COMPLETE QUESTIONS AND ANSWERS
◉ A nurse is assessing a client who has suspected appendicitis.
Which of the following manifestations should the nurse expect?
(select all that apply)
Elevated WBC count
Elevated amylase level
Rebound tenderness
Ascites
Anorexia.
Answer: Elevated WBC count
A client who has acute appendicitis will show a moderate elevation
of the WBC count from 10,000 to 18,000/mm3. If the WBC count is
greater than 20,000/mm3, it can indicate a perforated appendix.
Rebound tenderness
A client who has appendicitis develops localized pain over the right
lower quadrant of the abdomen. When the area is palpated, pain
occurs during release of pressure on the client's abdomen.
Anorexia
,A client who has acute appendicitis experiences nausea, vomiting,
and reduced appetite.
◉ A nurse is teaching a client who has a new diagnosis of type 1
diabetes mellitus. Which of the following statements by the client
indicates an understanding of the teaching?
"I am aware that my diabetes is caused by an autoimmune disorder."
"I know that my diabetes developed slowly over several years."
"If I lose weight, I may be able to stop taking insulin."
"I have developed a resistance to insulin.".
Answer: "I am aware that my diabetes is caused by an autoimmune
disorder."
Type 1 diabetes mellitus is an autoimmune disorder that destroys
pancreatic beta cells. This autoimmune reaction is often triggered by
a viral infection.
◉ A nurse is caring for a male client who has a new prescription for
cyclosporine following a kidney transplant. Which of the following
findings should the nurse identify as an adverse effect of this
therapy?
WBC count 8,000/mm3
RBC count 6 million/mm3
,BUN 24 mg/dL
Potassium 3.5 mEq/L.
Answer: BUN 24 mg/dL
A BUN of 24 mg/dL is above the expected reference range of 10 to
20 mg/dL, indicating renal impairment. An adverse effect of
cyclosporine is nephrotoxicity. The nurse should monitor the client
for increases in BUN and creatinine and report any elevation to the
provider. A rise in BUN could indicate transplant rejection.
◉ A nurse in a long-term care facility is caring for a client who has
dementia. Which of the following actions should the nurse take?
Give detailed directions when addressing the client.
Provide finger food at mealtime.
Use written signs to redirect the client.
Seat the client at a large table for meals..
Answer: Provide finger food at mealtime.
The nurse should provide the client who has dementia with fingers
foods. Clients who have dementia can have difficulty sitting still and
tend to wander, which makes weight loss and malnutrition a
concern. Therefore, foods that the client can hold while ambulating
are ideal.
, ◉ A nurse is caring for a client immediately following intubation
with an endotracheal (ET) tube. Which of the following methods
should the nurse identify as the most reliable for verifying
placement of the ET tube?
Feel for exhaled air emerging from the endotracheal tube.
Assess for bilateral breath sounds.
Observe for symmetric chest movement.
Check for end-tidal carbon dioxide levels..
Answer: Check for end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for
verifying ET tube placement is checking for end-tidal carbon dioxide
levels by using capnometry. A chest x-ray is another reliable method
for verifying placement.
◉ A nurse is providing teaching for a client who has neutropenia
and is receiving chemotherapy. Which of the following client
statements indicates an understanding of the teaching? (select all
that apply)
"I will avoid crowds."
"I will wash my toothbrush weekly."
"I will change my cat's litter box twice weekly."