1. An observation consistent with complete-airway obstruction is:
a. Loud crowing when attempting to speak
b. Inability to cough
c. Wheezes on auscultation
d. Gradual
2. The nurse assesses the client's home environment for the safe use crutches. Which one of the following would pose the greatest hazard to the client's safe use of crutches at home?
a. A 4-year old cocker spaniel
b. Scatter rugs
c. Snack tables
d. Diet high in fat
3. A patient who has kaposis sarcoma has all of the following nursing diagnoses. To which one should the nurse give priority?
a. Altered thought processes related to lesions
b. Altered with maintenance related to non compliance
c. Defensive coping related to loss of boundaries
d. Hopelessness, related to inability to control disease process
4. Which of the following statements, if made by a patient who has had a basal cell carcinoma removed, would indicate to the nurse the need for further instruction?
a. "I will use sunscreen with at least a sun protection factor (SPF) of 15.”
b. "I will use tanning booths rather than sunbathing from now on."
c. "I will stay out of the sun between 10:00 AM and 2:00 PM"
d. "I will wear a broad - brimmed heat when I am in the sun"
5. A patient who has a diagnosis is metastatic cancer of the kidney is told by the physician that the kidney needs to be removed. The patient asks the nurse. "What should I do?" Which of the following responses by the nurse would be most therapeutic?
a. "Let's talk about your options."
b. "You need to follow the doctor's advice."
c. "What does your family want you to do."
d. "I wouldn't have the surgery done without a second opinion.
6. Which of these groups should a nurse target when planning a community education presentation about testicular cancer?
a. Day care providers
b. Senior citizens
c. Middle - aged men
d. High - school students
7. A woman reports all of the following data when giving his history to a nurse. Which one would indicate a risk factor for developing cancer of cervix?
a. Diet high in fat
b. Exposure to pesticides
c. "What does your family want you to do."
d. "I wouldn't have the surgery done without a second opinion."
8. A nurse is planning a community education presentation about testicular cancer. The large groups should be men aged:
a. 20 to 39 years
b. 40 to 49 years
c. 50 to 64 years
d. 65 years and older
9. A 10-year-old boy who is in the terminal stages of Duchenne muscular dystrophy is being cared for at home. When evaluating for major complications of this disease, a nurse would give priority to assessing which of the following body systems?
a. Integumentary
b. Neurological
c. Respiratory
d. Gastrointestinal
10. Which of the following conditions, reported to a nurse by a 20 year old male patient, would indicate a risk for development of testicular cancer?
a. Genital Herpes
b. Undescended testicle
c. Measles
d. Hydrocele
11. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:
a. Limit fluid intake for 24 hours
b. Teach muscle tightening exercises
c. Teach the procedure for irrigation of the stoma
d. Provide cleansing enemas and laxatives as ordered
12. To gain access to a vein and an artery, an external shunt may be used for clients who require hemodialysis. The most serious problem with an external shunt is.
a. Septicemia
b. Clot-formation
c. Exsanguination
d. Sclerosis of vessels
13. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:
a. Limit fluid intake for 24 hours
b. Teach the procedure for irrigation of the stoma
c. Teach muscle-tightening exercises
d. Provide cleansing enemas and laxatives as ordered
14. Intramedullary nailing is used in the treatment of:
a. Slipped epiphysis of the femur
b. Fracture of shaft of the femur
c. Fracture of the neck of the femur
d. Intertrochanteric fracture of the femur
15. The nurse should know that, following a fracture of the neck of the femur, the desirable position for the
a. Internal rotation with extension of the knee
b. Internal rotation with flexion of the knee and hip
c. External rotation with flexion of the knee and hip
d. External rotation with extension of the knee and hip
16. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:
a. Stimulating the cerebral cortex
b. Blocking the action of cholinesterase
c. Replacing deficient neurotransmitters
d. Accelerating transmission along neural swaths
17. A client with myasthenia gravis ask the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
a. A genetic in the production acetylcholine
b. A reduced amount of neurotransmitter acetylcholine
c. A decreased number of functioning acetylcholine receptor sites
d. An inhibition of the enzyme ACHE leaving the end plates folded
18. A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit the nurse should
a. Maintain the same dial setting everyday
b. Turn the machine several times a day for 10 to 20 minutes
c. Adjust the TENS dial until the client perceives pain relief and comfort
d. Apply the color-coded electrodes anywhere it is comfortable for the client
19. Although no cause has been determined for scleroderma, it is thought to be caused by:
a. Autoimmunity
b. Ocular motility
c. Increased amino acid metabolism
d. Defective sebaceous gland formation
20. The nurse must help the client with pemphigus vulgaris deal with the resulting:
a. Infertility
b. Paralysis
c. Skin lesions
d. Impaired digestion
21. The nurse should explain to the client with psoriasis that treatment usually involves:
a. Avoiding exposure to the sum
b. Topical application of steroids
c. Potassium permanganate baths
d. Debridement of necrotic plaques
22. The nurses should assess a client with psoriasis
a. Pruritic lesions
b. Multiple petechiae
c. Shiny, scaly lesions
d. Erythematous macules
23. A urine specimen for ketones should be removed from a client's retention catheter by:
a. Disconnecting the catheter and draining it into a clean container
b. Cleansing the drainage valve and removing it from the catheter bag
c. Wiping the catheter with alcohol and draining it into a sterile test tube
d. Using a sterile syringe to remove it from clamped, cleansed catheter
24. Following an abdominal cholecystectomy, the nurse should assess for signs of respiratory complications because the:
a. Incision is in close proximity to the diaphragm
b. Length of time required for surgery is prolonged
c. Client's resistance is lowered because of bile in the blood
d. Bloodstream is invaded by microorganisms from the biliary tract
25. The nurse assess the client with cholecystitis for the development of obstructive jaundice, which would be evidenced by:
a. Inadequate absorption of fat-soluble K
b. Light amber urine, dark brown stools, yellow skin
c. Dark-colored urine, clay colored stools, itchy skin
d. Straw-colored urine, putty-colored stools, yellow sclerae
26. A client with cholelithiasis experience discomfort after ingesting fatty foods because.
a. Fatty foods are hard to digest
b. Bile flow into the intestine is obstructed
c. The liver is manufacturing inadequate bile
d. There is inadequate closure of the Ampulla of Vater
27. The chief complaint in a client with Vincent's Angina is:
a. Chest pain
b. Shortness of breath
c. Shoulder discomfort
d. Bleeding oral ulcerations
28. Clients with fractured mandibles usually have them immobilized with wires. The life-threatening problem that can develop postoperatively is:
a. Infection
b. Vomiting
c. Osteomyelitis
d. Bronchospasm
29. As a result of fractured ribs, the client may develop:
a. Scoliosis
b. Paradoxical respiration
c. Obstructive lung-disease
d. Hernation of the diaphragm
30. A client has a bone marrow aspiration performed, immediately after the procedure, the nurse should:
a. Position the client on the affected side
b. Begin frequent monitoring of vital signs
c. Cleanse the site with an antiseptic solution
d. Briefly apply pressure over the aspiration site
31. Following a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure but no. evidence of bleeding. The nurse recognizes that this is most likely caused by:
a. An inadequate fluid intake
b. The after effects of anesthesia
c. A reallocation of the blo6d supply
d. An increased level of epinephrine
32. The occurrence of chronic illness is greatest in:
a. Older adult
b. Adolescents
c. Young children
d. Middle-aged adults
33. A client with full-thickness burns on the chest has a skin graft. During the 1s124 hours after a skin graft, care of the donor site includes immediately reporting.
a. Small amount of yellowish green oozing
b. A moderate area of serosanguinous oozing
c. Epithelialization under the non-adherent dressing
d. Separation of the edges of the non-adherent dressing
34. During peritoneal dialysis the nurse observes that drainage of dialysate from the peritoneal cavity has ceased before the required amount has drained out The nurse should assist the client to:
a. Turn from side to side
b. Drink 8 ounces of water
c. Deep breathe and cough
d. Periodically rotate the catheter
35. A client has ear surgery. An early response that may be associated with possible damage to the motor branch of the facial nerve is:
a. A bitter metallic state
b. Dryness of the lips and mouth
c. A sensation of pain behind the ear
d. An inability to wrinkle the forehead
36. After a prostatectomy, a client complains of painful bladder spasms. To limit these spasms the nurse should:
a. Administer a narcotic every 4 hours
b. irrigate the Foley catheter with 60 ml of normal saline
c. Encourage the client not to contract his muscles as if he were voiding
d. Advance the catheter to relieve the pressure against the prostatic fossa
37. After 1 week a client with acute renal failure moves, into the diuretic phase. During this phase the client must be carefully assessed for signs of:
a. Hypovolemia
b. Hyperkalemia
c. Metabolic acidosis
d. Chronic renal failure
38. The nurse checks for hypocalcemia by placing a blood pressure cuff on a client's arm and inflating it. After about 3 minutes the client develops carpopedial spasm. The nurse records this finding as a positive:
a. Homan's sign
b. Romberg sign
c. Chvostek's skin
d. Trosseau's sign
39. A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured am and leg, and abdominal pain. The nurse wraps the man's hand in soiled cloth and drives him to the nearest hospital. The nurse is:
a. Negligent and can be sued for malpractice
b. Practicing under guidelines of the Nurse Practice Act
c. Protected for these actions, in most states, buy the Good Samaritan Law
d. Treating a health problem that can and should be handled by a physician
40. A client is scheduled for a below-the-knee amputation of the right leg. Legally, the client may not sign the operative consent if:
a. Ambivalent feelings regarding operation are present
b. Any sedative type of medication has recently been administration
c. A discussion of alternative with 2 physicians have not been performed and recorded
d. A complete history and physical have not been performed
41. The nurse is assigned to check a client's continuous bladder irrigation. Which one of the following solution is normally used for continuous or intermittent bladder and catheter irrigations?
a. Hydrogen peroxide
b. Bacteriostatic water
c. Sterile normal saline
d. Plain water
42. When continuous bladder irrigation is used following prostate surgery, the rate of flow is adjusted:
a. To run at 60 drops per minutes
b. According to the client's oral intake
c. To maintain an output of 500 ml every 8 hours
d. To keep the drainage to light pink
43. The nurse is assigned to teach a class in health behaviors to young man. Which of the following can be stated as a probably cause of cancer of the penis?
a. A diet high in acidic foods
b. Poor personal hygiene
c. Exercise
d. Circumcision
44. The nurse is assigned to give perineal care to an uncircumcised male client. Which of the following is correct?
a. The anal area is washed at a separate time
b. The foreskin is retracted and the area beneath the foreskin is cleansed
c. The foreskin should not be retracted except by a physician
d. The scrotum is carefully washed with sterile normal saline
45. A female nurse is assigned to obtain a history from & client with a urinary tract problem an sexual dysfunction. Which of the following statements might place the client more at ease and willing to give a. history of his problem?
a. "When dud you first notice this problem?
b. "Why do you think you have a problem?"
c. "Do you think you sexual dysfunction is psychological?"
d. "Does your sexual dysfunction seem to be related to your urinary tract problem?"
46. A client is scheduled for an ultrasound examination of the prostate. To describe the procedure to the client, the nurse should plan to relate that:
a. The procedure is performed using a cystoscope
b. A probe will be inserted into the rectum
c. A flat disk is placed on the abdomen
d. This procedure uses x-rays to produce a visual image
47. To effectively teach men the importance of testicular self-examination, the nurse should know that testicular carcinoma:
a. Rarely metastasizes
b. Has a high incidence of early metastasis
c. Cannot be detected by laboratory tests
d. Must first be biopsied to confirm the diagnosis
48. A nurse is assigned to instruct a client in the method of testicular self-examination. The instruction should include mention that the best time to perform this task is:
a. Immediately after getting out of bed in the morning
b. Immediately before going to bed
c. In the morning after breakfast
d. After a warm bath or shower
49. Mr. Dorn has vasectomy. He asks the nurse why he just use a method of birth control because today he, had a sterilization procedure. The most correct answer is:
a. The sperm count will not be negative until his testosterone level decrease
b. Some minor surgery usually is necessary to ensure sterilization
c. Some live sperm will be present in the ejaculatory fluid for a period of time
d. Even though a vasectomy is performed, a condom is still recommended for 1 to 2 years
50. A client is scheduled for a cystectomy and asks the nurse what the physician will be able to see during the procedure. The most correct reply is the:
a. Kidney and ureters
b. Bladder and rectum
c. Prostate and ureters
d. Urethra and bladder
51. Nurse assistant attending a nursing conference hears that one of her clients has hydrocele. She asks the nurse how this condition is treated. The most common response is:
a. Usually the problem requires more medical or surgical intervention
b. Surgery may be necessary to correct the problem
c. Wearing a scrotal support usually corrects She problem
d. Drug therapy usually helps control the collection of fluid
52. The nurse is participating in a health class for young women. One subject is cancer of the ovary. Which of the following statements is correct?
a. Early symptoms of cancer of the ovary are vague
b. This type of cancer has a high cure rate
c. Chemotherapy is not used for treating ovarian cancer
d. The most prominent early symptoms is an irregular menstrual cycle
53. The nurse is asked to discuss the signs and symptoms of vaginitis caused by the fungus candida albicans with Ms. Barrows. Which one of the following is a usual sign and symptoms of this infection?
a. Pain high in the abdomen
b. Intensive vaginal and perineal itching
c. Decrease in urinary output
d. High fever
54. The nurse prepares to give Ms. Edwards a vaginal suppository, which is inserted by means of a special applicator supplied with the drug. Which one of the following is correct?
a. Ask the client to void prior to inserting the suppository
b. Lubricate the tip of the suppository with petroleum jelly
c. Insert the applicator tip gently and with an upward and forward motion
d. Insert the applicator approximately ½ inch and depress the plunger
55. The nurse is assigned to give Ms. Milton perineal care. When cleansing the perineum, the cotton ball or wash cloth is gently directed:
a. Side to side across the labia majora
b. Downward from the pubic area to the anus
c. Upward from the anus to the pubic area
d. Prom the urinary meatus to the vagina
56. The nurse is assigned to administer a vaginal irrigation (douche). Which of the following is correct?
a. The irrigation is best administered with the client standing in a bathtub
b. Before inserting, the nozzle is lubricated with petroleum jelly
c. The temperature of the solution should be between 80°F and 84°F
d. The nozzle is inserted downward and backward within the vagina
57. The nurse is assigned to teach health-seeking behaviors to young women. One topic the nurse plans to includes is the importance of the Pap test, which is used mainly to detect:
a. Ovarian cyst
b. Patency of the fallopian tube
c. Cervical cancer
d. Uterine infections
58. The physician asks the nurse to position a client for a vaginal examination. Which of the following position is normally used for this type of examination?
a. Lithotomy position
b. Sim's position
c. Dorsal recumbent position
d. Left lateral position
59. Ms. Hull has had an electrocauterization of her cervix for chronic cervicitis. Following the procedure the nurse should instruct Ms. Hull to:
a. Douche the next day to remove debris and blood cloth
b. Avoid straining and heavy lifting until the physician permits this activity
c. Stay in bed for the next 5 days
d. Return in bed for the next 5 days
60. The nursing assistant is assigned to give Ms. Bailey, who has had an abdominal hysterectomy, a sitz bath. She is instructed to use the special sitz bath tub. She asks the nurse why the regular bath tub cannot be used. The most correct reply is based on the fact that a regular bath tab:
a. Is more slippery and is dangerous when used for surgical clients
b. Cannot supply water that is of the desired temperature for this procedure
c. Applies heat to the legs and alters the desired effect of heat directed to the pelvic region
d. Cannot be kept as clean as a special sitz bath tub
61. The physician asks the nurse to describe the laparoscopy procedure for sterilization to Ms. Bruce. Which of the following is part of a correct explanation of this procedure?
a. Two small abdominal incisions are made to introduce the instrument
b. Hospitalization for 4 to 5 days is normally required
c. This procedure is performed vaginally
d. This procedure requires the consent of the sexual partner
62. The nurse is asked to plan a health teaching program for women of child-bearing age with genital herpes. Which one of the following should the nurse include in a teaching session?
a. The physician will prescribe an antiviral drug as a pregnancy is confirmed
b. Genital herpes in the mother-has no effect on the infant
c. Wait until the infection has been cured before becoming pregnant
d. If pregnant, in form the physician of a history of genital herpes
63. Ms. Manning is scheduled for Papanicolaou test (Pap Smear) at the time of the next visit to the physician's office. Which one of the following instructions should the nurse give to Ms. Manning?
a. Do not douche for 2 to 3 days before this test
b. Do not drink coffee or alcoholic beverages for 2 days before this test
c. It will be necessary to fast from midnight the night before the test
d. Bring a sanitary napkin with you because bleeding usually occurs after this week
64. The nurse obtains a health history from Ms. Reeves who states that she usually has symptoms when she ovulates. If Ms. Reeves has a normal menstrual cycle, how many days after ovulation should menstruation begin?
a. 3 days
b. 7 days
c. 14 days
d. 21 days
65. The physician asks the nurse to discuss the use of an oral contraceptive with Ms. Sheppard. The nurse should instruct Ms. Sheppard that oral contraceptive:
a. Are taken at the same time each day, preferably in the evening
b. Must be taken on an empty stomach
c. Are started on the first day of menstruation
d. Are best taken in the morning before breakfast
66. Ms. Dodd has been told by her physician that she has genital warts, which are caused by a human .papilloma-virus-infection. She asks the nurse if there is any danger or problems associated with this condition. The most correct response-is based on the fact that genital warts:
a. Can be treated with an antibiotic, such as penicillin or tetracycline
b. Appear to increase the risk of cancer of the vulva, vagina, and cervix
c. Can be prevented of the individual takes birth control pills
d. Are of no danger and need not be treated
67. Which of the following are included in the instructions for a client having a pelvic examination?
a. Self-administer an enema or take a laxative for 2 nights prior to the examination
b. Void immediately before the examination
c. Douche the day before the examination
d. Do not eat or drink fluids after midnight
68. The nurse is assigned to teach young women attending a gynecology clinic. The physician suggests that the nurse include explaining ways to prevent toxic shock syndrome. Which one of the following suggestions can be included in this teaching session?
a. Avoid using super absorbed tampons
b. Take a diuretic at the onset of menstruation
c. Avoid the use of large sanitary pads
d. Use a tampon on(y during the night
69. Which of the following solutions would be best for the nurse to use when cleaning the inner cannula of a tracheostomy tube?
a. IsopropyI alcohol
b. Sodium hydrochloride
c. Hydrogen peroxide
d. Providone-iodine
70. The nurse observes that the client's knee is swollen and painful. Consequently; which one of the following nursing measures should be carried out?
a. Perform passive range of motion during each shift
b. Help to change positions to achieve comfort
c. Ambulate with him at frequent intervals
d. Encourage quadriceps setting exercises
71. If Ms. Drake tells the nurse her feet are cold. Which of the following nursing action would be best
a. Apply a hot water bottle
b Use an electric heating pad
c. Wrap them in a warm blanket
d. Elevate her feet on a stool
72. Which of the following would indicate to the nurse that the stationary thrombus in Ms. Fleming suddenly develops?
a. Chest pains
b. Leg cramps
c. Numbness in the foot
d. Swelling of the knee
73. Following a total abdominal hysterectomy Ms. Sara Fleming develops a slightly elevated temperature and swelling in the right call of her leg. The physician prescribes warm moist compresses for the client's affected leg. Which of the following nursing actions is correct when applying the warm moist compress? The nurse:
a. Heats the water to 120°F
b. Uses a sterile technique
c. Inspect the skin every 4 hours
d. Covers the wet gauze with a towel
74. Ms. Betty Lynch, age 29, holes that she has recently developed a skin problem and makes an appointment to be seen in a clinic specializing diagnosis of psoriasis is made by the physician. When examining Mr. Lynch's skin for areas of psoriasis, the nurse should look for:
a. Weeping lesions on the trunk of the body
b. Patches of redness covered with silvery scales
c. Areas of redness surrounded by crusts
d. A rash characterized by raised, pus-filled lesions
75. Before being discharged, Mr. Heywood must be taught principles f good body mechanics. The nurse would be correct in telling Mr. Heywood that when he picks up something, he should:
a. Flex both his knees
b. Keep his feet together
c. Lift with arms extended
d. Bend from the waist
76. The nurse applies a commercially made hot moist pack, called a hydrocollator, to the client's lower back. To reduce the potential for a thermal injury the nurse should plan to:
a. Wrap the pack in several thick towels
b. Rub skin lotion over the back area
c. Place a pillow between hint and the back
d. Position the client on rubber ring
77. Which one of the following observations would most indicate to the nurse that the skin over Mr. Heywood's coccyx is becoming impaired? The skin:
a. Looks shiny over boy prominences
b. Appears red when pressure in relieved
c. Feels cool and clammy
d. Is moist and warm
78. Before turning Mr. Heywood to wash his back, which instruction should the nurse provide to minimize his discomfort?
a. "Hold your breath as you are turning."
b. "Move your upper body first then legs."
c. "Curl up in a ball before you move."
d. "Avoid twisting your body while moving."
79. Which of the following should the nurse use to provide support to Mr. Heywood's spine?
a. A sheep skin pad
b. An air mattress
c. A bed board
d. A foam square
80. Mr. Heywood is to remain in bed for the time being. Which position would the nurse find gives Mr. Heywood the most comfort?
a. On his back with the head and knees elevated
b. On his side with hips and legs straight
c. On his abdomen with his head to the side
d. On his back with his head and knees straight
81. Mr. Heywood is receiving 10 mg of Diazepam (Vatium) orally t.i.d. Besides diminishing anxiety, the nurse explains that this medication is also used to:
a. Reduce emotional depression
b. Relax skeletal muscles
c. Promote restful sleep
d. Relieve inflammation
82. Mr. Barry Heywood, a construction worker, has been experiencing periodic bouts of law back pain. Now, in addition to the pain that radiates into his buttocks, he has some numbness and tingling in his legs. The physician suspects that Mr. Heywood has a herniated intervertebral disk in the lumbar spine. While assessing the disk to indicate that the pain is increased when:
a. Eating
b. Sneezing
c. Resting
d. Urinating
83. Mr. Rumsey, who has not regained consciousness, rushed to surgery where his arm is amputated above the elbow. When Mr. Rumsey reacts from the anesthesia, he sees that his forearm is missing. He screams obscenities and sobs uncontrollably. Which of the following is the best action the nurse can take at this time?
a. Leave the room until he has worked through his anger
b. Stay with him quietly in the room at his bedside
c. Tell him to get control of himself
d. Call the hospital chaplain for him
84. In what position should the nurse place Mr. Rumsey while continuing with his assessment and care?
a. Prone
b. Supine extended
c. On his back with his legs elevated
d. On his side with his neck
85. During a farming accident Mr. Steve Rumsey's arm gets caught in a corn auger. His lower left arm and band are crushed. Which of the following assessments would the nurse typically find when the paramedics bring Mr. Rumsey to the hospital in shock? The client would have:
a. Decreased heart rate
b. Decreasing blood pressure
c. Increasing bowel sounds
d. Increasing urine output
86. Ms. Angela Freeman has acute low back pain. She' has pelvic-belt traction, which she uses intermittently throughout the day. When the nurse helps Ms. Freeman apply the pelvic traction, it would be best to place the top of the belt:
a. Just below the ribcage
b. Even with her waistline
c. Level with the iliac crest
d. Where it is most comfortable
87. Ms. Rizal has acute rheumatoid arthritis. Her hands and spine are involved. When the nurse admits Ms. Rizal is most likely to tell the nurse that the first symptoms that caused her to seek health care was:
a. Stiff, sore joints
b. Generalized fatigue
c. Stabbing hand pain
d. Disuse of fingers
88. Before Ms. Elkins leaves the emergency department, the nurse demonstrates hew to apply the roller bandage. She is told to remove it for approximately 20 minutes and re-apply it three times a day. It is essential that the nurse tells Ms. Elkins to loosen-the bandage if:
a. Her toes feel fairly warm
b. Her ankle feels painful
c. Her toes appear swollen
d. She wears a cotton sock
89. The x-ray reveals that the bones are intact. The physician tells Ms. Elkins that she has severely sprained ankle. The physician directs the nurse to wrap Ms. Elkins foot with an elastic roller bandage referred to by some as an Ace bandage. Where should the nurse begin applying the bandage?
a. Below the knee
b. Above the knee
c. Across the phalanges
d. At the metatarsals
90. Following an injury in which Ms. Leona Elkins while climbing stairs, she experiencing immediate swelling of her ankle and pain on movement. Her physician has sent her to the hospital for x-ray. Which on of the following nursing measures would be most helpful for relieving the swelling while preparing to obtain the x-ray of Ms. Elkin's lower leg?
a. Dangle the foot
b. Elevate the foot
c. Exercise the foot
d. Immobilize the foot
SITUATION: Mr. Ramos was barbecuing outdoors when the gas tank exploded. He sustained second degree and third degree burns of the anterior portion of BOTH arms, the upper half of his anterior trunk and the anterior and posterior portions of his left lower extremity. - '
91. The BEST initial management of burns that can be employed at the scene is generally which of the following:
a. Pour cold water over the burned areas
b. Apply clean dressing to the affected area
c. Rinse the area with mild soap and water
d. Apply tomato juice and ointment over the area
92. At the emergency room, the nurse assessed the extent of the burn on the patient's body. Based on the rules of nine. Which of the following is the BEST estimate of the burn?
a. 36%
b. 45%
c. 27%
d. 54%
93. Which one of the following .blood value determinations is most likely be useful to evaluate the adequacy of the fluid replacement?
a. Creatinine levels
b. Blood urea nitrogen
c. Hematocrit level
d. C02 tension
94. The nurse is administering the prescribed IVF. When she evaluated the patient, she suspected fluid overload because of which finding?
a. Dark and scant urine output
b. Moist rates
c. Bradycardia and hypotension
d. Facial flushing and twitching
95. The doctor orders MAFENIDE for application over the bum area. The nurse understands that one disadvantage of this drug is that:
a. It causes lactic acidosis
b. It must be constantly applied
c. It has minimal eschar penetration
d. It is bacteriostatic
SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer. He had undergone lobectomy on the left lower lung. A two-bottle drainage system is inserted.
96. The patient is placed on bed post-operatively in what position?
a. Prone
b. Trendelenburg
c. Right side
d. Left side
97. Water-seal chest drainage involves attaching the chest tube to a:
a. Suction machine directly
b. Rubber tube/glass tube that is submerged underwater
c. Rubber tube that is left open to air
d. A closed drainage bottle with sterile water and no external opening
98. If the nurse sees fluid moving up and down during inspiration and expiration on the water seal bottle, she should:
a. Do nothing as this is expected
b. Immediately check the bottle for leaks
c. Call the physician immediately and damp the chest tube
d. Cover the wound with wet sterile gauze and send someone to calf the physician
99. If the nurse sees vigorous and continuous bubbling in the second bottle, she should:
a. Momentarily clamp the tube to note for air leak
b. Administer oxygen to the patient
c. Attempt to change a new bottle
d. Pull the chest tube out to remove the air leak
100. If the tube accidentally displaces from the chest of the patient, the nurse should do which action first?
a. Clamp the tube with the use of forceps
b. Obtain a new set of tubing and submerge the tube on the water
c. Attempt to reinsert the tube
d. Apply vaselinized gauze to the opening
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