RPN Integrated Test VIII (A):
1. Peter is young athlete, preparing for the Olympic competition, injures his knee on practice. The doctor prescribes rd Ibuprofen (Advil) for pain and to reduce inflammation. Peter went for a 3-week therapy. On his 3 week, he
notices petechiae all over his skin, and his blood test showed a platelet count of 9,000mm?. The PN can expect that
a. the patient will be able to continue therapy with this medication – due to the side effect (bleeding – platelet
deceased) of the drug, it should be discontinued
b. the dosage will be reduced from 3 to 2 tablets a day
c. the medication will be discontinued and an alternative agent will be prescribed
d. the lab studies will be repeated, as they are likely an error
Answer: C – petechiae are signs of bleeding, a complication of Motrin (Ibuprofen); the medication must be discontinued
th2. In the 12 week of gestation, the patient completely expels the products of conception. Because the patient is Rh
(-), the PN must:
a. Administer RhoGam within 72 hours after delivery
b. Make certain she receives RhoGam on her first clinic visit – this is too late
c. Not give RhoGam since it is not used with the birth of a stillborn
d. Make certain the patient does not receive RhoGam since the gestation was only 12 weeks Answer: A –this is to protect the succeeding pregnancy; – RhoGam must be given within 72 hours of
abortion or delivery to kill the Rh positive RBC from the fetus and thus prevent antibody formation
3. The PN who works on the night shift enters the medication room and finds a co-worker with tourniquet wrapped
around the upper arm. The co-worker was about to insert a needle, attached to a syringe containing a clear liquid,
into the antecubital area. The most appropriate initial action by the PN is which of the following?
a. call one of the staff to witness
b. confront your co-worker
c. obtain immediate help
d. call the nursing supervisor
Answer: D - the nurse should report the situation to the nursing supervisor. Proper channel of communication should be used to deal with legal matters.
4. Three days after admission for CVA, a patient has a nasogastric tube inserted and is receiving intermittent
feedings. To best evaluate if a prior feeding has been absorbed, the PN should:
a. Evaluate the intake in relation to the output.
b. Aspirate for a residual volume and reinstill it.
c. Instill air into the stomach while auscultating.
d. Compare the patient‘s body weight to the baseline data.
Answer: B – the presence of 50 ml or more of undigested formula may indicate impaired absorption; the volume of the next feeding may need to be reduced or the feeding postponed to reducing the risk of aspiration.
5. The most therapeutic diet for a patient with hepatic cirrhosis would be:
a. High protein, low carbohydrate, low fat.
b. Low protein, low carbohydrate, high fat, soft.
c. High carbohydrate, low saturated fat, 1200 calories.
d. Low sodium, protein to tolerance, moderate fat, high calorie, soft.
Answer: D – low sodium controls fluid retention, blood pressure, and consequently edema; low protein controls ammonia formation in proportion to the liver‘s ability to detoxify ammonia in forming urea; moderate fat and high calories and vitamins help repair a long standing nutritional deficit.
6. To prevent toxoplamosis, the PN should instruct to avoid:
a. Contact with cat feces
b. Working with heavy metals
c. Ingestion of fresh water fish
d. Excessive radiation exposure
Answer: A - Toxoplasma gondii, a protozoan, can be transmitted by exposure to infected cat feces or ingestion of undercooked contaminated meat.
7. John Sherman‘s medical history includes R CVA. He has difficulty swallowing. The PN taking care of the patient
will appropriately do the following:
a. Offer pureed diet and spoon feed the patient
b. Use straw and instruct the patient to drink one glass of water
c. Encourage Mrs. Sherman to bring home-cooked food so the patient can eat his favorite foods
d. Encourage the patient to feed himself with his good hand
d. Important, pertinent and relevant data from another hospice in the community.
8. In assessing an infant for congenital hip dysplasia the PN would observe for:
a. Uneven gluteal folds
b. Positive Babinski reflex
c. Pain when moving the lower extremities
d. Weakness on the affected side
Answer: A – Uneven gluteal folds are an indication that one hip is dislocated
9. Before eating a meal, a client with obsessive-compulsive behavior must wash his hands for 18 times, combs his
hair 444 times strokes, and switch the bathroom light on and off 44 times. What is the most appropriate long
term treatment goal for this client?
a. omit one unacceptable behavior each day
b. increase client‘s acceptance of therapeutic drug use
c. allow ample time for the client to complete all rituals before each meal
d. systematically decrease the amount of time spent in and the number of repetitions of rituals --
10. A 16-year-old patient who sustained partial thickness burn on both hands and left lower abdomen with total of
36% burn. The patient underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7ºC,
potential complication that can be possibly develop will be:
a. Sepsis - skin grafting may predispose the patient to septicemia
b. Hypovolemic – this will not happen from skin grafting
c. Pain – this is expected and not a complication
d. Electrolyte imbalance – this will not occur in skin grafting
11. A client admitted completely immobilized by an acute exacerbation of multiple sclerosis. Two days after
admission, the client cries frequently and refuses to see family members. For this client, the PN identifies a
nursing diagnosis of hopelessness. To address this diagnosis, which intervention should the PN include in the
client‘s care plan?
a. Obtain an order for a tranquilizer – this is not an appropriate treatment to a depressed patient
b. Limit visitors to 15 minutes per day – socialization is encouraged in depression
c. Encourage the client to verbalize his feelings – this decreases anxiety level
d. Reinforce the client‘s responsibility to the family
12. A 29-year-old-first-time mother came for her 6-week postpartum check up. Her, husband, who accompanies her
to the visit, reports that his wife is tearful much of the time. She has not been sleeping well, has little energy, and
a reduced appetite. She denies any suicidal thought, hallucinations or feelings that she wants to harm her baby.
Which of the following is the most likely diagnosis?
a. Maternal post partum blues
b. Post partum psychosis
c. Post partum depression
d. Normal response to the overwhelming responsibilities of motherhood Answer: C – this is post partum depression. The symptoms are identical to those of a major depressive episode. The
maternal blues is self limited that starts in the post partum week and resolved in the second. The patient does not
have any symptoms of post partum psychosis – mania, hallucination, and delusion. Management include medication, counselling and close follow up.
13. Which nursing intervention is most important when caring for a client with acute pyelonephritis?
a. Administer sitz bath twice daily
b. Increase the fluid intake to 3 Quarts per day
c. Use an indwelling catheter to measure output accurately
d. Encourage the client to drink cranberry juice to acidify the urine – this acidify urine; alkaline urine
is one cause of UTI (pyelonephritis)
14. A client admitted with increased ascites associated with cirrhosis. Which nursing diagnosis should receive top
a. Fatigue - this may not be due to ascites
b. Excess fluid volume
c. Ineffective breathing pattern – the distended abdomen (ascites) pushes the diaphragm up causing
d. Imbalanced nutrition less than body requirements
15. Oral hypoglycemic agents may be used for patients with:
a. Ketosis – this is due to hyperglycemia
b. Obesity – not related
c. Type I DM – uses insulin
d. Some insulin production
Answer: D – oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type II DM.
16. A diabetic young diabetic came to the clinic for oral contraceptive. Which of the following responses made by
the PN is appropriate?
a. ―Let‘s discuss the various methods of contraceptive‖
b. ―Oral contraceptives are not appropriate for your medical condition‖ – oral contraceptives are
family of steroids and increases blood sugar
c. ―You can probably use condom‖
d. ―You need to consult the physician‖
17. Diana brought her mother to the long term facility. The PN wanted to interview the daughter but the patient
started crying. What should the PN do?
a. Leave them alone for sometime then come back when the patient is feeling better – the patient may not feel
better right away
b. Leave them alone for sometime and allow the patient to regain her self-esteem and come back later – this
may take sometime to happen
c. Leave them alone for sometime and let the patient compose herself and come back later to do the
interview - this is an appropriate – once composure is regain, the patient may be able to cooperate
with the interview
d. Explain to the daughter that the RN needs to do the interview right now
18. Marion is a 43-year-old female patient who was admitted with a diagnosis of depression. When working
with the patient who is depressed, the PN should initially:
a. Accept the patient for what she is. – unconditional acceptance of the patient is most important in
establishing the nurse-client relationship
b. Attempt to divert the patient‘s attention.
c. Admit the patient in a private room.
d. Encourage the patient to join other patients in the patients‘ lounge.
Answer: A – accepting the patient for she is an important element in building trusting relationship.
19. Edgar is a 24-year-old male patient with history of alcoholism. He is admitted in your unit for detoxification.
When the patient experiences hallucination, it would be most appropriate for the nurse to:
a. Move the patient into 4-bedded room near the PN‘s station.
b. Inform the patient that the nurse does not see the spiders.
c. Ask the patient to describe what he sees that seems to frighten him.
d. Keep dim-light room to decrease hallucination.
Answer: C- the nurse should give the patient opportunity to describe the experience without reinforcing it.
20. A client in the psychiatric unit grabs the PN‘s hand while holding a broken chair in one hand. To promote
safety, the PN will take one of the following actions:
a. Tell the client, ‗You look angry.‘
b. Step away from the client and tell him to stop.
c. Call 911.
d. Try to talk to the client in a calm manner.
Answer: B- the nurse‘s safety is important.
21. Which of the following activities should be considered for a depress client?
a. Jigsaw puzzle.
b. Play music in the client‘s room.
c. Allow client to socialize with other clients.
d. Put the client in a private room.
Answer: C – isolation must be avoided on a depressed patient.
22. A pregnant woman states she wants to leave her husband because he doesn‘t understand her moods.Which of
the following would be the best response by the PN?
a. ―Have you discussed this with him?‖
b. ―It seems like you‘re making this decision alone.‖
c. ―It sounds like you and your husband are having some difficulties understanding the problems
caused by pregnancy.‖
d. ―Do you really want to leave him?‖
Answer: C - reflection is therapeutic and gives the patient to ventilate her feelings.
23. The nurse on an inpatient unit is speaking with a patient with an anxiety disorder. Suddenly the patient
begins pacing and crying. Which of the following should the PN do?
a. Signal for several staff members to approach the area.
b. Provide the patient with time alone to regain his composure.
c. Walk alongside the patient to maintain eye contact.
d. Speak to the patient in short, simple sentences.
Answer: D – anxious patient only see fragmented details, thus, simple, short sentences eliminate the unnecessary information overload which could be overwhelming to the patient.
24. Mrs. Emery asks the nurse what causes SIDS. Which response is the best explanation the PN gives?
a. The infant‘s nervous system is not mature enough for raising its head. Thus, suffocation can occur when it
is placed on the stomach.
b. There is a theory that the infant‘s autoimmune system cannot withstand an unknown virus that attacks the
upper respiratory system.
c. Some babies have a congenital weakness of the diaphragm and intercostals muscles, which results in
problems with expiration.
d. The exact cause of the deaths is unknown, but we do know that they suffer from periods of apnea,
which means they stop breathing during this time.
Answer: D - there‘s no known cause for SIDS.
25. A patient with behavior problem is admitted in your unit. After the morning group activity today, the patient
became physically hostile and aggressive. He punched and made hole on the wall. He also threw a chair in the
air and barely missed one female patient. The PN who witnessed the patient‘s aggressive and uncontrolled
behavior will do which of the following?
a. Cautiously approach the patient and apply physical restraints.
b. Remove all women in the unit.
c. Try to calm him down; speak in a firm, calm voice.
d. Pick up the telephone and call for a code white.
Answer: D – calling for code white should be the nurse‘s immediate action. This affords protection not only for the patient but for everyone else in the patient‘s immediate surroundings.
26. Edward became agitated and became very verbally abusive. Other patients in the unit are now raising concern
about their safety. What nursing action initiated by the PN is most appropriate?
a. Set firm limit and inform the patient that his actions are not acceptable.
b. Allow the patient to continue to express his feelings and decrease his anxiety level.
c. The patient must chemically sedated.
d. The patient must be locked in his room.
Answer: A – setting firm limit is actually very therapeutic to patient who loses control of self. Unacceptable behaviors should not be allowed in order to protect the patient as well as the others.
27. Antonio, 56 years old with stage 2 Alzheimer‘s is admitted from the nursing home due to week-old productive
cough. The sputum culture results confirm bacterial pneumonia. The attending physician prescribes an antibiotic
taken po QID. When the nurse offers the morning dose of antibiotic, Antonio irritatingly screams and says,
―Leave me alone, I‘m not taking any pills today.‖ Which of the following actions taken by the nurse reflect
good understanding of the patient‘s medical condition?
a. Explains the importance of taking the drug on time.
b. Documents that the client refuses to take his medication.
c. Leaves the room and come back in few minutes to offer the medication again.
d. Informs the physician that the client refuses his medication.
Answer: C – the patient is displaying anxiety and the nurse understands that as anxiety abates, the patient will most likely take his medication.
28. A patient is admitted to a unit with a diagnosis of HIV?/AIDS. Several staff members complain and said that
resent working with the HIV? patient. You are the charge nurse of the unit and you decided to hold a staff
meeting to discuss this specific staff concern. Prior to the staff meeting, it would be best for you to do an
inventory of and
a. review the universal precautions and transmission of HIV? protocol in your unit.
b. explore your own feelings about providing care to patients with sexually transmitted
disease like HIV/AIDS.
c. poll the staff as to how they feel about homosexuality.
d. invite a doctor to discuss the latest research on HIV.
Answer: B – exploring own feelings about the care of HIV patients puts the charge PN in a guarded position against any negative feelings on the care of HIV? patients.
29. Nathalie is receiving chemotherapy for her ovarian cancer. Last year she underwent surgery for the third time,
but neither the surgery nor medication has slowed down her deteriorating health. The patient states to the nurse,
―I do everything I‘m told and I still don‘t seem to be getting better‖. The appropriate nursing diagnosis
developed for this patient was
a. ―Inability to cope effectively.‖
b. ―Altered thought process secondary to the pathophysiologic effect of cancer.‖
d. ―High risk of self injury secondary to depression.‖
Answer: C – the patient‘s statement validates her frustration with her deteriorating health condition which is beyond her control.
30. Laura, a 23-year old with type A personality was admitted in your unit. She has been treated for severe
depression for several weeks now. She has a history of several suicidal attempts but none around admission. She
has been showing progressive improvement and the health is pleased with her good response to her treatments
and medications. She was allowed to go on overnight passes and even attended job interviews. A discharge date
was plan for next week. The patient, upon learning about the discharge plan, became quiet and stopped
participating in the unit group activity. On assessment, the nurse identifies that Laura has lapsed into another
depression mode and has increased risk for a suicidal attempt when she states
a. ―I want to put my suicide attempts behind me.‖
b. ―I just to take one day at a time.‖
c. ―I wonder if you would like to have my favorite art book.‖
d. ―I don‘t have a plan to kill myself right now.‖
Answer: C – putting things in order (like giving away something that is valuable to the patient) is a warning sign of suicide to patient with clinical depression.
31. The relationship of nurses and doctors in a healthcare facility was strained due to some disagreement on certain
medical protocol. What best approach would be helpful in resolving the conflict?
a. Nurses and doctors should meet to discuss the issue.
b. The doctors should be reported to medical regulatory board.
c. Encourage patients to refuse signing the consent.
d. Discuss the nursing concern with the unit manager.
Answer: A – an open discussion among nurses and physician is the best way of resolving the issue.
32. Mr. Harris‘ father died suddenly. Shortly after the funeral, the PN visits Mr. Harris. He tells her that he doesn‘t
want to see anybody, feels no enjoyment in anything and feels hopeless and useless. Which of the following
questions asked by the PN is most relevant to the patient‘s condition?
a. ―Is it your father‘s death that is affecting you?‖
b. ―Do you feel alright in spite of your problems?‖
c. ―Have you thought of killing yourself?
d. ―May I know what‘s bothering you?‖
Answer: C – depressed patients have suicidal ideation.
33. A client is admitted with a diagnosis of terminal colon cancer. Which of the following statements by the client
would best indicate that the client has reached the acceptance stage of illness?
a. ―I have a blue dress that I want to wear for my burial.‖
b. ―I know everyone has to go at some point.‖
c. ―I sometimes wonder why this had to happen to me.‖
d. ―I hope my family will forgive me for having this illness.‖
Answer: A—dying is a reality. Stages of death and dying include denial, anger, bargaining, depression, and
34. When a patient openly masturbates, the PN should most appropriately:
a. Not react to the behavior.
b. Put the patient in seclusion.
c. Restrain the patient‘s hands.
d. State that such behavior is unacceptable.
Answer: D – the nurse sets limits on the behavior; accepts the patient but rejects the behavior.
35. An activity that would be most appropriate for a depressed patient during the early part of the hospitalization
a. Playing solitaire.
b. Watching TV with other patients at the patient‘s lounge.
c. Reading her favorite book.
d. Enjoy the privacy of her room.
Answer: B – increased socialization like watching TV with other patients will be helpful to the patient who is depressed.
36. A patient is placed on Antabuse [disulfiram] and has received instructions about taking this medication at home.
Which of these comments by her indicates that she has an accurate understanding of Antabuse?
a. ―I have to be careful of what cough medications I take.‖
b. ―Alcohol won‘t any effect on me now.‖
c. ―I never liked smoked salmon and chicken livers anyway.‖
d. ―Antabuse will take away my craving for alcohol‖
Answer: A – cough medications contain alcohol which can result to antabuse syndrome
37. Characteristics of chest pain in MI is described as:
a. Heaviness on the chest, radiating to the right hand, indigestion-like, excruciating. b. Oppressive, tightness, stabbing pain, radiating to the L hand.
c. Sharp pain that starts on the center of the chest, indigestion-like, radiating to the jaw and upper shoulders.
d. Not usually relived by NTG, radiating, sharp and stabbing pain.
A – These are the descriptions of chest pain in MI.
38. Signs and symptoms of R sided heart failure include:
a. Leg edema, abdominal distension, nocturnal dyspnea, moist rales.
b. Pitting edema, ascites, elevated CVP reading, jugular neck vein distension.
c. Pink, frothy sputum, anxiety, moist rales, neck vein distension.
d. Parosxysmal nocturnal dyspnea, leg edema, orthopnea, ascites.
B – These are signs of R sided heart failure.
39. Mr. Cruz, diagnosed with heart failure, was also placed on another medication, Metoprolol 25 mg tablet twice a
day. Which of the following is an expected effect of beta-blocker?
a. Reduces myocardial oxygen use.
b. Increase myocardial contractility.
c. Increase blood pressure.
d. Increase heart rate.
Answer: A – Metoprolol, a beta blocker, decreases the contractility of the heart muscles and decreases heart rate, thus, oxygen consumption is conserved.
40. Mr. Cruz, diagnosed with heart failure, asks the nurse about her beta-blockers medication effect to her angina.
What would be the PN‘s response?
a. Decrease cardiac output.
b. Increase cardiac output.
c. Decrease cardiac contractility.
d. Increase cardiac contractility.
Answer: C – beta blocker decreases contraction of the heart muscles.
41. Which of the following statements about pulse oxymetry is correct?
a. It measures peripheral venous oxygen saturation.
b. Low hemoglobin level affects accuracy.
c. Hypothermia and the presence of shock don‘t affect accuracy.
d. Pulse oxymetry eliminates the need of ABGs.
Answer: B – pulse oxymetry is a noninvasive way to indirectly gauge arterial hemoglobin oxygen saturation through a sensor placed on the patient‘s finger, toe, or earlobe. In someone with severe dyspnea, it doesn‘t eliminate
the need to obtain ABG to evaluate the pH, CO, HCO levels; Low hemoglobin level causes vasoconstriction 23
affects SaO reading. 2
42. A diagnosis of COPD was confirmed on Mr. Holmes. Why is careful monitoring of supplemental oxygen so
important in the patient with COPD?
a. Increasing the PaO beyond what‘s needed will lead to oxygen toxicity. 2
b. High oxygen levels will promote microbial growth in the patient‘s lungs.
c. Increased PaOlevels can depress the drive to breathe in patient with COPD. 2
d. High level of oxygen will result to acid-base imbalance.
Answer: C – increased PaO can depress the patient‘s drive to breathe, which is largely driven by hypoxemia. 2
43. The nurse is aware that when emphysema is present there is a decreased O supply because of: 2
a. pleural effusion
b. infectious obstructions
c. loss of aerating surface –some alveoli become overdistended in emphysema decreasing the space
available for gas exchange
d. respiratory muscle paralysis
44. A patient with cystic fibrosis has an order of aerosol treatment and chest physiotherapy. Appropriate
sequence when these orders are carried out would be:
a. Chest physiotherapy then aerosol.
b. Aerosol then physiotherapy.
c. Do it at the same time.
d. Do it according to nurse convenience.
Answer: B – it will be easy to drain secretions from dilated airways during chest physiotherapy.
45. The patient is receiving Lasix. The doctor made his round this morning and ordered ampicillin medication. The
patient is to receive 3 grams of ampicillin per day. The ampicillin is available in 500 mg/capsule. How many
capsules would you administer to the patient?
a. 500 mg- 6 capsules.
b. 250 mg – 6 capsules.
c. 250 mg – 4 capsules.
d. 500 mg – 4 capsules
Answer: A – 3000 mg/500 mg = 6 capsules
46. One of the patients in your unit asks what is chemotherapy for. The nurse would appropriately respond by
a. ―This is a treatment for infections and other diseases caused by chemical agents.‖
b. ―Chemical use to treat diseases.‖
c. ―Use of chemical which selectively destroy cancer cells.”
d. ―Medication used to treat cancer and alter the growth of cancer cells.‖
Answer: D – chemotherapy kills both good and bad cells.
47. A PN assigned to the Pediatric Unit is taking care of a co-worker‘s patients during lunch break. Upon the co-
workers late return to the unit, the PN‘s most appropriate comment would be:
a. ―I have noticed that you return late from lunch.‖—this is focused on the issue.
b. ―We all have a determined amount of time for lunch.‖
c. ―Let me remind you about hospital policies regarding lunch time.‖
d. ―I have the obligation to inform the supervisor of your lateness.‖
48. The PN is about to administer pre-op medication for a woman who is to undergo a radical mastectomy. The
client says, ―I‘ll be so glad when this is all over. I will get rid of all the cancer in my body and I will still have
my breasts.‖ Which of the following would be the best action for the PN to take?
a. Medicate the client and tell the physician.
b. Hold the pre-op medications and call the doctor—the patient does not have a clear understanding of
the surgical procedure and therefore requires further explanation.
c. Correct the client‘s misconceptions.
d. Medicate the client and document her comment in the chart.
49. You are being asked to endorse a product that guarantees weight loss without exercise, diet, or side effects.
Which of the following would be the best response to take?
a. Endorse the product since there are no side effects.
b. Ask for proof of all the claims before you endorse the product.
c. Accept the offer since it will pay you $10,000.00.
d. Decline the offer—endorsing a product is against professional ethic.
50. When teaching a group of new parents about nutrition, the nurse includes information on introducing solid
foods at about:
a. 2 to 4 months
b. 4 to 6 months—this is when teething start; begin with small amount of mashed vegetables.
c. 6 to7 months
d. 8 to 9 months
51. A patient arrives in the ER, staggering, verbally abusive and thrashing about, demanding pain medication. The
patient refuses to calm down so the nurse obtains leather restraints and threatens to put the patient in the
restraints unless he calms down. Which of the following could the nurse be charged with?
a. Battery—physical harm through wilful touching of a person or his/her clothing.
b. Assault--threat or use of force on another that reasonably makes that person fear bodily harm.
c. Invasion of privacy
d. Malpractice--fails to follow generally accepted professional standards. It is committed by a professional or
her/his subordinates on behalf of a client or patient that causes damages to the client or patient.
52. The mother of a 14 year old boy states that he is always eating although his weight is appropriate for his height.
The PN explains to the mother:
a. ―This is normal behavior because of an increase in body mass‖
b. ―This is the beginning signs of an eating disorder‖
c. ―This may be the early signs of a serious medical problem‖
d. ―This may be an indication of him substituting food for love‖
Answer: A – During the adolescent growth spurt the child‘s appetite will increase significantly.
53. A patient who continuously checks windows and doors throughout the night says to the nurse, ‗Do you think
I‘m foolish to check so much?‘ Before responding, the PN needs to understand that the patient is:
a. Expressing his concern about the compulsive checking. – the patient is aware of his compulsive
checking, however, unable to control it as is it a mechanism to decrease his anxiety
b. Purposely putting the nurse ‗on the spot‘.
c. Asking for help in stopping the ritualistic behavior.
d. Testing to see if the nurse thinks this repetitive behavior is rational.
54. An elderly patient is admitted to the surgical unit from a nursing home for treatment of a pressure ulcer. During
the initial physical assessment, the nurse notes that the patient is dehydrated and the skin is dry and scaly. The
nurse immediately applies emollient to the skin and changes the dressing on the pressure ulcer. Legally:
a. The nurse should have instituted a plan to increase activity.
b. The nurse provided supportive nursing care for the well-being of the patient. – when necessary and
using prudence, the PN, is allowed to intervene to promote the welfare of the patient
c. No treatment should have instituted for the patient until a physician ordered it.
d. Debridement of the pressure ulcer should have been done by the nurse before the dressing was applied.
55. Oral hypoglycemic agents may be used for patients with:
c. Type I DM
d. Some insulin production
Answer: D – oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type II DM. 56. The primary treatment of diabetic acidosis will include administration of:
a. IV fluids
c. NPH insulin
Answer: A – IV fluids are given to combat dehydration in acidosis and to keep an IV open for administration of medications. When the electrolyte levels have been evaluated, potassium may be added it needed. 57. A urine specimen for ketones should be removed from a patient‘s retention catheter by:
a. Disconnecting and draining it into a clean container.
b. Cleansing the drainage valve and removing it from the collection bag.
c. Wiping the catheter with alcohol and draining it into a sterile test tube.
d. Using a sterile syringe to remove it from a clamped, cleansed catheter.
Answer: D – the urinary catheter and drainage bag should always remain a closed sterile system; urine should be drawn only from the catheter, not the collection bag.
58. The best indication that a patient with diabetes mellitus is successfully managing the disease after discharge is a:
a. Reduction in excess body weight.
b. Stabilization of serum glucose.
c. Demonstrated knowledge of the diseases.
d. Statement by the patient that insulin orders are being followed.
Answer: B- a combination of diet, exercise, and medication is necessary to control the disease; the interaction of these therapies is reflected by the serum glucose.
59. The PN should assess the patient with psoriasis for:
a. Pruritic lesions
b. Multiple petechiae
c. Shiny, scaly lesions
d. Erythematous macules
Answer: C- psoriasis is characterized by dry, scaly lesions that occur most frequently on their elbows, knees, scalp, and torso
60. The physician performs a colostomy. During the early postoperative period nursing care should include: a. Withholding all fluids for 72 hours.
b. Limiting fluids for several days.
c. Having the patient change the dressing.