NURSING PRACTICE IV

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART B

1. A client is hospitalized for treatment of a fractured femur. Suddenly, he becomes pale,

confused and very short of breath. He complains of pain to his chest. The nurse also notes

petechial hemorrhages on his legs and stomach. The nurse suspects that this clients.

a. Is having an acute anxiety attack c. May have a wound infection

b. May have a fat embolism d. Is having a myocardial infarction

Rationale: B

Because involvement of the long bone with shortness of breath involving respiration and

petechia this occur within 24 to 48 which not mention. What make (A) wrong because it is

psychosocial and (C, D) it didn’t answer the question.

2. The nurse is the first professional to arrive at the scene of a multi vehicle accident. Mr. R. was

riding a motorcycle. Upon impact, he fell off the bike and it fell back on his legs. Priority care

for Mr. R. should be directed toward:

a. assessing blood loss c. obtaining vital signs

b. monitoring respiratory status d. organizing lay people on the scene

Rationale: B

In the presence of multiple trauma, maintenance of a patent airway must always be the priority

in the sequence of care delivery. Assessing blood loss would be the second priority of care.

Obtaining vital signs would be the next action. Organizing lay people on the scene would be a

later action.

3. A client involved in a motor vehicle accidents is brought to the emergency department with

head and chest injuries. The client is unresponsive and is unable to give informed consent for

surgery. Which of the following actions is most appropriate for the nurse to take?

a. Have the physician and anesthesiologist sign the consent form.

b. Witness the consent form along with another nurse.

c. Prepare the client for surgery and omit the form since the client cannot consent.

d. Request that the nursing supervisor witness the consent form.

Rationale: C
Informed consent for adults is not needed when delay of treatment to obtain consent would be

harmful or lethal to the client or when the client waives the right to informed consent. In this

situation, the first circumstance applies, and the nurse should prepare the client for surgery.

Option A is incorrect; these two individuals do not sign the consent form. Options B and D are

incorrect because there is no client signature to witness.

4. What is the most important aspect to include when developing a home care plan for a client

with severe arthritis?

a. Maintaining and preserving function c. Supporting coping with limitations

b. Anticipating side effects of therapy d. Ensuring compliance with medications

Rationale: ATo maintain quality of life, the plan for care must emphasize preserving function. Proper
body

positioning and posture and active and passive range of motion exercises important

interventions for maintaining function of affected joints.

5. An adult client sustained a fractured tibia three hours ago. A long leg cast was applied. Now

the client is complaining of increasing pain. The pain is more intense with passive flexion of

the toes. The nurse suspects the client is developing compartment syndrome. Which initial

action should the nurse take?

a. Prepare for emergency fasciotomy.

b. Administer the ordered narcotic IV, then reassess the client’s pain in 15 minutes.

c. Raise the casted leg above the heart, apply ice and notify the physician.

d. Raise the casted leg to the level of the heart, notify the physician, and prepare to split

the cast.

Rationale: D

To decrease the pressure within the compartment, raise the affected extremity only to the level

of the heart and remove any constructive dressing or cast. If this does not work to decrease the

pressure, a fasciotomy may be necessary

Option A - Fasciotomy is performed if compartment pressure cannot be relieved

Option B – Pain from compartment syndrome does not respond well to pain medicine

Option C – Placing the extremely above the level of the heart increases compartment pressure
and should be avoided.

6. Mrs. Susan has a fractured right hip with 5 lb of Buck’s traction. The bed that Mrs. F. is in is

broken. How should the nurse best direct the team to move Mrs. F. to the new bed?

a. Slowly lift the traction to release the weight, support the right leg, and lift Mrs. F. to

the new bed

b. Slowly lift the 5 lb weight from the traction set up, and apply 10 lb of manual traction

during the move

c. It is not safe to move Mrs. F. with Buck’s traction. Support her position changes with

pillows until traction is no longer needed.

d. Decrease the weight of traction over a two hour period; then discontinue the traction

and move Mrs. F. into the new bed.

Rationale: A

5-8 lbs of traction is applied temporarily to provide immobilization prior to surgery. Buck’s

traction should be removed every eight hours to assess the skin under the traction device.

Skeletal traction should not be released unless there is a life-threatening emergency.

Option B - it is not necessary to maintain manual traction, especially at twice the weight, to

move a person in Buck’s traction.

Option C - it is safe to move persons with Buck’s traction and would be uncomfortable to use

pillow support for position changes.

Option D - Once the weight of traction has been established as effective, the weight should be

maintained until it is no longer needed.

7. A nurse is training a client for a swing-to gait. What is the most specific direction you can give

to your client?

a. “Move both crutches forward, then lift and swing your body past the crutches.”

b. “Place the two crutches forward, immediately follow your weak leg in lined to them, them

lift swing your other leg.”

c. “Look down at your feet before moving the crutches to ensure you won’t fall, then raise

your head as you sways away.”d. “Move both crutches forward, then lift and swing your body in
conjunction with
crutches.”

Rationale: D

This is the procedure for using the swing-to gait. Clients are instructed to look straight ahead

when walking with crutches. Looking down can lead to falls and uneven gait. Option A is swingthrough.
Option B is 3-point gait.

Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 311.

8. On the second postoperative day after the hip surgery for a fractured left hip, you are going to

help your client ambulate. The best thing that you can do is:

a. Allow minimal amount of weight on the hips when getting him up.

b. Let the client get up by having him flex the hips for about degrees to maintain proper

bodily contour.

c. Use a walker for balance when getting up the client.

d. Let the client dangle first his legs before moving up.

Rationale: C

Postoperatively hip replacement clients may get up the first day, but need to use a walker for

balance. They should not bear any weight on the affected side, dangle or sit in a chair, flexing

their hips. Positions with 60-90 degree flexion should be avoided.

Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 51.

9. A nursing student is problematic about her upcoming NCLEX exam, she tells you “If only my

skull can move! I think I can get an extra enlargement of my ideas too.” The skull is

functionally classified as what type of joint?

a. Syndesmosis c. Synarthrosis

b. Amphiarthrosis d. Diarthrosis

Rationale : C

Functional classification depends on the degree of movement the joint allows. A diarthrosis,

such as the knee, moves freely. A synarthrosis can’t move like the pelvis and skull.

Amphiarthrosis can move only slightly like the coccyx and sacrum. A syndesmosis like the

tibiofibular or radioulnar joint, is a type of amphiarthrosis with intervening connective tissue

forming an interosseous membrane or ligament.

10. Which among the following could be the best health teaching to a client who had sprained

her ankle and the toes?

a. “Place a lukewarm compress to the site.”

b. “Try to exercise the site a little to prevent loss of function and gangrene formation.”

c. “Place your toes and ankle in lined with your hips to prevent much blood loss.”

d. “You can try frozen water to the affected areas.”

Rationale: D

Treatment of a sprained muscle includes resting the affected leg and applying an elastic or

compression bandage to a sprained muscle to control swelling. Elevating the legs and applying

ice area also included. Option D is just the reword ICE! (RICE: rest, ice, compress, elevate)

Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 121.

11. After change-of-shift report, which patient should the nurse assist first?a. A client with fracture
complaining that the cast is tight

b. A client with right leg amputation complaining of phantom pain

c. A client with hyperthyroidism who tells you that he feels depressed

d. A client with carpal tunnel syndrome complaining of pain

Rationale: A

The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage.

While all of the other patients’ concerns are important and the nurse will want to see them as

soon as possible, none of their concerns is urgent.

Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62.

12. A client with Paget’s disease is admitted in your unit. After thorough assessment, which

finding indicates that the physician should be notified?

a. The patient is 4’11” and weighs 110 pounds.

b. The patient’s skull is soft and larger than normal.

c. The base of the patient’s skull is invaginated.

d. The patient has bowing legs

Rationale: C
Platybasia (basilar skull invagination) causes brain stem manifestations that threaten life.

Patients with Paget’s disease are usually short and often have bowing of the long bones that

results in asymmetric knees or elbow deformities. Their skull is typically soft, thick, and

enlarged.

Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62.

13. A 1year-old boy is admitted to the hospital with a fractured femur. Which of the following

lunches would be the most appropriate?

a. String beans b. Strained beans c. French fries d. Infant formula

Rationale: A

The finger foods appeal to a 1-year-old and offer appropriate nutrition as well. A fractured femur

does not require a special diet.

Option B, this may be a nutritious meal, but offers little variety in texture, and the child cannot

easily feed herself.

Option C, it is best to avoid fried foods when possible. Foods should be broiled, poached, or

baked rather than fried.

Option D, solids should be introduced to the child at around six months of age.

Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 65.

14. Which of the following assessment findings would a nurse expect in a client with gouty

arthritis?

a. Pruritus and increased calcium in the blood

b. Positive blood culture results and increased ESR

c. Abnormal ABG results and petechiae in the chest

d. Bone pain and increased WBC

Rationale: A

Hyperuricemia and pruritus are associated with gouty arthritis. Osteomyelitis causes localized

bone pain, tenderness, heat and swelling at affected area, high fever, increased WBC count and

ESR and positive blood culture results. Petechiae over the chest and abnormal ABG results

suggest fat embolism.Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd
ed. 2001. p.
433.

15. A 16-year-old client is admitted for scoliosis repair with a Harrington Rod insertion. The

Nurse should not fail in giving this information to the client before the postoperative care:

a. Take a soft diet

b. Elevate legs 5 times every 2 hours

c. Get off and on the bedpan by lifting hips

d. Take 10 deep breaths every 2 hours

Rationale: D

These clients must be monitored closely for the first 48-72 hours for respiratory problems. Bowel

and urinary problems need to be assessed along with neurological problems in the extremities.

Option A, incorrect because the client may have a nasogastric tube to low suction. Option C,

incorrect because the client will have a catheter. Option B, is not appropriate for the situation.

Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 28.

16. Client Morazella wrathfully goes to you for some advices. She yells to you, “What’s the fact

about being obese?!”

a. “Obese people have a lower percentage of water than lean people.”

b. “Obese people have a higher percentage of water than lean people.”

c. “Girls have a higher percentage of water than boys.”

d. “You are not obese, you are sexy! We are sexy”

Rationale: A

The proportion of body water varies inversely with the body’s fat content because fat contains

no water. Therefore, an obese person has a lower percentage of water than a lean person. Most

women have a lower percentage of water than men because their bodies normally have a

higher percentage of body fat. (Option D is the best answer nyahaha!)

Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.

17. The nurse made her diagnosis for a client who is having a shock, Fluid Volume Deficit

related to decreased plasma volume. Which of the following supports her diagnosis?

a. Shallow respirations with some bubbling crackling sounds.

b. Some pitting edema found in the ankles.

d. Flattened neck veins, which are obvious upon lying in.

Rationale: D

Normally, check veins are distended when the client is in the supine position. These veins flatten

as the client moves to a sitting position. The other three responses are characteristics of Fluid

Volume Excess.

Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 23.

18. If a client had a diagnosis of Syndrome of Inappropriate Anti-diuretic Hormone (SIADH),

which of the following electrolyte should a nurse watchful for?

a. Decreased sodium c. Increased potassium

b. Increased sodium d. Decreased potassium

Rationale: A

SIADH causes a relative sodium deficit due to excessive retention of water.Reference: LaCharity, Linda.
Prioritization, Delegation, and Assignment. 2006. p. 24.

19. Which of the following would the nurse suspect if the client’s ECG waveform is tall-tented T

waves?

a. Hyperkalemia c. Hypokalemia

b. Hypercalcemia d. Hypocalcemia

Rationale: A

An ECG waveform showing a shortened QT interval and bradycardia suggests hypercalcemia.

The ECG pattern typically associated with hyperkalemia reveals tall-tented T waves, a

prolonged PR interval and QRS duration, absent P waves, and ST depression. The ECG

associated with hypocalcemia typically shows a prolonged QT interval. With hypokalemia, the

ECG reveals a flattened T wave, prominent U wave, depressed ST segment, and prolonged PR

interval.

Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed., 2001. p.

66.

20. Which of the following clinical manifestations signifies hyperphosphatemia?

a. Increased respiratory rate

c. Hyperreflexia

d. Rhabdomyolysis and muscle pain

Rationale: C

Soft tissue calcification and hyperreflexia are indicative of hypermagnesemia. Increased RR and

depth are associated with metabolic acidosis. Hypermagnesemia is manifested by hot, flushed

skin and diaphoresis. Muscle pain and acute rhabdomyolysis are indicative of

hypophosphatemia.

Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed., 2001. p.

66.

21. Foods high in potassium should be avoided in which of the following anomalies?

a. Renal disease c. Ileostomy

b. Colostomy d. Metabolic alkalosis

Rationale: A

Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in

potassium. Clients receiving diuretics, with ileostomies, or with metabolic alkalosis may be

hypokalemic and should be encouraged to eat foods high in potassium.

Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.

65.

22. When assessing a client in the oliguric-anuric stage of acute renal failure, the nurse notices

a respiratory rate of 28, and the client complains of nausea, a dull headache, and general

malaise. The priority nursing action should be?

a. Provide oxygen at 2 L by nasal cannula.

b. Administer analgesic and antiemetic as ordered.

c. Check the chart for her latest electrolyte values.

d. Notify the physicianRationale: C

The nurse should look for the client’s latest potassium level, since these symptoms indicate

hyperkalemia, which can lead to death.

Option A, the client is not in respiratory distress.

level, which can lead to death.

Option D, the physician will want a complete assessment before being notified, and will require

the nurse to relate the potassium level.

Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159.

23. ICF as opposed to ECF has higher concentration of which of the following electrolyes?

a. Magnesium and potassium c. Calcium and potassium

b. Sodium and calcium d. Chloride and potassium

Rationale: A

ICF has higher concentrations of magnesium, potassium, protein, phosphate, and sulfate, and

lower concentrations of sodium, calcium, chloride and bicarbonate.

Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.

24. A client, admitted with aspirin intoxication, has the following results: pH=7.50, PaCO2=32,

HCO3=24. This client’s blood gas values indicate which of the following acid-base

disturbances?

a. Respiratory Alkalosis c. Respiratory Alkalosis, compensated

b. Metabolic Alkalosis d. Metabolic Alkalosis, uncompensated

Rationale: A

This is common due hyperventilation, which causes blowing off CO2 and hence a decrease in

plasma carbonic acid content. This should be uncompensated because the bicarbonate is

normal.

Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159.

25. The laboratory technician just handed to you the electrolyte profile. It is known that the major

cation of the body is

a. Bicarbonate b. Phosphate c. Magnesium d. Choride

Rationale: C

Major cations (positively charged) include Na, potassium, calcium, and magnesium. Major

anions (negatively charged) include chloride, bicarbonate and phosphate.

Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.
26. Twelve hours post lumbar laminectomy a client complains of discomfort and the inability to

void. Which is the best action for the nurse to take?

a. Assist the client to the bathroom

b. Palpate for fullness of the bladder

c. Apply manual pressure to the bladder as the client attempts to void

d. Insert an indwelling catheter

Rationale: B

After surgery, urinary retention may occur for may occur for many reasons: anesthesia

depresses the micturition reflex arch, voluntary micturition is impeded when the bladder is

distended, or the supine position reduces the ability to relax the perineal muscles and external
sphincter. If the bladder is distended and conservative measures have not induced voiding, an

order for catheterization should be obtained.

27. A normal sign of aging in the renal system is:

a. incontinence c. microscopic hematuria

b. concentrated urine d. a decreased glomerular filtration rate

Rationale : D

The glomerular filtration rate is decreased dramatically in the elderly because of changes in the

renal tubles. The person loses the ability to concentrate urine as aging occurs. Microscopic

hematuria is a symptom of pathology, not normal aging. Incontinence is not an expected

outcome of aging.

28. The nurse would expect to find an improvement in which of the blood values as a result of

dialysis treatment?

a. High serum creatinine levels c. Hypocalcemia

b. Low hemoglobin welve d. Hypokalemia

Rationale: A

High creatinine levels will be decreased. Anemia is a result of decreased production of

erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base

bicarbonate levels are present in renal failure clients.

29. There is a physician’s order to irrigate a client’s bladder. Which one of the following nursing
measures will ensure patency?

a. Use a solution of sterile water for the irrigation

b. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is

not patent

c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to remain for

10 hour, and then siphon it out

d. Irrigate with 20mL's of normal saline to establish patency

Rationale: D

Normal saline is the fluid of choice for irrigation. It is never advisable to force fluids into a tubing

to check for patency. Sterile water and aqueous Zephiran will affect the pH of the bladder as

well as cause irritation.

30. Nurse Joyce is putting a retention catheter for a male client. She is confused where to tape

the catheter. You are helping her if you suggested her to tape it where?

a. On the inner thigh c. Under the thigh

b. On the navel area d. On the upper thigh

Rationale: D

The catheter should be taped on the lower abdomen or upper thigh to prevent a penoscrotal

angle that can cause a fistula development.

Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 291.

31. Grandpa Daddy is ordered by the physician to take Finasteride (Proscar) for the treatment of

benign prostatic hyperthrophy (BPH). Which statement if made by him will you give him a

two thumbs up?

a. “I’m glad that this medication can have its effect within 6 months.”b. “I should maintain proper
hygiene because I know I will be catheterized for months.”

c. “Grandma will have some lonely nights, but I know I can express my love in some other

ways.”

d. “This drug does not give the guarantee that surgery will be another thing to be done.”

Rationale: C

Finasteride is an androgen inhibitor that may promote a reductionof prostatic hypertrophy,

not work for all clients. Some clients, therefore, will need surgery to relieve the obstructive

symptoms of BPH. One of the side effects of the drug is decreased libido.

Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 293.

32. Mrs. Hilary arrived in the emergency room because she made an overheated argument with

Obaman regarding the issue about sex change. Your blood pressure reading is 220/150.

Upon further assessments done by the primary physician, he decided to give her a loop

diuretic. What is the purpose of this medication?

a. This medication acts on the loop of Henle to control the flow of water and electrolytes.

b. Hydrogen ions and potassium are secreted and reabsorbed

c. Water is removed from the filtrate and returned to the interstitial fluid.

d. Solutes are reabsorbed from the glomerular filtrate back into the blood.

Rationale: A

Sodium and chloride are removed to maintain osmolality by ascending tubule of loop of Henle

Option B refers to the function of nephron’s distal tubule.

Option C, refers to descending tubule of the loop of Henle.

Option D, refers to proximal tubule..

Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 324.

33. A client put his call light on and tells the nurse that she has to urinate. The client has had a

Foley catheter in place since her surgery 3 days ago. What is the most appropriate nursing

action?

a. Checking the catheter and tubing for kinks, note also for the urine output in the drainage

bag.

b. Explain to him that the urge to void is a common occurrence for clients who have urinary

catheters.

c. Replace the Foley catheter with a new catheter.

d. Remind the client that she has a Foley catheter in place and does not need to go to the

bathroom.

Rationale: A
Checking the equipment is the best nursing action, since data will be obtained which will assist

the nurse with problem solving. This is a nursing process question, and assessment is always

the first nursing action in this type of question.

Option B - The urge to void usually occurs upon initial insertion of the Foley catheter, not 2 days

afterwards. There are several possible reasons for the client having urgency, and the nurse

must attempt to discover the cause in order to meet the client’s needs.

Option C - a new catheter might be necessary to meet the client’s needs, but the nurse must

assess the situation further to determine the cause of the client’s urge to void.

Option D - although a Foley catheter is in place, it may not be patent, which can result in

distention of the bladder and cause the patient to feel the urge to void. This action does not

meet the client’s needs.Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN.
1994. p. 54.

34. Which among the following statements made by the client would be the cause of his

impotence problem?

a. “I have never had an intimate sexual relationship for 2 years now.”

b. “I have urinary frequency and dribbling.”

c. “I have had diabetes for the last 5 years.”

d. “I don’t buy Men’s magazine anymore.”

Rationale: C

Impotence may result from psychogenic and organic causes. Endocrine conditions such as

diabetes, pituitary tumors, and hypogonadism are possible organic causes of impotence.

Options A & D are the result or effects of this impotence. Option B, are signs and symptoms of

BPH.

Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.

279.