0
Q
- The nurse assesses a surgical patient the morning of the first postoperative day. Signs of a local inflammatory response that the nurse expects to find include.
A. Redness and heat of the incision
B. Leukocyte sis with elevated monocytes
C. Pain and purulent drainage of the incision
D. Fever and increased pulse and respiration rate.
A
A. Redness and heat of the incision
1
Q
2. A paraplegic patient is admitted to the hospital for intensive management of an open, infected pressure ulcer on the left buttock at the prominence of the ischial tuberosity. The initial assessment of the patient's pressure ulcer indicates that it is 5cm long by 2.5cm wide and is 1.5cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as; A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
A
C stage 3
2
Q
Initial evidence that would indicate to the nurse that a patient is experiencing a systemic anaphylaxis to an injected allergen is the development of;
A. Dyspnea
B. Dilation of the pupils
C. Itching and Edelman at the injection site
D. A wheal-and-flare reaction at the injection site.
A
A. Dyspnea
3
Q
4. A patient with severe allergic reaction is treated with epinephrine. The nurse recognises that the rationale for the use of ephinephrine is that epinephrine opposes the effects of A. Histamine B. Lymphokines C. Interleukin-2 D. Lysosomal enzymes
A
A. Histamine
4
Q
- It is especially important for the nurse to determine the patients current use of medications during the preoperative because;
A. These medications may alter the patients perceptions about surgery
B. Anaesthetics alter renal and hepatic function, causing toxicity by other drugs
C. Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs
D. Routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments
A
C. Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs
5
Q
- Ten minutes after a patient has received his preoperative medication by IM injection, he asks to get up to go to the bathroom to urinate. The most appropriate by the nurse is to;
A. Offer him a urinal and position him bed to promote voiding
B. Assist him to the bathroom and stay with him to protect him from falling
C. Tell him to try to hold the urine because he will catheterised at the beginning of the surgical procedure
D. Allow him to go to the bathroom because the onset of the effect of the medication takes more than 10minutes
A
A. Offer Hume a urinal and position him in bed to promote voiding
6
Q
- When a patient is transferred from the post anaesthetic care unit (PACU) to the clinical surgical unit, the action by the nurse on the surgical should be to
A. Assess the patients pain
B. Take the patients vital signs
C. Check the rate of the IV infusion
D. Check the physicians postoperative orders
A
B. Take the patients vital signs
7
Q
- Postoperative a patient is receiving low molecular weight heparin (LMWH). When administering this drug, the nurse;
A. Explains that the drug will help prevent clot formation in the legs
B. Administers the dose with meals to prevent GI irritation and bleeding
C. Checks the results of the partial thromboplastin time before administration
D. Informs the patient that blood will be drawn every 6 hrs to monitor the prothrombin time
A
A. Explains that the drug will help prevent clot formation. In the legs
8
Q
9. The patient is hospitalised with vomiting of "coffee ground" emesis of unknown cause. The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. The nurses response is based on the knowledge that the diagnostic test which can most accurately identify the source of the bleeding is; A. An endoscopy B. An angiography C. A gastric analysis D. Barium contrast studies
A
A. An endoscopy
9
Q
- A dark-skinned person has been admitted to the hospital in severe respiratory distress. To assess for cyanosis in the patient, the nurse knows that;
A. Cyanosis in the patient with dark skin can be seen only in the sclera
B. It not not possible to assess abnormal colour changes in patients with dark skin
C. Cyanosis can be seen in the lips and mucous membranes of the patients with dark skin
D. Cyanosis will blanch out with direct pressure to the soles of the feet in dark skinned patients
A
C. Cyanosis can be seen in the lips and mucous membranes of patients with dark skin
10
Q
- The best example of nursing documentation of a normal assessment of the skin is
A. “Skin warm and dry; turgor good; nails flat and pink; old surgical scars noted on abdomen”.
B. “History of allergic rashes; skin very fair with numerous freckles, warm and intact; no lesions noted”
C. “Skin brown, slightly moist, and warm; turgor immediate return: no lesions noted. States no problems with skin.
D. “ No history of skin problems; skin intact, pink temperature consistent over body; no lesions expect numerous brown moles”.
A
D. “no history of skin problems; skin intact, pink, temperature consistent over body; no lesions expect numerous brown moles”.
11
Q
- During application of a wet dressing to the skin of a patient with impetigo, it is most important for the nurse to
A. Use cool solutions to debride the lesions
B. Use clean gloves to prevent the spread of infection to others
C. Use sterile gloves and dressings to prevent infection of the lesions
D. Apply a prescribed topical antibiotic ointment before the application of the dressings
A
B. Use clean gloves to prevent the spread of infection to others
12
Q
- A patient is scheduled for an outpatient ultrasound of the gallbladder. The nurse instructs the patient that the evening before the test will be necessary for her to
A. Eat a high-fat evening meal
B. Drink a liquid barium contrast medium
C. Use enemas until return is clear of stool
D. Take nothing by mouth for 8 hrs before test
A
D. Take nothing by mouth for 8 hrs before the test
13
Q
- Following diagnostic testing, a patient with recurring g heartburn and indigestion is diagnosed with a hiatal hernia. The nurse explains to the patient that this condition involves
A. Extension of the esophagus through the diaphragm
B. Displacement of the duodenum through the stomach to the esophagus
C. Twisting of the stomach around the esophagus, occluding the esophagus
D. Protrusion of the stomach into the esophagus through an opening in the diaphragm
A
D. Protrusion of the stomach into the esophagus through an opening in the diaphragm
14
Q
- A patient with upper gastrointestinal bleeding is diagnosed with a duodenal ulcer following an endoscopy, with a histology of a mucosal specimen is positive for Helicobacter pylori. When the nurse administers anti optic therapy for the H.pylori, the patient asks if ulcers are caused by an infection. The best response the nurse includes in the information that
A. H.pylori is strongly associated with gastric ulcers but it is rarely present in those with duodenal ulcers.
B. Although H.pylori is believed to be caused of gastritis, it’s role in the development of ulcers is not known
C. Because most of the population is infected with H.pylori, it is believed that other factors are responsible for u,cer development
D. Infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier
A
D. Infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier
15
Q
- A 78yr old patient is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhoea following a course of antibiotic therapy for pneumonia. Still cultures reveal the presence of Clostridium difficile. In planning care for the patient, the nurse recognises that a priority nursing goal is to
A. Maintain normal nutritional intake
B. Prevent transmission of the microorganism to others
C. Promote relief of abdominal pain with comfort measures
D. Control the diarrhoea with administration of anti diarrheal drugs
A
A. Maintain normal nutritional intake
16
Q
17. While obtaining a nursing history from a patient with inflammatory bowel disease, the nurse recognises that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing A. Weightloss B. Bloody diarrhoea C. Abdominal al pain and cramping D. The onset of the disease at age 20
A
C. Abdominal pain and cramping
17
Q
- An 81yr old patient has a large bowel obstruction that occurred as a result of a fecal impaction. During nursing assessment of the patient , a finding by the nurse that is consistent with a large bowel obstruction includes
A. Metabolic alkalosis
B. Referred pain to the back
C. Rapid onset of copious vomiting
D. Greatly increased abdominal distension
A
D. Greatly increased abdominal distension
18
Q
- During the initial postoperative assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to bve red with moderate edema and a small amount of bleeding. The most appropriate interpretation of this finding by the nurse is that there is
A. A viable stoma with high vascularity
B. Obstruction of the stoma with venous congestion
C. Inadequate blood supply to the stoma, caused by edema
D. An abnormal stoma condition that should be reported to the surgeon
A
A. A viable stoma with high vascularity
19
Q
- A patient has a newly formed ileostomy for treatment of ulcer colitis. In teaching the patient about the care of her ileostomy, the patients that she should
A. Restrict fluid intake to prevent constant liquid drainage from the stoma
B. Change the pouch every day to prevent leakage of contents onto the skin
C. Maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea
D. Irrigate the ileostomy daily or every other day to avoid having to wear a drainage appliance
A
C. Maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea
20
Q
- When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyper pronating the wrists. The nurse interprets this finding as
A. Decorticating posturing indicating an interruption of voluntary motor tracts
B. Decree rate posturing indicating an interruption of voluntary motor tracts
C. Decorticate posturing indicating a distrust ion of motor fibers in the midbrain and brainstem
D. Decerebrate posturing indicating a disruption of motor fibers in the midbrain and brainstem
A
D. Decerebrate posturing indicating a disruption of motor fibers in the midbrain and brainstem
21
Q
- When assessing a patient with a neurological disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the
A. Level of consciousness
B. Presence of cerebral edema
C. Presence of corneal and pupillary reflexes
D. Integrated functions of the cerebral cortex
A
A. Level of consciousness
22
Q
23. A 68yr old man has had several transient ischemic attacks (TIA's) with temporary hemiparesis and dysarthria that have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stroke may be reduce if therapy is initiated within 3 hrs with use of A. Intravenous heparin B. Transluminal angioplasty C. A surgical endarterectomy D. Tissue plasminogen activator (TPA)
A
D. Tissue plasminogen activator (TPA)
23
Q
24. When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increase risk for the patient who reports a family history of A. Osteoporosis B. Osteomalacia C. Osteomyelitis D. Bony tuberculosis
A
A. Osteoporosis
24
25. A patient is admitted to the emergency department, with possible fractures of the bones of the left lower extremity. Prior initiating treatment for the patient, it is most important for the nurse to
A. Sprint the lower leg
B. Elevate the injured leg
C. Check neurovascular stratus distal to the injury
D. Assess the patient's tetanus immunisation status
C. Check neurovascular stratus distal to the injury
Nur203- CK Study Help
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