GCC 101 - 125

A client is diagnosed with second-degree burns. The nurse expects the physician to order:

• Application of cool water or saline-soaked gauze to the burn.
• Application of ice to the burn.
• Cleansing with betadine.
• Cleansing with hydrogen peroxide.
• -

Answer explanation

Option 1: Application of cool water or saline-soaked gauze to the burn.

Option 2: Application of ice to the burn.

Option 3: Cleansing with betadine.

Option 4: Cleansing with hydrogen peroxide.

Option 5: -

Correct Option: Option 1 – Application of cool water or saline-soaked gauze to the burn.

Explanation: Cool water or saline-soaked gauze is preferred. Ice or agents like peroxide and betadine can delay healing.

The nurse is providing dietary teaching for a client with Meniere's disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?

• I can expect to see more problems with tinnitus if I eat a lot of dairy products.
• I need to limit foods that taste salty or that contain a lot of sodium.
• I can help control problems with vertigo if I avoid breads and cereals.
• I need to eat fewer foods that are high in potassium, such as raisins and bananas.
• -

Answer explanation

Option 1: I can expect to see more problems with tinnitus if I eat a lot of dairy products.

Option 2: I need to limit foods that taste salty or that contain a lot of sodium.

Option 3: I can help control problems with vertigo if I avoid breads and cereals.

Option 4: I need to eat fewer foods that are high in potassium, such as raisins and bananas.

Option 5: -

Correct Option: Option 2 – I need to limit foods that taste salty or that contain a lot of sodium.

Explanation: Sodium restriction helps manage Meniere’s symptoms like vertigo. Other foods listed don’t directly influence symptoms.

A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which of the following instructions would be helpful?

• Perform slow contraction and relaxation of the feet and ankles twice daily.
• Take frequent rest periods with the legs elevated above the hips.
• Avoid support hose that reach above the leg varicosities.
• Take a leave of absence from your job to avoid prolonged standing.
• -

Answer explanation

Option 1: Perform slow contraction and relaxation of the feet and ankles twice daily.

Option 2: Take frequent rest periods with the legs elevated above the hips.

Option 3: Avoid support hose that reach above the leg varicosities.

Option 4: Take a leave of absence from your job to avoid prolonged standing.

Option 5: -

Correct Option: Option 2 – Take frequent rest periods with the legs elevated above the hips.

Explanation: Leg elevation promotes venous return. Support hose may help; leaving work isn’t always feasible.

A client taking Laniazid (isoniazid) asks the nurse how long she must take the medication before her sputum cultures will return to normal. The nurse recognizes that the client should have a negative sputum culture within:

• 2 weeks
• 6 weeks
• 2 months
• 3 months
• -

Answer explanation

Option 1: 2 weeks

Option 2: 6 weeks

Option 3: 2 months

Option 4: 3 months

Option 5: -

Correct Option: Option 4 – 3 months

Explanation: Negative cultures are expected after about 3 months on isoniazid therapy for tuberculosis.

The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor?

• Bowel sounds of 5-20 seconds
• Intermittent left lower-quadrant pain
• Constipation alternating with diarrhea
• Hemoglobin 26% and hematocrit 32
• -

Answer explanation

Option 1: Bowel sounds of 5-20 seconds

Option 2: Intermittent left lower-quadrant pain

Option 3: Constipation alternating with diarrhea

Option 4: Hemoglobin 26% and hematocrit 32

Option 5: -

Correct Option: Option 4 – Hemoglobin 26% and hematocrit 32

Explanation: Low hemoglobin and hematocrit may suggest bleeding, which requires reporting. The others are typical symptoms.

Which medication provides artificially acquired passive immunity?

• Diptheria and tetanus toxoid.
• Snakebite antivenin.
• Haemophilus influenzae type B conjugate vaccine.
• Influenza virus vaccine.
• -

Answer explanation

Option 1: Diptheria and tetanus toxoid.

Option 2: Snakebite antivenin.

Option 3: Haemophilus influenzae type B conjugate vaccine.

Option 4: Influenza virus vaccine.

Option 5: -

Correct Option: Option 2 – Snakebite antivenin.

Explanation: Antivenin is passive immunity. Vaccines stimulate active immune responses.

A patient is injected with a radiographic contrast medium and immediately shows signs of dyspnea, flushing, and pruritus. Which intervention should take priority?

• Checking his vital signs
• Making sure his airway is patent
• Applying a cold pack to the I.V. site
• Calling the physician
• -

Answer explanation

Option 1: Checking his vital signs

Option 2: Making sure his airway is patent

Option 3: Applying a cold pack to the I.V. site

Option 4: Calling the physician

Option 5: -

Correct Option: Option 2 – Making sure his airway is patent

Explanation: Ensuring airway patency is the first priority in allergic reactions to contrast. Other actions come afterward.

A patient, age 32, is admitted with a diagnosis of endometriosis. Which of the following is the nurse most likely to find during an assessment of a patient with endometriosis?

• Chronic, severe pain related to menstruation
• Loss and grieving associated with infertility problems
• Changes in body image, self-concept, and sexuality
• High anxiety with a need for perfection and control
• -

Answer explanation

Option 1: Chronic, severe pain related to menstruation

Option 2: Loss and grieving associated with infertility problems

Option 3: Changes in body image, self-concept, and sexuality

Option 4: High anxiety with a need for perfection and control

Option 5: -

Correct Option: Option 1 – Chronic, severe pain related to menstruation

Explanation: Menstrual-related pain is the most prominent symptom. Infertility and psychological effects may follow.

An elderly client is admitted with dehydration and has a pitcher of water at the bedside. The nurse assesses the client's thirst with every visit to the room and the client denies thirst each time. While calculating the end-of-shift intake and output, the nurse notes the client has had very little to drink. What is the best explanation for this finding?

• The client has had enough to drink.
• The thirst mechanisms of elderly clients are depressed.
• The client does not like the choices of fluids offered.
• The client's family is bringing in fluids for the client to drink that are not included in the intake and output totals.
• -

Answer explanation

Option 1: The client has had enough to drink.

Option 2: The thirst mechanisms of elderly clients are depressed.

Option 3: The client does not like the choices of fluids offered.

Option 4: The client's family is bringing in fluids for the client to drink that are not included in the intake and output totals.

Option 5: -

Correct Option: Option 2 – The thirst mechanisms of elderly clients are depressed.

Explanation: Older adults often have impaired thirst perception, leading to reduced intake despite dehydration.

A client receives an implanted port. After insertion, an x-ray is performed to determine proper positioning. The tip of the catheter should be located in which vascular structure?

• Inferior vena cava.
• Superior vena cava.
• Left atrium.
• Aortic arch.
• -

Answer explanation

Option 1: Inferior vena cava.

Option 2: Superior vena cava.

Option 3: Left atrium.

Option 4: Aortic arch.

Option 5: -

Correct Option: Option 2 – Superior vena cava.

Explanation: Proper placement for central access devices like ports is the superior vena cava near the right atrium.