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Practice
Questions
Information provided by Kaplan Test Prep
| Physiological
Integrity |
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4. |
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A
58-year old man, diagnosed with chronic lymphocytic
leukemia, is admitted to the hospital for treatment
of hemolytic anemia. Which of the following measures,
if incorporated into the nursing care plan, would
BEST address the patient’s needs? |
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A. |
Encourage
activities with other patients in the day room |
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B. |
Isolate
him from visitors and patients to avoid infection
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C. |
Provide
a diet high in vitamin C |
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D. |
Provide
a quiet environment to promote adequate rest |
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The
correct answer is D. |
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A. |
Encourage
activities with other patients in the day room –
does not meet need for rest
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B. |
Isolate
him from visitors and patients to avoid infection
– no info given about
WBC or reverse isolation; on reverse isolation if
neutrophil count is less than 500/mm3 |
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C. |
Provide
a diet high in vitamin C – needed
for wound healing and resistance to infection; not
best choice |
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D. |
Provide
a quiet environment to promote adequate rest –CORRECT:
primary problem activity intolerance due to fatigue. |
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5. |
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A
16-year-old is admitted with complaints of severe
pain in the lower right quadrant of the abdomen.
To assist with pain relief, the nurse should take
which of the following actions? |
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A. |
Encourage
the patient to change positions frequently in bed
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B. |
Administer
Demerol 50 mg IM q 4 hours and PRN |
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C. |
Apply warmth
to the abdomen with a heating pad |
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D. |
Use comfort
measures and pillows to position the patient |
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The
correct answer is D. |
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A. |
Encourage
the patient to change positions frequently in bed
– unnecessary movement
will increase pain, should be avoided
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B. |
Administer
Demerol 50 mg IM q 4 hours and PRN – pain
medications usually withheld until a definite diagnosis
is made, may be appendicitis
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C. |
Apply warmth
to the abdomen with a heating pad – if
pain is caused by appendicitis, increased circulation
from heat may cause appendix
to rupture
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D. |
Use comfort
measures and pillows to position the patient –
CORRECT: non-pharmacological
methods of pain relief |
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6. |
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The
nurse cares for a 45-year-old man admitted for a
possible herniated intervertebral disk. Ibuprofen
(Motrin), propoxyphene hydrochloride (Davon), and
cyclobenzaprine hydrochloride (Flexeril) are ordered
PRN. Several hours after admission, the patient
complains of pain. Which of the following should
the nurse do FIRST? |
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A. |
Administer
ibuprofen (Motrin) |
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B. |
Call the
physician to determine which medication should be
given
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C. |
Gather
more information from the patient about the complaint
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D. |
Allow the
patient some time to rest and see if the pain subsides |
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The
correct answer is C. |
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A. |
A. Administer
ibuprofen (Motrin) – implementation;
not first step |
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B. |
B. Call
the physician to determine which medication should
be given —assess before
implement
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C. |
C. Gather
more information from the patient about the complaint
– CORRECT: assess;
first step in nursing process
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D. |
D. Allow
the patient some time to rest and see if the pain
subsides – implementation;
not first step |
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