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Nursing Exams
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A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include?
Expect to have a rapid pulse rate for the first few weeks.
Return in two weeks for a follow-up MRI.
Resume tub baths and swimming after 24 hr.
Wear loose-fitting clothing.
Correct Answer: D. Wear loose-fitting clothing
Explanation:
D. Wear loose-fitting clothing
Wearing loose-fitting clothing helps reduce irritation around the surgical site and prevents pressure or friction on the area where the implantable cardioverter/defibrillator (ICD) was placed. This promotes healing and comfort in the postoperative period.
Why Other Options Are Wrong:
A. Expect to have a rapid pulse rate for the first few weeks
A rapid pulse is not expected after ICD placement and could indicate a complication or an underlying arrhythmia that requires immediate medical attention.
B. Return in two weeks for a follow-up MRI
MRI procedures are contraindicated in most clients with ICDs unless the device is MRI-compatible. Clients should always verify MRI safety with their provider before undergoing the procedure.
C. Resume tub baths and swimming after 24 hr
Tub baths and swimming should be avoided until the surgical incision has completely healed, which typically takes several weeks, to reduce the risk of infection.
A client with end-stage kidney disease is being evaluated by a nurse. Which of the following outcomes is the nurse likely to anticipate? (Select all that apply.)
Anemia
Oliguria
Hypotension
Bradypnea
Edema
Correct Answers:
A. Anemia, B. Oliguria, E. Edema
Explanation:
A. Anemia – Expected. The kidneys produce erythropoietin, which stimulates red blood cell production. In end-stage kidney disease (ESKD), erythropoietin production declines, leading to anemia.
B. Oliguria – Expected. As kidney function deteriorates, urine output typically decreases, resulting in oliguria (less than 400 mL of urine per day).
E. Edema – Expected. Impaired renal function leads to fluid retention, contributing to peripheral and pulmonary edema.
Why Other Options Are Incorrect:
C. Hypotension – Not expected. Clients with ESKD often experience hypertension due to fluid overload and activation of the renin-angiotensin system, not hypotension.
D. Bradypnea – Not expected. Clients may experience tachypnea (rapid breathing) as a compensatory response to metabolic acidosis, which is common in ESKD, rather than bradypnea.
A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?
"You should not delegate this task because it requires nursing judgment."
"You can delegate this task to an AP for new clients before performing a nursing assessment."
"You can delegate this task if the AP has been trained to use our scales."
"You should not delegate this task because you have the capability to obtain clients' weights."
Correct Answer:
C. "You can delegate this task if the AP has been trained to use our scales."
Explanation:
C. "You can delegate this task if the AP has been trained to use our scales."
This is correct. Weighing clients is a routine, stable task that can be safely delegated to assistive personnel, provided they have been trained on the equipment and proper technique. Delegation is appropriate when the task does not require critical thinking or clinical judgment.
Why Other Options Are Wrong:
A. "You should not delegate this task because it requires nursing judgment."
This is incorrect. Weighing clients is not a complex task that requires nursing judgment. It’s a measurable, routine procedure that can be delegated safely.
B. "You can delegate this task to an AP for new clients before performing a nursing assessment."
This is incorrect because initial data collection for new clients should be completed by the nurse to ensure accuracy and context for the assessment.
D. "You should not delegate this task because you have the capability to obtain clients' weights."
This is incorrect because the ability of the nurse to do the task does not preclude appropriate delegation. Delegation helps manage workload efficiently and safely.
A nurse is caring for a client at the clinic.
Exhibit 1
Nurses' Notes
0900:
Client presents to the clinic at 10 weeks gestation. Client reports abdominal cramping and moderate, bright red vaginal bleeding. Cervix is open upon vaginal examination by provider. Client has a history of type 1 diabetes mellitus and recurrent chlamydia infections.
Exhibit 2
Laboratory Results
1000:
Human chorionic gonadotropin (hCG) level 30,000 international
units/L (greater than 25,000 international units/L)
Hemoglobin 12 g/dL (greater than 11 g/dL)
Hematocrit 35% (greater than 33%)
Complete the following sentence by using the lists of options.
The client is at risk for Select (molar pregnancy/ ectopic pregnancy/ spontaneous abortion) … as evidenced by Select …(cervical dilation/ history of chlamydia infections/ hCG levels)
Complete the sentence:
The client is at risk for spontaneous abortion as evidenced by cervical dilation.
Spontaneous abortion
Cervical dilation
Molar pregnancy
Ectopic pregnancy
History of chlamydia infections
hCG levels
Correct Options Explained:
Spontaneous abortion
A spontaneous abortion refers to the natural loss of a pregnancy before 20 weeks gestation. Signs include abdominal cramping, bright red vaginal bleeding, and an open cervix. The open cervix confirms that this is not just a threatened abortion, but likely an inevitable or ongoing miscarriage.
Cervical dilation
Cervical dilation in early pregnancy is abnormal and typically indicates the body is beginning to expel the products of conception, which is a hallmark sign of spontaneous abortion. In the absence of interventions like labor induction or delivery, dilation at this stage suggests miscarriage risk.
Incorrect Options Explained:
Molar pregnancy
Molar pregnancies are a form of gestational trophoblastic disease where abnormal tissue grows in place of a fetus. They often present with very high hCG levels, absence of fetal heart tones, and no cervical dilation early on. The client’s hCG level is normal for 10 weeks, and the presentation (vaginal bleeding and an open cervix) does not match a molar pregnancy.
Ectopic pregnancy
An ectopic pregnancy involves implantation outside the uterus, most commonly in the fallopian tube. While the client’s history of chlamydia increases her risk for ectopic pregnancy due to possible tubal scarring, an open cervix and vaginal bleeding at 10 weeks with a normal hCG suggest an intrauterine pregnancy that is failing, not an ectopic one.
History of chlamydia infections
This is a risk factor for certain complications like ectopic pregnancy, but it is not evidence of a current problem like spontaneous abortion. It supports background risk but is not diagnostic.
hCG levels
The hCG level of 30,000 IU/L is appropriate for a 10-week gestation. Elevated or low hCG could support other diagnoses (like molar or ectopic pregnancy), but in this case, hCG is within range and does not indicate a problem. Therefore, it does not support a diagnosis of spontaneous abortion.
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
Fibrinogen level
aPTT
INR
Platelet count
Correct Answer:
C. INR
Explanation:
C. INR (International Normalized Ratio) is the standard lab test used to monitor the effectiveness of warfarin therapy. It reflects how long it takes the blood to clot and helps guide dosing adjustments to maintain therapeutic anticoagulation and prevent bleeding or thrombotic complications.
Why Other Options Are Wrong:
A. Fibrinogen level
This measures the concentration of fibrinogen, a clotting factor, and is not typically used to monitor warfarin therapy. It’s more useful in assessing bleeding disorders or liver function.
B. aPTT (activated Partial Thromboplastin Time)
This test is used to monitor heparin therapy, not warfarin. Warfarin primarily affects the extrinsic pathway, which is best measured by the PT/INR, not aPTT.
D. Platelet count
While important for overall clotting function, platelet count does not reflect warfarin’s effect on clotting time and is not used to guide warfarin dosing decisions.
A nurse is collecting data from a client who received oxytocin 10 units IM 30 minutes ago for excessive vaginal bleeding. Which of the following findings should the nurse expect
Client report of burning with urination
Client report of uterine cramping
Boggy fundus 3 fingerbreadths above the umbilicus
Saturation of perineal pad in 15 minutes
Correct Answer B: Client report of uterine cramping
Explanation:
Oxytocin is a uterotonic medication that stimulates uterine contractions to reduce postpartum bleeding by promoting uterine involution and minimizing blood loss from the placental site. After administration of 10 units IM, the expected therapeutic effect is uterine contraction, often experienced by the client as cramping.
A report of uterine cramping indicates that the oxytocin is working effectively to contract the uterus and decrease bleeding—a desired and expected outcome.
Why the Other Options Are Incorrect:
A. Client report of burning with urination
This is not related to oxytocin administration. Burning with urination suggests a urinary tract infection (UTI) and is not an expected effect of oxytocin. It would require separate assessment and possible treatment.
C. Boggy fundus 3 fingerbreadths above the umbilicus
A boggy (soft) and elevated uterus is a sign of uterine atony, which contributes to postpartum hemorrhage. This indicates that the oxytocin has not been effective, and further intervention is required. This is not an expected finding if the medication is working properly.
D. Saturation of perineal pad in 15 minutes
Rapid saturation of a perineal pad suggests active hemorrhage. Oxytocin is given to prevent or control such bleeding, so this finding would indicate ineffective treatment, not an expected effect.
Summary:
The correct answer is B. Client report of uterine cramping. This indicates that oxytocin is producing its intended effect of stimulating uterine contractions to manage postpartum bleeding.
The nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?
Semi-Fowler's
Lateral recumbent
Reverse Trendelenburg
Pron
Correct Answer: Lateral recumbent
Correct Answer with Explanation:
Lateral recumbent
The lateral recumbent (side-lying) position is the correct position for a lumbar puncture. The nurse assists the client to lie on their side with knees drawn up to the chest and the chin tucked downward. This position helps maximize the space between the vertebrae, providing optimal access to the subarachnoid space for needle insertion. It also stabilizes the spine, reducing the risk of injury and facilitating accurate needle placement.
Explanation of Incorrect Options:
Semi-Fowler's
This position involves the client lying on their back with the head of the bed elevated to 30–45 degrees. It is typically used for patients with respiratory issues or after surgery. However, it does not allow sufficient spinal flexion for a lumbar puncture.
Reverse Trendelenburg
In this position, the body lies flat but the head is elevated higher than the feet. It is not appropriate for spinal procedures and does not assist in separating vertebrae.
Prone
Lying on the abdomen (prone) does not expose the lumbar spine effectively for the procedure and increases the risk of incorrect needle placement. It is not used for lumbar punctures.
Summary:
To perform a lumbar puncture, the client must be positioned to allow spinal flexion and access to the lumbar region. The lateral recumbent position provides the ideal angle and stability for the procedure.
A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally 3 times a day at home. Which of the following components of the prescription should the nurse question?
Dosage
Time
Route
Medication
Correct Answer: Dosage
Detailed Explanation of the Correct Answer:
Dosage
The prescription states "0.5 mL" of haloperidol orally, but medication dosages should be prescribed in milligrams (mg), not milliliters (mL), unless the concentration (e.g., mg/mL) is clearly specified. Without knowing the concentration of haloperidol, the nurse cannot confirm the correct dose. This lack of clarity poses a safety concern, and the nurse should clarify this with the provider.
Detailed Explanation of Incorrect Options:
Time
Taking haloperidol three times a day is a commonly prescribed frequency for managing symptoms of Tourette syndrome. There is no issue with the timing as presented.
Route
The oral route is appropriate and commonly used for haloperidol in managing Tourette syndrome. No clarification is needed here.
Medication
Haloperidol is an antipsychotic medication that is often used to manage tics in clients with Tourette syndrome. The medication choice itself does not need to be questioned based on the information provided.
Summary:
The issue lies in the lack of clarity regarding the dosage, which is given in milliliters without stating the concentration. The nurse should always ensure doses are clearly defined and measurable in terms of the drug’s active ingredient (usually in mg).
A nurse is caring for a client who has a potassium level of 3.2 mEq/L (3.5 to 5 mEq/L). Which of the following foods should the nurse recommend as being the best source of potassium?
1/2 cup apple juice
1/2 cup steamed cauliflower
1 cup boiled white rice
1 cup cantaloupe
Correct Answer:
D. 1 cup cantaloupe
Explanation:
D. 1 cup cantaloupe
Cantaloupe provides over 400 mg of potassium per cup, making it an excellent food choice for clients with hypokalemia. Potassium helps maintain fluid balance, nerve signals, and muscle contractions, and cantaloupe offers a high concentration in a small serving size.
Why Other Options Are Wrong:
A. 1/2 cup apple juice
Apple juice contains about 120 mg of potassium per half cup, which is a low amount and not sufficient for correcting hypokalemia through diet.
B. 1/2 cup steamed cauliflower
Steamed cauliflower provides approximately 150 mg of potassium per half cup, which is inadequate for clients needing to increase potassium intake.
C. 1 cup boiled white rice
Boiled white rice contains less than 60 mg of potassium per cup, making it one of the least effective options for potassium replenishment.
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
Refer to the hallucinations as if they are real.
Ask the client directly what they are hearing.
Avoid eye contact with the client.
Encourage the client to lie down in a quiet room.
Correct Answer:
B. Ask the client directly what they are hearing.
Explanation:
B. Asking the client directly what they are hearing allows the nurse to assess the content and nature of the hallucinations. This is critical for identifying potential safety concerns (such as command hallucinations) and planning appropriate interventions while still maintaining a therapeutic and nonjudgmental approach.
Why Other Options Are Wrong:
A. Refer to the hallucinations as if they are real.
This is incorrect because it reinforces the hallucinations as reality, which can increase confusion and impair the client’s ability to distinguish between reality and psychosis.
C. Avoid eye contact with the client.
Avoiding eye contact can be perceived as dismissive or unengaged. Therapeutic communication involves maintaining appropriate eye contact to build trust and convey empathy.
D. Encourage the client to lie down in a quiet room.
Encouraging isolation may increase focus on hallucinations and exacerbate psychotic symptoms. Clients benefit more from distraction, engagement in reality-based activities, and supportive interaction.
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