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General Exams (Nursing Physiologya) – Page 5

#81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
A Angina, double vision, and anorexia
B Pallor, bradycardia, and reduced pulse pressure
C Sore tongue, dyspnea, and weight gain
D Pallor, tachycardia, and a sore tongue
Answer: Pallor, tachycardia, and a sore tongue
#82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?
A Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
B Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.
C Page an anesthesiologist immediately and prepare to intubate the client.
D Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
Answer: Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
#83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include ________________.
A bilateral hearing loss
B respiratory acidosis
C fine motor tremors
D weight gain
Answer: bilateral hearing loss
#84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?
A Neutrophil
B Lymphocyte
C Monocyte
D Basophil
Answer: Lymphocyte
#85. In an individual with Sjögren’s syndrome, nursing care should focus on _______________.
A electrolyte balance.
B moisture replacement.
C nutritional supplementation.
D arrhythmia management.
Answer: moisture replacement.
#86. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order _______________.
A E-rosette immunofluorescence
B Western blot test with ELISA.
C enzyme-linked immunosorbent assay (ELISA)
D quantification of T-lymphocytes
Answer: Western blot test with ELISA.
#87. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?
A Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
B Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
C Electrolyte imbalance that could affect the blood’s ability to coagulate properly
D Low levels of urine constituents normally excreted in the urine
Answer: Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
#88. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
A Thrombin time, calcium levels, and potassium levels
B Fibrinogen level, WBC, and platelet count
C Platelet count, prothrombin time, and partial thromboplastin time
D Platelet count, blood glucose levels, and white blood cell (WBC) count
Answer: Platelet count, prothrombin time, and partial thromboplastin time
#89. When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?
A Bread
B Carrots
C Strawberries
D Orange
Answer: Strawberries
#90. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?
A A client with rheumatoid arthritis who states, “I am having trouble sleeping"
B A client with hepatitis A who states, “My arms and legs are itching.”
C A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat"
D A client with cast on the right leg who states, “I have a funny feeling in my right leg"
Answer: A client with cast on the right leg who states, “I have a funny feeling in my right leg"
#91. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?
A A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing. A 43-year-old who had a mastectomy two days ago
B A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.
C A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
D A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
Answer: A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.
#92. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?
A The client spontaneously flexes his wrist when the blood pressure is obtained.
B The client is drowsy and complains of sore throat.
C Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
D The client supports his head and neck when turning his head to the right.
Answer: The client spontaneously flexes his wrist when the blood pressure is obtained.
#93. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?
A Administer Demerol 50 mg IM q 4 hours and PRN.
B Encourage the client to change positions frequently in bed.
C Use comfort measures and pillows to position the client.
D Apply warmth to the abdomen with a heating pad.
Answer: Use comfort measures and pillows to position the client.
#94. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?
A Assess for a bruit and a thrill
B Position the client on the left side.
C Insert a Foley catheter
D Warm the dialysate solution.
Answer: Warm the dialysate solution.
#95. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?
A The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
B The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
C The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.
D The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
Answer: The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
#96. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?
A Suggest the woman eat her meals in the room with her roommate.
B Select a room with a bed by the door so the woman can look down the hall.
C Ask the woman’s family to provide personal items such as photos or mementos.
D Encourage the woman to ambulate in the halls twice a day.
Answer: Ask the woman’s family to provide personal items such as photos or mementos.
#97. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?
A The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.
B The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
C The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.
D The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.
Answer: The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
#98. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?
A Decreased visual, auditory, and gustatory abilities.
B Increased sensitivity to the side effects of medications.
C Decrease musculoskeletal function and mobility.
D Isolation from their families and familiar surroundings.
Answer: Isolation from their families and familiar surroundings.
#99. A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?
A Assess the client’s potassium level.
B Check the client’s temperature.
C Encourage the client to perform pursed lip breathing.
D Increase the client’s oxygen flow rate.
Answer: Encourage the client to perform pursed lip breathing.
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