Test Bank For Critical Care Nursing: Diagnosis and Managemen
u u u u u u u u
t 8th Edition By Linda D. Urden, DNSc, RN, CNS, NE-
u u u u u u u u u u
BC, FAAN, Kathleen M. Stacy, PhD, RN, CNS, CCRN, PCCN, CCNS
u u u u u u u u u u u
and Ma 9780323447522 Chapter 1-41 Complete Guide .
u u u u u u u
Au56-year-oldufemaleuclientuisureceivinguintracavitaryuradiationuviauauradiumuimplant.uWhich
nurseushouldubeuassignedutoucareuforuthisuclient?
A.uTheunurseuwhouisucaringuforuanotheruclientureceivinguintracavitaryuradiation.
B.uAunurseuwithuMarfan'susyndromeuwhouisupostmenopausal.
C.uAunurseuwithuoncologyuexperienceuwhoumayubeupregnant.
D.uTheunurseuwhouisucaringuforuanotheruclientuwhouhasuClostridiumudifficile.u-
uANSWER:uB.uAunurseuwithuMarfan'susyndromeuwhouisupostmenopausal.
RATIONALE:
Auclientureceivinguintracavityuradiationuposesuauradiationuhazarduasulonguasutheuintracavity
radiationusourceuisuinuplace.uAunurse'suabilityutoucareuofuthisuclientuisunotuaffectedubyuMarfan's
syndromeu(B),uwhichuisuauhereditaryudisorderuofuconnectiveutissues,ubones,umuscles,uligaments
anduskeletalustructures.uTheugoaluisutoulimituanyuoneustaffumember'suexposureutoutheucalculated
timeuspanubaseduonutheuhalf-lifeuofuradium,usuchuasutheunumberuofuminutesuatutheubedsideuperuday,
sou(A)ushouldunotubeuassigned.u(C)ushouldunotubeuexposedutoutheuradiationudueutoutheupossible
effectuonutheufetus.uAuradiationuexposureudecreasesutheuimmuneuresponseuinutheuclientuwhoushould
notubeuexposedutoutheupotentialuinadvertentutransmissionuofuanuinfectiousuorganismu(D).
1.Auclientuwhouhasuactiveutuberculosisu(TB)uisuadmittedutoutheumedicaluunit.uWhatuactionuisumost
importantuforutheunurseutouimplement?
A.uFitutheuclientuwithuaurespiratorumask.
B.uAssignutheuclientutouaunegativeuair-flowuroom.
C.uDonuaucleanugownuforuclientucare.
D.uPlaceuanuisolationucartuinutheuhallwayu-uANSWER:uAssignutheuclientutouaunegativeuair-flowuroom
RATIONALE:
Activeutuberculosisurequiresuimplementationuofuairborneuprecautions,usoutheuclientushouldube
assignedutouaunegativeupressureuair-flowuroomu(D).uAlthoughu(AuanduC)ushouldubeuimplemented
foruclientsuinuisolationuwithucontactuprecautions,uituisumostuimportantuthatuairuflowufromutheuroom
isuminimizeduwhenutheuclientuhasuTB.u(B)ushouldubeuimplementeduwhenutheuclientuleavesuthe
isolationuenvironment.
2.Auclientuisureceivinguatenololu(Tenormin)u25umguPOuafteruaumyocardialuinfarction.uTheunurse
determinesutheuclient'suapicalupulseuisu65ubeatsuperuminute.uWhatuactionushouldutheunurse
implement
next?
A.uMeasureutheubloodupressure.
B.uReassessutheuapicalupulse.
C.uNotifyutheuhealthcareuprovider.
D.uAdministerutheumedication.u-uANSWER:uAdministerutheumedication
RATIONALE:
Atenolol,uaubeta-blocker,ublocksutheubetaureceptorsuofutheusinoatrialunodeutoureduceutheuhearturate,
southeumedicationushouldubeuadministeredu(C)ubecauseutheuclient'suapicalupulseuisugreateruthanu60.
(A,uB,uanduD)uareunotuindicateduatuthisutime.
3.Theunurseuisuassessinguauclientuanduidentifiesuaubruituoverutheuthyroid.uThisufindinguisuconsistent
withuwhichuinterpretation?
A.uHypothyroidism.
B.uThyroiducyst.
C.uThyroiducancer.
D.uHyperthyroidismu-uANSWER:uHyperthyroidism
,Rationale:Hyperthyroidismu(D)uisuanuenlargementuofutheuthyroidugland,uoftenureferredutouasuaugoiter,ua
ndua
bruitumayubeuauscultateduoverutheugoiterudueutouanuincreaseuinuglandularuvascularityuwhich
increasesuasutheuthyroiduglandubecomesuhyperactive.uAubruituisunotucommonuwithu(A,uB,uanduC).
Au6-year-
olduchilduisualertubutuquietuwhenubroughtutoutheuemergencyucenteruwithuperiorbitaluecchymosisuanduec
chymosisubehindutheuears.uTheunurseususpectsupotentialuchilduabuseuanducontinuesutouassessutheuchild
uforuadditionalumanifestationsuofuaubasilaruskullufracture.uWhat
assessmentufindinguwouldubeuconsistentuwithuaubasilaruskullufracture?
A.uHematemesisuanduabdominaludistention.
B.uAsymmetryuofutheufaceuandueyeumovements.
C.uRhinorrhoeauoruotorrhoeauwithuHalousign.
D.uAbnormalupositionuandumovementuofutheuarm.u-
uANSWER:uRhinorrhoeauoruotorrhoeauwithuHalousign.
RATIONALE:
Raccoonueyesu(periorbitaluecchymosis)uanduBattle'susignu(ecchymosisubehindutheuearuoveruthe
mastoiduprocess)uareubothusignsuofuaubasilaruskullufracture,usoutheunurseushoulduassessuforupossible
meningealutearsuthatumanifestuasuauHalousignuwithuCSFuleakageufromutheuearsuorunoseu(D).u(A)uis
consistentuwithuorbitalufractures.u(B)uoccursuwithuwrenchingutraumasuofutheushoulderuoruarm
fractures.u(C)uoccursuwithubluntuabdominaluinjuries.
Theunurseuisuassessinguauclientuwhoucomplainsuofuweightuloss,uracinguhearturate,uandudifficulty
sleeping.uTheunurseudeterminesutheuclientuhasumoistuskinuwithufineuhair,uprominentueyes,ulid
retraction,uanduaustaringuexpression.uTheseufindingsuareuconsistentuwithuwhichudisorder?
A.uGrave'sudisease.
B.uMultipleusclerosis.
C.uAddison'sudisease.
D.uCushingusyndrome.u-uANSWER:uGrave'sudisease
RATIONALE:
ThisuclientuisuexhibitingusymptomsuassociateduwithuhyperthyroidismuoruGrave'sudiseaseu(A),
whichuisuanuautoimmuneuconditionuaffectingutheuthyroid.u(B,uC,uanduD)uareunotuassociateduwith
theseusymptoms.
Theunurseuisuassessinguanuolderuclientuandudeterminesuthatutheuclient'suleftuupperueyelidudroops,
coveringumoreuofutheuirisuthanutheurightueyelid.uWhichudescriptionushouldutheunurseuuseuto
documentuthisufinding?
A.uAunystagmusuonutheuleft.
B.uExophthalmosuonutheuright.
C.uPtosisuonutheuleftueyelid.
D.uAstigmatismuonutheuright.u-uANSWER:uPtosisuonutheuleftueyelid
Rationale:uPtosisuisutheutermutoudescribeuanueyelidudrooputhatucoversuaulargeuportionuofutheuirisu(A),uw
hich
mayuresultufromuoculomotorunerveuorueyelidumuscleudisorder.u(B)uisucharacterizedubyurapid,
rhythmicumovementuofubothueyes.u(C)uisuaudistortionuofutheulensuofutheueye,ucausingudecreased
visualuacuity.u(D)uisuautermuusedutoudescribeuauprotrusionuofutheueyeballsuthatuoccursuwith
hyperthyroidism.
Theunurseuisuassessinguauchild'suweightuanduheightuduringuauclinicuvisitupriorutoustartinguschool.
Theunurseuplotsutheuchild'suweightuonutheugrowthuchartuandunotesuthatutheuchild'suweightuisuinuthe
95thupercentileuforutheuchild'suheight.uWhatuactionushouldutheunurseutake?
A.uQuestionutheutypeuanduquantityuofufoodsueatenuinuautypicaluday.
B.uEncourageugivingutwouadditionalusnacksueachudayutoutheuchild.
C.uRecommenduaudailyuintakeuofuatuleastufouruglassesuofuwholeumilk.
D.uAssessuforusignsuofupoorunutrition,usuchuasuaupaleuappearanceu-
uANSWER:uA.uQuestionutheutypeuanduquantityuofufoodsueatenuinuautypicaluday.
RATIONALE:
,Theuchilduisuoverweightuforuheight,usouassessmentuofutheuchild'sudailyudietu(C)ushouldube
determined.uTheuchildudoesunotuneedu(AuoruB),ubothuofuwhichuwilluincreaseutheuchild'suweight.
Poorunutritionu(D)uisucommonlyuseenuinuunderweightuchildren,unotuoverweight.
Auchilduisureceivingumaintenanceuintravenousu(IV)ufluidsuatutheurateuofu1000umLuforutheufirstu10
kguofubodyuweight,uplusu50umL/kguperudayuforueachukilogramubetweenu10uandu20.uHowumany
millilitersuperuhourushouldutheunurseuprogramutheuinfusionupumpuforuauchilduwhouweighsu19.5ukg?
(Enterunumericuvalueuonly.uIfuroundinguisurequired,uroundutoutheunearestuwholeunumber.)
A.u24
B.u61
C.u73
D.u58u-uANSWER:uB.u61
RATIONALE:
Theuformulauforucalculatingudailyufluidurequirementsuis:u0utou10ukg,u100umL/kguperuday;uoru10uto
20ukg,u1000umLuforutheufirstu10ukguofubodyuweightuplusu50umL/kguperudayuforueachukilogram
betweenu10uandu20.uToudetermineuanuhourlyurate,udivideutheutotalumillilitersuperudayubyu24.u19.5
kguxu50umL/kgu=u475umLu+u1000umLu=u1475umLu/u24uhoursu=u61umL/hour
Theunurseuobtainsutheupulseurateuofu89ubeats/minuteuforuanuinfantubeforeuadministeringudigoxin
(Lanoxin).uWhichuactionushouldutheunurseutake?
A.uWithholdutheumedicationuanducontactutheuhealthcareuprovider.
B.uGiveutheumedicationudosageuasuscheduled.
C.uAssessurespiratoryurateuforuoneuminuteunext.
D.uWaitu30uminutesuandugiveuhalfuofutheudosageuofumedication.u-
uANSWER:uA.uWithholdutheumedicationuanducontactutheuhealthcareuprovider
RATIONALE:
Bradycardiauisuanuearlyusignuofudigoxinutoxicity,usouifutheuinfant'supulseurateuisulessuthanu100
beats/minute,udigoxinushouldubeuwithhelduandutheuhealthcareuproviderushouldubeunotifiedu(D).
Assessingutheurespiratoryurateu(A)uisunotuindicatedubeforeuadministeringuLanoxin.u(BuanduC)uplace
theuinfantuatufurtheruriskuforudigoxinutoxicity.
TheunurseuisudevelopinguauteachinguplanuforuanuadolescentuwithuauMilwaukeeubrace.uWhich
instructionushouldutheunurseuinclude?
A.uWearutheubraceuoveruauT-shirtu23uhoursuperuday.
B.uDressuwithutheubraceuoveruregularuclothing.
C.uShoweruwithutheubraceudirectlyuagainstutheuskin.
D.uRemoveutheubraceujustubeforeugoingutoubed.u-uANSWER:uA.uWearutheubraceuoveruauT-
shirtu23uhoursuperuday.
RATIONALE:
Idiopathicuscoliosisuisuanuabnormalulateralucurvatureuofutheuspineuinuadolescentufemales.uEarly
treatmentuusesuauMilwaukeeubraceuthatuplacesupressureuagainstutheulateraluspinalucurvature,uunder
theuneck,uanduagainstutheuiliacucrest,usouitushouldubeuwornuforu23uhoursuperudayuoveruauT-shirtu(D)
whichureducesufrictionuanduchafinguofutheuskin.u(A,uB,uanduC)ureduceutheueffectivenessuofuthe
brace.
Auclientuwithuasthmaureceivesuauprescriptionuforuhighubloodupressureuduringuauclinicuvisit.
Whichuprescriptionushouldutheunurseuanticipateutheuclientutoureceiveuthatuisuleastulikelyuto
exacerbateuasthma?
A.uCarteololu(Ocupress).
B.uPropranololuhydrochlorideu(Inderal).
C.uPindololu(Visken).
D.uMetoprololutartrateu(Lopressor)u-uANSWER:uD.uMetoprololutartrateu(Lopressor).
RATIONALE:
Theubestuantihypertensiveuagentuforuclientsuwithuasthmauisumetoprololu(Lopressor)u(C),uaubeta2
blockinguagentuwhichuisualsoucardio-selectiveuandulessulikelyutoucauseubronchoconstriction.
Pindololu(A)uisuaubeta2ublockeruthatucanucauseubronchoconstrictionuanduincreaseuasthmatic
symptoms.uAlthoughucarteololu(B)uisuaubetaublockinguagentuanduanueffectiveuantihypertensive
, agentuuseduinumanaginguangina,uitucanuincreaseuauclient'suriskuforubronchoconstrictionudueutouits
nonselectiveubetaublockeruaction.uPropranololu(D)ualsoublocksutheubeta2ureceptorsuinutheulungs,
causingubronchoconstriction,uanduisunotuindicateduinuclientsuwithuasthmauanduotheruobstructive
pulmonaryudisorders.
Aumaleuclientuwhouhasubeenutakingupropranololu(Inderal)uforu18umonthsutellsutheunurseuthatuthe
healthcareuproviderudiscontinuedutheumedicationubecauseuhisubloodupressureuhasubeenunormalufor
theupastuthreeumonths.uWhichuinstructionushouldutheunurseuprovide?
A.uObtainuanotheruantihypertensiveuprescriptionutouavoiduwithdrawalusymptoms.
B.uStoputheumedicationuandukeepuanuaccurateurecorduofubloodupressure
C.uReportuanyuuncomfortableusymptomsuafterustoppingutheumedication.
D.uAskutheuhealthcareuprovideruaboututaperingutheudrugudoseuoverutheunextuweek.u-
uANSWER:uD.uAskutheuhealthcareuprovideruaboututaperingutheudrugudoseuoverutheunextuweek.
RATIONALE:
Althoughutheuhealthcareuproviderudiscontinuedutheupropranolol,umeasuresutoupreventurebound
cardiacuexcitation,usuchuasuprogressivelyureducingutheudoseuoveruoneutoutwouweeksu(C),ushouldube
recommendedutoupreventureboundutachycardia,uhypertension,uanduventricularudysrhythmias.
Abruptucessationu(AuanduB)uofutheubeta-blockinguagentumayuprecipitateutachycardiauandurebound
hypertension,usougradualuweaningushouldubeurecommended.u(D)uisunotuindicated.
Auclientuwhouisutakinguclonidineu(Catapres,uDuraclon)ureportsudrowsiness.uWhichuadditional
assessmentushouldutheunurseumake?
A.uHasutheuclientuexperienceduconstipationurecently?
B.uDidutheuclientumissuanyudosesuofutheumedication?
C.uHowulonguhasutheuclientubeenutakingutheumedication?
D.uDoesutheuclientuuseuanyutobaccouproducts?u-
uANSWER:uC.uHowulonguhasutheuclientubeenutakingutheumedication?
RATIONALE:
Drowsinessucanuoccuruinutheuearlyuweeksuofutreatmentuwithuclonidineuanduwithucontinueduuse
becomesulessuintense,usoutheulengthuofutimeutheuclientuhasubeenuonutheumedicationu(A)uprovides
informationutoudirectuadditionaluinstruction.u(B,uC,uanduD)uareunoturelevant.
Theunurseuisupreparingutouadministeruatropine,uanuanticholinergic,utouauclientuwhouisuscheduled
foruaucholecystectomy.uTheuclientuasksutheunurseutouexplainutheureasonuforutheuprescribed
medication.uWhaturesponseuisubestuforutheunurseutouprovide?
A.uProvideuaumoreurapiduinductionuofuanesthesia.
B.uInduceurelaxationubeforeuinductionuofuanesthesia.
C.uDecreaseutheuriskuofubradycardiauduringusurgery.
D.uMinimizeutheuamountuofuanalgesiauneededupostoperatively.u-
uANSWER:uC.uDecreaseutheuriskuofubradycardiauduringusurgery.
RATIONALE:
Atropineumayubeuprescribedupreoperativelyutouincreaseutheuautomaticityuofutheusinoatrialunodeuand
preventuaudangerousureductionuinuhearturateu(B)uduringusurgicaluanesthesia.u(A,uCuanduD)udounot
addressutheutherapeuticuactionuofuatropineuuseuperioperatively.
Anu80-year-olduclientuisugivenumorphineusulphateuforupostoperativeupain.uWhichuconcomitant
medicationushouldutheunurseuquestionuthatuposesuaupotentialudevelopmentuofuurinaryuretentionuin
thisugeriatricuclient?
A.uAntacids.
B.uTricyclicuantidepressants.
C.uNonsteroidaluanti-inflammatoryuagents.
D.uInsulin.u-uANSWER:uB.uTricyclicuantidepressants.
RATIONALE:
Drugsuwithuanticholinergicuproperties,usuchuasutricyclicuantidepressantsu(C),ucanuexacerbate
urinaryuretentionuassociateduwithuopioidsuinutheuolderuclient.uAlthoughutricyclicuantidepressants
anduantihistaminesuwithuopioidsucanuexacerbateuurinaryuretention,utheuconcurrentuuseuofu(AuanduB)
withuopioidsudounot.uNonsteroidaluanti-inflammatoryuagentsu(D)ucanuincreaseutheuriskufor
u u u u u u u u
t 8th Edition By Linda D. Urden, DNSc, RN, CNS, NE-
u u u u u u u u u u
BC, FAAN, Kathleen M. Stacy, PhD, RN, CNS, CCRN, PCCN, CCNS
u u u u u u u u u u u
and Ma 9780323447522 Chapter 1-41 Complete Guide .
u u u u u u u
Au56-year-oldufemaleuclientuisureceivinguintracavitaryuradiationuviauauradiumuimplant.uWhich
nurseushouldubeuassignedutoucareuforuthisuclient?
A.uTheunurseuwhouisucaringuforuanotheruclientureceivinguintracavitaryuradiation.
B.uAunurseuwithuMarfan'susyndromeuwhouisupostmenopausal.
C.uAunurseuwithuoncologyuexperienceuwhoumayubeupregnant.
D.uTheunurseuwhouisucaringuforuanotheruclientuwhouhasuClostridiumudifficile.u-
uANSWER:uB.uAunurseuwithuMarfan'susyndromeuwhouisupostmenopausal.
RATIONALE:
Auclientureceivinguintracavityuradiationuposesuauradiationuhazarduasulonguasutheuintracavity
radiationusourceuisuinuplace.uAunurse'suabilityutoucareuofuthisuclientuisunotuaffectedubyuMarfan's
syndromeu(B),uwhichuisuauhereditaryudisorderuofuconnectiveutissues,ubones,umuscles,uligaments
anduskeletalustructures.uTheugoaluisutoulimituanyuoneustaffumember'suexposureutoutheucalculated
timeuspanubaseduonutheuhalf-lifeuofuradium,usuchuasutheunumberuofuminutesuatutheubedsideuperuday,
sou(A)ushouldunotubeuassigned.u(C)ushouldunotubeuexposedutoutheuradiationudueutoutheupossible
effectuonutheufetus.uAuradiationuexposureudecreasesutheuimmuneuresponseuinutheuclientuwhoushould
notubeuexposedutoutheupotentialuinadvertentutransmissionuofuanuinfectiousuorganismu(D).
1.Auclientuwhouhasuactiveutuberculosisu(TB)uisuadmittedutoutheumedicaluunit.uWhatuactionuisumost
importantuforutheunurseutouimplement?
A.uFitutheuclientuwithuaurespiratorumask.
B.uAssignutheuclientutouaunegativeuair-flowuroom.
C.uDonuaucleanugownuforuclientucare.
D.uPlaceuanuisolationucartuinutheuhallwayu-uANSWER:uAssignutheuclientutouaunegativeuair-flowuroom
RATIONALE:
Activeutuberculosisurequiresuimplementationuofuairborneuprecautions,usoutheuclientushouldube
assignedutouaunegativeupressureuair-flowuroomu(D).uAlthoughu(AuanduC)ushouldubeuimplemented
foruclientsuinuisolationuwithucontactuprecautions,uituisumostuimportantuthatuairuflowufromutheuroom
isuminimizeduwhenutheuclientuhasuTB.u(B)ushouldubeuimplementeduwhenutheuclientuleavesuthe
isolationuenvironment.
2.Auclientuisureceivinguatenololu(Tenormin)u25umguPOuafteruaumyocardialuinfarction.uTheunurse
determinesutheuclient'suapicalupulseuisu65ubeatsuperuminute.uWhatuactionushouldutheunurse
implement
next?
A.uMeasureutheubloodupressure.
B.uReassessutheuapicalupulse.
C.uNotifyutheuhealthcareuprovider.
D.uAdministerutheumedication.u-uANSWER:uAdministerutheumedication
RATIONALE:
Atenolol,uaubeta-blocker,ublocksutheubetaureceptorsuofutheusinoatrialunodeutoureduceutheuhearturate,
southeumedicationushouldubeuadministeredu(C)ubecauseutheuclient'suapicalupulseuisugreateruthanu60.
(A,uB,uanduD)uareunotuindicateduatuthisutime.
3.Theunurseuisuassessinguauclientuanduidentifiesuaubruituoverutheuthyroid.uThisufindinguisuconsistent
withuwhichuinterpretation?
A.uHypothyroidism.
B.uThyroiducyst.
C.uThyroiducancer.
D.uHyperthyroidismu-uANSWER:uHyperthyroidism
,Rationale:Hyperthyroidismu(D)uisuanuenlargementuofutheuthyroidugland,uoftenureferredutouasuaugoiter,ua
ndua
bruitumayubeuauscultateduoverutheugoiterudueutouanuincreaseuinuglandularuvascularityuwhich
increasesuasutheuthyroiduglandubecomesuhyperactive.uAubruituisunotucommonuwithu(A,uB,uanduC).
Au6-year-
olduchilduisualertubutuquietuwhenubroughtutoutheuemergencyucenteruwithuperiorbitaluecchymosisuanduec
chymosisubehindutheuears.uTheunurseususpectsupotentialuchilduabuseuanducontinuesutouassessutheuchild
uforuadditionalumanifestationsuofuaubasilaruskullufracture.uWhat
assessmentufindinguwouldubeuconsistentuwithuaubasilaruskullufracture?
A.uHematemesisuanduabdominaludistention.
B.uAsymmetryuofutheufaceuandueyeumovements.
C.uRhinorrhoeauoruotorrhoeauwithuHalousign.
D.uAbnormalupositionuandumovementuofutheuarm.u-
uANSWER:uRhinorrhoeauoruotorrhoeauwithuHalousign.
RATIONALE:
Raccoonueyesu(periorbitaluecchymosis)uanduBattle'susignu(ecchymosisubehindutheuearuoveruthe
mastoiduprocess)uareubothusignsuofuaubasilaruskullufracture,usoutheunurseushoulduassessuforupossible
meningealutearsuthatumanifestuasuauHalousignuwithuCSFuleakageufromutheuearsuorunoseu(D).u(A)uis
consistentuwithuorbitalufractures.u(B)uoccursuwithuwrenchingutraumasuofutheushoulderuoruarm
fractures.u(C)uoccursuwithubluntuabdominaluinjuries.
Theunurseuisuassessinguauclientuwhoucomplainsuofuweightuloss,uracinguhearturate,uandudifficulty
sleeping.uTheunurseudeterminesutheuclientuhasumoistuskinuwithufineuhair,uprominentueyes,ulid
retraction,uanduaustaringuexpression.uTheseufindingsuareuconsistentuwithuwhichudisorder?
A.uGrave'sudisease.
B.uMultipleusclerosis.
C.uAddison'sudisease.
D.uCushingusyndrome.u-uANSWER:uGrave'sudisease
RATIONALE:
ThisuclientuisuexhibitingusymptomsuassociateduwithuhyperthyroidismuoruGrave'sudiseaseu(A),
whichuisuanuautoimmuneuconditionuaffectingutheuthyroid.u(B,uC,uanduD)uareunotuassociateduwith
theseusymptoms.
Theunurseuisuassessinguanuolderuclientuandudeterminesuthatutheuclient'suleftuupperueyelidudroops,
coveringumoreuofutheuirisuthanutheurightueyelid.uWhichudescriptionushouldutheunurseuuseuto
documentuthisufinding?
A.uAunystagmusuonutheuleft.
B.uExophthalmosuonutheuright.
C.uPtosisuonutheuleftueyelid.
D.uAstigmatismuonutheuright.u-uANSWER:uPtosisuonutheuleftueyelid
Rationale:uPtosisuisutheutermutoudescribeuanueyelidudrooputhatucoversuaulargeuportionuofutheuirisu(A),uw
hich
mayuresultufromuoculomotorunerveuorueyelidumuscleudisorder.u(B)uisucharacterizedubyurapid,
rhythmicumovementuofubothueyes.u(C)uisuaudistortionuofutheulensuofutheueye,ucausingudecreased
visualuacuity.u(D)uisuautermuusedutoudescribeuauprotrusionuofutheueyeballsuthatuoccursuwith
hyperthyroidism.
Theunurseuisuassessinguauchild'suweightuanduheightuduringuauclinicuvisitupriorutoustartinguschool.
Theunurseuplotsutheuchild'suweightuonutheugrowthuchartuandunotesuthatutheuchild'suweightuisuinuthe
95thupercentileuforutheuchild'suheight.uWhatuactionushouldutheunurseutake?
A.uQuestionutheutypeuanduquantityuofufoodsueatenuinuautypicaluday.
B.uEncourageugivingutwouadditionalusnacksueachudayutoutheuchild.
C.uRecommenduaudailyuintakeuofuatuleastufouruglassesuofuwholeumilk.
D.uAssessuforusignsuofupoorunutrition,usuchuasuaupaleuappearanceu-
uANSWER:uA.uQuestionutheutypeuanduquantityuofufoodsueatenuinuautypicaluday.
RATIONALE:
,Theuchilduisuoverweightuforuheight,usouassessmentuofutheuchild'sudailyudietu(C)ushouldube
determined.uTheuchildudoesunotuneedu(AuoruB),ubothuofuwhichuwilluincreaseutheuchild'suweight.
Poorunutritionu(D)uisucommonlyuseenuinuunderweightuchildren,unotuoverweight.
Auchilduisureceivingumaintenanceuintravenousu(IV)ufluidsuatutheurateuofu1000umLuforutheufirstu10
kguofubodyuweight,uplusu50umL/kguperudayuforueachukilogramubetweenu10uandu20.uHowumany
millilitersuperuhourushouldutheunurseuprogramutheuinfusionupumpuforuauchilduwhouweighsu19.5ukg?
(Enterunumericuvalueuonly.uIfuroundinguisurequired,uroundutoutheunearestuwholeunumber.)
A.u24
B.u61
C.u73
D.u58u-uANSWER:uB.u61
RATIONALE:
Theuformulauforucalculatingudailyufluidurequirementsuis:u0utou10ukg,u100umL/kguperuday;uoru10uto
20ukg,u1000umLuforutheufirstu10ukguofubodyuweightuplusu50umL/kguperudayuforueachukilogram
betweenu10uandu20.uToudetermineuanuhourlyurate,udivideutheutotalumillilitersuperudayubyu24.u19.5
kguxu50umL/kgu=u475umLu+u1000umLu=u1475umLu/u24uhoursu=u61umL/hour
Theunurseuobtainsutheupulseurateuofu89ubeats/minuteuforuanuinfantubeforeuadministeringudigoxin
(Lanoxin).uWhichuactionushouldutheunurseutake?
A.uWithholdutheumedicationuanducontactutheuhealthcareuprovider.
B.uGiveutheumedicationudosageuasuscheduled.
C.uAssessurespiratoryurateuforuoneuminuteunext.
D.uWaitu30uminutesuandugiveuhalfuofutheudosageuofumedication.u-
uANSWER:uA.uWithholdutheumedicationuanducontactutheuhealthcareuprovider
RATIONALE:
Bradycardiauisuanuearlyusignuofudigoxinutoxicity,usouifutheuinfant'supulseurateuisulessuthanu100
beats/minute,udigoxinushouldubeuwithhelduandutheuhealthcareuproviderushouldubeunotifiedu(D).
Assessingutheurespiratoryurateu(A)uisunotuindicatedubeforeuadministeringuLanoxin.u(BuanduC)uplace
theuinfantuatufurtheruriskuforudigoxinutoxicity.
TheunurseuisudevelopinguauteachinguplanuforuanuadolescentuwithuauMilwaukeeubrace.uWhich
instructionushouldutheunurseuinclude?
A.uWearutheubraceuoveruauT-shirtu23uhoursuperuday.
B.uDressuwithutheubraceuoveruregularuclothing.
C.uShoweruwithutheubraceudirectlyuagainstutheuskin.
D.uRemoveutheubraceujustubeforeugoingutoubed.u-uANSWER:uA.uWearutheubraceuoveruauT-
shirtu23uhoursuperuday.
RATIONALE:
Idiopathicuscoliosisuisuanuabnormalulateralucurvatureuofutheuspineuinuadolescentufemales.uEarly
treatmentuusesuauMilwaukeeubraceuthatuplacesupressureuagainstutheulateraluspinalucurvature,uunder
theuneck,uanduagainstutheuiliacucrest,usouitushouldubeuwornuforu23uhoursuperudayuoveruauT-shirtu(D)
whichureducesufrictionuanduchafinguofutheuskin.u(A,uB,uanduC)ureduceutheueffectivenessuofuthe
brace.
Auclientuwithuasthmaureceivesuauprescriptionuforuhighubloodupressureuduringuauclinicuvisit.
Whichuprescriptionushouldutheunurseuanticipateutheuclientutoureceiveuthatuisuleastulikelyuto
exacerbateuasthma?
A.uCarteololu(Ocupress).
B.uPropranololuhydrochlorideu(Inderal).
C.uPindololu(Visken).
D.uMetoprololutartrateu(Lopressor)u-uANSWER:uD.uMetoprololutartrateu(Lopressor).
RATIONALE:
Theubestuantihypertensiveuagentuforuclientsuwithuasthmauisumetoprololu(Lopressor)u(C),uaubeta2
blockinguagentuwhichuisualsoucardio-selectiveuandulessulikelyutoucauseubronchoconstriction.
Pindololu(A)uisuaubeta2ublockeruthatucanucauseubronchoconstrictionuanduincreaseuasthmatic
symptoms.uAlthoughucarteololu(B)uisuaubetaublockinguagentuanduanueffectiveuantihypertensive
, agentuuseduinumanaginguangina,uitucanuincreaseuauclient'suriskuforubronchoconstrictionudueutouits
nonselectiveubetaublockeruaction.uPropranololu(D)ualsoublocksutheubeta2ureceptorsuinutheulungs,
causingubronchoconstriction,uanduisunotuindicateduinuclientsuwithuasthmauanduotheruobstructive
pulmonaryudisorders.
Aumaleuclientuwhouhasubeenutakingupropranololu(Inderal)uforu18umonthsutellsutheunurseuthatuthe
healthcareuproviderudiscontinuedutheumedicationubecauseuhisubloodupressureuhasubeenunormalufor
theupastuthreeumonths.uWhichuinstructionushouldutheunurseuprovide?
A.uObtainuanotheruantihypertensiveuprescriptionutouavoiduwithdrawalusymptoms.
B.uStoputheumedicationuandukeepuanuaccurateurecorduofubloodupressure
C.uReportuanyuuncomfortableusymptomsuafterustoppingutheumedication.
D.uAskutheuhealthcareuprovideruaboututaperingutheudrugudoseuoverutheunextuweek.u-
uANSWER:uD.uAskutheuhealthcareuprovideruaboututaperingutheudrugudoseuoverutheunextuweek.
RATIONALE:
Althoughutheuhealthcareuproviderudiscontinuedutheupropranolol,umeasuresutoupreventurebound
cardiacuexcitation,usuchuasuprogressivelyureducingutheudoseuoveruoneutoutwouweeksu(C),ushouldube
recommendedutoupreventureboundutachycardia,uhypertension,uanduventricularudysrhythmias.
Abruptucessationu(AuanduB)uofutheubeta-blockinguagentumayuprecipitateutachycardiauandurebound
hypertension,usougradualuweaningushouldubeurecommended.u(D)uisunotuindicated.
Auclientuwhouisutakinguclonidineu(Catapres,uDuraclon)ureportsudrowsiness.uWhichuadditional
assessmentushouldutheunurseumake?
A.uHasutheuclientuexperienceduconstipationurecently?
B.uDidutheuclientumissuanyudosesuofutheumedication?
C.uHowulonguhasutheuclientubeenutakingutheumedication?
D.uDoesutheuclientuuseuanyutobaccouproducts?u-
uANSWER:uC.uHowulonguhasutheuclientubeenutakingutheumedication?
RATIONALE:
Drowsinessucanuoccuruinutheuearlyuweeksuofutreatmentuwithuclonidineuanduwithucontinueduuse
becomesulessuintense,usoutheulengthuofutimeutheuclientuhasubeenuonutheumedicationu(A)uprovides
informationutoudirectuadditionaluinstruction.u(B,uC,uanduD)uareunoturelevant.
Theunurseuisupreparingutouadministeruatropine,uanuanticholinergic,utouauclientuwhouisuscheduled
foruaucholecystectomy.uTheuclientuasksutheunurseutouexplainutheureasonuforutheuprescribed
medication.uWhaturesponseuisubestuforutheunurseutouprovide?
A.uProvideuaumoreurapiduinductionuofuanesthesia.
B.uInduceurelaxationubeforeuinductionuofuanesthesia.
C.uDecreaseutheuriskuofubradycardiauduringusurgery.
D.uMinimizeutheuamountuofuanalgesiauneededupostoperatively.u-
uANSWER:uC.uDecreaseutheuriskuofubradycardiauduringusurgery.
RATIONALE:
Atropineumayubeuprescribedupreoperativelyutouincreaseutheuautomaticityuofutheusinoatrialunodeuand
preventuaudangerousureductionuinuhearturateu(B)uduringusurgicaluanesthesia.u(A,uCuanduD)udounot
addressutheutherapeuticuactionuofuatropineuuseuperioperatively.
Anu80-year-olduclientuisugivenumorphineusulphateuforupostoperativeupain.uWhichuconcomitant
medicationushouldutheunurseuquestionuthatuposesuaupotentialudevelopmentuofuurinaryuretentionuin
thisugeriatricuclient?
A.uAntacids.
B.uTricyclicuantidepressants.
C.uNonsteroidaluanti-inflammatoryuagents.
D.uInsulin.u-uANSWER:uB.uTricyclicuantidepressants.
RATIONALE:
Drugsuwithuanticholinergicuproperties,usuchuasutricyclicuantidepressantsu(C),ucanuexacerbate
urinaryuretentionuassociateduwithuopioidsuinutheuolderuclient.uAlthoughutricyclicuantidepressants
anduantihistaminesuwithuopioidsucanuexacerbateuurinaryuretention,utheuconcurrentuuseuofu(AuanduB)
withuopioidsudounot.uNonsteroidaluanti-inflammatoryuagentsu(D)ucanuincreaseutheuriskufor
