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Process Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be su... re to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: 1. Plan is developed for nursing care. 2. Physical assessment begins 3. List of priorities is determined. 4. Review of the assessment is conducted with other team members. 2. Planning is a category of nursing behaviors in which: 1. The nurse determines the health care needed for the client. 2. The Physician determines the plan of care for the client. 3. Client-centered goals and expected outcomes are established. 4. The client determines the care needed. 3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: 1. Physician 2. Non Emergent, non-life threatening needs 3. Future well-being. 4. Urgency of problems 4. A client centered goal is a specific and measurable behavior or response that reflects a client’s: 1. Desire for specific health care interventions 2. Highest possible level of wellness and independence in function. 3. Physician’s goal for the specific client. 4. Response when compared to another client with a like problem. 5. For clients to participate in goal setting, they should be: 1. Alert and have some degree of independence. 2. Ambulatory and mobile. 3. Able to speak and write. 4. Able to read and write. 6. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Client will have less pain. 2. Client will be pain free. 3. Client will report pain acuity less than 4 on a scale of 0-10. 4. Client will take pain medication every 4 hours around the clock. 17. As goals, outcomes, and interventions are developed, the nurse must: 1. Be in charge of all care and planning for the client. 2. Be aware of and committed to accepted standards of practice from nursing and other disciples. 3. Not change the plan of care for the client. 4. Be in control of all interventions for the client. 8. When establishing realistic goals, the nurse: 1. Bases the goals on the nurse’s personal knowledge. 2. Knows the resources of the health care facility, family, and the client. 3. Must have a client who is physically and emotionally stable. 4. Must have the client’s cooperation. 9. To initiate an intervention the nurse must be competent in three areas, which include: 1. Knowledge, function, and specific skills 2. Experience, advanced education, and skills. 3. Skills, finances, and leadership. 4. Leadership, autonomy, and skills. 10. Collaborative interventions are therapies that require: 1. Physician and nurse interventions. 2. Nurse and client interventions. 3. Client and Physician intervention. 4. Multiple health care professionals. 11. Well formulated, client-centered goals should: 1. Meet immediate client needs. 2. Include preventative health care. 3. Include rehabilitation needs. 4. All of the above. 12. The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): 1. Nursing diagnosis 2. Short-term goal 3. Long-term goal 4. Expected outcome 13. The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: 1. Nursing interventions 2. Short-term goals 3. Long-term goals 4. Expected outcomes. 14. The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement. 3. Performing nursing actions and documenting them. 4. Setting goals and selecting interventions. 15. The nursing care plan is: 1. A written guideline for implementation and evaluation. 2. A documentation of client care. 23. A projection of potential alterations in client behaviors 4. A tool to set goals and project outcomes. 16. After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: 1. Encourage client to implement guided imagery when pain begins. 2. Determine effect of pain intensity on client function. 3. Administer analgesic 30 minutes before physical therapy treatment. 4. Pain intensity reported as a 3 or less during hospital stay. 17. When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: 1. Apply a cold pack to the tibia. 2. Elevate the leg 5 inches above the heart. 3. Perform range of motion to right leg every 4 hours. 4. Administer aspirin 325 mg every 4 hours as needed. 18. Which of the following nursing interventions are written correctly? (Select all that apply.) 1. Apply continuous passive motion machine during day. 2. Perform neurovascular checks. 3. Elevate head of bed 30 degrees before meals. 4. Change dressing once a shift. 19. A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: 1. Notifying the physician. 2. Calling the wound care nurse 3. Changing the wound care treatment. 4. Consulting with another nurse. 20. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: 1. Length of time the current treatment has been in place. 2. The spouse’s reaction to the client’s dressing change. 3. Client’s concern about the current treatment. 4. Physician’s reluctance to change the current treatment plan. 21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: 1. Implement the specialist’s recommendations. 2. Report the recommendations to the primary physician. 3. Clarify the suggestions with the client and family members. 4. Discuss and review advised strategies with CNS. 22. After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion. 23. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? 31. A client’s family attending a diabetic teaching session. 2. Canceling physical therapy sessions on the weekend. 3. Normal VS and absence of wound infection in a post-op client. 4. A client demonstrating accurate medication administration following teaching. 24. The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? 1. A client who is ambulatory. 2. A client, who has a fever, is diaphoretic and restless. 3. A client scheduled for OT at 1300. 4. A client who just had an appendectomy and has just received pain medication. Answers and Rationale 1. A 2. B 3. D 4. B 5. A 6. C 7. B 8. B 9. A 10. D 11. D 12. B 13. D 14. D 15. A 16. D. This is measurable and objective. 17. B. This does not require a physician’s order. (A & D require an order; C is not appropriate for a fractured tibia) 18. C. It is specific in what to do and when. 19. B. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.) 20. A. This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new treatment plan by the nurse consultant.) 21. D. Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a. Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. b. This would be appropriate after first talking with the CNS about 4recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.) 22. C, D, A, B. 23. B. 24. B. This clients needs are a priority. Introduction An NCLEX practice exam dedicated to Coronary Artery Disease and Hypertension. This exam contains 50 items about the two diseases. Topics  Coronary Artery Disease  Hypertension Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? 1. Intake and output 2. Baseline peripheral pulse rates 3. Height and weight 4. Allergy to iodine or shellfish 2. A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? 1. “Have you ever had this pain before?” 2. “Can you describe the pain to me?” 3. “Does the pain get worse when you breathe in?” 4. “Can you rate the pain on a scale of 1-10, with 10 being the worst?” 3. A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? 1. Strict bed rest for 24 hours after transfer 2. Bathroom privileges and self-care activities 3. Unsupervised hallway ambulation with distances under 200 feet 4. Ad lib activities because the client is monitored. 54. A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 1. Review the intake and output records for the last 2 days 2. Change the time of diuretic administration from morning to evening 3. Request a sodium restriction of 1 g/day from the physician. 4. Order daily weights starting the following morning. 5. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: 1. Check the client status and lead placement 2. Press the recorder button on the electrocardiogram console. 3. Call the physician 4. Call a code blue 6. A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? 1. Seating the client with arm bared, supported, and at heart level. 2. Measuring the blood pressure after the client has been seated quietly for 5 minutes. 3. Using a cuff with a rubber bladder that encircles at least 80% of the limb. 4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. 7. IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate 8. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client’s prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is: 1. The same as the client’s own baseline level 2. Lower than the needed therapeutic level 3. Within the therapeutic range 4. Higher than the therapeutic range 9. A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin: 1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exert an anticoagulant effect. 2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. 3. Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for this to begin. 4. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic. 10. A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 64L/minute, blood work, chest x-ray, an ECG, and 2 mg of morphine given intravenously. The nurse should first: 1. Administer the morphine 2. Obtain a 12-lead ECG 3. Obtain the lab work 4. Order the chest x-ray 11. When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to: 1. Help keep him well hydrated 2. Dissolve clots he may have 3. Prevent kidney failure 4. Treat potential cardiac arrhythmias. 12. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply. 1. Reflects electrical impulse beginning at the SA node 2. Indicated electrical impulse beginning at the AV node 3. Reflects atrial muscle depolarization 4. Identifies ventricular muscle depolarization 5. Has duration of normally 0.11 seconds or less. 13. A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse’s next action would be to: 1. Call for the doctor 2. Start an intravenous line 3. Obtain a portable chest radiograph 4. Draw blood for laboratory studies 14. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 1. Cancer 2. Hypertension 3. Liver disease 4. Myocardial infarction 15. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II. 16. The most important long-term goal for a client with hypertension would be to: 1. Learn how to avoid stress 2. Explore a job change or early retirement 73. Make a commitment to long-term therapy 4. Control high blood pressure 17. Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of: 1. Cerebrovascular accident 2. Liver disease 3. Myocardial infarction 4. Pulmonary disease 18. During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting an invalid friend twice a week and now cannot walk up the second flight of steps to the friend’s apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? 1. Visit her friend earlier in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down once she reaches the friend’s apartment. 19. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? 1. A change in the pattern of her pain 2. Pain during sex 3. Pain during an argument with her husband 4. Pain during or after an activity such as lawn mowing 20. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: 1. Open and dilate the blocked coronary arteries 2. Assess the extent of arterial blockage 3. Bypass obstructed vessels 4. Assess the functional adequacy of the valves and heart muscle. 21. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug’s principal effects are produced by: 1. Antispasmodic effect on the pericardium 2. Causing an increased myocardial oxygen demand 3. Vasodilation of peripheral vasculature 4. Improved conductivity in the myocardium 22. The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: 1. Headache 2. High blood pressure 3. Shortness of breath 4. Stomach cramps 823. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? 1. Take one tablet every 2 to 5 minutes until the pain stops. 2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. 3. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists after three tablets. 4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician. 24. Which of the following arteries primarily feeds the anterior wall of the heart? 1. Circumflex artery 2. Internal mammary artery 3. Left anterior descending artery 4. Right coronary artery 25. When do coronary arteries primarily receive blood flow? 1. During inspiration 2. During diastolic 3. During expiration 4. During systole 26. Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart? 1. Anterior 2. Apical 3. Inferior 4. Lateral 27. A murmur is heard at the second left intercostal space along the left sternal border. Which valve is this? 1. Aortic 2. Mitral 3. Pulmonic 4. Tricuspid 28. Which of the following blood tests is most indicative of cardiac damage? 1. Lactate dehydrogenase 2. Complete blood count (CBC) 3. Troponin I 4. Creatine kinase (CK) 29. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? 1. Cardiac catheterization 2. Cardiac enzymes 3. Echocardiogram 4. Electrocardiogram (ECG) 30. Which of the following types of pain is most characteristic of angina? 1. Knifelike 2. Sharp 3. Shooting 4. Tightness 931. Which of the following parameters is the major determinant of diastolic blood pressure? 1. Baroreceptors 2. Cardiac output 3. Renal function 4. Vascular resistance 32. Which of the following factors can cause blood pressure to drop to normal levels? 1. Kidneys’ excretion of sodium only 2. Kidneys’ retention of sodium and water 3. Kidneys’ excretion of sodium and water 4. Kidneys’ retention of sodium and excretion of water 33. Baroreceptors in the carotid artery walls and aorta respond to which of the following conditions? 1. Changes in blood pressure 2. Changes in arterial oxygen tension 3. Changes in arterial carbon dioxide tension 4. Changes in heart rate 34. Which of the following terms describes the force against which the ventricle must expel blood? 1. Afterload 2. Cardiac output 3. Overload 4. Preload 35. Which of the following terms is used to describe the amount of stretch on the myocardium at the end of diastole? 1. Afterload 2. Cardiac index 3. Cardiac output 4. Preload 36. A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension. Before administered propranolol, which of the following actions should the nurse take first? 1. Monitor the apical pulse rate 2. Instruct the client to take medication with food 3. Question the physician about the order 4. Caution the client to rise slowly when standing. 37. One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Hypernatremia 38. A client is receiving spironolactone to treat hypertension. Which of the following instructions should the nurse provide? 1. “Eat foods high in potassium.” 2. “Take daily potassium supplements.” 103. “Discontinue sodium restrictions.” 4. “Avoid salt substitutes.” 39. When assessing an ECG, the nurse knows that the P-R interval represents the time it takes for the: 1. Impulse to begin atrial contraction 2. Impulse to transverse the atria to the AV node 3. SA node to discharge the impulse to begin atrial depolarization 4. Impulse to travel to the ventricles 40. Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn’t understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is: 1. “Cardiac rehabilitation is not a cure but can help restore you to many of your former activities.” 2. “Here we teach you to gradually change your lifestyle to accommodate your heart disease.” 3. “You are probably right but we can gradually increase your activities so that you can live a more active life.” 4. “Do you feel that you will have to make some changes in your life now?” 41. To evaluate a client’s condition following cardiac catheterization, the nurse will palpate the pulse: 1. In all extremities 2. At the insertion site 3. Distal to the catheter insertion 4. Above the catheter insertion 42. A client’s physician orders nuclear cardiography and makes an appointment for a thallium scan. The purpose of injecting radioisotope into the bloodstream is to detect: 1. Normal vs. abnormal tissue 2. Damage in areas of the heart 3. Ventricular function 4. Myocardial scarring and perfusion 43. A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? 1. Monitoring vital signs 2. Completing a physical assessment 3. Maintaining cardiac monitoring 4. Maintaining at least one IV access site 44. A client is experiencing tachycardia. The nurse’s understanding of the physiological basis for this symptom is explained by which of the following statements? 1. The demand for oxygen is decreased because of pleural involvement 2. The inflammatory process causes the body to demand more oxygen to meet its needs. 3. The heart has to pump faster to meet the demand for oxygen when there is lowered arterial oxygen tension. 4. Respirations are labored. 45. A client enters the ER complaining of chest pressure and severe epigastric distress. His VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were 11diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3 to 8 hours? 1. Creatine kinase (CK or CPK) 2. Lactic dehydrogenase (LDH) 3. LDH-1 4. LDH-2 46. A 45-year-old male client with leg ulcers and arterial insufficiency is admitted to the hospital. The nurse understands that leg ulcers of this nature are usually caused by: 1. Decreased arterial blood flow secondary to vasoconstriction 2. Decreased arterial blood flow leading to hyperemia 3. Atherosclerotic obstruction of the arteries 4. Trauma to the lower extremities 47. Which of the following instructions should be included in the discharge teaching for a patient discharged with a transdermal nitroglycerin patch? 1. “Apply the patch to a non hairy, nonfatty area of the upper torso or arms.” 2. “Apply the patch to the same site each day to maintain consistent drug absorption.” 3. “If you get a headache, remove the patch for 4 hours and then reapply.” 4. “If you get chest pain, apply a second patch right next to the first patch.” 48. In order to prevent the development of tolerance, the nurse instructs the patient to: 1. Apply the nitroglycerin patch every other day 2. Switch to sublingual nitroglycerin when the patient’s systolic blood pressure elevates to >140 mm Hg 3. Apply the nitroglycerin patch for 14 hours each and remove for 10 hours at night 4. Use the nitroglycerin patch for acute episodes of angina only 49. Direct-acting vasodilators have which of the following effects on the heart rate? 1. Heart rate decreases 2. Heart rate remains significantly unchanged 3. Heart rate increases 4. Heart rate becomes irregular 50. When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together, the nurse bases teaching on the knowledge that: 1. Moderate doses of two different types of diuretics are more effective than a large dose of one type 2. This combination promotes diuresis but decreases the risk of hypokalemia 3. This combination prevents dehydration and hypovolemia 4. Using two drugs increases osmolality of plasma and the glomerular filtration rate Answers and Rationale Gauge your performance by counter checking your answers to the answers below. Learn more about the question by reading the rationale. If you have any disputes or questions, please direct them to the comments section. 1. Answer: 4. This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. 2. Answer: 3. Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. 123. Answer: 2. On transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation for brief distances are encouraged, with distances gradually increased (50, 100, 200 feet). 4. Answer: 1. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms. 5. Answer: 1. Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. 6. Answer: 4. BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy. 7. Answer: 4. The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin. 8. . Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally Answer: 3. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at risk for thrombus. Based on the client’s control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within therapeutic range. 9. Answer: 2. Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. 10. Answer: 1. Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse’s priority action would be to relieve the crushing chest pain. 11. Answer: 2. Thrombolytic drugs are administered within the first 6 hours after onset of a MI to lyse clots and reduce the extent of myocardial damage. 12. Answer: 1, 3, 5. In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height. 13. Answer: 2. Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood are important but secondary to starting the intravenous line. 14. Answer: 4detected about one hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction (Remember, less than 90 mg/L is normal). 15. Answer: 1. Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction. 16. Answer: 3. Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance. 17. Answer: 1. Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVA’s can be related to 13long-term hypertension. Liver or pulmonary disease is generally not associated with hypertension. Myocardial infarction is generally related to coronary artery disease. 18. Answer: 3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode. 19. Answer: 1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD. 20. Answer: 2. Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. 21. Answer: 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium. 22. Answer: 1. Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or shit down to avoid fainting. Nitro does not cause shortness of breath or stomach cramps. 23. Answer: 3. The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of 3 tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. 24. Answer: 3. The left anterior descending artery is the primary source of blood flow for the anterior wall of the heart. The circumflex artery supplies the lateral wall, the internal mammary supplies the mammary, and the right coronary artery supplies the inferior wall of the heart. 25. Answer: 2. Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are irrelevant to blood flow. 26. Answer: 3. The right coronary artery supplies the right ventricle, or the inferior portion of the heart. Therefore, prolonged occlusion could produce an infarction in that area. The right coronary artery doesn’t supply the anterior portion (left ventricle), lateral portion (some of the left ventricle and the left atrium), or the apical portion (left ventricle) of the heart. 27. Answer: 3. Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricupsid valve abnormalities are heard at the 3rd and 4th intercostal spaces along the sternal border. 28. Answer: 3. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren’t detectable in people without cardiac injury. 29. Answer: 4. The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can’t determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the study may not be performed immediately. 1430. Answer: 4. The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms. 31. Answer: 4. Vascular resistance is the impedance of blood flow by the arterioles that most predominantly affects the diastolic pressure. Cardiac output determines systolic blood pressure. 32. Answer: 3. The kidneys respond to a rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic pressure by regulating blood volume. 33. Answer: 1. Baroreceptors located in the carotid arteries and aorta sense pulsatile pressure. Decreases in pulsatile pressure cause a reflex increase in heart rate. Chemoreceptors in the medulla are primarily stimulated by carbon dioxide. Peripheral chemoreceptors in the aorta and carotid arteries are primarily stimulated by oxygen. 34. Answer: 1. Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled from the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole. 35. Answer: 4. Preload is the amount of stretch of the cardiac muscle fibers at the end of diastole. The volume of blood in the ventricle at the end of diastole determines the preload. Afterload is the force against which the ventricle must expel blood. Cardiac index is the individualized measurement of cardiac output, based on the client’s body surface area. Cardiac output is the amount of blood the heart is expelling per minute. 36. Answer: 3. Propranolol and other beta-adrenergic blockers are contraindicated in a client with asthma, so the nurse should question the physician before giving the dose. The other responses are appropriate actions for a client receiving propranolol, but questioning the physician takes priority. The client’s apical pulse should always be checked before giving propranolol; if the pulse rate is extremely low, the nurse should withhold the drug and notify the physician. 37. Answer: 3. Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia. 38. Answer: 4. Because spironolactone is a potassium-sparing diuretic, the client should avoid salt substitutes because of their high potassium content. The client should also avoid potassium-rich foods and potassium supplements. To reduce fluid-volume overload, sodium restrictions should continue. 39. Answer: 4. The P-R interval is measured on the ECG strip from the beginning of the P wave to the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle. 40. Answer: 1. Such a response does not have false hope to the client but is positive and realistic. The answer tells the client what cardiac rehabilitation is and does not dwell upon his negativity about it. 41. Answer: 3. Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong. 42. Answer: 4. This scan detects myocardial damage and perfusion, an acute or chronic MI. It is a more specific answer than (1) or (2). Specific ventricular function is tested by a gated cardiac blood pool scan. 43. Answer: 3. Even though initial tests seem to be within normal range, it takes at least 3 hours for the cardiac enzyme studies to register. In the meantime, the client needs to be watched for bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be accomplished around the MI monitoring. 44. Answer: 3. The arterial oxygen supply is lowered and the demand for oxygen is increased, which results in the heart’s having to beat faster to meet the body’s needs for oxygen. 1545. Answer: 1. Creatine kinase (CK, formally known as CPK) rises in 3-8 hours if an MI is present. When the myocardium is damaged, CPK leaks out of the cell membranes and into the bloodstream. Lactic dehydrogenase rises in 24-48 hours, and LDH-1 and LDH-2 rises in 8-24 hours. 46. Answer: 1. Decreased arterial flow is a result of vasospasm. The etiology is unknown. It is more problematic in colder climates or when the person is under stress. Hyperemia occurs when the vasospasm is relieved. 47. Answer: 1. A nitroglycerin patch should be applied to a non hairy, nonfatty area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and the drug should be continued if headache occurs because tolerance will develop. Sublingual nitroglycerin should be used to treat chest pain. 48. Answer: 3. Tolerance can be prevented by maintaining an 8- to 12-hour nitrate-free period each day. 49. Answer: 3. Heart rate increases in response to decreased blood pressure caused by vasodilation. 50. Answer: 2. Spironolactone is a potassium-sparing diuretic; furosemide is a potassium-losing diuretic. Giving these together minimizes electrolyte imbalance. Introduction This is a 40-item examination about Hematologic Disorders like Hemophilia, Sickle Cell Disease, Anemia and Polycythemia Vera. This is an NCLEX style examination. Topics  Hemophilia  Sickle Cell Disease  Anemia  Polycythemia Vera Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? 1. Eggs 2. Lettuce 3. Citrus fruits 4. Cheese 2. The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? 1. Whole grains 2. Green leafy vegetables 3. Meats and dairy products 4. Broccoli and Brussels sprouts 163. The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? 1. Total bilirubin, 0.3 mg/dL 2. Serum creatinine, 0.5 mg/dL 3. Hemoglobin, 16 g/dL 4. Folate, 1.5 ng/mL 4. The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? 1. Schilling’s test, elevated 2. Intrinsic factor, absent. 3. Sedimentation rate, 16 mm/hour 4. RBCs 5.0 million 5. The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? 1. Eat animal protein and dark leafy vegetables each day 2. Avoid exposure to others with acute infection 3. Practice yoga and meditation to decrease stress and anxiety 4. Get 8 hours of sleep at night and take naps during the day 6. A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? 1. “I have been drinking plenty of fluids.” 2. “I have been gargling with warm salt water for my sore tongue.” 3. “I have 3 to 4 loose stools per day.” 4. “I take a vitamin B12 tablet every day.” 7. A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: 1. Adds dried fruit to cereal and baked goods 2. Cooks tomato-based foods in iron pots 3. Drinks coffee or tea with meals 4. Adds vitamin C to all meals 8. A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client’s activity intolerance? 1. “What activities were you able to do 6 months ago compared with the present?” 2. “How long have you had this problem?” 3. “Have you been able to keep up with all your usual activities?” 4. “Are you more tired now than you used to be?” 9. The primary purpose of the Schilling test is to measure the client’s ability to: 1. Store vitamin B12 2. Digest vitamin B12 3. Absorb vitamin B12 4. Produce vitamin B12 10. The nurse implements which of the following for the client who is starting a Schilling test? 171. Administering methylcellulose (Citrucel) 2. Starting a 24- to 48 hour urine specimen collection 3. Maintaining NPO status 4. Starting a 72 hour stool specimen collection 11. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse’s best response? 1. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid.” 2. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor.” 3. “The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction.” 4. “The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production.” 12. The nurse is assessing a client’s activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response? 1. Pulse rate increased by 20 bpm immediately after the activity 2. Respiratory rate decreased by 5 breaths/minute 3. Diastolic blood pressure increased by 7 mm Hg 4. Pulse rate within 6 bpm of resting phase after 3 minutes of rest. 13. When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate? 1. Check the dressing and drains for frank bleeding 2. Call the physician 3. Continue to monitor vital signs 4. Start oxygen at 2L/min per NC 14. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? 1. Hematocrit 2. Partial thromboplastin time 3. Hemoglobin concentration 4. Prothrombin time 15. A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse’s best response to relieve these fears? 1. “Vitamin B12 will cause ringing in the eats before a toxic level is reached.” 2. “Vitamin B12 may cause a very mild skin rash initially.” 3. “Vitamin B12 may cause mild nausea but nothing toxic.” 4. “Vitamin B12 is generally free of toxicity because it is water soluble.” 16. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client’s nutritional needs and personal preferences? 1. Egg yolks 2. Brown rice 3. Vegetables 4. Tea 1817. A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse’s first response? 1. Assess for potential abuse 2. Check for diminished sensations 3. Document the findings 4. Clean and dress the area 18. Which of the following nursing assessments is a late symptom of polycythemia vera? 1. Headache 2. Dizziness 3. Pruritus 4. Shortness of breath 19. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply. 1. Hearing loss 2. Visual disturbance 3. Headache 4. Orthopnea 5. Gout 6. Weight loss 20. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? 1. Bleeding tendencies 2. Intake and output 3. Peripheral sensation 4. Bowel function 21. Which of the following blood components is decreased in anemia? 1. Erythrocytes 2. Granulocytes 3. Leukocytes 4. Platelets 22. A client with anemia may be tired due to a tissue deficiency of which of the following substances? 1. Carbon dioxide 2. Factor VIII 3. Oxygen 4. T-cell antibodies 23. Which of the following cells is the precursor to the red blood cell (RBC)? 1. B cell 2. Macrophage 3. Stem cell 4. T cell 24. Which of the following symptoms is expected with hemoglobin of 10 g/dl? 1. None 2. Pallor 3. Palpitations 4. Shortness of breath 1925. Which of the following diagnostic findings are most likely for a client with aplastic anemia? 1. Decreased production of T-helper cells 2. Decreased levels of white blood cells, red blood cells, and platelets 3. Increased levels of WBCs, RBCs, and platelets 4. Reed-Sternberg cells and lymph node enlargement 26. A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? 1. “Take the medication with an antacid.” 2. “Take the medication with a glass of milk.” 3. “Take the medication with cereal.” 4. “Take the medication on an empty stomach.” 27. Which of the following disorders results from a deficiency of factor VIII? 1. Sickle cell disease 2. Christmas disease 3. Hemophilia A 4. Hemophilia B 28. The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? 1. Autoimmune reaction complicated by hypoxia 2. Lack of oxygen in the red blood cells 3. Obstruction to circulation 4. Elevated serum bilirubin concentration. 29. The mothers asks the nurse why her child’s hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate? 1. “The placenta bars passage of the hemoglobin S from the mother to the fetus.” 2. “The red bone marrow does not begin to produce hemoglobin S until several months after birth.” 3. “Antibodies transmitted from you to the fetus provide the newborn with temporary immunity.” 4. “The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth.” 30. Which of the following would the nurse identify as the priority nursing diagnosis during a toddler’s vaso-occlusive sickle cell crisis? 1. Ineffective coping related to the presence of a life-threatening disease 2. Decreased cardiac output related to abnormal hemoglobin formation 3. Pain related to tissue anoxia 4. Excess fluid volume related to infection 31. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent infections. The nurse responds based on the understanding of which of the following? 1. Little is known about iron-deficiency anemia and its relationship to infection in children. 2. Children with iron deficiency anemia are more susceptible to infection than are other children. 3. Children with iron-deficiency anemia are less susceptible to infection than are other children. 4. Children with iron-deficient anemia are equally as susceptible to infection as are other children. 32. Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply. 201. “He drinks over 3 cups of milk per day.” 2. “I can’t keep enough apple juice in the house; he must drink over 10 ounces per day.” 3. “He refuses to eat more than 2 different kinds of vegetables.” 4. “He doesn’t like meat, but he will eat small amounts of it.” 5. “He sleeps 12 hours every night and take a 2-hour nap.” 33. Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? 1. Rice cereal, whole milk, and yellow vegetables 2. Potato, peas, and chicken 3. Macaroni, cheese, and ham 4. Pudding, green vegetables, and rice 34. The physician has ordered several laboratory tests to help diagnose an infant’s bleeding disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to indicate hemophilia? 1. Bleeding time 2. Tourniquet test 3. Clot retraction test 4. Partial thromboplastin time (PTT) 35. Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? 1. Child’s reluctance to move a body part 2. Cool, pale, clammy extremity 3. Eccymosis formation around a joint 4. Instability of a long bone in passive movement 36. Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client’s family to recognize and report which of the following? 1. Yellowing of the skin 2. Constipation 3. Abdominal distention 4. Puffiness around the eyes 37. A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease? 1. Platelet count 2. Hematocrit level 3. Reticulocyte count 4. Hemoglobin level 38. A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? 1. Infection 2. Trauma 3. Fluid overload 4. Stress 39. Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? 211. An elevated hemoglobin level 2. A decreased reticulocyte count 3. An elevated RBC count 4. Red blood cells that are microcytic and hypochromic 40. A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion? 1. Hemophilia is a Y linked hereditary disorder 2. Males inherit hemophilia from their fathers 3. Females inherit hemophilia from their mothers 4. Hemophilia A results from a deficiency of factor VIII Answers and Rationale 1. Answer: 1. One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium. 2. Answer: 3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C). 3. Answer: 4. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits. 4. Answer: 2. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia. 5. Answer: 2. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest. 6. Answer: 4. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple 22loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn’s disease and small bowel resection may cause several loose stools a day. 7. Answer: 3. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed. 8. Answer: 1. It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client’s activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client’s activity tolerance. Also, the client may not even identify that a “problem” exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual. 9. Answer: 3. Pernicious anemia is caused by the body’s inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling’s test helps diagnose pernicious anemia by determining the client’s ability to absorb vitamin B12. 10. Answer: 2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of non-radioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered. 11. Answer: 2. Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition. 12. Answer: 2. The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The post activity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest. 13. Answer: 3. The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; 23however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit. 14. Answer: 1. Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug. 15. Answer: 4. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration. 16. Answer: 2. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption. 17. Answer: 2. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client’s sensations first. The decision of how to treat the burn should be determined by the physician. 18. Answer: 3. Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange. 19. Answer: 2, 3, 4, 5. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera. 20. Answer: 1. Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia. 21. Answer: 1. Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells). Thrombocytopenia is a decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a type of white blood cells). 22. Answer: 3. Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to the body’s ability to form blood clots and aren’t related to anemia, not is carbon dioxide of T antibodies. 23. Answer: 3. The precursor to the RBC is the stem cell. B cells, macrophages, and T cells and lymphocytes, not RBC precursors. 24. Answer: 1. Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all associated with severe anemia. 2425. Answer: 2. In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn’t decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin’s disease. 26. Answer: 4. Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption. 27. Answer: 3. Hemophilia A results from a deficiency of factor VIII. Sickle cell disease is caused by a defective hemoglobin molecule. Christmas disease, also called hemophilia B, results in a factor IX deficiency. 28. Answer: 3. Characteristic sickle cells tend to cause “log jams” in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease. 29. Answer: 4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy. 30. Answer: 3. For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusion and subsequent tissue ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vaso occlusive crisis. Typically, a sickle cell crisis can be precipitated by a fluid volume deficit or dehydration. 31. Answer: 2. Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis. 32. Answer: 1, 2. Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including ironrich foods that have the needed nutrients. 33. Answer: 2. Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron. 34. Answer: 4. PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting factors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient, resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test measures vasoconstriction and platelet function; and the clot retraction test measures capillary fragility. All of these are unaffected in people with hemophilia. 35. Answer: 1. Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child’s reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis. 36. Answer: 1. Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous 25membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes. 37. Answer: 3. A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened. 38. Answer: 3. Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration. 39. Answer: 4. The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated. 40. Answer: 4. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. Introduction In this 20-item NCLEX style exam, you knowledge about the different Peripheral Vascular Diseases will be challenged. Topics  Peripheral Vascular Diseases  Heparin and Warfarin  Deep Vein Thrombosis Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is: 1. Hormonal secretion 2. Independent arterial wall activity. 3. The influence of circulating chemicals 4. The sympathetic nervous system 2. With peripheral arterial insufficiency, leg pain during rest can be reduced by: 1. Elevating the limb above heart level 2. Lowering the limb so it is dependent 263. Massaging the limb after application of cold compresses 4. Placing the limb in a plane horizontal to the body 3. Buerger’s disease is characterized by all of the following except: 1. Arterial thrombosis formation and occlusion 2. Lipid deposits in the arteries 3. Redness or cyanosis in the limb when it is dependent 4. Venous inflammation and occlusion 4. A significant cause of venous thrombosis is: 1. Altered blood coagulation 2. Stasis of blood 3. Vessel wall injury 4. All of the above 5. When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: 1. At least 12 hours 2. The first 24 hours 3. 2-3 days 4. 1 week 6. Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike’s symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: 1. Alteration in tissue perfusion related to compromised circulation 2. Dysfunctional use of extremities related to muscle spasms 3. Impaired mobility related to stress associated with pain 4. Impairment in muscle use associated with pain on exertion. 7. A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: 1. Familial tendency toward peripheral vascular disease 2. Smoking history 3. Recent exposures to allergens 4. History of insect bites 8. Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate 9. A client who has been receiving heparin therapy also is started on warfarin sodium (coumadin). The client asks the nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium: 1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this is exhibit an anticoagulant effect. 2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect. 273. Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for it to begin. 4. Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic. 10. A nurse has an order to begin administering warfarin sodium (coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate 11. A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: 1. Normal because of the increased blood flow through the leg 2. Slightly deteriorating and should be monitored for another hour 3. Moderately impaired, and the surgeon should be called. 4. Adequate from the arterial approach, but venous complications are arising. 12. A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: 1. Has a pale colored base 2. Is deep, with even edges 3. Has little granulation tissue 4. Has brown pigmentation around it. 13. In preparation for discharge of a client with arterial insufficiency and Raynaud’s disease, client teaching instructions should include: 1. Walking several times each day as an exercise program. 2. Keeping the heat up so that the environment is warm 3. Wearing TED hose during the day 4. Using hydrotherapy for increasing oxygenation 14. A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? 1. An acute obstruction in the vessels of the legs 2. Peripheral vascular problems in both legs 3. Diabetes 4. Calcium deficiency 15. Which of the following characteristics is typical of the pain associated with DVT? 1. Dull ache 2. No pain 3. Sudden onset 4. Tingling 16. Cancer can cause changes in what component of Virchow’s triad? 1. Blood coagulability 2. Vessel walls 283. Blood flow 4. Blood viscosity 17. Varicose veins can cause changes in what component of Virchow’s triad? 1. Blood coagulability 2. Vessel walls 3. Blood flow 4. Blood viscosity 18. Which technique is considered the gold standard for diagnosing DVT? 1. Ultrasound imaging 2. Venography 3. MRI 4. Doppler flow study 19. A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in that area 3. Systolic bruit over the area of the mass 4. Subjective sensation of “heart beating” in the abdomen. 20. A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: 1. Thrombosis and infection 2. Bleeding and infection 3. Bleeding and wound dehiscence. 4. Wound dehiscence and evisceration. Answers and Rationale 1. Answer: 4 2. Answer: 2 3. Answer: 2 4. Answer: 4 5. Answer: 3 6. Answer: 1 7. Answer: 2. The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger’s disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component. 8. Answer: 4. The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur 9. Answer: 2. Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. 10. Answer: 1. The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if excessive bleeding or hemorrhage should occur. 11. Answer: 1. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations. 2912. Answer: 4. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due to tissue malnutrition; and thus us an arterial problem) 13. Answer: 2. The client’s instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain. 14. Answer: 2. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking. 15. Answer: 3. DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain. 16. Answer: 1 17. Answer: 3 18. Answer: 2 19. Answer: 2. Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the “heart beating” in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. 20. Answer: 2. After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client. Introduction A simple 10 item NCLEX style examination about Valvular Diseases. Topics  Valvular Diseases Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the nice lady, the nurse would most likely learn that the client’s childhood health history included: 1. Chicken pox 2. poliomyelitis 303. Rheumatic fever 4. meningitis 2. Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? 1. Exertional dyspnea 2. Confusion 3. Elevated creatine phosphokinase concentration 4. Chest pain 3. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: 1. Aorta 2. Right atrium 3. Superior vena cava 4. Pulmonary circulation 4. Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client’s past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client? 1. Medication therapy 2. Diet modification 3. Activity restrictions 4. Dental care 5. Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: 1. A manual toothbrush 2. An electric toothbrush 3. An irrigation device 4. Dental floss 6. A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication the nurse will constantly observe for is: 1. Presence of heart murmur 2. Systemic emboli 3. Fever 4. Congestive heart failure 7. Cholesterol, frequently discussed in relation to atherosclerosis, is a substance that: 1. May be controlled by eliminating food sources 2. Is found in many foods, both plant and animal sources 3. All persons would be better off without because it causes the disease process 4. Circulates in the blood, the level of which usually decreases when unsaturated fats are substituted for saturated fats. 8. When teaching a client with a cardiac problem, who is on a high-unsaturated fatty-acid diet, the nurse should stress the importance of increasing the intake of: 1. Enriched whole milk 2. Red meats, such as beef 3. Vegetables and whole grains 4. Liver and other glandular organ meats 319. A 2-gram sodium diet is prescribed for a client with severe hypertension. The client does not like the diet, and the nurse hears the client request that the spouse “Bring in some good home-cooked food.” It would be most effective for the nurse to plan to: 1. Call in the dietician for client teaching 2. Wait for the client’s family and discuss the diet with the client and family 3. Tell the client that the use of salt is forbidden, because it will raise BP 4. Catch the family members before they go into the client’s room and tell them about the diet. 10. What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. 1. The RR intervals are relatively consistent 2. One P wave precedes each QRS complex 3. Four to eight complexes occur in a 6-second strip 4. The ST segment is higher than the PR interval 5. The QRS complex ranges from 0.12 to 0.2 seconds Answers and Rationale Gauge your performance by counter checking your answers to the answers below. Learn more about the question by reading the rationale. If you have any disputes or questions, please direct them to the comments section. 1. Answer: 3. Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. 2. Answer: 1. Weight gain, due to fluid retention and worsening heart failure, causes exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward into pulmonary veins, capillaries, and arterioles and eventually to the right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow. 3. Answer: 4. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure. 4. Answer: 1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Post-op, all clients with mechanical valves and some with bioprostheses are maintained indefinitely on anticoagulation therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence from rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, GI, or GU surgery. 5. Answer: 1. Daily dental care and frequent checkups by a dentist who is informed about the client’s condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis. 6. Answer: 2. Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs and left chamber emboli may travel anywhere in the arteries. Heart murmurs, fever, and night sweats may be present, but do not indicate a problem with emboli. CHF may be a result, but this is not as dangerous an outcome as emboli. 7. Answer: 4. Cholesterol is a sterol found in tissue; it is attributed in part to diets high in saturated fats. 8. Answer: 3. Vegetables and whole grains are low in fat and may reduce the risk for heart disease. 9. Answer: 2. Clients’ families should be included in dietary teaching; families provide support that promotes adherence. 3210. Answers: 1 and 2. (1) The consistency of the RR interval indicates a regular rhythm. (2) A normal P wave before each complex indicates the impulse originated in the SA node. (3) The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. (4) Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. (5) The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 seconds. This NCLEX exam has 80 questions that covers the diseases of the Gastrointestinal and Digestive System. Topics  Liver Failure  Liver Disorders  Ostomy Care Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure because of which change that is associated with the liver failure? 1. Hypoalbuminemia 2. Increased capillary permeability 3. Abnormal peripheral vasodilation 4. Excess rennin release from the kidneys 2. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear: 1. Pale, pink and moist 2. Red and moist 3. Dark or purple colored 4. Dry and black 3. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is: 1. Formed 2. Semisolid 3. Semiliquid 4. Watery 4. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend? 331. Peas 2. Cabbage 3. Broccoli 4. Yogurt 5. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer: 1. To the exact size of the stoma. 2. About 1/16” larger than the stoma. 3. About 1/8” larger than the stoma. 4. About 1/4″ larger than the stoma. 6. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed? 1. Observation, percussion, palpation, auscultation 2. Observation, auscultation, percussion, palpation 3. Percussion, palpation, auscultation, observation 4. Palpation, percussion, observation, auscultation 7. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include? 1. A reservoir is created that exits through the abdominal wall. 2. A second surgery is required 12 months after the first surgery. 3. A permanent ileostomy is created. 4. The surgery occurs in two stages. 8. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy? 1. 100 ml 2. 500 ml 3. 1500 ml 4. 5000 ml 9. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan? 1. There is no need to change eating habits. 2. Eat six small meals a day. 3. Eat the largest meal in the evening. 4. Restrict fluid intake. 10. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic? 1. “I know just how you feel.” 2. “You seem upset.” 3. “Oh, don’t worry about it, everything will be just fine.” 4. “Why do you think you have cancer?” 11. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure? 1. Flushed, dry skin. 2. Headache and bradycardia. 343. Dizziness and sweating. 4. Dyspnea and chest pain. 12. You’re developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include? 1. Omit fluids with meals. 2. Increase carbohydrate intake. 3. Decrease protein intake. 4. Decrease fat intake. 13. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective? 1. Pruritus 2. Dyspnea 3. Jaundice 4. Peripheral Neuropathy 14. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Before her paracentesis, you instruct her to: 1. Empty her bladder. 2. Lie supine in bed. 3. Remain NPO for 4 hours. 4. Clean her bowels with an enema. 15. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate? 1. Irrigate the wound & organs with Betadine. 2. Cover the wound with a saline soaked sterile dressing. 3. Apply a dry sterile dressing & binder. 4. Push the organs back & cover with moist sterile dressings. 16. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her? 1. Asterixis 2. Chvostek’s sign 3. Trousseau’s sign 4. Hepatojugular reflex 17. You are developing a care plan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include? 1. Administering a lactulose enema as ordered. 2. Encouraging a protein-rich diet. 3. Administering sedatives, as necessary. 4. Encouraging ambulation at least four times a day. 18. You have a patient with achalasia (incomplete muscle relaxtion of the GI tract, especially sphincter muscles). Which medications do you anticipate to administer? 1. Isosorbide dinitrate (Isordil) 2. Digoxin (Lanoxin) 3. Captopril (Capoten) 4. Propranolol (Inderal) 3519. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following: 1. Swallow foods while leaning forward. 2. Omit fluids at mealtimes. 3. Eat meals sitting upright. 4. Avoid soft and semi soft foods. 20. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient? 1. Serum creatinine and BUN 2. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) 3. Serum amylase and lipase 4. Cardiac enzymes 21. A patient with Crohn’s disease is admitted after 4 days of diarrhea. Which of the following urine specific gravity values do you expect to find in this patient? 1. 1.005 2. 1.011 3. 1.020 4. 1.030 22. Your goal is to minimize David’s risk of complications after a herniorrhaphy. You instruct the patient to: 1. Avoid the use of pain medication. 2. Cough and deep breathe Q2H. 3. Splint the incision if he can’t avoid sneezing or coughing. 4. Apply heat to scrotal swelling. 23. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the following instructions do you include? 1. Eat a low-fiber diet. 2. Resume heavy lifting in 2 weeks. 3. Lose weight, if obese. 4. Resume sexual activity once discomfort is gone. 24. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include? 1. “You’ll need to lie on your stomach during the test.” 2. “You’ll need to lie on your right side after the test.” 3. “During the biopsy you’ll be asked to exhale deeply and hold it.” 4. “The biopsy is performed under general anesthesia.” 25. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax? 1. Dyspnea and reduced or absent breath sounds over the right lung 2. Tachycardia, hypotension, and cool, clammy skin 3. Fever, rebound tenderness, and abdominal rigidity 4. Redness, warmth, and drainage at the biopsy site 26. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation? 361. “It empties the stomach of fluids and gas.” 2. “It prevents spasms at the sphincter of Oddi.” 3. “It prevents air from forming in the small intestine and large intestine.” 4. “It removes bile from the gallbladder.” 27. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an NG tube for liquid enteral feedings? 1. Aspirate for gastric secretions with a syringe. 2. Begin feeding slowly to prevent cramping. 3. Get an X-ray of the tip of the tube within 24 hours. 4. Clamp off the tube until the feedings begin. 28. Stephanie, a 28 y.o. accident victim, requires TPN. The rationale for TPN is to provide: 1. Necessary fluids and electrolytes to the body. 2. Complete nutrition by the I.V. route. 3. Tube feedings for nutritional supplementation. 4. Dietary supplementation with liquid protein given between meals. 29. Type A chronic gastritis can be distinguished from type B by its ability to: 1. Cause atrophy of the parietal cells. 2. Affect only the antrum of the stomach. 3. Thin the lining of the stomach walls. 4. Decrease gastric secretions. 30. Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions? 1. Restrict intake of high-carbohydrate foods. 2. Increase fluid intake with meals. 3. Increase fat intake. 4. Eat three regular meals a day. 31. Jerod is experiencing an acute episode of ulcerative colitis. Which is priority for this patient? 1. Replace lost fluid and sodium. 2. Monitor for increased serum glucose level from steroid therapy. 3. Restrict the dietary intake of foods high in potassium. 4. Note any change in the color and consistency of stools. 32. A 29 y.o. patient has an acute episode of ulcerative colitis. What diagnostic test confirms this diagnosis? 1. Barium Swallow. 2. Stool examination. 3. Gastric analysis. 4. Sigmoidoscopy. 33. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care? 1. Low-fiber diet and fluid restrictions. 2. Total parenteral nutrition and bed rest. 3. High-fiber diet and administration of psyllium. 4. Administration of analgesics and antacids. 34. Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like: 1. Watery and frothy. 2. Bloody and mucous. 373. Firm and well-formed. 4. Alternating constipation and diarrhea. 35. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by: 1. Periodic rectal hemorrhage. 2. Hypertension and tachycardia. 3. Vomiting and elevated temperature. 4. Crampy and lower left quadrant pain and low-grade fever. 36. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes: 1. Continuous peritoneal lavage. 2. Regular diet with increased fat. 3. Nutritional support with TPN. 4. Insertion of a T tube to drain the pancreas. 37. Glenda has cholelithiasis (gallstones). You expect her to complain of: 1. Pain in the right upper quadrant, radiating to the shoulder. 2. Pain in the right lower quadrant, with rebound tenderness. 3. Pain in the left upper quadrant, with shortness of breath. 4. Pain in the left lower quadrant, with mild cramping. 38. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to: 1. Irrigate the incision with a saline solution. 2. Prevent bacterial infection of the incision. 3. Measure the amount of fluid lost after surgery. 4. Prevent accumulation of drainage in the wound. 39. Anthony, a 60 y.o. patient, has just undergone a bowel resection with a colostomy. During the first 24 hours, which of the following observations about the stoma should you report to the doctor? 1. Pink color. 2. Light edema. 3. Small amount of oozing. 4. Trickles of bright red blood. 40. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance? 1. 1/16” 2. 1/4″ 3. 1/2” 4. 1” 41. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her? 1. Obtain daily weights. 2. Measure abdominal girth. 3. Keep strict intake and output. 4. Encourage her to increase fluids. 42. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient? 1. TPN 2. PPN 383. NG feeding 4. Oral liquid supplements 43. You’re patient is complaining of abdominal pain during assessment. What is your priority? 1. Auscultate to determine changes in bowel sounds. 2. Observe the contour of the abdomen. 3. Palpate the abdomen for a mass. 4. Percuss the abdomen to determine if fluid is present. 44. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next? 1. Discontinue the procedure. 2. Lower the height of the enema container. 3. Complete the procedure as quickly as possible. 4. Continue administration of the enema as ordered without making any adjustments. 45. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective? 1. There is no skin breakdown. 2. Her appetite improves. 3. She loses more than 10 lbs. 4. Stools are less fatty and decreased in frequency. 46. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated? 1. Calcium 2. Glucose 3. Magnesium 4. Potassium 47. Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary and she undergoes partial gastrectomy. Postoperative nursing care includes: 1. Giving pain medication Q6H. 2. Flushing the NG tube with sterile water. 3. Positioning her in high Fowler’s position. 4. Keeping her NPO until the return of peristalsis. 48. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor? 1. Blanched stoma 2. Edematous stoma 3. Reddish-pink stoma 4. Brownish-black stoma 49. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity? 1. Restrict fluids 2. Encourage ambulation 3. Increase sodium in the diet 4. Give antacids as prescribed 3950. Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium in the diet, which food should be included in the diet? 1. Fruit 2. Whole grains 3. Milk and cheese products 4. Dark green, leafy vegetables 51. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort? 1. Give tepid baths. 2. Avoid lotions and creams. 3. Use hot water to increase vasodilation. 4. Use cold water to decrease the itching. 52. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care? 1. Regular exercise. 2. A low-protein diet. 3. Allow patient to select his meals. 4. Rest period after small, frequent meals. 53. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient? 1. “Now I can never get hepatitis again.” 2. “I can safely give blood after 3 months.” 3. “I’ll never have a problem with my liver again, even if I drink alcohol.” 4. “My family knows that if I get tired and start vomiting, I may be getting sick again.” 54. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response? 1. “You’ll need to turn from side to side every 2 hours.” 2. “It’s always a good idea to rest quietly after surgery.” 3. “The doctor will probably order you to lie flat for 24 hours.” 4. “Why don’t you decide about activity after you return from the recovery room?” 55. You’re caring for a 28 y.o. woman with hepatitis B. She’s concerned about the duration of her recovery. Which response isn’t appropriate? 1. Encourage her to not worry about the future. 2. Encourage her to express her feelings about the illness. 3. Discuss the effects of hepatitis B on future health problems. 4. Provide avenues for financial counseling if she expresses the need. 56. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam? 1. Give diazepam in the I.V. port closest to the vein. 2. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes. 3. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture. 4. Question the order because I.V. administration of diazepam is contraindicated. 57. Annabelle is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma? 1. “At first, the stoma may bleed slightly when touched.” 2. “The stoma should appear dark and have a bluish hue.” 403. “A burning sensation under the stoma faceplate is normal.” 4. “The stoma should remain swollen away from the abdomen.” 58. A patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe? 1. Rapidly instill a stream of irrigating solution into the wound. 2. Apply a wet-to-dry dressing to the wound after the irrigation. 3. Moisten the area around the wound with normal saline solution after the irrigation. 4. Irrigate continuously until the solution becomes clear or all of the solution is used. 59. Hepatic encephalopathy develops when the blood level of which substance increases? 1. Ammonia 2. Amylase 3. Calcium 4. Potassium 60. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room? 1. A suture kit. 2. Sterile water and a suture kit. 3. Sterile water and sterile dressings. 4. Sterile saline solution and sterile dressings. 61. Findings during an endoscopic exam include a cobblestone appearance of the colon in your patient. The findings are characteristic of which disorder? 1. Ulcer 2. Crohn’s disease 3. Chronic gastritis 4. Ulcerative colitis 62. What information is correct about stomach cancer? 1. Stomach pain is often a late symptom. 2. Surgery is often a successful treatment. 3. Chemotherapy and radiation are often successful treatments. 4. The patient can survive for an extended time with TPN. 63. Dark, tarry stools indicate bleeding in which location of the GI tract? 1. Upper colon. 2. Lower colon. 3. Upper GI tract. 4. Small intestine. 64. A patient has an acute upper GI hemorrhage. Your interventions include: 1. Treating hypovolemia. 2. Treating hypervolemia. 3. Controlling the bleeding source. 4. Treating shock and diagnosing the bleeding source. 65. You promote hemodynamic stability in a patient with upper GI bleeding by: 1. Encouraging oral fluid intake. 2. Monitoring central venous pressure. 3. Monitoring laboratory test results and vital signs. 4. Giving blood, electrolyte and fluid replacement. 4166. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy. The patient tells you he’s anxious. What should your initial step be in working with this patient? 1. Determine what the patient already knows about colostomies. 2. Show the patient some pictures of colostomies. 3. Arrange for someone who has a colostomy to visit the patient. 4. Provide the patient with written material about colostomy care. 67. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication? 1. Fistula. 2. Bowel perforation. 3. Bowel obstruction. 4. Abscess. 68. A patient has a severe exacerbation of ulcerative colitis. Long-term medications will probably include: 1. Antacids. 2. Antibiotics. 3. Corticosteroids. 4. Histamine2-receptor blockers. 69. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet? 1. Meats and beans. 2. Butter and gravies. 3. Potatoes and pastas. 4. Cakes and pastries. 70. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding? 1. Notify the doctor immediately. 2. Stop the feeding, and clamp the NG tube. 3. Discard the 220ml, and clamp the NG tube. 4. Give a prescribed GI stimulant such as metoclopramide (Reglan). 71. Your patient with peritonitis is NPO and complaining of thirst. What is your priority? 1. Increase the I.V. infusion rate. 2. Use diversion activities. 3. Provide frequent mouth care. 4. Give ice chips every 15 minutes. 72. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate? 1. He has fresh, active upper GI bleeding. 2. He needs immediate saline gastric lavage. 3. His gastric bleeding occurred 2 hours earlier. 4. He needs a transfusion of packed RBC’s. 73. A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color? 421. Brown. 2. Clear. 3. Red. 4. Yellow. 74. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy? 1. Peristalsis. 2. Gastric acidity. 3. Gastric motility. 4. Gastric pH. 75. Christina is receiving an enteral feeding that requires a concentration of 80 ml of supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding? 1. 60 ml. 2. 70 ml. 3. 80 ml. 4. 90 ml. 76. Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is yellow, green, or brown? 1. Ileostomy. 2. Ascending colostomy. 3. Transverse colostomy. 4. Descending colostomy. 77. George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage? 1. “If there is any drainage, notify the surgeon immediately.” 2. “The drainage will decrease daily until the bile duct heals.” 3. “First, the drainage is dark green; then it becomes dark yellow.” 4. “If the drainage stops, milk the tube toward the puncture wound.” 78. Your patient Maria takes NSAIDS for her degenerative joint disease, has developed peptic ulcer disease. Which drug is useful in preventing NSAID-induced peptic ulcer disease? 1. Calcium carbonate (Tums) 2. Famotidine (Pepcid) 3. Misoprostol (Cytotec) 4. Sucralfate (Carafate) 79. The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer? 1. Janice, a 45 y.o. with a 25-year history of ulcerative colitis 2. George, a 50 y.o. whose father died of colon cancer 3. Herman, a 60 y.o. who follows a low-fat, high-fiber diet 4. Sissy, a 72 y.o. with a history of breast cancer 80. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority? 1. Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet. 2. Obtain vital signs, call the doctor, and obtain emergency orders. 433. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s knees. 4. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution. Answers and Rationale 1. Answer: 1. Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney’s aren’t direct ramifications of liver failure. 2. Answer: 2. Good circulation causes tissues to be moist and red, so a healthy, well-healed stoma appears red and moist. 3. Answer: 1. A colostomy in the sigmoid colon produces a solid, formed stool. 4. Answer: 4. High-fiber foods stimulate peristalsis, and a result, flatus. Yogurt reduces gas formation. 5. Answer: 2. A proper fit protects the skin, but doesn’t impair circulation. A 1/16” should be cut. 6. Answer: 2. Observation, auscultation, percussion, palpation 7. Answer: 4. An ileoanal reservoir is created in two stages. The two surgeries are about 2 to 3 months apart. First, diseased intestines are removed and a temporary loop ileostomy is created. Second, the loop ileostomy is closed and stool goes to the reservoir and out through the anus. 8. Answer: 3. The large intestine absorbs large amounts of water so the initial output from the ileostomy may be as much as 1500 to 2000 ml/24 hours. Gradually, the small intestine absorbs more fluid and the output decreases. 9. Answer: 2. To avoid overloading the small intestine, encourage the patient to eat six small, regularly spaced meals. 10. Answer: 2. Making observations about what you see or hear is a useful therapeutic technique. This way, you acknowledge that you are interested in what the patient is saying and feeling. 11. C After a Billroth II procedure, a large amount of hypertonic fluid enters the intestine. This causes extracellular fluid to move rapidly into the bowel, reducing circulating blood volume and producing vasomotor symptoms. Vasomotor symptoms produced by dumping syndrome include dizziness and sweating, tachycardia, syncope, pallor, and palpitations. 12. A Gastric emptying time can be delayed by omitting fluids from your patient’s meal. A diet low in carbs and high in fat & protein is recommended to treat dumping syndrome. 13. B Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing pressure on the diaphragm. The goal is to improve the patient’s breathing. The others are signs of cirrhosis that aren’t relieved by paracentesis. 14. A A full bladder can interfere with paracentesis and be punctured inadvertently. 15. B Cover the organs with a sterile, nonadherent dressing moistened with normal saline. Do this to prevent infection and to keep the organs from drying out. 16. A Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex. 17. A You may administer the laxative lactulose to reduce ammonia levels in the colon. 18. A Achalasia is characterized by incomplete relaxation of the LES, dilation of the lower esophagus, and a lack of esophageal peristalsis. Because nitrates relax the lower esophageal sphincter, expect to give Isordil orally or sublingually. 19. C Eating in the upright position aids in emptying the esophagus. Doing the opposite of the other three also may be helpful. 20. C Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These levels are elevated in a patient with acute pancreatitis. 4421. D The normal range of specific gravity of urine is 1.010 to 1.025; a value of 1.030 may be seen with dehydration. 22. C Teach the pt to avoid activities that increase intra-abdominal pressure such as coughing, sneezing, or straining with a bowel movement. 23. C Because obesity weakens the abdominal muscles, advise weight loss for the patient who has had a hernia repair. 24. B After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce the risk of bleeding or bile leakage. 25. A Signs and Symptoms of pneumothorax include dyspnea and decreased or absent breath sounds over the affected lung (right lung). 26. A An NG tube is inserted into the patients stomach to drain fluid and gas. 27. A Aspirating the stomach contents confirms correct placement. If an X-ray is ordered, it should be done immediately, not in 24 hours. 28. B TPN is given I.V. to provide all the nutrients your patient needs. TPN isn’t a tube feeding nor is it a liquid dietary supplement. 29. A Type A causes changes in parietal cells. 30. B Increasing fluids helps empty the stomach. A high carb diet isn’t restricted and fat intake shouldn’t be increased. 31. A Diarrhea d/t an acute episode of ulcerative colitis leads to fluid & electrolyte losses so fluid replacement takes priority. 32. D Sigmoidoscopy allows direct observation of the colon mucosa for changes, and if needed, biopsy. 33. C She needs a high-fiber diet and a psyllium (bulk laxative) to promote normal soft stools. 34. B Stools from ulcerative colitis are often bloody and contain mucus. 35. D One sign of acute diverticulitis is crampy lower left quadrant pain. A low-grade fever is another common sign. 36. C With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support. 37. A The gallbladder is located in the RUQ and a frequent sign of gallstones is pain radiating to the shoulder. 38. D A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. 39. D After creation of a colostomy, expect to see a stoma that is pink, slightly edematous, with some oozing. Bright red blood, regardless of amount, indicates bleeding and should be reported to the doctor. 40. A Only a small amount of skin should be exposed and more than 1/16” of skin allows the excretement to irritate the skin. 41. B Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention. 42. C Because the GI tract is functioning, feeding methods involve the enteral route which bypasses the mouth but allows for a major portion of the GI tract to be used. 43. B The first step in assessing the abdomen is to observe its shape and contour, then auscultate, palpate, and then percuss. 44. B Lowering the height decreases the amount of flow, allowing him to tolerate more fluid. 45. D Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance. 46. B Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to the islets of langerhans. 4547. D After surgery, she remains NPO until peristaltic activity returns. This decreases the risk for abdominal distention and obstruction. 48. D A brownish-black color indicates lack of blood flow, and maybe necrosis. 49. A Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space. 50. D Dark green, leafy vegetables are rich in calcium. 51. A For pruritus, care should include tepid sponge baths and use of emollient creams and lotions. 52. D Rest periods and small frequent meals is indicated during the acute phase of hepatitis B. 53. D Hepatitis B can recur. Patients who have had hepatitis are permanently barred from donating blood. Alcohol is metabolized by the liver and should be avoided by those who have or had hepatitis B. 54. A To prevent venous stasis and improve muscle tone, circulation, and respiratory function, encourage her to move after surgery. 55. A Telling her not to worry minimizes her feelings. 56. A Diazepam is absorbed by the plastic I.V. tubing and should be given in the port closest to the vein. 57. A For the first few days to a week, slight bleeding normally occurs when the stoma is touched because the surgical site is still new. She should report profuse bleeding immediately. 58. D To wash away tissue debris and drainage effectively, irrigate the wound until the solution becomes clear or all the solution is used. 59. A Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter systemic circulation, which carries it to the brain. 60. D Saline solution is isotonic, or close to body fluids in content, and is used along with sterile dressings to cover an eviscerated wound and keep it moist. 61. B Crohn’s disease penetrates the mucosa of the colon through all layers and destroys the colon in patches, which creates a cobblestone appearance. 62. A Stomach pain is often a late sign of stomach cancer; outcomes are particularly poor when the cancer reaches that point. Surgery, chemotherapy, and radiation have minimal positive effects. TPN may enhance the growth of the cancer. 63. C Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It occurs with bleeding from the upper GI tract. 64. A A patient with an acute upper GI hemorrhage must be treated for hypovolemia and hemorrhagic shock. You as a nurse can’t diagnose the problem. Controlling the bleeding may require surgery or intensive medical treatment. 65. D To stabilize a patient with acute bleeding, NS or LR solution is given I.V. until BP rises and urine output returns to 30ml/hr. 66. A Initially, you should assess the patient’s knowledge about colostomies and how it will affect his lifestyle. 67. B An inflammatory condition that affects the surface of the colon, ulcerative colitis causes friability and erosions with bleeding. Patients with ulcerative colitis are at increased risk for bowel perforation, toxic megacolon, hemorrhage, cancer, and other anorectal and systemic complications. 68. C Medications to control inflammation such as corticosteroids are used for long-term treatment. 69. A Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted. 70. B A gastric residual greater than 2 hours worth of feeding or 100-150ml is considered too high. The feeding should be stopped; NG tube clamped, and then allow time for the stomach to empty before additional feeding is added. 71. C Frequent mouth care helps relieve dry mouth. 4672. C Coffee-ground emesis occurs when there is upper GI bleeding that has undergone gastric digestion. For blood to appear as coffee-ground emesis, it would have to be digested for approximately 2 hours. 73. C Normally, drainage is bloody for the first 24 hours after a partial gastrectomy; then it changes to brown-tinged and then to yellow or clear. 74. D If the vagus nerve is cut as it enters the stomach, gastric acid secretion is decreased, but intestinal motility is also decreased and gastric emptying is delayed. Because gastric acids are decreased, gastric pH increases. 75. A Dosage problem. It’s 80/20 = 240/X. X=60. 76. A The output from an Ileostomy is described. 77. B As healing occurs from the bile duct, bile drains from the tube; the amount of bile should decrease. Teach the patient to expect dark green drainage and to notify the doctor if drainage stops. 78. C Misoprostol restores prostaglandins that protect the stomach from NSAIDS, which diminish the prostaglandins. 79. C 80. D Introduction Questions about Substance Abuse, Alcoholism, Therapeutic Communication and more are included in the 25-item NCLEXsample exam. Topics  Substance Abuse  Therapeutic Communication  Alcohol Abuse and Withdrawal Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client? 1. Ping pong 2. Writing 3. Chess 4. Basketball 2. A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is: 1. Explain to the client the importance of a good nutritional intake 2. Weight the client 3 times per week before breakfast 3. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as 47possible. 4. Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing interactions with the client during these times. 3. In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best? 1. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book. 2. Plan nothing until the client asks to participate in milieu. 3. Offer the client a menu of daily activities and insist the client participate in all of them 4. Provide a structured daily program of activities and encourage the client to participate. 4. The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure… I can’t do anything right!” The best nursing response would be: 1. To tell the client this is not true; that we all have a purpose in life. 2. To remain with the client and sit in silence; this will encourage the client to verbalize feelings 3. To reassure the client that you know how the client is feeling and that things will get better 4. To identify recent behaviors or accomplishments that demonstrates skill ability. 5. A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client’s: 1. Disturbed thought processes 2. Imbalanced nutrition 3. Self-care deficit 4. Deficient knowledge 6. A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states: 1. “I’ll never let this happen to me again. I won’t let my boss or my job or my family get to me!” 2. “It’s important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I’ve got to get in to see my doctor.” 3. “I’ve learned that I’m a good person and that I am worthy of giving and receiving love. I don’t need anyone; I have myself to rely on!” 4. “I don’t know what happened to me. I’ve always been able to make decisions for myself and for my business. I don’t ever want to feel so weak or vulnerable again!” 7. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse’s immediate intervention is the client’s: 1. Outlandish behaviors and inappropriate dress 2. Grandiose delusions of being a royal descendent of King Arthur. 3. Nonstop physical activity and poor nutritional intake 4. Constant, incessant talking that includes sexual innuendoes and teasing the staff 8. The nurse reviews the activity schedule for the day and plans which activity for the manic client? 1. Brown-bag luncheon and book review 2. Tetherball 3. Paint-by-number activity 4. Deep breathing and progressive relaxation group 489. A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client’s mother begins to cry and states “My son’s brain will be destroyed. How can the doctor do this to him?” The nurses best response is: 1. “It sounds as though you need to speak with the psychiatrist” 2. “Your son has decided to have this treatment. You should be supportive to him.” 3. “Perhaps you’d like to see the ECT room and speak to the staff.” 4. “It sounds as though you have some concerns about the ECT procedure. Why don’t we sit down together and discuss any concerns you may have.” 10. The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the most appropriate action would be to: 1. With assistance, escort the manic client to her room and administer Haldol as prescribed if needed 2. Tell the client that smoking privileges are revoked for 24 hours 3. Orient the client to time, person, and place 4. Tell the client that the behavior is not appropriate. 11. Select all nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. 1. Communicate expected behaviors to the client 2. Enforce rules and inform the client the he or she will not be allowed to attend group therapy sessions. 3. Ensure that the client knows that he or she is not in charge of the nursing unit 4. Be clear with the client regarding the consequences of exceeding limits set regarding behavior. 5. Assist the client in testing out alternative behaviors for obtaining needs 12. A woman comes into the ER in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to: 1. Remain with the client 2. Put the client in a quiet room 3. Teach the client deep breathing 4. Encourage the client to talk about their feelings and concern. 13. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The most appropriate maintenance goal should focus on which of the following? 1. Continued contact with a crisis counselor 2. Identifying anxiety-producing situations 3. Ignoring feelings of anxiety 4. Eliminating all anxiety from daily situations 14. The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors? 1. Hypertension, changes in LOC, hallucinations 2. Hypotension, ataxia, hunger 3. Stupor, agitation, muscular rigidity 4. Hypotension, coarse hand tremors, agitation 15. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse “I should get out of this bad situation.” The most helpful response by the nurse would be: 491. “I agree with you. You should get out of this situation.” 2. “What do you find difficult about this situation?” 3. “Why don’t you tell your husband about this?” 4. “This is not the best time to make that decision.” 16. The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group when she hears the wife say: 1. “My attendance at the meetings has helped me to see that I provoke my husband’s violence.” 2. “I no longer feel that I deserve the beatings my husband inflicts on me.” 3. “I can tolerate my husband’s destructive behavior now that I know they are common with alcoholics.” 4. “I enjoy attending the meetings because they get me out of the house and away from my husband.” 17. The client has been hospitalized and is participating in a substance abuse therapy group sessions. On discharge, the client has consented to participate in AA community groups. The nurse is monitoring the client’s response to the substance abuse sessions. Which statement by the client best indicates that the client has developed effective coping response styles and has processed information effectively for self use? 1. “I know I’m ready to be discharged. I feel I can say ‘no’ and leave a group of friends if they are drinking… ‘No Problem.’” 2. “This group has really helped a lot. I know it will be different when I go home. But I’m sure that my family and friends will all help me like the people in this group have… They’ll all help me… I know they will… They won’t let me go back to my old ways.” 3. “I’m looking forward to leaving here. I know that I will miss all of you. So, I’m happy and I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong and that everyone isn’t going to be as helpful as you people.” 4. “I’ll keep all my appointments; go to all my AA groups; I’ll do everything I’m supposed to… Nothing will go wrong that way.” 18. A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want anymore treatment. I have things that I have to do right away.” The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. The most important nursing action is to: 1. Restrain the client until the physician can be reached 2. Call security to block all areas 3. Tell the client that the client cannot return to this hospital again if the client leaves now. 4. Call the nursing supervisor. 19. Select the appropriate interventions for caring for the client in alcohol withdrawal. 1. Monitor vital signs 2. Provide stimulation in the environment 3. Maintain NPO status 4. Provide reality orientation as appropriate 5. Address hallucinations therapeutically 20. Which of the following nursing actions would be included in a care plan for a client with PTSD who states the experience was “bad luck”? 1. Encourage the client to verbalize the experience 2. Assist the client in defining the experience 503. Work with the client to take steps to move on with his life 4. Help the client accept positive and negative feelings 21. Which of the following psychological symptoms would the nurse expect to find in a hospitalized client who is the only survivor of a train accident? 1. Denial 2. Indifference 3. Perfectionism 4. Trust 22. Which of the following communication guidelines should the nurse use when talking with a client experiencing mania? 1. Address the client in a light and joking manner 2. Focus and redirect the conversation as necessary 3. Allow the client to talk about several different topic 4. Ask only open ended questions to facilitate conversations 23. What information is important to include in the nutritional counseling of a family with a member who has bipolar disorder? 1. If sufficient roughage isn’t eaten while taking lithium, bowel problems will occur. 2. If the intake of carbohydrates increases, the lithium level increases. 3. If the intake of calories is reduced, the lithium level will increase 4. If the intake of sodium increases, the lithium level will decrease. 24. In conferring with the treatment team, the nurse should make which of the following recommendations for a client who tells the nurse that everyday thoughts of suicide are present? 1. A no-suicide contract 2. Weekly outpatient therapy 3. A second psychiatric opinion 4. Intensive inpatient treatment 25. Which of the following short term goals is most appropriate for a client with bipolar disorder who is having difficulty sleeping? 1. Obtain medication for sleep 2. Work on solving a problem 3. Exercise before bedtime 4. Develop a sleep ritual Answers and Rationale 1. Answer: B. Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games can stimulate aggression and increase psychomotor activity. 2. Answer: D. Change in appetite is one of the major symptoms of depression. Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake. 3. Answer: D. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Option 3 is a forceful and absolute approach. 4. Answer: D. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences 51for the client that are challenging but will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client’s feelings. 5. Answer: A. major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 1 is correct. 6. Answer: B. The exact cause of depression is not known but is believed to be related to biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatment for the disease process. 7. Answer: C. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client’s possible symptomatology. Option 3, however, clearly presents a problem that compromises one’s physiological integrity and needs to be addressed immediately. 8. Answer: B. A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow use of excess energy yet not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities lead to increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy that the client is experiencing. 9. Answer: D. The nurse encourages the client and the family to verbalize fears and concerns. The other options avoid dealing with concerns and are blocks to communication. 10. Answer: A. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol. Option 2 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. 11. Answers: A, D, and E. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a non-punishment manner; and assisting the client in identifying strengths and in testing out alternative behaviors for obtaining needs. Enforcing rules and informing the client that he or she will not be allowed to attend group therapy sessions is a violation of the client’s rights. Ensuring the client knows that he or she is not in charge of the nursing unit is inappropriate, power struggles need to be avoided. 12. Answer: A. If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased. 13. Answer: B. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing 52situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination anxiety from life is impossible. 14. Answer: A. Some of the symptoms associated with delirium tremors typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions. 15. Answer: B. The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations. 16. Answer: B. Al-Anon support groups are protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavior changes. Option 2 is the most healthy response because is exemplifies and understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. 17. Answer: C. In the defense mechanism of denial the person denies reality. Option 1 identifies denial. In option 2 the client is relying heavily on others, and the client’s focus of control is external. In option 4 the client is concrete and procedure oriented; again the client identifies that “Nothing will go wrong that way” if the client follows all the directions. In option 3 the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in that statement. 18. Answer: D. A nurse can be charged with false imprisonment if a client is made to believe wrongfully that the client cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client’s responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold him against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise. 19. Answers: A, D, and E. When the client is experiencing withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained. 20. Answer: B. The client must define the experience as traumatic to realize the situation wasn’t under his personal control. Encouraging the client to verbalize the experience without first addressing the denial isn’t a useful strategy. The client can move on with life only after acknowledging the trauma and processing the experience. Acknowledgement of the actual trauma and verbalization of the event should come before the acceptance of feelings. 21. Answer: A. Denial can act as a protective response. The client tends to be overwhelmed and disorganized by the trauma, not indifferent to it. Perfectionism is more commonly seen in clients with eating disorders, not in clients with PTSD. Clients who have had a severe trauma often experience an inability to trust others. 22. Answer: B. To decrease stimulation, the nurse should attempt to redirect and focus the client’s communication, not allow the client to talk about different topics. By addressing the client in a light and joking manner, the conversation may contribute to the client’s feeling out of control. For a manic client, it’s best to ask closed questions because open-minded questions may enable the client to talk endlessly, again possibly contributing to the client’s feeling out of control. 5323. Answer: D. Any time the level of sodium increases, such as with a change in the dietary intake, the levels of lithium will decrease. 24. Answer: D. For a client thinking about suicide on a daily basis, inpatient care would be the best intervention. Although a no-suicide contract is an important strategy, this client needs additional care. The client needs a more intensive level of care than weekly outpatient therapy. Immediate intervention is paramount, not a second psychiatric opinion. 25. Answer: D. A sleep ritual or nighttime routine helps the client to relax and prepare for sleep. Obtaining sleep medication is a temporary solution. Working on problem solving may excite the client rather than tire him. Exercise before retiring is inappropriate. Introduction This is a 45-item examination that can help you in your NCLEX test. Questions here include topics like Renal Failure, Dialysis and more. Topics  Renal Failure  Dialysis Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions? 1. Osmosis and diffusion 2. Passage of fluid toward a solution with a lower solute concentration 3. Allowing the passage of blood cells and protein molecules through it. 4. Passage of solute particles toward a solution with a higher concentration. 2. A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions? 1. Follow a high potassium diet 2. Strictly follow the hemodialysis schedule 3. There will be a few changes in your lifestyle. 4. Use alcohol on the skin and clean it due to integumentary changes. 3. A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? 1. Change the client’s position. 2. Call the physician. 3. Check the catheter for kinks or obstruction. 4. Clamp the catheter and instill more dialysate at the next exchange time. 544. A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? 1. Administer oxygen 2. Elevate the foot of the bed 3. Restrict the client’s fluids 4. Prepare the client for hemodialysis. 5. A client has a history of chronic renal failure and received hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which of the following interventions is included in this client’s plan of care? 1. Keep the AV fistula site dry. 2. Keep the AV fistula wrapped in gauze. 3. Take the blood pressure in the left arm 4. Assess the AV fistula for a bruit and thrill 6. Which of the following factors causes the nausea associated with renal failure? 1. Oliguria 2. Gastric ulcers 3. Electrolyte imbalances 4. Accumulation of waste products 7. Which of the following clients is at greatest risk for developing acute renal failure? 1. A dialysis client who gets influenza 2. A teenager who has an appendectomy 3. A pregnant woman who has a fractured femur 4. A client with diabetes who has a heart catherization 8. In a client in renal failure, which assessment finding may indicate hypocalcemia? 1. Headache 2. Serum calcium level of 5 mEq/L 3. Increased blood coagulation 4. Diarrhea 9. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? 1. Absence of bruit on auscultation of the fistula. 2. Palpation of a thrill over the fistula 3. Presence of a radial pulse in the left wrist 4. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand. 10. The client with chronic renal failure is at risk of developing dementia related to excessive absorption of aluminum. The nurse teaches that this is the reason that the client is being prescribed which of the following phosphate binding agents? 1. Alu-cap (aluminum hydroxide) 2. Tums (calcium carbonate) 3. Amphojel (aluminum hydroxide) 4. Basaljel (aluminum hydroxide) 5511. The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching. 12. A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client’s status after dialysis? 1. Potassium level and weight 2. BUN and creatinine levels 3. VS and BUN 4. VS and weight. 13. The hemodialysis client with a left arm fistula is at risk for steal syndrome. The nurse assesses this client for which of the following clinical manifestations? 1. Warmth, redness, and pain in the left hand. 2. Pallor, diminished pulse, and pain in the left hand. 3. Edema and reddish discoloration of the left arm 4. Aching pain, pallor, and edema in the left arm. 14. A client is admitted to the hospital and has a diagnosis of early stage chronic renal failure. Which of the following would the nurse expect to note on assessment of the client? 1. Polyuria 2. Polydipsia 3. Oliguria 4. Anuria 15. The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client’s temperature is 100.2. Which of the following is the most appropriate nursing action? 1. Encourage fluids 2. Notify the physician 3. Monitor the site of the shunt for infection 4. Continue to monitor vital signs 16. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? 1. Notify the physician 2. Monitor the client 3. Elevate the head of the bed 4. Medicate the client for nausea 17. The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which of the following food items, if selected by the client, would indicate an understanding of this dietary restriction? 1. Cantaloupe 2. Spinach 3. Lima beans 4. Strawberries 5618. The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose: 1. Prevents excess glucose from being removed from the client. 2. Decreases risk of peritonitis. 3. Prevents disequilibrium syndrome 4. Increases osmotic pressure to produce ultrafiltration. 19. The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1. Monitor the clients level of consciousness 2. Maintain strict aseptic technique 3. Add heparin to the dialysate solution 4. Change the catheter site dressing daily 20. A client newly diagnosed with renal failure is receiving peritoneal dialysis. During the infusion of the dialysate the client complains of abdominal pain. Which action by the nurse is most appropriate? 1. Slow the infusion 2. Decrease the amount to be infused 3. Explain that the pain will subside after the first few exchanges 4. Stop the dialysis 21. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk of: 1. Infection 2. Hyperglycemia 3. Fluid overload 4. Disequilibrium syndrome 22. The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan which of the following as a priority action? 1. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration. 2. Encourage increased vegetables in the diet 3. Place the client on a cardiac monitor 4. Check the sodium level 23. The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: 1. Just before dialysis 2. During dialysis 3. On return from dialysis 4. The day after dialysis 24. The client with chronic renal failure has an indwelling catheter for peritoneal dialysis in the abdomen. The client spills water on the catheter dressing while bathing. The nurse should immediately: 1. Reinforce the dressing 2. Change the dressing 573. Flush the peritoneal dialysis catheter 4. Scrub the catheter with povidone-iodine 25. The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The nurse should: 1. Continue the dialysis at a slower rate after checking the lines for air 2. Discontinue dialysis and notify the physician 3. Monitor vital signs every 15 minutes for the next hour 4. Bolus the client with 500 ml of normal saline to break up the air embolism. 26. The nurse has completed client teaching with the hemodialysis client about selfmonitoring between hemodialysis treatments. The nurse determines that the client best understands the information given if the client states to record the daily: 1. Pulse and respiratory rate 2. Intake, output, and weight 3. BUN and creatinine levels 4. Activity log 27. The client with an arteriovenous shunt in place for hemodialysis is at risk for bleeding. The nurse would do which of the following as a priority action to prevent this complication from occurring? 1. Check the results of the PT time as they are ordered. 2. Observe the site once per shift 3. Check the shunt for the presence of a bruit and thrill 4. Ensure that small clamps are attached to the AV shunt dressing. 28. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. 1. Place the client in good body alignment 2. Check the level of the drainage bag 3. Contact the physician 4. Check the peritoneal dialysis system for kinks 5. Reposition the client to his or her side. 29. The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate? 1. Excess fluid volume related to the kidney’s inability to maintain fluid balance. 2. Increased cardiac output related to fluid overload. 3. Ineffective tissue perfusion related to interrupted arterial blood flow. 4. Ineffective therapeutic Regimen Management related to lack of knowledge about therapy. 30. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply. 1. Excess Fluid Volume 2. Imbalanced Nutrition; Less than Body Requirements 3. Activity Intolerance 4. Impaired Gas Exchange 5. Pain. 31. What is the primary disadvantage of using peritoneal dialysis for long term management of chronic renal failure? 581. The danger of hemorrhage is high. 2. It cannot correct severe imbalances. 3. It is a time consuming method of treatment. 4. The risk of contracting hepatitis is high. 32. The dialysis solution is warmed before use in peritoneal dialysis primarily to: 1. Encourage the removal of serum urea. 2. Force potassium back into the cells. 3. Add extra warmth into the body. 4. Promote abdominal muscle relaxation. 33. During the client’s dialysis, the nurse observes that the solution draining from the abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place. Which interpretation of this observation would be correct? 1. Bleeding is expected with a permanent peritoneal catheter 2. Bleeding indicates abdominal blood vessel damage 3. Bleeding can indicate kidney damage. 4. Bleeding is caused by too-rapid infusion of the dialysate. 34. Which of the following nursing interventions should be included in the client’s care plan during dialysis therapy? 1. Limit the client’s visitors 2. Monitor the client’s blood pressure 3. Pad the side rails of the bed 4. Keep the client NPO. 35. Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to take at home. What is the purpose of giving this drug to a client with chronic renal failure? 1. To relieve the pain of gastric hyperacidity 2. To prevent Curling’s stress ulcers 3. To bind phosphorus in the intestine 4. To reverse metabolic acidosis. 36. The nurse teaches the client with chronic renal failure when to take the aluminum hydroxide gel. Which of the following statements would indicate that the client understands the teaching? 1. “I’ll take it every 4 hours around the clock.” 2. “I’ll take it between meals and at bedtime.” 3. “I’ll take it when I have a sour stomach.” 4. “I’ll take it with meals and bedtime snacks.” 37. The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesia) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because: 1. MOM can cause magnesium toxicity 2. MOM is too harsh on the bowel 3. Metamucil is more palatable 4. MOM is high in sodium 38. In planning teaching strategies for the client with chronic renal failure, the nurse must keep in mind the neurologic impact of uremia. Which teaching strategy would be most appropriate? 591. Providing all needed teaching in one extended session. 2. Validating frequently the client’s understanding of the material. 3. Conducting a one-on-one session with the client. 4. Using videotapes to reinforce the material as needed. 39. The nurse helps the client with chronic renal failure develop a home diet plan with the goal of helping the client maintain adequate nutritional intake. Which of the following diets would be most appropriate for a client with chronic renal failure? 1. High carbohydrate, high protein 2. High calcium, high potassium, high protein 3. Low protein, low sodium, low potassium 4. Low protein, high potassium 40. A client with chronic renal failure has asked to be evaluated for a home continuous ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major advantage of this approach is that it: 1. Is relatively low in cost 2. Allows the client to be more independent 3. Is faster and more efficient than standard peritoneal dialysis 4. Has fewer potential complications than standard peritoneal dialysis 41. The client asks whether her diet would change on CAPD. Which of the following would be the nurse’s best response? 1. “Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more effective technique.” 2. “Diet restrictions are the same for both CAPD and standard peritoneal dialysis.” 3. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because dialysis is constant.” 4. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because CAPD works more quickly.” 42. Which of the following is the most significant sign of peritoneal infection? 1. Cloudy dialysate fluid 2. Swelling in the legs 3. Poor drainage of the dialysate fluid 4. Redness at the catheter insertion site 43. The main indicator of the need for hemodialysis is: 1. Ascites 2. Acidosis 3. Hypertension 4. Hyperkalemia 44. To gain access to the vein and artery, an AV shunt was used for Mr. Roberto. The most serious problem with regards to the AV shunt is: 1. Septicemia 2. Clot formation 3. Exsanguination 4. Vessel sclerosis 45. When caring for Mr. Roberto’s AV shunt on his right arm, you should: 1. Cover the entire cannula with an elastic bandage 2. Notify the physician if a bruit and thrill are present 603. User surgical aseptic technique when giving shunt care 4. Take the blood pressure on the right arm instead Answers and Rationale [Show More]

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