1. ANSWER C. Before development and implementation of the teaching plan, it is vital to determine what the client currently knows regarding diabetes and what the client needs to know.
2. ANSWER A. The goal of the education program is to instruct the client to take his or her pulse; therefore, the expected outcome would be the ability to give a return demonstration of palpation of the heart rate.
3. ANSWER C. PUBS is a useful procedure for diagnosing Rh disease, obtaining fetal complete blood count, and karyotyping chromosomes to evaluate for genetic disorders. Ultrasound commonly is used to detect twins. A lecithin–sphingomyelin ratio is the procedure of choice to diagnose fetal lung maturation. A maternal blood test is used to determine -fetoprotein level.
4. ANSWER B. The client should report tinnitus, because vancomycin (Vancocin) can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.
5. ABSWER D. Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acid.
6. ANSWER C. When a client with a nasogastric tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the physician should be called.
7. ANSWER D. Increased, not decreased, body temperature resulting from occupations or infections can contribute to low sperm counts caused by decreased sperm production. Heat can destroy sperm. Varicocele, an abnormal dilation of the veins in the spermatic cord, is an associated cause of a low sperm count. The varicosity increases the temperature within the testes, inhibiting sperm production. Frequent use of saunas or hot tubs may lead to a low sperm count. The temperature of the scrotum becomes elevated, possibly inhibiting sperm production. Endocrine imbalances (eg, thyroid problems) are associated with low sperm counts in men because of possible interference with spermatogenesis.
8. ANSWER A. The clinical findings of edema are consistent with fluid excess in the interstitial compartment. The extracellular compartment consists of fluid in two locations, the interstitial (tissue) spaces and plasma (intravascular) spaces. Fluid shifts within the extracellular compartment can occur either from the plasma space to the interstitial space, or from the interstitial space to the plasma space. When fluid shifts from the plasma space into the interstitial space, frequently as a result of abnormal retention of fluids in conditions such as heart failure or renal failure, edema results. The intracellular compartment consists of fluid within the cells.
9. ANSWER A. Low potassium can cause imbalance at the cellular level that leads to dysrhythmias and cardiac arrest. Hyperglycemia is caused by elevated blood sugar. Hypertension is unrelated to potassium levels. Increased energy is unrelated to potassium levels.
10. ANSWER B. Handwashing with the correct technique is the best method for preventing cross-contamination. The hands do serve as a source of infection. Waterless commercial products containing at least 60% alcohol are as effective for killing organisms as handwashing.
11. ANSWER C. The third maneuver is used to identify the presenting part. While facing the client, the nurse places the tips of the first three fingers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fingers of both hands to palpate the uterine fundus. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. The second maneuver identifies the back of the fetus, and the fourth maneuver identifies the cephalic prominence
12. ANSWER B. The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body’s preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.
13. ANSWER C. Fluctuation of fluid with respirations in the water-seal column indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client’s skin around the chest tube insertion site. A leak in the system is indicated when bubbling occurs in the water-seal column.
14. ANSWER D. It is important to dry the feet carefully after a bath to prevent a fungal infection. Diabetic clients should seek medical attention when they injure their toes or feet to prevent complications. Iodine is highly toxic to the tissues. Diabetic clients should inspect their feet on a daily basis and should wear shoes that support their feet while in the house.
15. ANSWER B. Diverticular rupture causes peritonitis from the release of intestinal contents (chemicals and bacteria) into the peritoneal cavity. A rigid abdominal wall results from a diverticular cavity. The inflammatory response of the peritoneal tissue produces severe abdominal rigidity and pain, diminished intestinal motility, and retention of intestinal contents (air, fluid, and stool). Hyperactive bowel sounds, explosive diarrhea, and excessive flatulence do not indicate peritonitis.
16. ANSWER A, B, C and D. Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.
17. ANSWER A. The nurse should firmly yet gently strike the chest wall with the hand cupped to make a hollow popping sound. A slapping sound indicates that an incorrect technique is being used. The area over the rib cage is percussed to loosen mucus from the underlying lung passages. The child should wear a thin piece of clothing (eg, T-shirt) over the chest area to protect the skin without diminishing the effect of the percussion.
18. ANSWER A. The nurse should call to the desk to ask for assistance. The nurse needs to notify the doctor of the client’s death and the family must then be notified. A code should not be called. Nursing personnel should begin postmortem care so that the family does not walk in unannounced to find their loved one deceased and looking disarrayed.
19. ANSWER B. One pound of weight is approximately equivalent to 3,500 calories. Removing 1,000 calories per day results in a 2-pound weight loss per week (7,000 calories divided by 7 days). If a client wanted to lose 1 pound in a 7-day period, he would need to cut out 500 calories per day (3,500 calories divided by 7 days). It is unsafe to try to lose more than 2 pounds per week.
20. ANSWER A. The nurse should instruct the client to take the medication immediately or as soon as she remembers that she missed the medication. There is only a slight risk that the client will become pregnant when only one pill has been missed, so there is no need to use another form of contraception. However, if the client wishes to increase the chances of not getting pregnant, a condom can be used by the male partner. The client should not omit the missed pill and then restart the medication in the morning because there is a possibility that ovulation can occur, after which intercourse could result in pregnancy. Taking two pills is not necessary and also will result in putting the client off her schedule.