Simulated Test Part 2
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- 1.
Situation:Nurse Madonna is entrusted with the task of promoting nursing care in clients with disturbances in the respiratory pattern. 1. When a chest tube is being removed, the nurse should instruct the client to:
- A.
Cough vigorously
- B.
Deep breath
- C.
Inhale and hold breath
- D.
Exhale deeply
Correct Answer
D. Exhale deeplyExplanation
Rationale: Avoiding sudden inspiratory efforts by exhaling deeply during chest tube removal will prevent pnuemothorax.Rate this question:
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- 2.
Which of the following equipment does not interfere with eating or talking and can best deliver oxygen in a hypoxic client?
- A.
Oxygen tent
- B.
Oxygen mask
- C.
Nasal Cannula
- D.
Endotracheal tube
Correct Answer
C. Nasal CannulaExplanation
Rationale: Among the options, nasal cannula is the best equipment that can deliver oxygen in a hypoxic client. A nasasl cannula delivers 40 % oxygen and it does not interfere with the client's ability to eat and talk.Rate this question:
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- 3.
Which reading of pulmonary capillary wedge pressure( in mmHg) needs to be reported to the physician immediately?
- A.
5-10 mmHg
- B.
15-20 mmHg
- C.
25-30 mmHg
- D.
35-40 mmHg
Correct Answer
D. 35-40 mmHgExplanation
Rationale: A reading of 35-40 mmHg indicates severe pulmonary edema.Rate this question:
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- 4.
Which of the following clients is at most risk for tuberculosis?
- A.
A 35-year-old newly married
- B.
A 86-year-old client
- C.
A 12-year-old child
- D.
A 17-year old adolescent
Correct Answer
B. A 86-year-old clientExplanation
Rationale: recent literature suggests that the elderly client is most at risk for tuberculosis.Rate this question:
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- 5.
Which of the following statements best describes the primary purpose of pursed-lip-breathing:
- A.
Increase oxygen inhalation
- B.
Maximize diaphragmatic extension
- C.
Facilitate elimination of carbon dioxide
- D.
Minimize the use of intercostal muscles
Correct Answer
C. Facilitate elimination of carbon dioxideExplanation
Rationale:Pursed-lip breathing promotes carbon dioxide elimination by enabling the client to control the rate and depth of respiration.Rate this question:
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- 6.
Which assessment finding best indicates deterioration of liver function?
- A.
Anorexia
- B.
Constipation
- C.
Weight gain
- D.
Lethargy
Correct Answer
D. LethargyExplanation
Rationale: Lethargy or difficulty in arousal indicates accumulation of metabolic waste products in the brain resulting in deterioration of mental function from lethargy, delirium, coma and eventually death.Rate this question:
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- 7.
Which of the following aspects of care should have the highest priority for a client admitted due to cholecystitis?
- A.
Comfort
- B.
Hydration
- C.
Heath instructions
- D.
Obtaining thorough history.
Correct Answer
A. ComfortExplanation
Rationale: the priority for the client with cholecystitis is pain relief or promotion of comfort.Rate this question:
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- 8.
Which of the following laboratory values is NOT expected in a client with pancreatitis?
- A.
Serum Magnesium: 3.2 mEq/L
- B.
Serum Glucose: 45mg/dL
- C.
Serum potassium: 5.5 mEq/L
- D.
Serum Calcium: 8 mg/dL
Correct Answer
B. Serum Glucose: 45mg/dLExplanation
Rationale: Hypoglycemia, a blood sugar level below 50mg/dL, is not expected in a client with pancreatitis In pancreatitis, hyperglcemia occurs.Rate this question:
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- 9.
Which client is best candidates for rthe use of insulin pump?
- A.
A 42-year-old businessman
- B.
A 35-year-old working single mother
- C.
A 12-year-old mentally retarded
- D.
An 82-year-old cognitively impaired.
Correct Answer
A. A 42-year-old businessmanExplanation
Rationale: An insulin pump provides continuous infusion of insulin in the abdomen for 24h. it is suited for busy people.Rate this question:
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- 10.
Which statement made by a client with ulcer indicates understanding of the medication therapy?
- A.
"Antacids can be taken with other drugs"
- B.
"Tagamet will decrease the acids in my stomach"
- C.
" Maalox will coat my stomach"
- D.
" I can take my antacids with aspirin"
Correct Answer
B. "Tagamet will decrease the acids in my stomach"Explanation
Rationale: Tagamet (cimitidine) inhibits histamine at the h2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.Rate this question:
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- 11.
To decrease the anxiety of the client and his/her family about an impending surgery, the nurse should:
- A.
Describe the details of the surgery to the client and family.
- B.
Provide general information and answer appropriate questions of the client and family.
- C.
Empower the client to make decision by obtaining the client's consent.
- D.
Give full reassurance that the surgical team is experienced to handle the surgery.
Correct Answer
B. Provide general information and answer appropriate questions of the client and family.Explanation
Rationale: the main role of the nurse when preparing a client for surgery is to provide general information.Rate this question:
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- 12.
Which of the following procedure for using an incentive spirometer is appropriate for the nurse to provide the client with during preoperative instructions?
- A.
Inhale completely and exhale rapidly through the spirometer.
- B.
Exhale completely, take slow deep breath through the spirometer, hold breath then exhale through purse lip.
- C.
Inhale completely through the spirometer, exhale and hold breath.
- D.
Exhale through the spirometer, hold breath then then inhale.
Correct Answer
B. Exhale completely, take slow deep breath through the spirometer, hold breath then exhale through purse lip.Explanation
Rationale: the use of intensive spirometer requires complete exhalation followed by slow deep breathing through the mouthpiece of the spirometer.Rate this question:
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- 13.
The stages of surgical anesthesia proceeds in which of the following order?
- A.
Excitement, surgical anesthesia, loss of consciousness, danger stage
- B.
Loss of consciousness, excitement, surgical anesthesia, danger stage.
- C.
Surgical anesthesia, excitement, loss of consciousness, danger stage.
- D.
Loss of consciousness, surgical anesthesia excitement, danger stage.
Correct Answer
B. Loss of consciousness, excitement, surgical anesthesia, danger stage.Explanation
Stage 1
Stage 1 anaesthesia, also known as the "induction", is the period between the initial administration of the induction agents and loss of consciousness. During this stage, the patient progresses from analgesia without amnesia to analgesia with amnesia. Patients can carry on a conversation at this time.
Stage 2
Stage 2 anaesthesia, also known as the "excitement stage", is the period following loss of consciousness and marked by excited and delirious activity. During this stage, respirations and heart rate may become irregular. In addition, there may be uncontrolled movements, vomiting, breath holding, and pupillary dilation. Since the combination of spastic movements, vomiting, and irregular respirations may lead to airway compromise, rapidly acting drugs are used to minimize time in this stage and reach stage 3 as fast as possible.
Stage 3
Stage 3, "surgical anaesthesia". During this stage, the skeletal muscles relax, and the patient's breathing becomes regular. Eye movements slow, then stop, and surgery can begin. It has been divided into 4 planes:
eyes initially rolling, then becoming fixed
loss of corneal and laryngeal reflexes
pupils dilate and loss of light reflex
intercostal paralysis, shallow abdominal respiration
Stage 4
Stage 4 anaesthesia, also known as "overdose", is the stage where too much medication has been given relative to the amount of surgical stimulation and the patient has severe brain stem or medullary depression. This results in a cessation of respiration and potential cardiovascular collapse. This stage is lethal without cardiovascular and respiratory support.Rate this question:
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- 14.
What common side effect should the nurse monitor in a client who just received epidural anesthesia?
- A.
Fever
- B.
Bradycardia
- C.
Hypotension
- D.
Pallor
Correct Answer
C. HypotensionExplanation
hypotension is a common side effect of epidural anesthesia. the nurse should monitor the client's blood status in post-operative period.Rate this question:
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- 15.
Which of the following complications can result from the use of general anesthesia during surgery.?
- A.
Fluid loss
- B.
Peripheral fluid retention
- C.
Atelectasis
- D.
Muscle rigidity
Correct Answer
C. AtelectasisExplanation
Rationale: general Anesthesia may tend to cause relaxation of the airway. atelectasis may develop if coughing and deep breathing is not done by the client.Rate this question:
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- 16.
Physical preparation for a client scheduled for cystectomy and ileal conduit includes the administration of:
- A.
Intravenous vitamin C
- B.
Neomycin sulfate
- C.
Bladder Analgesic
- D.
Urinary antibiotic
Correct Answer
B. Neomycin sulfateExplanation
Rationale: Noemycin, an antibiotic will kill pathogens in the urinary tract.Rate this question:
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- 17.
Which of the follwing methods of assessment is correct to assess distension in a post operative client?
- A.
Palpate the perineal area
- B.
Palpate the epigastric area
- C.
Percuss and palpate the lower abdomen
- D.
Percuss and palpate the upper abdomen
Correct Answer
C. Percuss and palpate the lower abdomenExplanation
Rationale: To assess for bladder distention, the nurse should percuss and palpate the lower abdomen. A distended bladder will produce a dull sound and may feel firm palpated.Rate this question:
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- 18.
After thyroidectomy, which of the following interventions is the highest priority of the nurse?
- A.
Monitor the client's vital sign every 4h.
- B.
Observe the dressing at the back of the neck for the presence of blood
- C.
Press gently around the incision to assess for subcutaneous emphysema
- D.
Position the client laterally to promote drainage of secretions from the mouth.
Correct Answer
B. Observe the dressing at the back of the neck for the presence of bloodExplanation
Rationale: After thyroidectomy, bleeding occurs,. The nurse should slip his/ her hands behind the client's neck to assess for bleeding. blood usually pools behind the clients' neck due to gravitational pull.Rate this question:
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- 19.
Following cataract extraction, which client activity is allowed.?
- A.
Coughing deeply to prevent pneumonia
- B.
Bending from the waist to prevent contracture deformity
- C.
Remaining in a lying down supine position for 48 h after surgery
- D.
Deep breathing to promote lung expansion.
Correct Answer
D. Deep breathing to promote lung expansion.Explanation
Rationale: deep breathing will not decrease client's intraocular pressure.Rate this question:
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- 20.
What is the highest priority, in terms of goal of cvare, by the nurse after a client's prostatectomy?
- A.
To prevent infection
- B.
To prevent bleeding
- C.
To prevent impotence
- D.
To prevent respiratory distress.
Correct Answer
B. To prevent bleedingExplanation
Rationale: Hemorrhage is one of the most common complication of prostatectomy.Rate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
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Apr 29, 2012Quiz Created by
Joy_loriaga26
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