RNPedia: PNLE NP3 Test 1 QUESTIONS |\ |\ |\ |\ |\ |\
WITH ANSWERS |\
1. Nurse Michelle should know that the drainage is normal 4 days
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
after a sigmoid colostomy when the stool is:
|\ |\ |\ |\ |\ |\ |\ |\
A. Green liquid
|\ |\
B. Solid formed
|\ |\
C. Loose, bloody
|\ |\
D. Semi formed - CORRECT ANSWERS ✔✔Answer: (C) Loose,
|\ |\ |\ |\ |\ |\ |\ |\ |\
bloody. |\
Normal bowel function and soft-formed stool usually do not occur
|\ |\ |\ |\ |\ |\ |\ |\ |\
until around the seventh day following surgery. The stool
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consistency is related to how much water is being absorbed. |\ |\ |\ |\ |\ |\ |\ |\ |\
2. Where would nurse Kristine place the call light for a male
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client with a right-sided brain attack and left homonymous
|\ |\ |\ |\ |\ |\ |\ |\ |\
hemianopsia?
A. On the client's right side
|\ |\ |\ |\ |\
B. On the client's left side
|\ |\ |\ |\ |\
C. Directly in front of the client
|\ |\ |\ |\ |\ |\
D. Where the client like - CORRECT ANSWERS ✔✔Answer: (A) On
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the client's right side.
|\ |\ |\ |\
,The client has left visual field blindness. The client will see only
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
from the right side.
|\ |\ |\
3. A male client is admitted to the emergency department
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
following an accident. What are the first nursing actions of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse?
A. Check respiration, circulation, neurological response.
|\ |\ |\ |\ |\
B. Align the spine, check pupils, and check for hemorrhage.
|\ |\ |\ |\ |\ |\ |\ |\ |\
C. Check respirations, stabilize spine, and check circulation.
|\ |\ |\ |\ |\ |\ |\
D. Assess level of consciousness and circulation. - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔Answer: (C) Check respirations, stabilize spine, and
|\ |\ |\ |\ |\ |\ |\ |\
check circulation. |\ |\
Checking the airway would be priority, and a neck injury should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
be suspected.
|\
4. In evaluating the effect of nitroglycerin, Nurse Arthur should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
know that it reduces preload and relieves angina by:
|\ |\ |\ |\ |\ |\ |\ |\
A. Increasing contractility and slowing heart rate.
|\ |\ |\ |\ |\ |\
B. Increasing AV conduction and heart rate.
|\ |\ |\ |\ |\ |\
C. Decreasing contractility and oxygen consumption.
|\ |\ |\ |\ |\
D. Decreasing venous return through vasodilation. - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔Answer: (D) Decreasing venous return through
|\ |\ |\ |\ |\ |\ |\
vasodilation.
,The significant effect of nitroglycerin is vasodilation and
|\ |\ |\ |\ |\ |\ |\ |\
decreased venous return, so the heart does not have to work |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hard.
5. Nurse Patricia finds a female client who is post-myocardial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
infarction (MI) slumped on the side rails of the bed and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
unresponsive to shaking or shouting. Which is the nurse next |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
action?
A. Call for help and note the time.
|\ |\ |\ |\ |\ |\ |\
B. Clear the airway
|\ |\ |\
C. Give two sharp thumps to the precordium and check the pulse.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
D. Administer two quick blows. - CORRECT ANSWERS ✔✔Answer:
|\ |\ |\ |\ |\ |\ |\ |\ |\
(A) Call for help and note the time.
|\ |\ |\ |\ |\ |\ |\ |\
Having established, by stimulating the client, that the client is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
unconscious rather than sleep, the nurse should immediately call |\ |\ |\ |\ |\ |\ |\ |\
for help. This may be done by dialing the operator from the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client's phone and giving the hospital code for cardiac arrest and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the client's room number to the operator, of if the phone is not
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
available, by pulling the emergency call button. Noting the time
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
is important baseline information for cardiac arrest procedure.
|\ |\ |\ |\ |\ |\ |\
6. Nurse Monett is caring for a client recovering from gastro-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
intestinal bleeding. The nurse should: |\ |\ |\ |\
A. Plan care so the client can receive 8 hours of uninterrupted
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
sleep each night. |\ |\
B. Monitor vital signs every 2 hours.
|\ |\ |\ |\ |\ |\
, C. Make sure that the client takes food and medications at
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
prescribed intervals. |\
D. Provide milk every 2 to 3 hours. - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔Answer: (C) Make sure that the client takes food and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
medications at prescribed intervals. |\ |\ |\ |\
Food and drug therapy will prevent the accumulation of
|\ |\ |\ |\ |\ |\ |\ |\ |\
hydrochloric acid, or will neutralize and buffer the acid that does
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
accumulate.
7. A male client was on warfarin (Coumadin) before admission,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and has been receiving heparin I.V. for 2 days. The partial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
thromboplastin time (PTT) is 68 seconds. What should Nurse |\ |\ |\ |\ |\ |\ |\ |\ |\
Carla do? |\
A. Stop the I.V. infusion of heparin and notify the physician.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
B. Continue treatment as ordered.
|\ |\ |\ |\
C. Expect the warfarin to increase the PTT.
|\ |\ |\ |\ |\ |\ |\
D. Increase the dosage, because the level is lower than normal. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔Answer: (B) Continue treatment as
|\ |\ |\ |\ |\ |\ |\
ordered. |\
The effects of heparin are monitored by the PTT is normally 30 to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
45 seconds; the therapeutic level is 1.5 to 2 times the normal
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
level.
8. A client undergone ileostomy, when should the drainage
|\ |\ |\ |\ |\ |\ |\ |\ |\
appliance be applied to the stoma? |\ |\ |\ |\ |\
A. 24 hours later, when edema has subsided.
|\ |\ |\ |\ |\ |\ |\
WITH ANSWERS |\
1. Nurse Michelle should know that the drainage is normal 4 days
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
after a sigmoid colostomy when the stool is:
|\ |\ |\ |\ |\ |\ |\ |\
A. Green liquid
|\ |\
B. Solid formed
|\ |\
C. Loose, bloody
|\ |\
D. Semi formed - CORRECT ANSWERS ✔✔Answer: (C) Loose,
|\ |\ |\ |\ |\ |\ |\ |\ |\
bloody. |\
Normal bowel function and soft-formed stool usually do not occur
|\ |\ |\ |\ |\ |\ |\ |\ |\
until around the seventh day following surgery. The stool
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consistency is related to how much water is being absorbed. |\ |\ |\ |\ |\ |\ |\ |\ |\
2. Where would nurse Kristine place the call light for a male
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client with a right-sided brain attack and left homonymous
|\ |\ |\ |\ |\ |\ |\ |\ |\
hemianopsia?
A. On the client's right side
|\ |\ |\ |\ |\
B. On the client's left side
|\ |\ |\ |\ |\
C. Directly in front of the client
|\ |\ |\ |\ |\ |\
D. Where the client like - CORRECT ANSWERS ✔✔Answer: (A) On
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the client's right side.
|\ |\ |\ |\
,The client has left visual field blindness. The client will see only
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
from the right side.
|\ |\ |\
3. A male client is admitted to the emergency department
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
following an accident. What are the first nursing actions of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse?
A. Check respiration, circulation, neurological response.
|\ |\ |\ |\ |\
B. Align the spine, check pupils, and check for hemorrhage.
|\ |\ |\ |\ |\ |\ |\ |\ |\
C. Check respirations, stabilize spine, and check circulation.
|\ |\ |\ |\ |\ |\ |\
D. Assess level of consciousness and circulation. - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔Answer: (C) Check respirations, stabilize spine, and
|\ |\ |\ |\ |\ |\ |\ |\
check circulation. |\ |\
Checking the airway would be priority, and a neck injury should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
be suspected.
|\
4. In evaluating the effect of nitroglycerin, Nurse Arthur should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
know that it reduces preload and relieves angina by:
|\ |\ |\ |\ |\ |\ |\ |\
A. Increasing contractility and slowing heart rate.
|\ |\ |\ |\ |\ |\
B. Increasing AV conduction and heart rate.
|\ |\ |\ |\ |\ |\
C. Decreasing contractility and oxygen consumption.
|\ |\ |\ |\ |\
D. Decreasing venous return through vasodilation. - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔Answer: (D) Decreasing venous return through
|\ |\ |\ |\ |\ |\ |\
vasodilation.
,The significant effect of nitroglycerin is vasodilation and
|\ |\ |\ |\ |\ |\ |\ |\
decreased venous return, so the heart does not have to work |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hard.
5. Nurse Patricia finds a female client who is post-myocardial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
infarction (MI) slumped on the side rails of the bed and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
unresponsive to shaking or shouting. Which is the nurse next |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
action?
A. Call for help and note the time.
|\ |\ |\ |\ |\ |\ |\
B. Clear the airway
|\ |\ |\
C. Give two sharp thumps to the precordium and check the pulse.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
D. Administer two quick blows. - CORRECT ANSWERS ✔✔Answer:
|\ |\ |\ |\ |\ |\ |\ |\ |\
(A) Call for help and note the time.
|\ |\ |\ |\ |\ |\ |\ |\
Having established, by stimulating the client, that the client is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
unconscious rather than sleep, the nurse should immediately call |\ |\ |\ |\ |\ |\ |\ |\
for help. This may be done by dialing the operator from the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client's phone and giving the hospital code for cardiac arrest and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the client's room number to the operator, of if the phone is not
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
available, by pulling the emergency call button. Noting the time
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
is important baseline information for cardiac arrest procedure.
|\ |\ |\ |\ |\ |\ |\
6. Nurse Monett is caring for a client recovering from gastro-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
intestinal bleeding. The nurse should: |\ |\ |\ |\
A. Plan care so the client can receive 8 hours of uninterrupted
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
sleep each night. |\ |\
B. Monitor vital signs every 2 hours.
|\ |\ |\ |\ |\ |\
, C. Make sure that the client takes food and medications at
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
prescribed intervals. |\
D. Provide milk every 2 to 3 hours. - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔Answer: (C) Make sure that the client takes food and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
medications at prescribed intervals. |\ |\ |\ |\
Food and drug therapy will prevent the accumulation of
|\ |\ |\ |\ |\ |\ |\ |\ |\
hydrochloric acid, or will neutralize and buffer the acid that does
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
accumulate.
7. A male client was on warfarin (Coumadin) before admission,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and has been receiving heparin I.V. for 2 days. The partial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
thromboplastin time (PTT) is 68 seconds. What should Nurse |\ |\ |\ |\ |\ |\ |\ |\ |\
Carla do? |\
A. Stop the I.V. infusion of heparin and notify the physician.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
B. Continue treatment as ordered.
|\ |\ |\ |\
C. Expect the warfarin to increase the PTT.
|\ |\ |\ |\ |\ |\ |\
D. Increase the dosage, because the level is lower than normal. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔Answer: (B) Continue treatment as
|\ |\ |\ |\ |\ |\ |\
ordered. |\
The effects of heparin are monitored by the PTT is normally 30 to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
45 seconds; the therapeutic level is 1.5 to 2 times the normal
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
level.
8. A client undergone ileostomy, when should the drainage
|\ |\ |\ |\ |\ |\ |\ |\ |\
appliance be applied to the stoma? |\ |\ |\ |\ |\
A. 24 hours later, when edema has subsided.
|\ |\ |\ |\ |\ |\ |\
