lOMoARcPSD 40206794 A B and D are incorrect 222 Answer A is correct Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders It is not unusual for the client to complain of muscles spasms with multiple fractures so answer B is incorrect Dizziness can be associated with blood loss and is nonspecific making answer C incorrect Nausea as stated in answer D is also common in the client with multiple traumas 223 Answer C is correct The client s statement They are trying to kill me indicates paranoid delusions There is no data to indicate that the client is hearing voices or is intoxicated so answers A and D are incorrect Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person making answer B incorrect 224 Answer B is correct Because the nurse is unaware of when the bottle was opened or whether the saline is sterile it is safest to obtain a new bottle Answers A C and D are not safe practices 225 Answer C is correct Infants with an Apgar of 9 at five minutes most likely have acryocyanosis a normal physiologic adaptation to birth It is not related to the infant being hypothermic experiencing bradycardia or being lethargic thus answers A B and D are incorrect 248 Chapter 3 226 Answer A is correct Rapid continuous rewarming of a frostbite primarily lessens cellular damage It does not prevent formation of blisters It does promote movement but this is not the primary reason for rapid rewarming It might increase pain for a short period of time as the feeling comes back into the extremity therefore answers B C and D are incorrect C are incorrect 227 Answer D is correct Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH so answers A B and 228 Answer B is correct The client who is immune suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation so answers A C and D are incorrect lOMoARcPSD 40206794 229 Answer D is correct The client with MRSA should be placed in isolation Gloves a gown and a mask should be used when caring for the client and hand washing is very important The door should remain closed but a negative pressure room is not necessary so answers A and B are incorrect MRSA is spread by contact with blood or body fluid or by touching the skin of the client It is cultured from the nasal passages of the client so the client should be instructed to cover his nose and mouth when he sneezes or coughs It is not necessary for the client to wear the mask at all times the nurse should wear the mask so answer C is incorrect 230 Answer B is correct Pain related to phantom limb syndrome is due to peripheral nervous system interruption Answer A is incorrect because phantom limb pain can last several months or indefinitely Answer C is incorrect because it is not psychological It is also not due to infections as stated in answer D 231 Answer A is correct During a Whipple procedure the head of the pancreas which is a part of the stomach the jejunum and a portion of the stomach are removed and reanastomosed Answer B is incorrect because the proximal third of the small intestine is not removed The entire stomach is not removed as in answer C and in answer D the esophagus is not removed 232 Answer C is correct Pepper is not processed and contains bacteria Answers A B and D are incorrect because fruits should be cooked or washed and peeled and salt and ketchup are allowed 233 Answer A is correct Coumadin is an anticoagulant One of the tests for bleeding time is a Protime This test should be done monthly Eating more fruits and vegetables is not necessary and dark green vegetables contain vitamin K which increases clotting so answer B is incorrect Drinking more liquids and avoiding crowds is not necessary so answers C and D are incorrect 234 Answer A is correct The client who is having a central venous catheter removed should be told to hold his breath and bear down This prevents air from entering the line Answers B C and D will not facilitate removal Practice Exam 3 and Rationales 249 235 Answer B is correct Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective There is no reason to assess the lOMoARcPSD 40206794 client for allergies to pineapples or bananas there is no correlation to the use of phenytoin and streptokinase and a history of alcohol abuse is also not a factor in the order for streptokinase therefore answers A C and D are incorrect 236 Answer B is correct The client who is immune suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased Using oils and cream based soaps is allowed as is eating salt and using an electric razor therefore answers A C and D are incorrect 237 Answer A is correct The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones B is incorrect because having a helper is good but the helper might not prevent the client from coughing out the tracheotomy Answer C is not the best way to prevent the client from coughing out the tracheotomy D is incorrect because asking the doctor to suture the tracheotomy in place is not appropriate 238 Answer D is correct The output of 300mL is indicative of hemorrhage and should be reported immediately Answer A does nothing to help the client Milking the tube is done only with an order and will not help in this situation and slowing the intravenous infusion is not correct thus answers B and C are incorrect 239 Answer A is correct The infant with tetralogy of Fallot has four heart defects He will be treated with digoxin to slow and strengthen the heart Epinephrine aminophyline and atropine will speed the heart rate and are not used in this client therefore answers B 240 The correct answer is marked by an X in the diagram The Tail of Spence is located in the C and D are incorrect upper outer quadrant of the breast x 241 Answer A is correct The toddler with a ventricular septal defect will tire easily He will not grow normally but will not need more calories He will be susceptible to bacterial infection but he will be no more susceptible to viral infections than other