Professional Documents
Culture Documents
pace. You can also copy this exam and make a print out.
1. The nurse is caring for an elderly woman who has had a fractured hip repaired. In
the first few days following the surgical repair, which of the following nursing
measures will best facilitate the resumption of activities for this client?
A. arranging for the wheelchair
B. asking her family to visit
C. assisting her to sit out of bed in a chair qid
D. encouraging the use of an overhead trapeze
2. What do you think is the most important nursing order in a client with major head
trauma who is about to receive bolus enteral feeding?
A. measure intake and output.
B. check albumin level.
C. monitor glucose levels.
D. increase enteral feeding.
3. The pathological process causing esophageal varices is:
A. ascites and edema.
B. systemic hypertension.
C. portal hypertension.
D. dilated veins and varicesitis.
4. Which of the following interventions will help lessen the effect of GERD (acid
reflux)?
A. Elevate the head of the bed on 4-6 inch blocks.
B. Lie down after eating.
C. Increase fluid intake just before bedtime.
D. Wear a girdle.
5. What is the main benefit of therapeutic massages is:
C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
15. A nurse is assessing several clients in a long term health care facility. Which
client is at highest risk for development of decubitus ulcers?
A. A 79 year-old malnourished client on bed rest
B. An obese client who uses a wheelchair
C. An incontinent client who has had 3 diarrhea stools
D. An 80 year-old ambulatory diabetic client
16. Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided
weakness. She has been taught to walk with a cane. The nurse is evaluating her use
of the cane prior to discharge. Which of the following reflects correct use of the
cane?
A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her
right leg, and finally her left leg
B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her
left leg, and finally her right leg
C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg
forward, then moves her left leg forward.
D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward,
then moves her right leg forward
17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the
following food choices, if selected by the client, indicate an understanding of a lowfat, high-fiber diet?
A. Tuna salad sandwich on whole wheat bread.
B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with
toasted oat bread
C. Chefs salad with hard boiled eggs and fat-free dressing
D. Broiled chicken stuffed with chopped apples and walnuts
18. An 85-year-old male patient has been bedridden for two weeks. Which of the
following complaints by the patient indicates to the nurse that he is developing a
complication of immobility?
A. Stiffness of the right ankle joint
B. Soreness of the gums
C. Short-term memory loss.
D. Decreased appetite.
19. An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects
that the child has iron deficiency anemia. Because iron deficiency anemia is
suspected, which of the following is the most important information to obtain from
the infants parents?
A. Normal dietary intake.
B. Relevant socio cultural, economic, and educational background of the family.
C. Any evidence of blood in the stools
D. A history of maternal anemia during pregnancy
20. A 46-year-old female with chronic constipation is assessed by the nurse for a
bowel training regimen. Which factor indicates further information is needed by the
nurse?
A. The clients dietary habits include foods high in bulk.
B. The clients fluid intake is between 2500-3000 ml per day
C. The client engages in moderate exercise each day
D. The clients bowel habits were not discussed.
Sitting in a wheelchair would require too great hip flexion initially. Asking her family to visit
would not facilitate the resumption of activities. Sitting in a chair would cause too much hip
flexion. The client initially needs to be in a low Fowlers position or taking a few steps (as
ordered) with the aid of a walker.
2. Answer: A. measure intake and output
It is important to measure intake and output, which should equal. Enteral feeding are
hyperosmotic agents pulling fluid from cells into vascular bed. Water given before feeding
will present a hyperosmotic diuresis. I and O measures assess fluid balance.
3. Answer: C. portal hypertension
Esophageal varices results from increased portal hypertension. In portal hypertension, the
liver cannot accept all of the fluid from the portal vein. The excess fluid will back flow to the
vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal
varices or hemorrhoids.
4. Answer: A. Elevate the head of the bed on 4-6 inch blocks
Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid
into the esophagus. Fluid does not flow uphill. The other three options all increase fluid
backflow into the esophagus through position or increasing abdominal pressure.
5. Answer: D. to improve circulation and muscles tone
Particularly in the elderly adults, therapeutic massage will help improve circulation and
muscle tone as well as the personal attention and social interaction that a good massage
provides. A massage is contraindicated in any condition where massage to damaged tissue
can dislodge a blood clot.
6. Answer: C. Chocolate
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to
reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.
Mrs. Kennedy. moved the cane and her strong foot at the same time, she would be left
standing on her weak leg at one point. This would be unstable at best; at worst, impossible
17. Answer: B. Vegetable soup made with vegetable stock, carrots, celery, and
legumes served with toasted oat bread
Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. This choice
shows a low-fat soup (which would have been higher in fat if made with chicken or beef
stock) and high-fiber bread and soup contents (both the vegetables and the legumes).
Salad is high in fiber, but hard boiled eggs are high in fat. There is some fiber in the apples
and walnuts. The walnuts are high in fat, as is the chicken.
18. Answer: A. Stiffness of the right ankle joint
Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy.
Soreness of the gums is not related to immobility. Short-term memory loss is not related to
immobility. Decreased appetite is unlikely to be related to immobility.
19. Answer: A. Normal dietary intake.
Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to
5 months of infancy iron stores laid down for the baby during pregnancy are adequate.
When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet
the infants rapid growth needs. Iron deficiency may occur in the infant who drinks mostly
milk, which contains no iron, and does not receive adequate dietary iron or supplemental
iron. Daily dietary intake is much more related to the diagnosis of iron deficiency anemia
than is sociocultural, economic, and educational background of the family. Iron deficiency
anemia in an infant is very unlikely to be related to gastrointestinal bleeding. Anemia during
pregnancy is unlikely to be the cause of the infants iron deficiency anemia. Fetal iron stores
are drawn from the mother even if she is anemic.
20. Answer: D. The clients bowel habits were not discussed.
Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen.
To assess the client for a bowel training program the factors causing the bowel alteration
should be assessed. A routine for bowel elimination should be based on the clients
previous bowel habits and alterations in bowel habits that have occurred because of illness
or trauma. The client and the family should assist in the planning of the program which
should include foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml.