Exam (elaborations)
PTB 1-15 (1).
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Exam of 64 pages for the course unit 9 at unit 9 (PTB 1-15 (1).)
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PTB 1-15A client returns from the operating room after a right orchiectomy. Which of the outcomes below
would be the priority for the nurse postoperatively?
A. Ambulate the client within a few hours after surgery
B. Manage postoperative pain
C. Maintain fluid and electrolyte balance
D. Control bladder spasms - ANS-B. Manage postoperative pain
Orchiectomy is the removal of the testicles; the penis and the scrotum are left intact. It is usually
done to stop production of testosterone; this helps relieve symptoms, prevents complications
and prolongs survival for advanced prostate caner. Due to the location of the incision, pain
management is the priority. Bladder spasms are more related to prostate surgery. However, the
other options may be a later focus.
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most
stress at this age?
A. Separation anxiety
B. Loss of control
C. Bodily injury
D. Fear of pain - ANS-A. Separation anxiety
While a toddler will experience all of the stresses, separation from parents is the major stressor.
Separation anxiety peaks in the toddler years.
The nurse is reviewing the laboratory results for several clients. Which laboratory result
indicates that one of the clients is in metabolic acidosis?
A. Carbon dioxide 20 mEq/L
B. Chloride 100 mEq/L
,C. Hemoglobin 15 gm/dL
D. Sodium 130 mEq/L - ANS-A. Carbon dioxide 20 mEq/L
Serum carbon dioxide is an indicator of acid-base status. This finding would indicate metabolic
acidosis because the lungs compensate by blowing off CO2 so it will be low. Normal carbon
dioxide is 35 to 45 mEq/L.
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced
hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have
had the worst headache for the past two days. It pounds and by the middle of the afternoon
everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next?
A. Ask the client to stay on the line, get the address, and send an ambulance to the home
B. Advise the client that the swings in her hormones may be the problem; suggest that she call
her health care provider
C. Advise the client to have someone bring her to the emergency room as soon as possible
D. Ask the client to explain what she has taken and how often, and then evaluate other specific
complaints - ANS-A. Ask the client to stay on the line, get the address, and send an ambulance
to the home
The woman is at risk for seizure activity. The ambulance needs to bring the woman to the
hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and
eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery.
Which individual is at greatest risk for the development of hypertension?
A. 45 year-old African-American attorney
B. 40 year-old Caucasian nurse
C. 60 year-old Asian-American shop owner
D. 55 year-old Hispanic teacher - ANS-A. 45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the
United States. The incidence among the Hispanic population is rising.
,The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal
bypass graft procedure. Which of the following assessments requires immediate notification of
the health care provider?
A. Absent left pedal pulse using Doppler analysis
B. Acute pain in the left lower leg
C.Left foot is cool to the touch
D.Inability to palpate the left pedal pulse - ANS-A. Absent left pedal pulse using Doppler
analysiS
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the
left lower leg are important findings, they all require additional nursing assessment prior to
contacting the health care provider. In clients without palpable pedal pulses, the next step in the
assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using
the Doppler analysis requires immediately notifying the health care provider.
A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the
following should the nurse focus on first?
A. Weight reduction
B. Smoking cessation
C. Physical exercise
D. Stress management - ANS-B. Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result
in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors
should be addressed at some point in time.
The nurse working in the intensive care unit (ICU) is told that a client is being newly admitted
with a diagnosis of hyperglycemic hyperosmolar nonketotic state (HHNS). The nurse would
expect which of the following clinical findings in this client? (Select all that apply.)
A. Severe dehydration
B. Ketonuria
, C. Blood glucose level of at least 600 mg/dL
D. Metabolic acidosis
E. History of type 1 diabetes mellitus - ANS-A. Severe dehydration
C. Blood glucose level of at least 600 mg/dL
The typical client with HHNS will have a plasma glucose level of 600 mg/dL or greater, high
serum osmolality, profound dehydration, a serum pH greater than 7.3 and some alteration in
consciousness. Unlike diabetic ketoacidosis, however, there is little to no ketosis. HHNS usually
presents in older clients with type 2 diabetes mellitus who have some concomitant illness
(usually an infection) that leads to reduced fluid intake, or who do not adhere to their diabetic
medications and diet. All clients with HHNS require hospitalization and rapid treatment to correct
the profound hypovolemia and hyperglycemia characteristic of this condition.
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related
Group) manual for which purpose?
A. Determine reimbursement for a medical diagnosis
B. Implement nursing care based on case management protocol
C. Identify findings related to a medical diagnosis
D. Classify nursing diagnoses from the client's health history - ANS-A. Determine
reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other
insurance companies often use it as a standard for determining payment.
A client expresses anger when a call light is not answered within five minutes. The client
demanded a blanket. How should the nurse respond?
A. "I see this is frustrating for you. I have a few minutes so let's talk."
B. "I apologize for the delay. I was involved in an emergency."
C. "Let's talk. Why are you upset about this?"
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