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PTB 1-15/ Questions and 100% Verified Correct Answers Guaranteed A+, Complete Document for Exam
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PTB 1-15/ Questions and 100% Verified Correct Answers Guaranteed A+, Complete Document for Exam
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PTB 1-15A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client
is incorrect and indicates a need for additional teaching?
"I should inspect my skin under the brace every day"
"I will only have to wear this for six months."
"I can take it off when I shower or take a bath."
"The brace has to be worn all day and night." - ANS-"I will only have to wear this for six months."
The brace must be worn long-term, during periods of growth, usually for one to two years. It is
used to correct scoliosis, the lateral curvature of the spine.
A 25 year-old client, who is unresponsive after diagnosis of traumatic brain injury, is to be
transferred from the hospital to a long-term care facility (LTC) today. To which staff member
should the charge nurse assign this client?
Unlicensed assistive personnel (UAP)
Nursing student in final semester before graduation
Registered nurse (RN)
Licensed practical nurse (LPN) - ANS-Registered nurse (RN)
The RN is responsible for coordination of discharge to home or other agencies. The transfer to a
LTC facility often requires referrals.
A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing
action will be the priority?
Apply waterproof plastic tape to the cast around the genital area
Position the child flat in bed, repositioning from back to stomach every two to four hours
Drying the cast using a hair dryer set to "warm"
,Use the crossbar to help turn the child from side to side - ANS-Apply waterproof plastic tape to
the cast around the genital area
The most important aspects of caring for the cast is to keep it clean and dry. Shortly after
returning from surgery, waterproof plastic tape will be applied around the genital area to prevent
soiling. The child should be turned every two hours to help facilitate drying, from side to side
and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it
should not be used to turn the child (it may break off). After the cast has completely dried and it
becomes damp, it can be either exposed to air or a hair dryer (set to warm or cool) may be used
to help dry the cast.
A 35 year-old female client talks to the nurse in her health care provider's office about her new
diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more
teaching is needed?
"Even if the fibroids cause no problems, they will still need to be taken out."
"I sometimes experience pelvic pressure and pain, heavy menstrual bleeding, and I feel the
need to urinate more often."
"Fibroids occur more frequently in women my age but no one knows what causes them."
"Uterine fibroids are noncancerous tumors that grow slowly." - ANS-"Even if the fibroids cause
no problems, they will still need to be taken out."
Fibroids that cause no findings may require only "watchful waiting." The client may just need
pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth. Treatment for
the symptoms of fibroids (such as painful menses and heavy periods) may include oral
contraceptives, IUDs, iron supplements to prevent or treat anemia (due to heavy periods),
NSAIDs for cramps or pain or even short-term hormonal therapy to help shrink the fibroids.
Surgical removal using myomectomy or hysterectomy is usually reserved as a final alternative
after other treatment options have failed to provide adequate relief. In addition, concerns about
loss of fertility with this diagnosis and its treatment may be important to this client who is still in
her childbearing years.
A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The
admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing
diagnosis for this client during the first 24 hours?
A. Anxiety
,B. Altered tissue perfusion
C. Activity intolerance
D. Risk for fluid volume excess - ANS-B. Altered tissue perfusion
In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial
tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be
directed toward promoting tissue perfusion and oxygenation. The other problems are also
relevant, but tissue perfusion is the priority.
A child is treated with succimer (Chemet) for lead poisoning. Which of these assessments
should the nurse perform first?
A. Test deep tendon reflexes
B. Check complete blood count (CBC) with differential
C. Check serum potassium level
D. Check blood calcium level - ANS-B. Check complete blood count (CBC) with differential
Succimer (Chemet) is used in the management of lead or other heavy metal poisoning.
Although it has generally well tolerated and has a relatively low toxicity, it may cause
neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC)
is below 1200/µ.
A client asks the nurse to call the police and states: "I need to report that I am being abused by
a nurse." The nurse should take which action?
Obtain more details of the client's claim of abuse by a nurse
Assist with the report of the client's complaint to the police
Document the statement on the client's chart with a report to the manager
Focus on reality orientation to time, place and person - ANS-Obtain more details of the client's
claim of abuse by a nurse
The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent
nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally
accountable for actions delegated to others. The application of the nursing process requires that
, the nurse gather more information, assessment before interventions and before documenting or
reporting the complaint.
A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client
expresses fears about his prognosis prior to discharge. What information would the nurse want
to include when helping the client better understand this type of cancer?
This surgery causes impotence and infertility
With early intervention, the cure rate for teticular cancer is about 50%
Intensive chemotherapy is the treatment of choice following surgery
Testicular cancer has a five-year survival rate of 95% with early diagnosis and treatment -
ANS-Testicular cancer has a five-year survival rate of 95% with early diagnosis and treatment
With aggressive treatment and early detection/diagnosis the cure rate is 90%. The other options
are incorrect information. After unilateral orchiectomy, the remaining testicle can produce
adequate sperm for fertility and impotence is unlikely. In bilateral orchiectomy, fertility is lost, so
sperm banking prior to surgery is recommended. Dissection of lymph nodes for surgical cancer
treatment may cause nerve injury, which would increase the risk of impotence.
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?"
D. "I am surprised that you are upset. The request could have waited a few more minutes." -
ANS-A. "I see this is frustrating for you. I have a few minutes so let's talk."
This is the best response because it gives credence to the client's feelings and then concerns.
To say "let's talk" and ask a why question is not a therapeutic approach because it does not
acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is
inappropriate. To say it could have waited a few minutes is rude and non-accepting of the
client's verbalized needs
A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During
the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark,
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