1

Which of the following is an important component of a teaching plan for the client

recently diagnosed with peptic ulcer disease?

Incorrect: Antacids should not be taken concurrently with other ulcer drugs such

as H2 blockers because they will decrease drug absorption by 10% to 20%.Correct: The

GI complications of NSAID use are strongly linked to mucosal injury and the

development of gastric ulcers.Incorrect: Although milk-based diets may provide symptom

relief, research has shown they do not influence healing and in fact actually act to

increase acid secretion. Diet plays no defined role in ulcer development and current

management of ulcers.Incorrect: The individual with an ulcer does not need to restrict

activity to enhance healing. Most clients are able to continue usual activities, although

adequate rest is encouraged.

Antacids and H2 receptor antagonists can be taken together.

Avoid the use of NSAIDs for pain control.

Increase milk products in the diet to enhance healing.

Limit physical activity to reduce stomach acid.

2

A nurse admits a 42-year-old female with the following characteristics: excessive

sleeping, fatigue, constipation, weight gain, and complaint of intolerance to cold. These

signs and symptoms are most consistent with:

Incorrect: Although some of the symptoms mentioned would be consistent with

acute renal failure (i.e. fatigue, weight gain), there is no mention of the classic symptoms

of acute renal failure. These would include signs and symptoms of fluid overload and

electrolyte imbalance such as hypertension, neck vein distention, low urine output,

confusion.Incorrect: Although fatigue is consistent with aplastic anemia, the remaining

symptoms are not. Aplastic anemia results from impaired erythrocyte production and is

manifested by pale skin color, fatigue, exertional dyspnea, palpations, low hemoglobin,

and signs of bleeding tendency such as petechiae and ecchymosis.Correct: This client

presents with some of the classic characteristics of hypothyroidism. Recall that a lack of

thyroid hormone results in a general depression of the basal metabolic rate. A typical

clinical picture includes fatigue, weakness, intolerance to cold, constipation, menstrual

irregularities, reduced appetite, dry skin, edema.Incorrect: The hallmark of diabetes is

insulin deficiency manifested by hyperglycemia, polyuria, polydipsia, polyphagia, visual

blurring, fatigue, and weight loss. This client does not present with this symptom

combination.

acute renal failure.

aplastic anemia.

hypothyroidism.

diabetes mellitus.

3

A client newly diagnosed with HIV says to the nurse, "I can't believe this is happening.

There must be some new treatments that can help." The most appropriate nursing

diagnosis for this client based on his comments would be:

Incorrect: The defining characteristics of altered family processes include verbal

hostility between family members and a general lack of communication and respect

between family members. Although this may be a problem for the client with HIV, more

data is needed to formulate this nursing diagnosis in this situation.Incorrect: The client

has not expressed a feeling of aloneness or verbalized discomfort in social situations,

which are characteristics of social isolation. Although clients with a diagnosis of HIV or

AIDS may experience social isolation, there is insufficient data to validate this as a

problem for this individual.Correct: The client's statement is most consistent with

anticipatory grieving which is characterized by the normal grief response including anger,

denial, disbelief, and guilt.Incorrect: The defining characteristics of ineffective individual

coping include verbalization of the inability to cope, inability to problem-solve, altered

social participation, inability to meet basic needs and role expectations and inappropriate

use of defense mechanisms to mention a few. Although the client is expressing disbelief,

there is insufficient data to support a nursing diagnosis of ineffective individual coping.

altered family processes.

social isolation.

anticipatory grieving.

ineffective individual coping.

4

The nature of systemic lupus erythematosus (SLE) requires the nurse to teach the patient

and family:

Incorrect: Pregnancy is not necessarily contraindicated in clients with SLE.

Although pregnancy does not induce SLE exacerbations, pregnancy should be planned

with the client's primary care provider.Correct: Factors such as fatigue, sun exposure,

stress, and infection can exacerbate systemic lupus erythematosus. Nursing interventions

should include teaching the client and family measures to reduce stress and cope with the

chronic disease.Incorrect: Neither discoid nor systemic lupus erythematosus is a

contagious disease. Both are thought to be autoimmune disorders.Incorrect: The lesions

of SLE are well demarcated and are relatively benign in nature. The rash is generally

confined to the face, scalp, and neck. Although other parts of the body may be involved

(i.e. mucous membranes), the rash does not actually spread like an allergic dermatitis (i.e.

when an irritant or allergen is spread by the hands to another body part as in poison ivy).

birth control measures to prevent pregnancy.

strategies to prevent and cope with stress.

measures to prevent spread of the disease.

methods to diminish spread of skin lesions.

5

A Type I diabetic is prescribed to take Regular and NPH insulin before breakfast. The

client administers his insulin at 6:00 a.m. prior to breakfast. The nurse should teach the

client to:

Incorrect: The onset of NPH insulin is approximately 1-2 hours with peak effect

between 6-12 hours. Therefore a snack eaten between breakfast and lunch, when the NPH

insulin is beginning to reach it's peak action would be important to prevent hypoglycemia

before lunch. In addition, regular or quick acting insulin requires that a supplemental

snack of 15 g of carbohydrate be given to match the peak action of the insulin. Since

regular insulin is peaking at 2-4 hours post administration, a 10:00 a.m. snack would be

recommended.Incorrect: Because the NPH insulin will still be peaking from

approximately 12:00 p.m. to 6:00 p.m., delaying the evening meal (dinner) until after 6:00

p.m. would put the client at risk for hypoglycemia.Incorrect: Carbohydrate intake must be

coordinated with the peak action of insulin. Therefore, the client should be taught to

consistently eat carbohydrates at meals, ranging from 45-60% of the total caloric

intake.Correct: The peak time of NPH insulin is 4-12 hours. If the client takes the NPH

insulin at 6:00 a.m., the insulin will be peaking between 12:00 p.m. and 6:00 p.m.

Therefore it is important that food be scheduled between this time period to prevent

hypoglycemia.

avoid any snacks between breakfast and lunch.

delay dinner until after 6:00 p.m..

eat a low carbohydrate lunch at noon.

schedule a snack at 3:00 p.m..

6

A client with a fractured femur was recently admitted to the orthopedic unit in traction. In

planning care to minimize the risk for fat embolism, the nurse should implement which

intervention?

Correct: Immobilization, surgery or trauma to the skeletal system, poor hydration

and low tidal volume in the lung are predisposing factors to fat embolism syndrome.

Nursing interventions to reduce the risk of fat embolism include good respiratory care,

adequate hydration, and stable traction. Other measures include: the use of intermittent

pneumatic compression, leg elevation, elastic stockings, and medications (anticoagulant,

anti-platelet agents).Incorrect: Fat embolism is not related to diet. The use of

supplementary oxygen may require an order, particularly to the client with chronic

obstructive pulmonary disease. Range of motion is not recommended for the affected

leg.Incorrect: A liquid diet is not necessary for the client in traction. Physical therapy is

essential in the rehabilitative phase.Incorrect: Sedation and analgesia are not related to the

prevention of fat emboli.

The client is encouraged to move the unaffected extremities to reduce the

risk of fat embolism syndrome, pressure-related skin injury, and muscle soreness.

Provide a low-fat, high-carbohydrate diet, give oxygen, and encourage

range of motion in the affected leg.

Keep the client on a liquid diet, and have physical therapy start the client

on an exercise program for upper body strengthening.

Maintain sedation and administer intravenous fluids and medications for

pain as needed.

7

The nurse is caring for a client who has just developed ventricular tachycardia following

a myocardial infarction. The nurse anticipates the client will immediately be given which

of the following medications?

Incorrect: Atropine sulfate is an anticholinergic drug used to increase the heart

rate in symptomatic bradycardia (defined as 40 beats per minute).Incorrect: Epinephrine

is an adrenergic agent that increases the heart rate. This drug would be contraindicated in

fast-rate dysrhythmias. It is one of the first line drugs administered during CPR. By

constricting peripheral blood vessels, epinephrine shunts blood to the central circulation

and increases blood flow to the heart and brain. It is also given for asystole to stimulate

electrical and mechanical activity to produce myocardial contraction.Correct: The first

line drug for management of serious ventricular dysrhythmias is lidocaine, which

decreases myocardial irritability (automaticity) in the ventricles.Incorrect:

Nitroglycerin is used to dilate coronary arteries and improve blood flow. It has no

antidysrhythmic effect.

Atropine sulfate

Epinephrine

Lidocaine

Nitroglycerin

8

During a home visit the nurse determines that the client is experiencing dumping

syndrome following his recent total gastrectomy. Which dietary recommendation should

the nurse convey to the client?

Incorrect: Oral vitamins will have no effect on dumping syndrome. Further, they

are of no benefit to the client following total gastrectomy due to loss of intrinsic factor

normally secreted by the parietal cells of the stomach. Intrinsic factor is essential for the

absorption of vitamin B12. Monthly injection of vitamin B12 will prevent the

development of pernicious anemia.Incorrect: Malabsorption of fat may occur after

gastrectomy from reduced acid secretion and availability of pancreatic enzymes required

for fat absorption. Dumping syndrome occurs because of the rapid entry of hypertonic

food into the upper small intestine without undergoing the usual breakdown and dilution

in the stomach. This stimulates motility and diarrhea. Preventive measures include a

moderate-fat, high-protein diet with limited carbohydrates.Correct: Fluids with meals are

discouraged because they increase total volume and further promote diarrhea.Incorrect:

Rest on the left side for 20-30 minutes after eating is thought to delay gastric emptying

and may be helpful for some individuals.

Begin taking a vitamin B complex supplement.

Eat a high carbohydrate, low fat, low protein diet.

Decrease fluid intake with meals.

Go for a slow, short walk after eating.

9

A client with asthma goes into status asthmaticus. Which clinical signs, if present, would

indicate that intubation and mechanical ventilation are needed?

Incorrect: Both hyperresonance (air-trapping) and tachypnea are characteristic of

an acute asthma attack.Incorrect: Severe inspiratory and expiratory wheezing is consistent

with an acute asthma attack. Clients with status asthmaticus may be moving minimal

amounts of air into and out of the lungs therefore audible wheezing may NOT be

present.Correct: These blood gas values indicate respiratory acidosis and hypoxemia. This

occurs as a result of a prolonged attack where respiratory muscle exhaustion causes

hypoventilation. If respiratory acidosis and hypoxemia are present, intubation and

ventilatory assistance may be required if oxygen and other treatment measures are

ineffective.Incorrect: Tachycardia and an elevated blood pressure are expected findings

during an acute asthma attack. However, clients with status asthmaticus may exhibit

pulsus paradoxus. Pulsus paradoxus is an accentuation of the normal decrease in systolic

arterial pressure with inspiration. This is a result of changes in intrapleural pressure

during respiration that occurs in obstructive airway disease.

Hyperresonance and tachypnea

Severe inspiratory and expiratory wheezing

pH 7.32, PCO2 55 mm Hg, PO2 74 mm Hg

Pulse 110/minute, BP 150/88

10

Which nursing intervention is the priority for care of the client during the acute phase of a

cerebrovascular accident (CVA)?

Incorrect: Following a CVA clients are at risk for a variety of complications

associated with immobility and subsequent disuse such as contractures and skin

breakdown. While preventive nursing care measures are incorporated into the daily

routine, during the acute phase of a stroke, the immediate priority is maintaining a patent

airway and adequate oxygenation to support cerebral perfusion.Correct: During the acute

phase of a cerebrovascular accident it is essential to assess respiratory function and

maintain a patent airway to support oxygenation and cerebral perfusion. Because of motor

of sensory deficits, the client with a CVA is at risk of aspiration of food, fluid, and

secretions.Incorrect: The effects of a CVA are life altering. The emotional changes and

physical limitations that commonly occur, challenge the coping abilities of the client and

family. Although a nursing care plan would be incomplete without addressing the coping

needs of the client and family, the immediate priority post CVA is respiratory and

neurological assessment and promotion of oxygenation to the brain.Incorrect: Problems

with urinary incontinence are common after stroke and the plan of care during

hospitalization and rehabilitation will include measures to restore continence. However,

the immediate care priority in the acute phase of stroke is airway, oxygenation, and

cerebral perfusion.

Decrease the complications of disuse.

Monitor the status of respiratory function.

Maintain effective coping by the family.

Assess for bladder distention.

11

Of the following nursing diagnoses, which one would most effectively address primary

prevention as it relates to drug management in the elderly population?

Incorrect: The nursing diagnosis that most effectively guides primary prevention

of drug reactions and interactions involves identifying the risk and taking measures to

prevent adverse reactions, self-care deficit, and/or injuries. Although elderly clients

taking multiple drugs are at greater risk for adverse reactions because of complex drug

regimens and age-related physiological changes, a diagnosis of 'self-care deficit related to

adverse reactions to prescribed drugs' addresses an actual problem with drug

management.Incorrect: The prevention of drug mismanagement, adverse reactions and

side effects is best addressed using a potential nursing diagnosis that identifies risk factors

in the elderly population. The other answer options are nursing diagnosis that

address 'actual' problems.Incorrect: Although elderly clients may be noncompliant with

the drug regimen due to lack of sufficient knowledge regarding drug administration, this

diagnosis does not focus on problem prevention.Correct: Because elders consume

disproportionately more of all kinds of drugs than do middle-aged adults, 'risk for injury

related to polypharmacy' is the nursing diagnosis that would focus on prevention of

complications for this group of individuals.

Self-care deficits related to adverse reactions to prescribed drugs

Body image disturbance related to drug side effects

Noncompliance related to knowledge deficit

Risk for injury related to polypharmacy

12

The nurse is planning care for a 48-year-old female following a total hysterectomy.

Which of the following interventions would be contraindicated?

Incorrect: Frequent ambulation is encouraged as the most reliable means of

stimulating peristalsis. In addition, ambulation supports oxygenation through natural deep

breathing and assists in the elimination of residual anesthetic.Incorrect: The risk of

thromboembolism is significant in the post-hysterectomy client because of venous

pooling and pelvic congestion. Nursing interventions to prevent thromboembolism

include compression stockings and leg/foot flexion and extension exercises.Incorrect:

Pain relief should be promoted not only for comfort but to promote frequent turning,

coughing and deep breathing, and early ambulation. Narcotic analgesics are the most

effective in relieving pain during the immediate postoperative period and should be

encouraged to prevent severe pain and enhance activity.Correct: Venous pooling and

pelvic congestion are common complications after hysterectomy, especially if the

lithotomy position was used. Efforts should be taken to avoid positioning the client with

the knees bent since this promotes pelvic congestion.

Early ambulation

Compression stockings

Narcotic analgesics

Pillows under the knees

13

The nurse is teaching an asthmatic client how to treat episodes of acute

bronchoconstriction. Of the following inhaled agents, if prescribed, the nurse should

teach the client to immediately take the:

Incorrect: The anticholinergic Atrovent is ineffective in acute bronchospasm when

a rapid response is required. It is used in maintenance therapy in chronic,

bronchoconstrictive conditions such as chronic bronchitis and emphysema.Correct: The

1st drug of choice in an acute asthma attack is a short-acting inhaled beta2-adrengergic

agonist such as albuterol sulfate (Proventil) or metaproterenol sulfate (Alupent). These

drugs cause smooth muscle relaxation and bronchodilation and start to act within 10

minutes.Incorrect: Inhaled steroids do not play a role in acute situations. Corticosteroids

primarily work by suppressing inflammation in the airways, thereby decreasing mucus

secretion and edema. Another important action is to increase the number and sensitivity

of beta2-adrenergic receptors, which increases the effectiveness of beta2-adrengergic

bronchodilators. In maintenance therapy, it should be noted that the inhaled beta2-agonist

should be given first to open the airway; followed by the inhaled steroid, which will be

more effective when inhaled deeper into the lung.Incorrect: Cromolyn (Intal) is used to

prevent acute asthma attacks in clients with chronic asthma. The drugs in this category

are used only for prophylaxis and are not effective in acute bronchospasm. Mast cell

stabilizers prevent the release of bronchoconstrictive and inflammatory substances when

mast cells are confronted with allergens.

anticholinergic (Atrovent).

beta2-adrenergic agonist (Albuterol).

corticosteroid (Azmacort).

mast cell stabilizer (Cromolyn).

14

A client is admitted to the Intensive Care Unit following a femoral-popliteal bypass graft.

Which intervention provides the most relevant data about graft patency?

Incorrect: This activity evaluates neurological status and would not provide any

significant data regarding graft patency, circulation, and perfusion.Incorrect: Monitoring

ECG activity is a critical nursing intervention because clients with vascular disease

commonly have problems with CAD or hypertension. However, palpating arterial pulses

gives the most information about the patency of the graft and perfusion of blood to areas

below the bypass.Incorrect: Because coronary artery disease and hypertension are

common in clients with vascular disease, dysrhythmias or cardiac failure are potential

complications of vascular surgery. Therefore, accurate documentation of I & O is also

essential to quality nursing care to detect alterations in cardiac output and renal perfusion.

However, palpating arterial pulses gives the most information about the patency of the

graft and perfusion of blood to areas below the bypass.Correct: Graft patency is a priority

concern in the postoperative client because the risk of reocclusion from thrombosis,

restenosis, or debris is significant. The nurse should monitor the client's peripheral pulses

and limb temperature, as well as the degree of pain, pallor, sensation, and movement.

Check the equality of the client's hand grasps.

Check the electrocardiogram every four hours.

Record the client's intake and output.

Palpate all arterial pulse sites as frequently as every hour.

15

A preoperative order is written for meperidine 50 mg IM. Which desired effects can the

nurse anticipate following drug administration?

Incorrect: Anticholinergic agents such as Robinul are often given preoperatively

to inhibit salivation and excessive respiratory secretions.Correct: Meperidine (Demerol) is

an opioid analgesic. Meperidine binds to opiate receptors in the central nervous system

resulting in altered perception of and response to painful stimuli. As a secondary

response, the client's blood pressure can be expected to decrease as pain diminishes. It

should be noted that hypotension can be an adverse reaction.Incorrect: Meperidine is not

known to have any antiemetic or GI stimulant effects. A drug expected to have these

effects would be metoclopramide (Reglan). Recall that opioids can have a constipating

effect.Incorrect: The therapeutic effects described are characteristic of Versed, a sedative/

hypnotic that induces short-term sedation and postoperative amnesia.

Decreased salivation and mucous production

Pain reduction and decreased blood pressure

Reduced nausea and increased peristalsis

Sedation and amnesia following the surgical procedure

21

When treating clients with chronic obstructive pulmonary disease (COPD) who are

hypoxemic, the standard of care is to:

Correct: Breathing very high concentrations of O2 for prolonged periods is

associated with acute respiratory distress syndrome. A firm general principle is to use the

lowest amount of O2 that will achieve an acceptable PO2.Incorrect: It is true that

precautions must be taken when giving O2 to clients with COPD. These persons

chronically retain carbon dioxide; low O2 levels produce the drive to breathe.Incorrect:

This is a common misunderstanding by clients requiring O2 therapy. Studies have shown

that clients receive the most benefit from O2 therapy if the oxygen is used

continuously.Incorrect: Clients with COPD who are carbon dioxide retainers must receive

supplemental O2 by controlled O2 delivery devices. When low-flow O2 is desired,

oxygen is given by nasal cannula. The Venturi mask can also be used to deliver O2 at

controlled levels.

administer the least amount of O2 that achieves an acceptable PO2.

maintain low-flow O2 under all circumstances.

institute O2 therapy only when dyspnea occurs.

use a nasal cannula rather than a facial mask.