1.

A client with a traumatic injury who is in the intensive care unit develops a tension
pneumothorax. The nurse knows to assess the client for which of the following signs and
symptoms of tension pneumothorax?

Select all that apply.

1. Decreased cardiac output

2. Flattened neck veins
3. Tracheal deviation to the affected side
4. Hypotension
5. Tracheal deviation to the opposite side
6. Bradypnea

Answer: 1, 4, 5 Rationale: Tension pneumothorax results when air in the pleural space is
under higher pressure than air in the adjacent lung. The site of the rupture of the pleural
space acts as a one-way valve, allowing the air to enter on inspiration but not to escape
on expiration. The air presses against the mediastinum, causing a tracheal shift to the
opposite side and decreased venous return (reflected by decreased cardiac output and
hypotension). Neck veins bulge with tension pneumothorax. This also leads to
compensatory tachycardia and tachypnea. (p 74)

2. A nurse is caring for a client with chronic renal failure. The laboratory results indicate
hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be
alert for which of the following?

Select all that apply.

1. Trousseau’s sign
2. Cardiac arrhythmias
3. Constipation
4. Decreased clotting time
5. Drowsiness and lethargy
6. Fractures

Answer: 1, 2, 6 Rationale: Hypocalcemia is a calcium deficit that causes nerve fiber

irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include
Trousseau’s sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and
irritability. The calcium-phosphorus imbalance leads to brittle bones and pathologic
fractures. Drowsiness and lethargy aren’t typically associated with hypercalcemia.
3. Sodium and water retention in a client with Cushing’s syndrome contribute to which
common disorder?

1. Hypoglycemia and dehydration

2. Hypotension and hyperglycemia
3. Pulmonary edema and dehydration
4. Hypertension and heart failure

Answer: 4 Rationale: In Cushing’s syndrome, increased mineralocorticoid activity results

in sodium and water retention, which commonly contributes to hypertension and heart
failure. Hypoglycemia and dehydration are uncommon in a client with Cushing’s
syndrome. Diabetes mellitus and hyperglycemia may develop, but hypotension isn’t part
of the disease process. Pulmonary edema and dehydration also aren’t complications of
Cushing’s syndrome

4. A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the
clamp is opened to allow the dialysate to drain. The nurse notes that drainage has
stopped and that only 500 ml has drained; the amount of dialysate instilled was 1,500
ml.

Which intervention should be done first?

1. Change the client’s position.

2. Call the physician.
3. Check the catheter for kinks or obstruction.
4. Clamp the catheter and instill more dialysate at the next exchange time.

Answer: 3 Rationale: The first intervention should be to check for kinks and obstructions
because that could be preventing drainage. After checking for kinks, have the client
change position to promote drainage. Don’t give the next scheduled exchange until the
dialysate is drained because abdominal distention will occur, unless the output is within
the parameters set by the physician. If unable to get more output despite checking for
kinks and changing the client’s position, the nurse should then call the physician to
determine the proper intervention.

5. A 23-year-old client develops cardiac tamponade when the car he was driving hits a
telephone pole; he wasn’t wearing a seatbelt. The nurse helps the physician perform
pericardiocentesis. Which outcome would indicate that pericardiocentesis has been
effective?

1. Neck vein distention 2. Pulsus paradoxus 3. Increased blood pressure 4. Muffled

heart sounds
 Answer: 3 Rationale: Cardiac tamponade is associated with decreased cardiac output,
which in turn reduces blood pressure. By removing a small amount of blood,
pericardiocentesis increases blood pressure. Neck vein distention, pulsus paradoxus,
and muffled heart sounds indicate persistent cardiac tamponade, meaning
pericardiocentesis hasn’t been effective.

6. Which sign or symptom of increased intracranial pressure (ICP) after head trauma would
the nurse expect to appear first?

1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure

Answer: 3 Rationale: The earliest symptom of increased ICP is a change in mental

status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may
void large amounts of very dilute urine if there’s damage to the posterior pituitary

7. A 46 y.o. Female client is admitted for ARF secondary to DM and HTN. Which test is the
best indicator of adequate glomerular filtration?

1.Serum Creatinine
2.Blood Urea Nitrogen (BUN)
3.Sedimentation Rate
4.Urine Specific gravity

Answer: A. Rationale ; Creatinine (A) is a product of muscle metabolism that is filtered by

the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An
elevated creatinine strongly indicates nephron loss, reducing filtration. (B) is also an indicator of
renal activity, but it can be affected by non-renal factors such as hypovolemia and increased
protein intake. (C) is a nonspecific test for acute or chronic inflammatory processes. (D) is useful
in assessing hydration status, but not as useful in assessing glomerular function

8. A client is placed on a respirator following a cerebral hemorrhage, and vecuronium

bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the
priority for this client?

A) Impaired communication related to paralysis of skeletal muscles.

B) High risk for infection related to increased intracranial pressure.
C) Potential for injury related to impaired lung expansion
D) Social isolation related to inability to communicate.

Answer: A) Impaired communication related to paralysis of skeletal muscles.

To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a
skeletal-muscle relaxant such as vecuronium is usually prescribed. Impaired communication (A)
is a serious outcome because the client cannot communicate his/her needs. Although this client
might also experience (D), it is not a priority when compared to (A). Infection is not related to
increased intracranial pressure (B). The respirator will ensure that the lungs are expanded (C).

9. The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1

tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion.
What intervention should the nurse implement?

A) Administer 30 minutes before eating.

B) Evaluate the effectiveness 1 hour after administration.
C) Instruct the client to swallow the tablet whole.
D) Question the healthcare provider's prescription.

Answer: D) Question the healthcare provider's prescription. Magnesium agents are not
usually used for clients with renal failure due to the risk of hypermagnesemia, so this
prescription should be questioned by the nurse (D). (A, B, and C) are not recommended
nursing actions for the administration of aluminum and magnesium hydroxide (Maalox)

10. The nurse is assessing a client with chronic renal failure (CRF). Which finding is most
important for the nurse to respond to first?

A) Potassium 6.0 mEq.

B) Daily urine output of 400 ml.
C) Peripheral neuropathy.
D) Uremic fetor.

Answer : A) Potassium 6.0 mEq. Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a
serious electrolyte disorder that can cause fatal arrhythmias, so (A) is the nursing
priority. (B) is an expected finding associated with renal tubular destruction. In CRF, an
increase in serum nitrogenous waste products, electrolyte imbalances, and
demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous
odor of the breath related to the accumulation of blood urea nitrogen and is a common
complication of CRF, but not as significant as hyperkalemia.

11. Physical examination of a comatose client reveals decorticate posturing. Which

statement is accurate regarding this client's status based upon this finding?

A) A cerebral infectious process is causing the posturing.

B) Severe dysfunction of the cerebral cortex has occurred.
C) There is a probable dysfunction of the midbrain.
D) The client is exhibiting signs of a brain tumor.
 Answer: B) Severe dysfunction of the cerebral cortex has occurred. Decorticate
posturing (adduction of arms at shoulders, flexion of arms on chest with wrists flexed and
hands fisted and extension and adduction of extremities) is seen with severe dysfunction
of the cerebral cortex (B). (A) is characteristic of meningitis. (C) is characterized by
decerebrate posturing (rigid extension and pronation of arms and legs). A client with (D)
may exhibit decorticate posturing, depending on the position of the tumor and the
condition of the client.

12. Physical examination of a comatose client reveals decorticate posturing. Which

statement is accurate regarding this client's status based upon this finding?

A) A cerebral infectious process is causing the posturing.

B) Severe dysfunction of the cerebral cortex has occurred.
C) There is a probable dysfunction of the midbrain.
D) The client is exhibiting signs of a brain tumor.

Answer: B) Severe dysfunction of the cerebral cortex has occurred. Decorticate

posturing (adduction of arms at shoulders, flexion of arms on chest with wrists flexed and hands
fisted and extension and adduction of extremities) is seen with severe dysfunction of the
cerebral cortex (B). (A) is characteristic of meningitis. (C) is characterized by decerebrate
posturing (rigid extension and pronation of arms and legs). A client with (D) may exhibit
decorticate posturing, depending on the position of the tumor and the condition of the client.

13. A patient sustained a leg injury from a blast. The nurse can palpate +2 dorsal pedis and
+1 posterior tibia pulses. The triage nurse would assign which color category?

A. Black
B. Green
C. Red
D. Yellow

Answer: D. Rationale: NATO secondary triage injury categories places the injuries into
certain categories based
on their severity. Red tagged patients are those with airway obstruction or shock, and
they require
immediate attention. Yellow tagged patients are those with an open fractures with a
distal pulse and
large wounds that need treatment within 30 minutes to 2 hours. Green tagged patients
are those
with a closed fractures, sprains, strains, abrasions, and contusions. Can be managed in
a delayed
fashion, generally more than 2 hours. Black tagged patients are those with massive
head trauma,
extensive full-thickness body burns, and high cervical spinal cord injury requiring
mechanical
ventilation. They are allowed to die or treated when others have already received care
 14. EMS brought a patient sustained multiple injuries after a fall from the subway track.
Trauma assessment follows the ABCDE method. Which action is completed by the
nurse when implementing the “E” element of the method?

a. Assess the patient’s Glascow Coma Scale

b. Insert foley catheter
c. Perform jaw-thrust maneuver
d. Remove all clothing to allow thorough assessment

Answer: E

15. The client has a newly placed L forearm internal arteriovenous (AV) fistula for hemodialysis.
Which intervention should the nurse plan to implement? Select all that apply.

a. Tell the nursing assistant to take the BP on the right arm

b. Palpate for a thrill over the left forearm fistula
c. Aspirate blood from the fistula for lab tests
d. Check the L radial pulse, finger movement and sensation
e. Instruct about the hand exercises that start in about a week

Answer: A,B,D,E

Rationale: A - It could damage the fistula,

B- an AV fistula is created by the anastomosies of an artery to a vein. A thrill is
the arterial blood rushing into the vein. Its presence indicates that the fistula is not
occluded.
C-Aspirating for blood can damage the fistula because it takes 4-6 weeks to
mature
D. CMS is important to assess because complications of the fistula creation
include impairment of circulation and nerve damage.
E - Hand exercises such as squeezing a rubber ball help the fistula to mature.
These are not started until the incision heals. The fistula is not used until it matures.

16. A nursing home resident returns to the facility after receiving a hemodialysis treatment.
Which symptom observed by the nurse suggests that the client may have developed
disequilibrium syndrome.

a. Shortness of breath with a nonproductive cough

b. Pitting edema in both of the hands and feet
c. Inability to palpate a thrill in the AV fistula
d. Headache with a decreased level of consciousness

Answer: D

Rationale: A- SOB is a symptom ssociated with fluid volume excess

B - Pitting edema is associated with fluid volume excess
C -Loss of palpable thrill is associated with a thrombosed AV fistula
D - Rapid changes in fluid volume and BUN levels during hemodialysis can result in
disequilibirum syndrome. Symptoms include HA and decreased level of consciousness from the
assoicated cereval edema and increased ICP
17. After determining that the client with CRF has no signs of infection, the nurse initiates the
first peritoneal dialysis treatment for the client. During the infusion of the dialysate, the client
reports abdominal pain, How should the nurse BEST respond to the situation?

a. Raise the bed to a high fowler’s position

b. Stop the infusion rate until the pain goes away
c. Ask when the client last had a bowel movement
d. Explain that the pain will subside after a few exchanges

Answer: D

Rationale:

a. Positioning the client supine in a low Fowler’s position reduces intra-abdominal pressure
b. The infusion should not be stopped or slowed; the pain due to initial peritoneal irritation,
will subside after a few exchanges
c. A full bowel may cause slowing during inflow of the dialysate solution, and the client may
feel pressure, but not pain. This is not the best response by the nurse
d. Peritoneal irritation, from the inflow of the dislysate, commonly causes pain during the
first few exchanges and usually subsidies with 1 to 2 weeks. THe nurse should monitor
for signs of peritonitis, such as cloudy effluent and abdominal pain.

18. The nurse is assessing the client receiving peritoneal dialysis. Which finding suggests that
the client may be developing peritonitis.

a. Abdominal numbness
b. Cloudy dialysis output
c. Radiating sternal pain
d. Decreased WBC count

Answer: B

Rationale:

a. The client would experience abdominal tenderness and pain with peritonitis, not
numbness
b. Cloudy dialysate output suggests peritonitis
c. Abdominal pain rather than sternal pain occurs with peritonitis
d. WBC would increase (NOT decrease) in the presence of an infection

19. The nurse in the ED documents that the newly admitted client who sustained a TBI is
“postictal upon transfer”. What did the nurse observe

a. Yellowing of the skin due to a liver condition

b. Drowsy or confused state following a seizure
c. Severe itching of the eyes from an allergic reaction
d. Abnormal sensations including tingling of the skin

Answer: B
Rationale:

a. Jaundice and icterus are terms for yellowing of the skin

b. The client had experienced a tonic-clonic seizure recently and is now in a state of deep
relaxation and is breathing quietly. During this period, the client may be unconscious or
awaken gradually but is often confused and disoriented. Often the client is amnesic
regarding the seizure.
c. Pruritus is a term for itching
d. Paresthesia is the term for abnormal sensation such as tingling and burning of the skin

20. The client undergoing testing for a possible brain tumor, asks the nurse about treatment
options. The nurse’s response should be based on knowing that treatment of a brain tumor
depnds on which factors? Select all that apply?

a. How rapidly the tumor is growing

b. Whether the tumor is malignant or benign
c. Cell type from which the tumor originates
d. Where the tumor is located within the brain
e. The client’s age and type of insurance

Answer: A,B,C,D

Rationale:

A-C - Surgery, radiation therapy, and/or chemotherapy may be used to treat or rapidly growing
tumor
D. - The tumor’s location in the brain may affect whether surgery is an option or whether the
surgical approach with radiation therapy and/or chemotherapy is used to treat the tumor
E. - Co morbid conditions, not age, may be determining factors in treatment options. The type of
insurance is irrelevant to treatment unless treatment is experimental.