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1. After obtaining 3 L of fluid from a client via parecentesis, thenurse would be alert for which complication?

a. Respiratory distress b. Bleeding from the sitec. Encephalopathy d. Vascular collapse

Rationale: The removal of large amount of fluid, such as 2-3 L,via paracentesis may lead to acute fluid shifting andhypotension, subsequently leading to vascular collapse.

2. Open glove method is preferred to use except:a. In the emergency department when donning sterile

gloves for suturing lacerationsb. Intravenous cutdown or administering of spinal

anesthesiac. Changing a glove during an operation

d. When donning gloves for procedures requiring gown

Rationale: Open glove technique is used when only sterilegloves are worn, as far intravenous cutdown or administering ofspinal anesthesia, or in the emergency department whendonning sterile gloves for suturing lacerations. It is also for

changing a glove during an operation and for procedures notrequiring gown.

3. Correction of a drooping upper eyelid:a. Excision of chalazionb. Blepharaptosis repairc. Correction of entropiond. Canthotomy

Rationale: Blepharaptosis repair is the Correction of adrooping upper eyelid. Correction of Entropion is the correctionof an eversion and drooping of the lower eyelid. Canthotomy is

the incision of the canthus. Exicision of the chalazion is theincision and curettage if a granulomatous swelling of themeibomian glands.

4. Which statement best explains the scientific rationale forperforming urinary catheterization on a client following anabdominal hysterectomy if she is unable to void within 8 hours?a. Temporary atony may result from surgical manipulationin the areab. The bladder is removed along with the uterusc. Infection from surgery interferes with the clients ability tovoid

d. Surgically induced menopause impairs the client urinaryfunction

Rationale: With a hysterectomy, the area around the bladdertypically undergoes surgical manipulation. This causes edemaand nerve trauma, possibly leading to temporary atony.Therefore if the client cannot void within 8 hours, urinarycatheterization is performed to prevent urinary retention.

5. A client arrives at the clinic for a routine physicalexamination. During the examination, the nurse performs asotoscopic examination. Which finding would nurse expect asnormal? a. Pale optic disk

b. Pearly gray tympanic membranec. Tactile fremitusd. Positive red reflex

Rationale: An otoscopic examination uses an otoscope toinspect the external canal and middle ear, specifically thetympanic membrane and its landmarks. Normally, the tympanicmembrane appears pearly gray ad intact. A pale optic disk isan abnormal fining during an ophthalmoscopic examination ofthe eyes. A positive red reflex is a normal finding with anophthalmoscopic examination, not an otoscopic examination.

Tactile frmitus is an abnormal finding when the chest ispalpated.

6. Following a bee sting a client who develops shortness ofbreath and hives on his face and neck receives an epinephrineinjection. Which assessment data would indicate that theepinephrine is effective?

a. Increased itchingb. Drowsiness

c. Easier breathingd. Reduced pain at the sting site

Rationale: The client is exhibiting allergi reaction to thebeesting. Epinephrine acts as a bronchodilator to ease theclients breathing. It has no effect on pain and will not causedrowsiness or increase itching.

7. An adult client has the following laboratory results: whiteblood cells 6,300/ mm3; platelets 250,000 mm3; serum sodium140 mEq/L; serum potassium 6 mEq/L. which condition ispresent?

a. Leukocytosis b. Hyperkalemiac. Hypernatremia d. Thrombocytopenia

Rationale: The clients serum potassium level is above thenormal range of 3.5 to 5.5 mEq/L. indicating hyperkalemia.

8. It is the resection of the half of the colon and a segment ofthe terminal ileum and their mesenteries.

a. Ileostomyb. Hemicolectomyc. Transverse colectomyd. Colostomy

Rationale: Hemicolectomy is the resection of the half of thecolon and a segment of the terminal ileum and theirmesenteries. Colostomy is the formation of a permanent ortemporary opening into the colon brought out onto theabdominal wall as a stoma. Transverse colectomy is theresection of a segment of the transverse colon with an end-to-end anastomosis to reestablish continuity of the colon.

9. Which instruction is most important to provide whendischarging a client from the emergency department followingpenetrating foot injury?

a. Call the health care provider at the first signs ofany red streaks appearing on the foot or legb. Watch for signs and symptoms of anaphylaxis from

the tetanus toxoidc. Avoid smoking until the entire wound is no longer

open to the aird. Refrain from crossing the legs at the knee or ankle

Rationale: The appearance of red streaks indicateslymphadenitis and evidence of spreading infection. The clientshould call the health care provider because further treatmentis necessary. Not crossing the legs will aid in venous return butfoot edema is not a serious threat to health as a spreadinginfection. Avoiding smoking is always an important healthconsideration. However, their effect is not an immediate asthose of the spreading infection. Signs and symptoms ofanaphylactic shock would most likely occur immediately afterthe administration of tetanus toxoid while the client is still in thehealth care facility.

10. Following a thyroidectomy, the client experienceshemorrhage. The nurse would prepare for which emergencyintervention?

a. I.V administration of thyroid hormone

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b. Creation of a tracheostomyc. Insertion of an oral airwayd.I.V administration of calcium

Rationale: Following a thyroidectomy, postoperativehemorrhage may cause compression of the trachea,necessitating an emergency tracheostomy to maintain airway

patency. Calcium and thyroid hormones may be administeredpostoperatively, but these agents are unrelated to hemorrhage.

Insertion of an oral airway would be ineffective in maintainingairway patency because the compression from the hemorrhageis below the airway insertion site.

11. Which intervention must be implemented first during theinitial assessment of a client with major burn injury?

a. Inserting a nasogastric tubeb. Treating for burn shockc. Ensuring a patent airwayd. Eliminating the source of the burn

Rationale: Before any other action can be taken, the source of

the burn injury must be eliminated. The airway patency isensured, any associated injuries are assessed, and then burnshock is treated.

12. Prior the operation the nurse checks the client receivingwarfarin sodium, an anticoagulant, has a prothrombin time of22 and a partial thromboplastin time of 39. The control valuesare PT 12.9; and PTT 37. The International Normalized Ratio(INR) is 2.8. Which nursing intervention would be mostappropriate?

a. Notifying the health care provider immediatelyb. Administering the medication as ordered

c. Holding the medication and assessing for bleedingd. Preparing to administer protamine sulfate

Rationale: When a client is receiving warfarin, the PT valueshould be 1.5 to 2 times the control value. The INR should bebetween 2 to 3. The clients INR value is therapeutic, so themedication should be administered as ordered.

13. A client is 4 hours postoperative abdomino-peritonealresection with sigmoid colostomy. He is complaining of rectalpain that ranks 8 on a scale of 1 to 10. Which interventionsshould he nurse implement? (select all that apply)

a. Assisting the client with distraction to help the painb. Notifying the health care provider that the stoma is pinkc. Assessing the abdominal incisiond. Assessing the clients blood pressure and pulsee. Medicating the client as ordered

Rationale: The nurse should rule out surgical complications,such as hemorrhage, by assessing the clients blood pressureand pulse. The nurse also should medicate the clientimmediately because the client is only 4 hours postoperative.The client will not have an abdominal incision with the surgery(rectal dressing). The nurse would be concerned if the stoma is

purple not pink. The clients need medication not distraction at 4hours postoperative. Sitting on the side of the bed will not helpthe clientspain.

14. Which intervention should the nurse implement first whenbeginning preoperative teaching?

a. Assessing the clients knowledge base relatedto the surgical procedure

b.Describing the possible risks of the surgicalprocedure

c. Having the client read the printed instructionalbooklet

d. Using a standardized preoperative teaching plan forconsistency

Rationale: Before beginning any teaching program; the nursemust first assess the clients knowledge base. Doing so allowsthe nurse to identify the clients teaching needs, avoid repetitionof areas the client is already familiar with, and identify orcorrect in misconceptions or misinformation that the clientmight have.

15. Which topic would be most important to include in thepostoperative teaching for the client scheduled for a vaginalhysterectomy?

a. Lower-extremity exercises and deep breathingb. Pelvic muscle strengthening exercisesc. Use of a bedpan and call lightd. Availability of support persons

Rationale: Use of lithotomy position for a vaginal hysterectomypredisposes the client to DVT. Additionally, atelectasis fromsurgery may also occur. Thus, the client needs instructions on

lower extremity exercises to minimize the risk of DVT. She alsoneeds deep breathing exercises to prevent atelectasis.