1. The nurse is assessing the child with a suspected diagnosis of appendicitis, In assessing the intensity and progression of the pain, the nurse palpates the child at McBurney's point. In performing this assessment ,the nurse knows that McBurney's point is located midway between the
1. Right anterior inferior iliac crest and the umbilicus.
2. Left anterior superior iliac crest and the umbilicus.
3. Right anterior superior iliac crest and the umbilicus.
4. Left anterior superior iliac crest and the umbilicus.
Answers 3.
2. The nurse is caring for a client with a bum injury to the lower legs. Nitrofurazone (Furacin) is prescribed to be applied to the sites of injury. The nurse documents which of the following in the plan of care as the appropriate method to apply this medication?
1. Apply saline-soaked dressings over the medication.
2. Apply 1-inch film directly to the burn sites.
3. Apply 1/16-inch film directly to the burn sites.
4. Apply 1/2-inch film directly to the bum sites after cleansing the wounds.
Answers 3.
3. A client suspected of having an abdominal tumor is scheduled for a computerized tomography scan with dye injection. The nurse tells the client that
1. The test may be painful.
2. The dye injected may cause a warm, flushing sensation. "
3. Fluids will be restricted following the test.
4. The test takes about 2 hours.
Answers 2.
4. The nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment sign/symptom would the nurse most likely expect to note in the client based on this magnesium level?
1. Tetany
2. Twitches
3. Positive Trousseau's sign.
4. Loss of deep tendon reflexes
Answers 4.
5. The nurse is caring for a client with a diagnosis of hyperthyroidism. Laboratory studies are performed, and the serum calcium level is 12 mg/dL. Which medication would the nurse anticipate to be pre-scribed for the client?
1. Calcium gluconate
2. Calcium chloride
3. Calcitonin (Calcimar)
4. Large doses of vitamin D
Answers 3.
6. The nurse prepares to administer sodium polystyrene sulfonate ( Kayexalate ) to the client. Before administering the medication, the nurse reviews the action of the medication and understands that it releases
1. Bicarbonate in exchange primarily for sodiumions.
2. Sodium ions in exchange primarily for bicarbonate ions.
3. Sodium ions in exchange primarily for potassiumions.
4. Potassium ions in exchange primarily for sodiumions.
Answers 3.
7. Which of the following clients is least likely at risk for the development of third spacing?
1. The client with cirrhosis
2. The client with diabetes mellitus
3. The client with liver failure
4. The client with renal failure
Answers 2.
8. The nurse is preparing to care for a client following a gastroscopy procedure The nurse includes which most appropriate component in the nursing care plan?
1. Place the client in a supine position to providing comfort.
2. Monitor the client's vital signs every hour for 4 hours
3. Provide saline gargles immediately on return to the unit to aid in comfort. 4. Check the gag reflex by using a tongue depressor to stroke the back of client's throat.
Answers 4.
9. Intravenous Ringer's lactate solution is prescribed for the postoperative client. The nursing instructor asks the nursing student who is caring for the client about the tonicity of the prescribed intravenous solution . the nursing student responds correctly by stating that this solution is
1. Isotonic
2. Normotonic
3. Hypotonic
4. Hypertonic
Answers 1.
10. The nurse reviews the arterial blood gas results of a client with Guillain-barre syndrome .The pH is 7.35 and the Pco2 is 50 mmHg .The nurse interprets that this client is experiencing which acid-base imbalance ?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Answers 1.
11. The client is admitted 24 hours following an aspirin overdose . The nurse assesses this client for which signs and symptoms indicating the acid-base disturbance that can occur in the client ?
1. Bradycardia and hyperactivity
2. Restlessness , confusion , and a positive Trousseau”s sign
3. Headache ,nausea ,vomiting ,and diarrhea
4. Bradypnea ,dizziness ,and paresthesias.
Answers 3.
12. The adult client with hepatic encephalopathy has a serum ammonia level of
95mcg/dL and receives treatment with lactulose (Chronulac).The nurse would evaluate that the client had the best and most realistic response ,if the serum ammonia level changed to which of the following after medication administration ?
1. 80 mcg/dL
2. 60 mcg/dL
3. 10 mcg/dL
4. 5 mcg/dL
Answers 2.
13. The client who suffered a crush injury to the leg has a highly positive urine myoglobin level .The nurse assesses this particular client carefully for signs of
1. Cerebrovascular accident
2. Acute tubular necrosis
3. Respiratory failure
4. Myovardial infarction
Answers 2.
14. The adult male client admitted to the hospital with shock has received replacement .The nurse evaluates that the client has had adequate fluid resuscitation if the client’s repeat hematocrit level has decreased to which of the following values in the normal range?
1. 56%
2. 48%
3. 39%
4. 34%
Answers 2.
15. The nurse is formulating a plan of care for feeding refuses to participate in the plan of care ,will not make eye contact ,and does not speak to the family or visitors .The nurse assesses that this client is using which type of coping mechanism?
1. Imbalanced Nutrition ,Less Than body Requirements
2. Risk for Aspiration
3. Risk for Deficient Fluid Volume
4. Distancing
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