1. The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
❍ A. Nasal
... [Show More] congestion
❍ B. Abdominal tenderness
❍ C. Muscle tetany
❍ D. Oliguria
- Answer A is correct. Removal of the pituitary gland is usually done by a transphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.
2. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?
❍ A. Taking the vital signs
❍ B. Obtaining the permit
❍ C. Explaining the procedure
❍ D. Checking the lab work
- Answer A is correct. The primary responsibility of
the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
3. The nurse is making initial rounds on a client with a C5 fracture and Crutchfield tongs. Which equipment should be kept at the bedside?
❍ A. A pair of forceps
❍ B. A torque wrench
❍ C. A pair of wire cutters
❍ D. A screwdriver
- Answer B is correct. A torque wrench is kept at the bedside to tighten and loosen the screws of Crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.
4. A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?
❍ A. Hemiplegia
❍ B. Aphasia
❍ C. Nausea
❍ D. Bone pain
- Answer D is correct. Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.
5. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
❍ A. Uric acid of 5mg/dL
❍ B. Hematocrit of 33%
❍ C. WBC 2,000 per cubic millimeter
❍ D. Platelets 150,000 per cubic millimeter
- Answer C is correct. Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are incorrect.
6. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
❍ A. "Tell me about his pain."
❍ B. "What does his vomit look like?"
❍ C. "Describe his usual diet."
❍ D. "Have you noticed changes in his abdominal size?"
- Answer C is correct. The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.
7. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
❍ A. Teaching how to irrigate the ileostomy
❍ B. Stopping electrolyte loss in the incisional area
❍ C. Encouraging a high-fiber diet
❍ D. Facilitating perineal wound drainage
- Answer D is correct. The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an ileostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.
8. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?
❍ A. Foul breath
❍ B. Dysphagia
❍ C. Diarrhea
❍ D. Chronic hiccups
- Answer C is correct. Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings.
9. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
❍ A. A cephalohematoma
❍ B. Molding
❍ C. Subdural hematoma
❍ D. Caput succedaneum
- Answer A is correct. A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.
10. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?
❍ A. Bradycardia
❍ B. Tachycardia
❍ C. Premature ventricular beats
❍ D. Heart block
- Answer A is correct. Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely.
11. The nurse is caring for a client scheduled for a surgical repair of a secular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
❍ A. Assessment of the client's level of anxiety
❍ B. Evaluation of the client's exercise tolerance
❍ C. Identification of peripheral pulses
❍ D. Assessment of bowel sounds and activity
- Answer C is correct. The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.
12. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
❍ A. "You will be sitting for the examination procedure."
❍ B. "Portions of the procedure will cause pain or discomfort."
❍ C. "You will be given some medication to anesthetize the area."
❍ D. "You will not be able to drink fluids for 24 hours before the study."
- Answer B is correct. Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.
13. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
❍ A. That cannot be assessed
❍ B. That is in situ
❍ C. With increasing lymph node involvement
❍ D. With distant metastasis
- Answer B is correct. Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and metastasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.
14. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
❍ A. Hearing aid
❍ B. Contact lenses
❍ C. Wedding ring
❍ D. Artificial eye
- Answer B is correct. It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.
15. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
❍ A. Call the surgeon and ask him or her to see the client to clarify the information
❍ B. Explain the procedure and complications to the client
❍ C. Check in the physician's progress notes to see if understanding has been documented
❍ D. Check with the client's family to see if they understand the procedure fully - Answer A is correct. It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse's purview [Show Less]