hot flashes. Menopause is not the end of a woman’s sex life. It is the end of her capacity to reproduce. Menopause occurs when a woman is in her 40s or 50s. 

Question 5312) 

A 42-year-old woman sees her physician because of painless spotting between periods that is worse after intercourse. A Pap smear is done. The results come back as stage III. The client asks the nurse what a stage III Pap smear means. The nurse’s response is based on the knowledge that a stage III Pap smear indicates that: 

A. only normal cells are present. 

B. atypical cells are present. 

C. cells suggestive but not diagnostic of malignancy are present 

D. many malignant cells are present. 

Answer: C 

Explanation: Stage III is characterized by cells suggestive but not diagnostic of malignancy. Stage I contains normal cells. Stage II contains atypical cells. Stage IV contains malignant cells. 

Question 5313) 

A woman is to have internal radiation as part of her treatment for cancer of the cervix. In teaching her about the preoperative preparation for this procedure, the nurse should include which information? 

A. A high-residue diet will be ordered. 

B. An indwelling catheter will be inserted

C. A nasogastric tube will be inserted. 

D. Several units of blood will be ready for transfusion if needed 

Answer: B 

Explanation: During the time the radium rods are in place, the client should move as little as possible to prevent dislodgment of the radium. She will have an indwelling catheter in place so her bladder will not become full and also to prevent damage to the bladder from the radiation. She will have an enema before the procedure and a lowresidue or clear liquid diet before surgery and while the rods are in place. There is no need for a nasogastric tube or blood transfusions. 

Question 5314) 

The nurse is caring for a woman after insertion of radium rods for treatment of cancer of the cervix. The nurse positions her in a supine position with legs extended for which reason? 

A. To keep the rods in the correct position 

B. To prevent the urinary bladder from becoming overdistended 

C. To reduce pressure on the pelvic and back areas 

D. To limit the amount of radiation exposure 

Answer: A 

Explanation: The client is kept flat to prevent the rods from becoming dislodged. She will have an indwelling catheter in place. Positioning does not reduce radiation exposure. 

Question 5315) 

The nurse is caring for a woman after the insertion of radium rods for treatment of cancer of the cervix. Which discomfort should the nurse anticipate that the client may have while the rods are in place? 

A. Headache 

B. Urinary retention 

C. Constipation 

D. Uterine cramps 

Answer: D 

Explanation: Uterine cramping occurs frequently. She will be on a clear liquid or low-residue diet so that she is not likely to be constipated. Prior to the procedure, she will have had a laxative bowel prep. She will have a catheter in place so she will not have urinary retention. 

Question 5316) 

The nurse is caring for a woman the day after the insertion of radium rods for treatment of cancer of the cervix. The woman calls the nurse and says, “There is something between my legs. It fell out of me.” What is the most appropriate initial action for the nurse to take? 

A. Call the radiation safety officer 

B. Put on rubber gloves and put the radiation rod in the bathroom until help arrives 

C. Using long forceps, place the radium needle in a lead-lined container 

D. Calmly reinsert the rod in the vagina 

Answer: C 

Explanation: There should always be long forceps and a lead-lined container readily available whenever a person has radium inserted. The nurse should pick up the rod with the long forceps and immediately place it in a leadlined container. The radiation safety officer should then be notified. Leaving the rod between the client’s legs exposes her and others to unnecessary radiation. Rubber gloves offer no protection from radiation. The nurse does not reinsert the radium 

Question 5317) 

A young woman comes to the clinic for contraceptive advice. She says she wants to take the pill. Vital signs are within normal limits. She tells the nurse she has been having intercourse for the past year without protection. What question is it most important for the nurse to ask her? 

A. How much exercise do you get each day? 

B. What do you usually eat each day? 

C. How many cigarettes do you smoke each day? 

D. Are you under stress? 

Answer: C 

Explanation: Cigarette smoking is a contraindication for the use of the pill. There is a higher incidence of thromboembolic problems when a person smokes. 

Question 5318) 

A young woman asks the nurse if oral contraceptives have any side effects. What is the best response for the nurse to make? 

A. “Nausea, fluid retention, and weight gain.” 

B. “Why do you ask? Look at the benefits.” 

C. “Are you concerned about something?” 

D. “Increased libido, decreased breast size, and diarrhea.” 

Answer: A 

Explanation: These are side effects of the pill. Answers 2 and 3 do not answer the question asked. Answer 4 is not correct. 

Question 5319) 

A client asks the nurse the difference between an intrauterine device (IUD) and a diaphragm. The nurse’s response should be based on which information? 

A. The diaphragm is inserted into the uterine cavity, and the IUD covers the cervix. 

B. The IUD is 97% effective, and the diaphragm is 50% effective. 

C. The IUD is placed into the uterine cavity by the doctor, and the diaphragm is placed into the vagina each time by the user. 

D. The IUD must be used with contraceptive jelly, and the diaphragm does not require contraceptive jelly. 

Answer: C 

Explanation: The IUD must be inserted into the uterus by the physician. The woman inserts the diaphragm before each act of intercourse. Both types are very effective when used as directed. The diaphragm requires contraceptive jelly; the IUD does not. 

Question 5320) 

A young woman tells the nurse that her boyfriend used a “rubber” once. What is the most important information about condoms for the nurse to provide the client? 

A. Always use Vaseline as a lubricant. 

B. Apply the condom to the penis right before ejaculation.

C. You do not need a medical prescription for condoms. 

D. The condom must be applied before any penilevaginal contact. 

Answer: D 

Explanation: Preejaculatory secretions may contain sperm. A condom must be applied before there is any penilevaginal contact. Vaseline should never be used as a lubricant. Lubricants should always be water soluble, such as KY jelly or Surgilube. Answer 3 is a true statement but not the most important information to give the client.

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Question 5301) 

The nurse is teaching a class on the prevention of cancer. Which information should be included regarding how to reduce the risk of skin cancer? 

A. Avoid prolonged exposure to the sun. 

B. Shower immediately after being outdoors 

C. Avoid strong perfumes, hand creams, and body lotions. 

D. After being in the woods or in tall grass, check for ticks. 

Answer: A 

Explanation: Prolonged exposure to ultraviolet rays is the major risk factor for skin cancer. Showering immediately after being outdoors will not reduce the risk of skin cancer. Skin cancer is not caused by perfumes, hand creams, or body lotions. Checking for ticks after being outdoors is helpful in preventing Rocky Mountain spotted fever and Lyme disease but will not prevent skin cancer. 

Question 5302) 

The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately? 

A. A small mole on the right thigh that has looked the same ever since the client can remember 

B. A pigmented area that is pink-red in color and has been present since birth 

C. Three small warts on the right hand that have been present for some time 

D. A black and purple mole that is growing larger and has a funny shape 

Answer: D 

Explanation: A mole that changes shape and has multiple colors and irregular borders is suggestive of malignant melanoma. This should be reported immediately. A mole that has not changed in appearance is of no particular concern. The pigmented area that has been present since birth sounds like a nevus or a birthmark and is not of particular concern. The client may want to report the three small warts and have them removed for cosmetic reasons. They are not an immediate threat to her health and do not need to be reported immediately. 

Question 5303) 

The nurse is caring for an adult who has herpes zoster. What medication is most likely to be administered to this client? 

A. Penicillin 

B. Acyclovir 

C. Tetracycline 

D. Benadryl 

Answer: B 

Explanation: Acyclovir, an antiviral agent, is most likely to be given to the person who has herpes zoster, an infection with the chickenpox virus that affects the nerves. Penicillin and tetracycline are given for bacterial infections. Benadryl is an antihistamine and will help with itching. The person who has herpes zoster or shingles is likely to need pain medication, not antihistamines. 

Question 5304)

The nurse is caring for a person who has severe poison ivy. Soaks with Burrow’s solution are ordered. What is the primary reason for using Burrow’s solution soaks? 

A. To disinfect the wound 

B. To prevent pain from the lesions 

C. To stop the pruritus associated with the condition 

D. To help dry the oozing lesions 

Answer: D 

Explanation: Burrow’s solution is used to help dry up oozing lesions such as poison ivy. It does not disinfect, prevent pain, or stop itching. 

Question 5305) 

A woman who has herpes simplex 1 (HSV1) around the mouth and nose asks the nurse if she can give the sores to her husband. What should the nurse include when answering this client? 

A. Herpes simplex 1 (HSV1) is a fever blister and is not contagious 

B. She should not kiss her husband or anyone else because it can be transmitted to susceptible persons 

C. Fever blisters are seen only in persons who have fevers. 

D. The virus is transmitted through coughing and sneezing. 

Answer: B 

Explanation: Herpes simplex 1 (HSV1) can be transmitted through direct contact if the other person has any breaks in the skin or mucous membrane. She should not kiss anyone until after the lesions have disappeared. While blisters do sometimes occur when a person has a fever, a fever is not necessary for a herpes simplex infection. Herpes simplex virus is transmitted by direct contact, not coughing and sneezing. 

Question 5306)

A 45-year-old woman has been having menorrhagia and metrorrhagia for several months. She is also feeling very tired and run down. Which is the most likely explanation for her fatigue? 

A. Hormonal changes related to menopause 

B. Psychological exhaustion produced by continuous worry about her illness 

C. Interference with digestion due to pressure on the small bowel 

D. Decreased oxygen-carrying capacity of the blood due to chronic loss of iron stores Answer: D 

Explanation: Menorrhagia means heavy menstrual flow, and metrorrhagia means bleeding between periods. Such increased loss of blood results in fatigue due to the chronic loss of blood (iron stores). Hormonal changes may cause fatigue, but the data in this question do not support that reason. Excessive worry can cause fatigue, but the data in this question do not support that. There are no data to support interference with digestion due to pressure on the small bowel. If the woman has fibroid tumors, there may be pressure on the bowel, but that would not cause interference with digestion and fatigue. 

Question 5307) 

A 45-year-old woman was found to have several large fibroid tumors. She is to have an abdominal panhysterectomy. She asks what a panhysterectomy includes. The nurse tells the client that a panhysterectomy consists of the removal of which of the following? 

A. Uterine fundus and body 

B. Uterine fundus and body and uterine cervix 

C. Uterine fundus and body, uterine cervix, fallopian tubes, and ovaries 

D. Uterine fundus and body, uterine cervix, fallopian tubes, ovaries, and vagina 

Answer: C 

Explanation: A panhysterectomy consists of the removal of the entire uterus, including the cervix and the tubes and ovaries. The vagina is left intact. 

Question 5308) 

The nurse is caring for a woman who had a hysterectomy. Which vascular complication should the nurse be especially alert for because of the location of the surgery? 

A. Thrombophlebitis 

B. Varicose veins 

C. Cerebral embolism 

D. Aortic aneurysm 

Answer: A 

Explanation: Persons who have had surgery in the pelvic area are apt to develop thrombophlebitis. Varicose veins are a complication of pregnancy. 

Question 5309) 

The nurse is caring for an adult woman who had a vaginal hysterectomy today. The client is now returned to the nursing care unit following an uneventful stay in the postanesthesia care unit. What is the priority nursing action for this client? 

A. Offer her the bedpan. 

B. Encourage coughing and deep breathing 

C. Immediately administer pain medication 

D. Assess chest tubes for patency. 

Answer: B 

Explanation: Coughing and deep breathing are very important in the immediate postoperative period. She will have an catheter after a vaginal Hysterectomy. Pain management medication is given for pain. There is no indication of pain. She will not have chest tubes after pelvic surgery. 

Question 5310) 

A young woman has been having lower abdominal pain and amenorrhea. She is diagnosed as having an ovarian cyst. She asks the nurse what the usual treatment is for an ovarian cyst. What is the best response for the nurse to make? 

A. “Most women with your condition are placed on estrogen therapy for 6 to 12 months until the symptoms disappear. 

B. “The most effective treatment for ovarian cysts is to shrink the cyst with radiation therapy.” 

C. “Ovarian cysts are usually surgically removed.” 

D. “Steroid therapy is often given. The cyst usually resolves in three months.” 

Answer: C 

Explanation: Large ovarian cysts are usually surgically removed. Women who have small ovarian cysts may be given birth control pills (progesterone) to suppress ovarian activity and resolve the cyst. Radiation therapy, estrogen, and steroids are not appropriate for persons with ovarian cysts. 

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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 

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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. 

87 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5241) 

The client is a 64-year-old male admitted to the hospital with severe pain in his right big toe, which is red and swollen. Which nursing care measure is most essential for the nurse to perform at this time? 

A. Use a bed cradle on the bed 

B. Put a bed board on the bed 

C. Obtain a heat lamp 

D. Prepare to catheterize the client 

Answer: A 

Explanation: The pain of gout is very severe. A bed cradle will keep the bed linens off his toe. There is no indication for a bed board. Bed boards are indicated for back problems. A heat lamp is not part of the therapy for gout. There is no indication of a need to catheterize the client. 

Question 5242) 

The nurse is to give the client with gout one tablet of colchicine every hour until relief or toxicity occurs. Which of the following is an indication for stopping the colchicine? A. Ringing in the ears B. Nausea and vomiting C. A rash on the client’s hips D. A temperature of 101°F Answer: B Explanation: Nausea, vomiting, and diarrhea indicate toxicity to colchicine. Tinnitus indicates aspirin toxicity. Rash and fever are not usual signs of colchicine toxicity. Question 5243) The nurse is teaching the client with gout about a diet low in purines. Which of the following is lowest in purine? 

A. Roast chicken 

B. Beef liver 

C. Fried shrimp 

D. Scrambled eggs 

Answer: D 

Explanation: Eggs are lowest in purine. Chicken, organ meats such as liver, and shrimp are high in purines. 

Question 5244) 

The client is now over an acute episode of gout. He is to be discharged on allopurinol (Zyloprim). What instruction must the nurse give to this client? 

A. “Take your medicine on an empty stomach.” 

B. “Report any nausea to your physician at once.” 

C. “Drink two to three quarts of fluids daily.” 

D. “Do not take over-the-counter cold medicine.” 

Answer: C 

Explanation: It is essential to force fluids when taking allopurinol, a uricosuric drug. This will help the uric acid crystals to be excreted in the urine and not collect in the kidneys and form stones. The medicine does not need to be taken on an empty stomach. Nausea can be a side effect of the allopurinol. However, the priority instruction is to drink large amounts of fluid. There is no contraindication with over-the-counter cold medicine. 

Question 5245) 

The client with arthritis is receiving sodium salicylate and asks the nurse what the drug will do for her. The nurse’s reply should include information that the drug is given for which of the following effects? 

A. Antipyretic 

B. Antibiotic 

C. Anticoagulant 

D. Anti-inflammatory 

Answer: D 

Explanation: Sodium salicylate has all of the effects except antibiotic. However, it is given to a person with arthritis primarily for its anti-inflammatory effect. The anticoagulant action can be an adverse effect for this client. 

Question 5246) 

The client with newly diagnosed rheumatoid arthritis asks what can happen if no treatment is done. The nurse knows that if rheumatoid arthritis is left untreated, which of the following would be most apt to develop? 

A. Bony ankylosis 

B. Chronic osteomyelitis 

C. Pathological fractures 

D. Joint hypermobility 

Answer: A 

Explanation: Bony ankylosis occurs in untreated rheumatoid arthritis. Osteomyelitis is a bone infection and is not related to rheumatoid arthritis. Pathological Fractures are result of severe osteoporosis, not arthritis. Joints lose mobility and become ankylosed; they do not have hypermobility. 

Question 5247) 

The client with rheumatoid arthritis is to receive prednisone 2.5 mg P.O. before meals and at bedtime. What is the primary expected action of the drug? 

A. Maintenance of sodium and potassium balance 

B. Improvement of carbohydrate metabolism 

C. Production of androgen-like effects 

D. Interference with inflammatory reactions 

Answer: D 

Explanation: Prednisone is a corticosteroid and has an anti-inflammatory effect. It does affect sodium and potassium balance and carbohydrate metabolism and causes androgen-like effects; however, these are seen as bothersome side effects when given to a client who has arthritis. 

Question 5248) 

The client is admitted to the hospital for a diagnostic workup. The client has vague symptoms of malaise, coughing, chest discomfort, low-grade fever, diffuse rashes, and musculoskeletal aches and pains. A diagnosis of probable lupus erythematosus has been made. The night nurse finds the client crying and saying, “I would rather die than suffer with this disease for the rest of my life.” Which response by the nurse would be most therapeutic at this time? 

A. Telling the client there are support groups to join after discharge 

B. Offering to stay with the client to discuss concerns and questions 

C. Advising the client to write concerns on paper to discuss with the doctors and nurses tomorrow 

D. Offering the client a back rub and a warm cup of milk 

Answer: B 

Explanation: Offering help and letting the client express feelings is most therapeutic at this time. Telling the client about support groups may be appropriate later. Advising the client to write her concerns on paper to discuss tomorrow could be appropriate after the nurse had listened to the client’s concerns and feelings. At this time, that response closes communication. Giving the client a back rub and a warm cup of milk could be done after listening to the client. 

Question 5249) 

The elderly client having diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation? 

A. Encouraging deep breathing 

B. Asking him if he understands the full effects of the planned surgery 

C. Discussing the effects of diabetes on the vascular system 

D. Having a recovered amputee visit him 

Answer: D 

Explanation: Seeing an amputee who is living successfully will do the most to help him adjust to having an amputation. All of the others might be done but do not help him to adjust to an amputation. 

Question 5250) 

The client has returned to the nursing unit following a right below-the-knee amputation. How should the nurse position the client? 

A. Supine with head turned to the side 

B. With shock blocks placed under the foot of the bed 

C. Semi-sitting position with knees bent 

D. Left lateral with pillows between the knees 

Answer: B 

Explanation: The foot of the bed should be raised to prevent edema formation in the stump. Shock blocks are the best way to accomplish this. Pillows can be used for the first 24 to 28 hours only. Note that the client has returned to the nursing unit. The client will be awake before returning to the nursing unit, so turning the head to the side is not needed. Positioning the client in a semi-sitting position with knees bent would cause swelling of the surgical site and is contraindicated. Positioning the client on the side with pillows between the knees is not the most appropriate position. 

Question 5251) 

The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first? 

A. Apply a pressure dressing to the stump 

B. Place a tourniquet above the stump 

C. Notify the physician 

D. Apply an ice pack to the stump 

Answer: B 

Explanation: Applying a tourniquet is the best action because the bleeders are usually too large to be controlled by pressure. This is one of the very few times when applying a tourniquet is indicated. An ice pack will be ineffective in controlling hemorrhage from the stump. The nurse should notify the physician but should attempt to stop the bleeding before leaving the client to call the physician 

Question 5252) 

The client continues to recover following a below-the-knee amputation. What nursing action should the nurse employ to help prevent the most common complication following leg amputation? 

A. Clean the wound with hydrogen peroxide three times a day 

B. Have the client lie prone several times a day 

C. Ask the client to flex and extend the toes on the remaining leg 

D. Encourage the client to completely empty his/ her bladder 

Answer: B 

Explanation: The most common complication is flexion contracture of the hip or knee. Having the client lie prone will help to prevent flexion contractures of the hip and knee. The wound should be kept clean, but not usually with hydrogen peroxide three times a day. Asking the client to flex and extend the toes on the remaining leg will help to prevent thrombophlebitis in the remaining leg and is certainly appropriate. However, thrombophlebitis is not the most common complication following leg amputation. It is appropriate to encourage the client to empty the bladder. However, a bladder infection is not the most common complication following leg amputation. 

Question 5253) 

A young adult is discharged to home with crutches. Which exercise should the nurse teach the client in order to strengthen the hand muscles for crutch walking? 

A. Pushing the buttocks up off the mattress 

B. Pulling the body up, using an overhead trapeze 

C. Raising the legs straight up and down 

D. Squeezing a rubber ball in each hand 

Answer: D 

Explanation: Squeezing a rubber ball strengthens finger flexors. Pull-ups strengthen the biceps muscles. Straight leg raises strengthen the hip flexor and quadriceps. 

Question 5254) 

The client is ordered to be in a semi-reclining position following a myelogram. The nurse understands that the primary reason for this is which of the following? 

A. To prevent infection 

B. To prevent spinal headache 

C. To prevent seizures 

D. To promote excretion of dye 

Answer: C 

Explanation: When a client is ordered to be semi-reclining following a myelogram, the nurse knows the physician used a water-based dye. The reason for the semi-reclining position is to prevent development of seizures. With a water-based dye, fluids are encouraged to promote excretion of the dye. Positioning does not prevent development of infection. 

Question 5255) 

The client has a fractured right ankle that has just been casted. The nurse is instructing the client in crutch walking techniques. Which method is most appropriate? 

A. Move the right crutch, then the left foot, then the left crutch, and finally the right foot. 

B. Balance weight on the left foot and move right foot and both crutches forward, then bear weight on both crutches and move the left foot forward. 

C. Move the right crutch and left foot forward together; then move the left crutch and right foot.

D. Move the right crutch and right foot together; then move the left crutch and the left foot. 

Answer: B 

Explanation: A three-point gait is indicated when the client can bear no weight on one foot. This correctly describes a three-point gait for someone with a right foot problem. Answer 1 describes a fourpoint gait. The client must be able to bear weight on both feet for this gait. Answer 3 correctly describes a two-point gait. The client must be able to bear weight on both feet for this gait. Answer 4 does not correctly describe any gait. 

Question 5256) 

What should be included in the nursing care plan for a client with diabetes insipidus? 

A. Blood pressure every hour 

B. Strict intake and output 

C. Urine for ketone bodies 

D. Glucose monitoring four times a day 

Answer: B 

Explanation: Diabetes insipidus is excessive urine output due to decreased amounts of antidiuretic hormone. Because of the excessive urine output, it is necessary to monitor intake and output. 

Question 5257) 

What must the nurse do when preparing a client for a computed tomography (CT) scan? 

A. Administer a laxative prep 

B. Encourage fluids 

C. Explain the procedure 

D. Administer a radioisotope 

Answer: C 

Explanation: Explanation is all that is necessary. The client is not given a radioisotope. Fluids are not pushed prior to the procedure. The client frequently is given an iodine dye, so the nurse should ask about allergies to shellfish. 

Question 5258) 

Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information? 

A. Antibiotics will help to prevent respiratory complications following surgery. 

B. Meningitis is a complication following transsphenoidal hypophysectomy. 

C. Fluid retention can cause dangerously high cerebro spinal fluid pressure. 

D. Hormone replacement is essential after hypophysectomy 

Answer: B 

Explanation: A transsphenoidal approach goes through the roof of the mouth, which has many organisms. Meningitis can occur. Answer 1 is a true statement but not the primary reason in this case. Antibiotics do not lower spinal fluid pressure. Answer 4 is a true statement, but antibiotics are not hormones. 

Question 5259) 

Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test the fluid for: 

A. sugar. 

B. protein. 

C. bacteria. 

D. blood. 

Answer: A 

Explanation: Dripping in the back of the throat after a transsphenoidal hypophysectomy may be cerebrospinal fluid (CSF). CSF contains glucose. Saliva and mucus do not. 

Question 5260) 

The client is ready for discharge following an adrenalectomy. Which statement that the client makes indicates the best understanding of the client’s condition? 

A. “I will continue on a low-sodium, lowpotassium diet.” 

B. “My husband has arranged for a marriage counselor because of our fights.” 

C. “I will stay out of the sun so I will not turn splotchy brown.” 

D. “I will take all of those pills every day.” 

Answer: D 

Explanation: The client must take steroid replacements every day for the rest of his/her life. Answer 1 is not an appropriate diet. The client should be on a highsodium, low-potassium diet. The fights should decrease as mood swings decrease after surgery. The medications do not cause photosensitivity.