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Introductory Medical Surgical Nursing 10 Timby and Smith
Introductory Medical Surgical Nursing 10 Timby and Smith
MULTIPLE CHOICE. Choose the one alternative that best completes the statement
or answers the question.
1)The nurse is assisting a postoperative client in using an incentive spirometer. Which
of the following postoperative complications is this nurse attempting to avoid with
this client? 1) _______
A)Hemorrhage B) Pulmonary embolism
C)Deep vein thrombosis D) Atelectasis
2)A client who is recovering from abdominal surgery has a penrose drain. Which of
the following should the nurse include in the care of this client? 2) _______
A)Make sure there is a safety pin on the end of the drain.
B)Clean the wound with normal saline every two hours.
C)Empty the drain every 30 minutes.
14)A client has just arrived in the recovery room. How often should the nurse assess
the client? 14) ______
A)Every 15 minutes for 30 minutes and then every one hour afterwards.
B)Every 15 minutes for the first hour.
C)Every hour.
D)Every two hours.
15)A client who is being admitted for surgery asks the nurse why information is being
collected about the client's use of herbal and natural supplements. Which of the
following statements is an appropriate nursing response? 15) ______
A)"The physician is in charge of medications."
B)"Herbal supplements may interact with anesthesia agents."
C)"Herbal remedies may cause pain relievers to be ineffective."
D)"There is no need to take these preparations."
16)An elderly client is completing preoperative diagnostic testing. The nurse notes
that the client's carbon dioxide level is elevated. Which of the following nursing
interventions would be indicated for this client? 16) ______
A)Monitor serum sodium level.
B)Monitor serum potassium level.
C)Monitor respiratory status and arterial blood gases.
D)Monitor intake and output.
17)A client is prescribed patient-controlled analgesia for postoperative pain. Which of
the following should the nurse instruct the client about this analgesia? 17) ______
A)"Use this analgesia every hour on the hour."
B)"Use this analgesia only when the pain is extremely severe."
C)"Avoid the use of this because of the risk of addiction."
D)"Use this analgesia regularly."
18)A client has received conscious sedation for a surgical procedure. The nurse
realizes this client will most likely: 18) ______
A)Respond to physical and verbal stimuli.
B)Not respond to any stimuli.
C)Need an endotracheal tube inserted.
D)Need blood product replacements.
19)A client is in his fifth postoperative day and has sanguineous drainage with a thick,
reddish appearance. The nurse realizes this client's wound is in which stage of healing?
19) ______
A)Stage III B) Stage IV C) Stage I D) Stage II
20)A recovery room nurse is consulting with a circulating nurse about a client who is
having a surgical procedure. These nurses are most likely in which zone of the
surgical department? 20) ______
A)Banned B) Semi-restricted
C)Restricted D) Unrestricted
21)A nurse has delegated the collection of vital signs, including blood pressure
readings, to two unlicensed assistive personnel. The of this work means the nurse is:
21) ______
A)Not accountable for these vital signs.
B)Responsible to re-measure all of the vital signs.
C)Not responsible for these vital signs.
D)Accountable for the care that was delegated.
22)The nurse working on a quality improvement study wants to evaluate a client care
process. Which of the following can the nurse use to evaluate this process? 22)
______
A)Variance analysis B) Critical pathway
C)Evidence-based practice D) Nursing process
23)The new nurse is studying the five core competencies for healthcare providers.
Which of the following are a part of these core competencies? (Select all that apply.)
23) ______
A)Work in interdisciplinary teams.
B)Use informatics to deliver care.
C)Use evidence-based practice.
D)Replace quality improvement initiatives with work redesign methods.
E)Use primary nursing to deliver care.
24)A client tells the nurse, "I have an advance directive that I want you to follow."
Which of the following will this document provide for the nurse? 24) ______
A)A complete plan of care for the client
B)The answers to any care dilemmas for the client
C)The client's preferences for healthcare should the client become mentally
incapacitated
D)Directions regarding when to use universal precautions for the client
25)Client chart audits provide the nurses with information that impacts the future
outcomes of client care. What should the nurses do with this information? 25) ______
A)Use the information to create an action plan to address any negative findings.
B)Nothing
C)Submit it to the agency's accrediting body.
D)Place it in a file to compare with the next set of audits.
26)The nurse is preparing a client to go home. Which of the following skills are the
most important for the nurse to adequately prepare this client? 26) ______
A)Familiarity with adult learning principles
B)The ability to support client decision making
C)The ability to use critical thinking
D)The ability to follow written orders
27)The nurse is implementing a plan of care for a client. After providing care, what
should the nurse do as the final step in the process? 27) ______
A)Reassess the client.
B)Give the charge nurse a report.
C)Document
D)Nothing
28)At the completion of an assessment, the nurse chooses a nursing diagnosis that
best defines the client's health problems. Which type of clinical judgment will this
nurse use? 28) ______
A)Diagnostic reasoning B) Evidence-based practice
C)Nursing process D) Critical pathway
29)A client tells the nurse, "I have pain in my leg when I stand too long." This
information would be considered: 29) ______
A)Subjective data B) Objective data
C)Evaluative data D) Qualitative data
30)The nurse is consulting a critical pathway to help make client care decisions.
Which type of care delivery model is this nurse most likely using to provide client
36)A client care issue has been raised about the actions taken by a nurse who was
asked to provide care to a client whose healthcare decisions were considered
controversial. The unit's nurse manager is concerned that care was not appropriately
provided. Which of the following should be consulted to protect the client and to
evaluate the care in question? 36) ______
A)Nursing code of ethics
B)Hospital quality improvement guidelines
C)Critical pathway
D)Nurse practice act
37)The nurse is reviewing the outcome of client care that was provided. Which of the
following nursing process steps should the nurse use next? 37) ______
A)Implementation B) Planning
C)Assessment D) Evaluation
38)The nurse is preparing to provide client care information to a group of unlicensed
assistive personnel. Which type of care delivery system is this nurse most likely using
to provide client care? 38) ______
A)Primary nursing B) Team nursing
C)Functional nursing D) Case management
39)A new nurse tells her mentor "you always seem so poised when you interact with
the client. It is as if you always know what to do. Can you teach me how to do that?"
What characteristic does this mentor possess in relation to critical thinking? 39)
______
A)Independent thinking B) Discipline
C)Empathy D) Self-confidence
40)Which of the following best demonstrates a nurse using critical thinking when
providing client care? 40) ______
A)A nurse checks a laboratory manual before providing care.
B)A nurse lists alternative interventions available to provide client care.
C)A nurse checks every intervention with the charge nurse before providing care.
D)A nurse is confused when the only planned intervention fails to help a client.
SHORT ANSWER. Write the word or phrase that best completes each statement or
answers the question.
41)The nurse assesses a client's weight loss as being 22 lbs. How many liters of fluid
did this client lose? 41) _____________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement
or answers the question.
42)A client is admitted with hypernatremia caused by being stranded on a boat in the
Atlantic Ocean for five days without a fresh water source. Which of the following is
this client at risk for developing? 42) ______
A)Pulmonary edema B) Stress fractures
C)Atrial dysrhythmias D) Cerebral bleeding
43)The blood gases of a client with an acid-base disorder show a blood pH outside of
normal limits. The nurse realizes that this client is: 43) ______
A)Fully compensated.
B)In need of intravenous fluids.
C)Demonstrating anaerobic metabolism.
D)Partially compensated.
44)A client with fluid retention related to renal problems is admitted to the hospital.
The nurse realizes that this client could possibly have which of the following
electrolyte imbalances? 44) ______
A)Hypokalemia B) Magnesium
C)Carbon dioxide D) Hypernatremia
45)An elderly client who is being medicated for pain had an episode of incontinence.
The nurse realizes that this client is at risk for developing: 45) ______
A)Fecal incontinence. B) Dehydration.
C)Over-hydration. D) A stroke.
46)The nurse is reviewing a client's blood pH level. Which of the systems in the body
regulate blood pH? (Select all that apply.) 46) ______
A)Buffers B) Respiratory
C)Renal D) Cardiac
47)A client is prescribed 20 mEq of potassium chloride. The nurse realizes that the
client is receiving this replacement: 47) ______
A)To help regulate acid-base balance.
B)To keep a vein open.
and the respirations are very deep. The metabolic disorder this client might be
demonstrating is: 53) ______
A)Hypertension.
B)Pain.
C)Increasing carbon dioxide in the blood.
D)Hypernatremia.
54)A client is admitted for treatment of hypercalcemia. The nurse realizes that this
client's intravenous fluids will most likely be: 54) ______
A)Dextrose 5% and normal saline.
B)Normal saline.
C)Dextrose 5% and water.
D)Dextrose 5% and normal saline.
55)An elderly postoperative client is demonstrating lethargy, confusion, and a
respiratory rate of 8 per minute. The nurse sees that the last dose of pain medication
administered via a patient controlled anesthesia (PCA) pump was within 30 minutes.
Which of the following acid-base disorders might this client be experiencing? 55)
______
A)Metabolic acidosis B) Respiratory alkalosis
C)Metabolic alkalosis D) Respiratory acidosis
56)A 28-year-old male client is admitted with diabetic ketoacidosis. The nurse
realizes that this client will have a need for which of the following electrolytes? 56)
______
A)Sodium B) Magnesium
C)Calcium D) Potassium
57)An elderly client does not complain of thirst. What should the nurse do to assess
that this client is not dehydrated? 57) ______
A)Ask the physician to order a chest x-ray.
B)Assess the urine for osmolality.
C)Ask the physician for an order to begin intravenous fluid replacement.
D)Ask the physician for an order for a brain scan.
58)An elderly client is at home after being diagnosed with fluid volume overload.
Which of the following should the home care nurse instruct this client to do? 58)
______
D) abdominal cramping.
63)A nurse is preparing to discharge a client who has had outpatient surgery. It is
important for the nurse to assess the client's: 63) ______
A)family support at home.
B)food preferences.
C)knowledge of sterile technique.
D)understanding of the surgical procedure.
64)When changing the client's sterile dressings on the second postoperative day, the
nurse notes that the suture line is red and slightly inflamed. The nurse recognizes
these findings are: 64) ______
A)abnormal and need to be documented.
B)normal signs of the inflammatory response.
C)abnormal and need to be reported to the charge nurse.
D)signs of infection and need to be reported to the physician.
65)During the preoperative assessment, the nurse learns that the client had gestational
diabetes with her three pregnancies. The nurse will obtain an order for the following
test: 65) ______
A)electrolytes.
B)urinalysis.
C)partial thromboplastin time (PTT).
D)blood sugar.
66)After abdominal surgery, a client feels bloated and is unable to pass gas.
Appropriate nursing interventions include: 66) ______
A)encourage fluid intake of 3000 mL/day.
B)assist with ambulation.
C)restrict foods to reduce gas production.
D)press gently on the abdomen to promote expulsion of gas.
67)A postoperative client complains of dizziness when getting out of bed to ambulate.
The nurse should: 67) ______
A)have the client use a walker.
B)administer medication for dizziness.
C)return the client to bed.
D)walk alongside the client.
68)The nurse is preparing to obtain a client's signature on an informed consent. It is
the nurse's responsibility to: 68) ______
A)witness the signature.
B)determine the client's understanding about the procedure.
C)describe surgical risks.
D)explain the procedure.
69)A client is being given 0.6 mg atropine (an anticholinergic) IM preoperatively and
asks the nurse what the medication is for. The nurse explains the medication will
75)A 5-year-old client was admitted with severe dog bites and was experiencing pain.
The nurse can best evaluate level of pain intensity by: 75) ______
A)recognizing the level of intensity cannot be evaluated at that early age.
B)asking the parents about how much pain the client seems to be experiencing.
C)asking the child to rate the pain on a scale of 1 to 10.
D)showing pictures of happy, sad, and crying faces and have the client point to the
one like him.
76)A client feels reluctant to ask for pain medication frequently to keep from
bothering the nurse. The nurse recognizes an appropriate type of pain control for this
client would be: 76) ______
A)relaxation exercises.
B)narcotic tablets left at the bedside.
C)transcutaneous electrical nerve stimulation (TENS) unit.
D)patient-controlled analgesia (PCA) pump.
77)A client with a right lower extremity amputation complains of pain in the lost limb.
The nurse plans care of the client based on the understanding that phantom limb pain
should be: 77) ______
A)referred to a grief counselor.
B)ignored, as it is not possible to have pain in the lost limb.
C)treated as any other client experiencing pain.
D)given small doses of pain medication to prevent addiction.
78)A client who has just had a heart attack reports experiencing intense pain in the
left shoulder. The nurse explains this type of pain is called: 78) ______
A)referred pain. B) phantom pain.
C)acute pain. D) chronic pain.
79)A client in hospice care has received large doses of morphine but is still unable to
sleep. The nurse should administer which of the following adjuvant drugs? 79)
______
A)lisinopril (Zestril) B) acetaminophen (Tylenol)
C)amitriptyline (Elavil) D) meperidine (Demerol)
80)The nurse is caring for a postoperative client who is experiencing sweating,
tachycardia, and increased blood pressure. The nurse recognizes these symptoms are
due to: 80) ______
92)A client with chronic pain tells the nurse that he "rarely sleeps more than 3 hours a
night." The nurse realizes that this client is at risk for developing: 92) ______
A)Depression.
B)Chronic insomnia.
C)High pain tolerance.
D)Adult attention deficit disorder.
93)A client who is receiving pain medication around the clock complains of an acute
exacerbation of pain. What should the nurse do to help this client? 93) ______
A)Give the client a nonsteroidal anti-inflammatory drug (NSAID).
B)Provide the medication ordered for breakthrough pain.
C)Encourage the client to ignore the pain.
D)Talk the client through the pain.
94)The nurse is helping a client in pain by gently massaging the painful area. The
nurse is utilizing which form of pain control with the client? 94) ______
A)Guided imagery B) Biofeedback
C)Cutaneous stimulation D) Acupuncture
95)A client with a long history of pain rarely appears to be in pain and often forgoes
the use of pain medication. The nurse realizes that this client: 95) ______
A)Is addicted to pain medication.
B)Does not really have pain.
C)Has a low pain tolerance.
D)Has a high pain tolerance.
96)A client asks the nurse, "What does it matter what grade the tumor I had in my
stomach?" The best response by the nurse is: 96) ______
A)"It explains if the tumor has spread."
B)"It explains how aggressive the tumor is."
C)"It is a method of explaining the extent of the tumor to your insurance provider."
D)"It is a way to name the tumor."
97)A client with uterine cancer is prescribed a treatment in which radioactive material
will be inserted and maintained within her vagina. Which of the following types of
treatment does this describe? 97) ______
A)Extracavitary radiation B) Chemotherapy
C)Brachytherapy D) Teletherapy
98)A client who is newly diagnosed with cancer says to the nurse, "I don't want to
spend my final days on earth in a hospital bed." The best response by the nurse is: 98)
______
A)"Why do you feel so negative about being in the hospital?"
B)"If I were you I would go home and enjoy the life you have left."
C)"Please tell me more about how you are feeling right now."
D)"I know how you feel. It must be hard to know that you are dying."
99)The nurse is preparing to change the postoperative dressing of a client with a
mastectomy. During the dressing change the client looks away. Which of the
following should the nurse do to assist this client? 99) ______
A)Recommend that the client receive home care upon discharge because the client
will not be able to provide self dressing changes.
B)Hand the client a mirror so that she can look at the incision while the dressing is
being changed.
C)Suggest that the client identify a family member who will have to do the dressing
since the client refuses to learn.
D)Support the client; however, do not avoid discussing the incision.
100)A client is informed that the tumor removed from his abdomen had well-defined
borders, was encapsulated, and totally removed. The nurse realizes that this client has
just learned the tumor was most likely: 100) _____
A)Benign.
B)Malignant.
C)One that would not respond to chemotherapy.
D)Metastatic.
101)A 65-year-old male client is diagnosed with lymphoma while being treated for
bladder cancer. The nurse realizes that this client is demonstrating: 101) _____
A)A weakened immune system.
B)Two unrelated cancers.
C)Identification of the primary cancer.
D)Metastasis.
102)A client who was treated for bladder cancer 15 years ago tells the nurse, "I live
each day like it is my last yet plan for the future." The nurse realizes that this client is
107)A client is prescribed external radiation as part of his cancer treatment. Which of
the following should be included in this client's instructions? (Select all that apply.)
107) _____
A)Do not wash off the treatment marks.
B)Wash the skin with soap and water.
C)Use an electric razor to shave the treatment area.
D)Avoid applying heat or cold to the area.
108)A client with cancer is diagnosed with pain associated with the cancer treatment.
The nurse realizes that this client is most likely experiencing: 108) _____
A)Metastatic bone pain.
B)Incisional pain.
C)No pain.
D)Pain within a hollow visceral organ.
109)A client who is being treated for cancer says, "I thought the pain that I had before
I was diagnosed with cancer was bad. This is horrible." The nurse's best response is:
109) _____
A)"Pain is a frame of mind."
B)"The treatment for the cancer must not be working."
C)"Pain is the main indication of cancer."
D)"The pain might be worse because of the cancer treatment."
110)A client with abdominal cancer is asking why the physician wants to perform
surgery. An appropriate response for the nurse to make to this client is: 110) _____
A)"Maybe the physician wants to confirm that you don't have cancer."
B)"The physician must think this will help get rid of the cancer."
C)"Surgical resection is used for diagnosis and staging of 90% of all cancers."
D)"That's a good question."
111)The client tells the nurse, "The doctor says my breast tumor was at B stage. What
does that mean?" The nurse explains the staging describes: 111) _____
A)"Where the tumor tissue first originated."
B)"The size of the tumor and extent of the cancer."
C)"The rate of growth of the cancer cells."
D)"The type of cancer cells."
112)Which of the following statements indicates a need for further teaching by the
D) type of diet.
117)The nurse is caring for a hospitalized cancer client with a radiation implant. The
nurse plans to take the following precautions: 117) _____
A)Avoid touching the patient.
B)Encourage family involvement with client care.
C)Wear a lead apron when administering care.
D)Organize care to limit exposure.
118)A client with breast cancer who is receiving chemotherapy tells the nurse she
does not care what happens to her anymore, since she cannot work or care for her
family. The nurse can assist by: 118) _____
A)finding a helper for her.
B)allowing her to express her feelings, fears, and concerns.
C)telling her that she has the right to feel depressed.
D)referring her to counseling services.
119)An eighth-grade class is taking a field trip to the beach to explore sea life. The
school nurse suggests that the students: 119) _____
A)use SPF 15 lotion on their exposed skin to prevent sunburn.
B)go on the field trip in the evening to avoid exposure to the sun.
C)wear long-sleeved shirts and long pants to protect them from the sun.
D)stay out of the water.
120)A 78-year-old client has been diagnosed with prostate cancer. The nurse should
educate the client about the prevention or treatment of: 120) _____
A)urinary retention. B) recurrent headaches.
C)constipation. D) urinary incontinence.
121)A client in the outpatient clinic is scheduled to have blood drawn for an iron level.
Recognizing that certain medications will affect the results, the nurse should
determine if the client is taking: 121) _____
A)acetaminophen. B) antidepressants.
C)antihypertensives. D) oral contraceptives.
122)When checking laboratory values, the nurse notes the client's platelet count is
100,000 mm3. The nurse should include which of the following actions in the client's
plan of care? 122) _____
A)Hold pressure over injection sites to ensure clotting has occurred.
B)Encourage client to increase ambulation to prevent a deep venous thrombosis.
C)Use strict sterile technique with wound care in order to prevent infection.
D)Instruct client to increase intake of vitamin C to assist in blood coagulation.
123)It is reported a client has leukocytosis. When checking the laboratory results, the
nurse will expect to find: 123) _____
A)white blood cell count is less than 5,000/mm3.
B)neutrophil count is greater than 50%.
C)eosinophil count is less than 5%.
129)A nurse is bathing a client who had a bone marrow aspiration from the right iliac
crest 5 days ago. Which of the following findings would be of concern to the nurse?
129) _____
A)The client is doing isometric leg exercises.
B)The needle insertion site is scabbed over and without drainage.
C)The needle aspiration site is ecchymotic.
D)The client complains of moderate pain in the right iliac crest.
130)A client being prepared to have a bone marrow transplant expresses concern the
procedure will be painful. The nurse explains: 130) _____
A)"You will be given some analgesic since it can be painful."
B)"It should not be any more painful than having an injection."
C)"The procedure is very quick and not very painful."
D)"A local anesthetic is given and so you won't feel any pain."
131)When making morning rounds, a client with acute leukemia reports having
nosebleeds off and on throughout the night. Which of the following actions should be
taken by the nurse? 131) _____
A)Determine if client has pain anywhere.
B)Apply a water-soluble lubricant to the nares.
C)Check the client's blood pressure and pulse.
D)Report the findings to the physician.
132)A client with hemophilia A is being prepared to receive a transfusion of clotting
factors and expresses concern about contracting HIV from the transfusion. The best
explanation the nurse can provide is: 132) _____
A)"The blood that is donated is screened so you should not worry."
B)"That certainly is always a concern. You can refuse the treatment if you prefer."
C)"Rigorous screening of donors and treatment of donated blood has significantly
reduced the risk."
D)"You won't be receiving whole blood so you shouldn't worry about HIV
contamination."
133)When caring for a client with a history of alcoholism the nurse recognizes the
client is at increased risk for which of the following conditions? 133) _____
A)hemolytic anemia B) Von Willibrand's disease
C)folic acid deficiency D) pernicious anemia
134)The nurse is preparing a client recovering from sickle cell crisis for discharge. To
prevent future crises from occurring, the nurse instructs the client to: 134) _____
A)keep well hydrated.
B)avoid doing any types of exercise.
C)eat a high-protein diet.
D)abstain from alcohol use.
135)A client with multiple myeloma has been started on filgrastin (Neupogen) for
treatment of neutropenia. The nurse identifies the drug is being effective when: 135)
_____
A)the client is no longer hypotensive.
B)the hemoglobin level is within normal limits.
C)the client no longer has bone pain.
D)an increase in the white blood cell count occurs.
136)Infectious mononucleosis is suspected in a client being seen in the clinic. In
addition to swollen lymph glands and an increased lymphocyte count, the nurse can
expect the client to: 136) _____
A)have petechiae over the anterior chest.
B)have an enlarged liver.
C)report having insomnia.
D)complain of headaches and malaise.
137)The nurse learns a client with sepsis has developed disseminated intravascular
coagulation (DIC). The nurse should plan to: 137) _____
A)encourage frequent ambulation in the hallway.
B)restrict fluid intake to prevent vascular fluid overload.
C)keep client in a low-Fowler's position to promote venous return.
D)check peripheral pulses and capillary refill frequently.
138)A client with secondary polycythemia being seen in the clinic informs the nurse
he will be taking a long flight overseas in the near future. The nurse reminds the client:
138) _____
A)to be sure to wear support stockings during the flight.
B)that he will need supplemental oxygen when at a higher altitude.
C)to restrict intake of high-protein foods the day of the flight.
D)that he should start taking an antibiotic 1 week before leaving.
139)A client with chronic lymphangitis of the lower extremities asks the nurse how
often she should wear elastic stockings. The nurse explains: 139) _____
A)"It is only necessary to wear them if you notice an increase in swelling."
B)"You should wear them at all times, only taking them off to bathe."
C)"You should wear them when your legs feel heavy or are painful for you."
D)"It is best to wear them during the waking hours and remove them when sleeping."
140)When caring for the client with a history of pica the nurse assesses the client for
signs of chronic iron deficiency anemia. These may include: 140) _____
A)chelosis. B) clubbing of the fingernails.
C)jaundice. D) petechiae.
141)A client tells the nurse, "I had this arthritis pain under control but then I learned I
might lose my job." Which of the following should the nurse say in response to this
client? 141) _____
A)"Stress can cause an exacerbation of the arthritis."
B)"Well, we better do everything to help you before you lose your health benefits."
C)"I'm sure you'll find another job."
D)"Have you considered going on disability?"
142)During the physical assessment of a client, the nurse wants to include the client's
immunity function. Which of the following techniques would provide the nurse with
the best information? 142) _____
A)Auscultation of the heart B) Palpation of the abdomen
C)Percussion of the lungs D) Inspection of the skin
143)The client is diagnosed with a type IV hypersensitivity response. The nurse
realizes that this client will most likely need treatment with: 143) _____
A)Renal dialysis. B) Antihistamines.
C)Endotracheal intubation. D) Cardiac output medications.
144)A differential diagnosis for a client is food allergies. The nurse escorts the client
into an examination room and begins to ask questions about what the client has most
recently eaten. Which of the following has the nurse observed about this client? 144)
_____
A)Cachexia B) Obesity C) Anorexia D) Urticaria
145)An HIV positive client is not adhering to the prescribed medication therapy.
Which of the following actions by the nurse will best improve client compliance and
long-term treatment of the disease process? 145) _____
A)Talk with the client about not adhering to the medication schedule.
B)Refer the client to a social worker so that lower-cost medications can be obtained.
C)Suggest that the client take the medication at bedtime to prevent nausea.
D)Confront the client about the noncompliant behavior.
146)The nurse is preparing to instruct a class of young adults about ways to achieve
safe sex. What should be included in the nurse's presentation? (Select all that apply.)
146) _____
A)Only use water-based lubricants with condoms.
B)Be HIV tested if entering into a new monogamous relationship and have the test
repeated in six months.
C)Avoid sexual activity until both partners found HIV negative for two tests.
D)Avoid spermicidal agents.
147)A client who received a kidney transplant six months prior is demonstrating an
alteration in his blood-urea-nitrogen level. The nurse realizes that this client is
demonstrating: 147) _____
A)An allergic response.
B)A functional decline as an early indicator of rejection.
C)An expected response.
D)A functional decline as an early indicator of acceptance.
148)An HIV-positive client is being treated for thrush. Client teaching by the nurse
should include which of the following side effects? 148) _____
A)"Hepatitis can develop as a side effect."
B)"Nausea, vomiting, and diarrhea are common side effects."
C)"Skin discoloration is a common side effect."
D)"There are few side effects associated with the medication to treat thrush."
149)A client tells the nurse, "I've never had this before" and exposes an area of
redness, itching, and skin thickness on his left hand. The nurse realizes that this client
is demonstrating which of the following? 149) _____
A)A type I allergic response B) A type IV allergic response
C)A type II allergic response D) A type III allergic response
150)A client is prescribed a monoclonal antibody after an allograft on his left thigh.
Which of the following should be done for this client? 150) _____
A)Closely observe the client for four hours following the original dose.
B)Encourage the client to have a chest x-ray one week after the first dose.
C)Premedicate with hydrocortisone.
D)Instruct the client that side effects will occur after at least six doses of the
medication.
151)A client with an autoimmune disorder tells the nurse, "My family keeps telling
me that I don't look sick." The nurse should utilize which of the following nursing
diagnoses to help this client? 151) _____
A)Ineffective Coping B) Activity Intolerance
C)Interrupted Family Processes D) Ineffective Protection
152)A young HIV female client tells the nurse she does not want to see the
gynecologist because, "I'm going to die anyway." Which of the following should the
nurse say in response to this client? 152) _____
A)"But you still should be on birth control."
B)"The gynecologist will help diagnose any Hodgkin's disease."
C)"Why do you think that you are going to die?"
D)"Having a PAP smear will help detect the onset of cervical cancer."
153)An adolescent client asks the nurse about sexual practices and the onset of HIV.
Which of the following should the nurse instruct this client? 153) _____
A)The only safe sex is no sex.
B)Be sure to be tested for HIV every six months.
C)There is no such thing as safe sex.
D)Always use a condom.
154)An HIV positive client comes into the clinic complaining of increasing pain in
his feet and legs. The nurse realizes that this client is demonstrating: 154) _____
A)A reaction to the medication.
B)A nervous system manifestation of the disease.
C)An opportunistic infection.
D)A secondary cancer.
155)Before a bone marrow transplant, a client is prescribed ganciclovir (Cytovene).
Which of the following should be included in the instructions to the client about this
161)A client scheduled for a pulmonary function test asks what is involved in the test.
The nurse explains: 161) _____
A)"You will be asked to breathe in breathe in a specific manner and measurements
are taken."
B)"An x-ray of your lungs is taken after a dye is injected into your vein."
C)"You will have blood drawn from an artery in your wrist."
D)"A sensor is placed on your fingertip or earlobe and your oxygen levels will be
measured."
162)The nurse obtains a pulse oximetry reading of 95% on a client 2 days
postoperative. Which of the following actions should be taken by the nurse? 162)
_____
A)Increase level of oxygen delivery by 1 L/min.
B)Document the findings.
C)Encourage client to do more coughing and deep breathing.
D)Recheck the pulse oximetry after ambulating client.
163)A client has blood drawn for an arterial blood gas. When applying pressure to the
puncture site it is important for the nurse to: 163) _____
A)hold the pressure for at least 60 seconds.
B)have a tourniquet available in case bleeding does not stop.
C)keep the extremity elevated above the heart.
D)hold pressure for 2 minutes or longer.
164)The nurse is assessing an elderly client who is 2 days postop abdominal surgery.
The nurse recognizes alterations in the respiratory system of the elderly put the client
at risk for: 164) _____
A)increased vital capacity. B) upper respiratory infections.
C)pulmonary embolus. D) rib fractures.
165)When assessing the respiratory status of a client, the nurse auscultates the lungs
by: 165) _____
A)checking breath sounds in the anterior and posterior thorax.
B)listening for air exchange in the bronchus and anterior lobes.
C)checking for adventitious sounds while having client cough.
D)listening to breath sounds in the anterior and posterior lung bases.
166)The nurse caring for a client who has sustained a head trauma closely monitors
respirations because: 166) _____
A)breathing is controlled by the respiratory center in the brain.
B)the client will be unable to cough and clear secretions.
C)the client will be lethargic and forget to breathe.
D)the trauma may cause the client to be disoriented.
167)The nurse observes the serum alpha1-antitrypsin level of a client is 40 mg/dL and
recognizes this reading could be influenced by which of the following client
conditions? 167) _____
A)gastroesophageal reflux disease
B)cellulitis of a lower extremity
C)osteoporosis
D)migraine headaches
168)A client scheduled to have blood drawn for a serum alpha1-antitrypsin level asks
the nurse if any special preparation is necessary. Since the client has a history of
hyperlipidemia the nurse explains: 168) _____
A)"A low-fat diet should be eaten for twenty-four hours prior to the test."
B)"A fasting specimen will be necessary."
C)"No special preparation is needed."
D)"Any lipid-lowering medications should be held the day of the test."
169)When assessing a client with streptococcal pharyngitis, the nurse can expect the
client to complain of pain and: 169) _____
A)headache. B) dysphagia.
C)nausea and vomiting. D) palpitations
170)A postoperative client with a tracheostomy requires tracheal suctioning. The first
intervention in completing this procedure would be to: 170) _____
A)change the tracheostomy dressing.
B)perform oral or nasal suctioning.
C)provide humidity with a trach mask.
D)deflate the tracheal cuff.
171)When caring for clients who have had a tonsillectomy, the nurse should monitor
closely for which of the following complications: 171) _____
A)hemorrhage.
187)A client informs the nurse he is having pleuritic pain. Before documenting this
complaint, the nurse should verify if the pain: 187) _____
A)is constant along the costal borders.
B)increases with expiration.
C)subsides when client coughs.
D)increases with deep breathing.
188)A client has just been diagnosed with a pulmonary embolism. The nurse
anticipates the physician will order which of the following medication therapies?
188) _____
A)antibiotic therapy
B)nitroglycerin therapy
C)heparin therapy
D)bronchodilator and nebulizer treatments
189)A client who was diagnosed with the flu is demonstrating rapid, shallow
respirations. Which of the following is this client most at risk for developing? 189)
_____
A)Increased tidal volume B) Pneumonia
C)Dehydration D) Atelectasis
190)A client tells the nurse, "After I leave here, I need to get to the dentist. My upper
teeth are hurting and I don't know why." Which of the following should the nurse do?
190) _____
A)Tell the client there is nothing wrong with his teeth.
B)End the visit so the client can get to the dentist.
C)Reschedule the appointment at another time.
D)Assess the client for a sinus infection.
191)While eating a meal in the hospital, a client begins to demonstrate difficulty
breathing and signs of choking. The nurse realizes that the client is experiencing: 191)
_____
A)An acute myocardial infarction.
B)Pulmonary emboli.
C)Epiglottitis.
D)Laryngeal obstruction.
192)The nurse observes a client's respirations during sleep and notes the absence of
respirations that lasts from 15 to 45 seconds. This finding is consistent with: 192)
_____
A)Respiratory acidosis. B) Renal failure.
C)Laryngeal spasm. D) Sleep apnea.
193)A client says, "My nose is always congested and it just seems to get worse with
the nasal spray I've been using." The nurse realizes that this client is describing: 193)
_____
A)Rebound nasal congestion.
B)A side effect of the nasal spray.
C)An incorrect use of the nasal spray.
D)An acute sinus infection that needs to be treated with antibiotics.
194)During an assessment, the nurse learns that the only thing that helps a client with
a daily morning headache is "taking a mentholated cough drop" before eating
breakfast. The nurse realizes that this client is experiencing: 194) _____
A)Allergic rhinitis. B) Symptoms of sinusitis.
C)Acute rhinitis. D) After-effects from the flu.
195)While recovering at home from a total laryngectomy, a client notices an increase
in left shoulder weakness. This symptom is consistent with: 195) _____
A)Damage to the spinal accessory nerve.
B)Normal recovery.
C)Medication complication.
D)Side effect of neck radiation therapy.
196)The nurse suspects that a client is demonstrating signs of tonsillitis. Which of the
following would be indications of this disorder? (Select all that apply.) 196) _____
A)Thirst
B)Pain around the ears
C)Low grade fever
D)Hoarse voice
E)Nucal rigidity
197)A middle-age adult client who is diagnosed with pertussis is complaining of
right-sided thoracic pain. The nurse realizes that this client should be assessed for:
(Select all that apply.) 197) _____
204)During the assessment of a client's lower extremities, the nurse notes slight
pitting. This assessment finding should be documented as: 204) _____
A)1+. B) 4+. C) 2+. D) 3+.
205)A client is diagnosed with an abnormally low red blood cell (RBC) count. The
nurse realizes that this disorder is: 205) _____
A)Anemia. B) Bacteremia.
C)Leukemia. D) Polycythemia.
206)A client is diagnosed with an alteration in peripheral vascular resistance. The
nurse realizes that this resistance is determined by: (Select all that apply.) 206) _____
A)Blood flow.
B)Blood pressure.
C)Vessel length.
D)Vessel diameter.
E)Blood viscosity.
207)A client is experiencing a disorder in which large amounts of red blood cells
(RBCs) are being destroyed. An outcome of this disorder can be demonstrated as: 207)
_____
A)Nausea. B) Anxiety.
C)Dysphagia. D) Jaundice.
208)A client with some blood loss is maintaining a blood pressure of 100/60 mm Hg.
The nurse interprets this to mean that the client's blood pressure is being maintained
through the help of: 208) _____
A)Venules. B) Veins.
C)Arterioles. D) Capillaries.
209)During the assessment, a client's pedal pulses are increased. The nurse should
document this finding as: 209) _____
A)+3. B) +1. C) +4. D) +2.
210)A client who is diagnosed with a blood disorder has a platelet value of
>400,000/ml. The nurse interprets this to mean that this client is exhibiting: 210)
_____
A)Thrombocytosis. B) Anemia.
C)Thrombocytopenia. D) Leukemia.
211)A client needs a blood transfusion. The nurse realizes that the function of the
blood includes: (Select all that apply.) 211) _____
A)Regulate fluid and electrolyte balance.
B)Oxygenation of body tissues.
C)Transmit impulses.
D)Aids in joint mobility.
E)Digestion of protein.
212)A client is demonstrating a sign of blood pressure stabilization accompanied by a
decreased urine output. The nurse explains that the body mechanism responsible for
this blood pressure stabilization is: 212) _____
A)Change in body temperature.
B)Response to chemoreceptors in the aortic arch.
C)Renal conservation of sodium and water.
D)Intake of dietary fat and protein.
213)A client has an inflammation of his gastrointestinal tract. When interpreting the
labwork for this client, the nurse expects an increase in which of the following types
of white blood cells (WBCs)? Select all that apply. 213) _____
A)Neutrophils B) Eosinophils
C)Basophils D) Lymphocytes
214)A client who is being treated for malignant lymphoma is experiencing pruritis.
Which of the following interventions would be appropriate for this client? (Select all
that apply.) 214) _____
A)Bathe with cool water.
B)Cleanse bedding and clothing in mild detergent with a second rinse cycle.
C)Vigorously rub the skin after bathing.
D)Apply lavender-scented body lotion.
E)Keep room temperature above normal.
215)A client with disseminated intravascular coagulation is not responding to
infusions of fresh frozen plasma and platelets. Which of the following interventions
might be indicated for this client? Select all that apply. 215) _____
A)Begin normal saline infusion.
B)Prepare for a bone marrow biopsy.
221)A client diagnosed with leukemia says, "If I have too many white blood cells and
white blood cells fight infections, why do I have to be careful not to be exposed to
germs?" An appropriate response for the nurse to make is: 221) _____
A)"That's not what leukemia is."
B)"Your bone marrow can become infected."
C)"Leukemia means you have the wrong kind of white blood cells."
D)"The white blood cells with leukemia aren't effective to fight infections."
222)Upon analysis, a client's red blood cells (RBCs) appear microcytic and
hypochromic. The nurse interprets this information to mean that this client is
demonstrating signs of: 222) _____
A)Iron deficiency anemia.
B)Chronic blood loss anemia.
C)Vitamin B12 deficiency anemia.
D)Acute blood loss anemia.
223)The nurse is preparing an analgesic for a client with leukemia. Which of the
following routes is preferred for this client? 223) _____
A)Intramuscular B) Oral
C)Intravenous D) Subcutaneous
224)A client in sickle cell crisis is experiencing edema of the hands and feet. The
nurse realizes that this edema is caused by: 224) _____
A)Fluid overload. B) Small vessel infarction.
C)Poor venous return. D) Dehydration.
225)A client with idiopathic thrombocytopenia purpura continues to experience
symptoms of the disease after completing several courses of prednisone (Meticorten)
therapy. The nurse anticipates that which of the following will most likely be
indicated for this client? 225) _____
A)Life-long prednisone therapy
B)Splenectomy
C)Weekly platelet transfusions
D)Aspirin therapy
226)The nurse is planning to instruct a client with secondary polycythemia about
ways to prevent blood stasis. Which of the following should be included in these
Since the client is planning a long airplane flight, the nurse instructs the client to:
231) _____
A)do deep-breathing exercises every hour while awake.
B)perform isometric exercises of the lower extremities every 2 hours.
C)keep the lower extremities elevated as much as possible during the flight.
D)restrict intake of fluids during the flight.
232)A client is being sent home with a 24-hour Holter monitor device. The nurse
instructs the client to: 232) _____
A)remove the Holter monitor when sleeping.
B)avoid drinking any alcoholic beverages.
C)record any unusual symptoms you may experience.
D)change the chest electrodes every 4 hours.
233)A client tells the nurse his recent blood work indicated his high density lipids
(HDLs) were 40 mg/dL and asks if this is a "good level"? The nurse should respond:
233) _____
A)"You should ask your primary care provider to explain the results."
B)"HDLs should be lower than your cholesterol level."
C)"It is desirable to have a level above 60 mg/dL."
D)"That is a good level. You must be eating healthy."
234)Before an electron beam computed tomography (EBCT) study is done, the nurse
needs to determine if the client: 234) _____
A)has any metal implants.
B)is pregnant.
C)has an allergy to iodine or shellfish.
D)is taking any antihypertensive medications.
235)The nurse is performing a cardiovascular assessment on an elderly client. Which
of the following findings should be reported to the charge nurse? 235) _____
A)sparse hair growth on lower extremities
B)weak, thready, irregular pulse
C)presence of bruising on upper extremities
D)thin, pale facial hair
236)A client being seen in the office is scheduled to have an ankle-brachial index test.
When the client asks what the purpose of the test is, the nurse explains that it: 236)
_____
A)measures the pressure of varicose veins.
B)predicts the likelihood of developing hypertension.
C)measures cardiac ejection fraction.
D)will determine if atherosclerosis is present.
237)The nurse instructs the client scheduled to have blood drawn for a C-reactive
protein level to do which of the following prior to the test? 237) _____
A)Hold any cardiac medication for 24 hours prior to the test.
B)Restrict intake of caffeine containing products 24 hours prior to the test.
C)Fast for 8 hours prior to the test.
D)No special fasting or preparation is required.
238)A client being seen in the outpatient clinic has had a radionuclear scan of the
heart. Upon discharge the client should be instructed to: 238) _____
A)increase fluid intake to 2000 mL in 24 hours.
B)dispose of urine in specially provided containers.
C)avoid close physical contact with others for 24 hours.
D)return in 24 hours for follow up x-rays.
239)A client being discharged following treatment for a deep venous thrombosis
(DVT), will be taking warfarin (Coumadin) at home. The nurse instructs the client to:
239) _____
A)"Use over-the-counter anti-inflammatory drugs for pain or a headache."
B)"Include a lot of dark green leafy vegetables in your diet."
C)"If you miss a dose of the drug, wait until the next day to take the next dose."
D)"Avoid drinking any alcohol while taking this med."
240)In management of a newly diagnosed, low-risk client with hypertension, the
nurse understands that the initial treatment generally consists of: 240) _____
A)restriction of fluid and sodium intake.
B)lifestyle modification and a diuretic medication.
C)dietary management; exercise regimen; and stress reduction.
D)aggressive treatment with diuretics, beta blockers, and 1,000-calorie diet.
241)The nurse instructs clients with hypertension to drink beverages with caffeine
(coffee, tea, cola drinks) in moderation because caffeine causes: 241) _____
A)accumulation of plaque in blood vessels.
failure is associated with an abrupt onset of: (Select all that apply.) 252) _____
A)Myocardial infarction (MI).
B)Heart valve disease.
C)Cardiomyopathy.
D)Coronary heart disease (CHD).
253)The nurse is caring for an ICU client whose fluid volume status needs to be
closely watched. The most likely type of monitoring that will be used is: 253) _____
A)Central venous pressure monitoring.
B)Arterial pressure monitoring.
C)Intra-aortic balloon pump monitoring.
D)Pulmonary artery pressure monitoring.
254)Clinical signs and symptoms of pericarditis include: (Select all that apply.) 254)
_____
A)Pericardial friction rub.
B)Chest pain.
C)Bradycardia
D)Abdominal discomfort and nausea.
255)When obtaining the health history of a client who is being assessed for possible
congestive heart failure, it is significant when the client says: 255) _____
A)"I break out into a cold sweat when I eat a large meal".
B)"I have to prop myself up on three pillows to sleep at night. I cannot breathe
otherwise".
C)"I am sleepy after I eat lunch each day".
D)"I feel better with my legs down when I sit up in my favorite chair."
256)When caring for a chronic heart failure client with left-sided failure, the nurse
would most likely hear which of the following statements from the physician after a
cardiac catheterization? 256) _____
A)"Pressures in the left ventricle and atrium are increased."
B)"Pressures in the right ventricle are reflective of how both sides of the heart are
functioning."
C)"Pressures in the right ventricle and atrium match the left ventricle pressures."
D)"Pressures in the left ventricle and atrium are decreased."
257)A pulmonary artery (PA) catheter is used in critical care clients who: 257) _____
262)The most important first action the nurse should initiate on a client who arrives to
the hospital in pulmonary edema is: 262) _____
A)Administer oxygen and attach a pulse oximeter.
B)Monitor the blood glucose level.
C)Initiate a peripheral intravenous catheter.
D)Seek an order to medicate for discomfort.
263)The nurse is caring for a client who now has invasive hemodynamic monitoring.
The highest priority of care for this client is: 263) _____
A)Prevent infection at the catheter site by changing the dressing as ordered.
B)Set alarm limits and turn monitor alarms on.
C)Coil IV tubing on the bed.
D)Explain to family members why the monitoring is in use.
264)The nurse is assessing a client who arrives at the hospital with dyspnea,
orthopnea, cyanosis, clammy skin, a productive cough with pink, frothy sputum, and
crackles. The nurse realizes that the client is likely suffering from which of the
following conditions? 264) _____
A)Endocarditis B) Pulmonary edema
C)Angina D) Chronic heart failure
265)What is the initial indication of valve disease? 265) _____
A)A murmur is heard during physical exam.
B)It is discovered only through cardiac catheterization.
C)It is discovered by accident on a chest x-ray.
D)An echocardiography study is done to preventatively check the valves.
266)A client is admitted with acute heart failure. The nurse realizes that acute heart
failure is associated with an abrupt onset of: (Select all that apply.) 266) _____
A)Cardiomyopathy.
B)Coronary heart disease (CHD).
C)Heart valve disease.
D)Myocardial infarction (MI).
267)The nurse recognizes which of the following as a sign of decreased cardiac
output and tissue perfusion in a client with heart failure? 267) _____
A)Decreased mental alertness. B) Abdominal distention
C)Strong peripheral pulses D) Increased urine output
268)Typical medications taken by heart failure clients include: (Select all that apply.)
268) _____
A)Furosemide (Lasix). B) Digoxin (Lanoxin).
C)Promethazine (Phenergan). D) Enalapril (Vasotec).
269)A client on the Pritikin Diet is eating foods high in complex carbohydrates and
fiber, low in cholesterol, and low in fat. The program also includes: 269) _____
A)Supervised exercise twice a week and a daily multivitamin.
B)Aerobic exercise daily for 30 minutes and only organic foods.
C)Walking 45 minutes daily and vitamin supplements including vitamins C, E, and
folate.
D)Exercising three times a week for 30 minutes and eating high-protein red meats.
270)A 52-year-old obese male client who is admitted with elevated triglycerides and a
history of smoking two packs of cigarettes a day for 20 years: 270) _____
A)Possesses all modifiable risk factors for coronary artery disease that can be
overcome.
B)Possesses all nonmodifiable risk factors for coronary artery disease that cannot be
overcome.
C)Is not at risk for coronary artery disease.
D)Is at risk for coronary artery disease.
271)The nurse is caring for an adult client who is admitted with chest pain that began
four hours ago. Which of the following tests will be most specific in identifying acute
heart damage? 271) _____
A)CK-MB B) Troponin
C)Cholesterol D) CPK
272)The term pacemaker noncapture requires the nurse to do the following: (Select all
that apply.) 272) _____
A)Contact the physician and describe what is documented on the ECG strip.
B)Assess the client to determine their response to the pacemaker noncapture.
C)Document the event by printing an ECG strip and making it part of the client's
record.
D)Administer nitroglycerin sublingual stat times one dose from standing orders.
273)Drugs used to treat hyperlipidemia: 273) _____
A)Hyperlipidemia B) Hypotension
C)Diabetes D) Positive family history
279)The nurse is assessing a client who presents with chest pain. The client has been
previously diagnosed with chest pain and now reports an increase in the frequency
and duration of the chest pain. Appropriate nursing care for this type of chest pain
includes: 279) _____
A)Atropine (Atropair) 0.4 mg IVP.
B)Pepto Bismol 30 cc prn.
C)Bed rest with bathroom privileges.
D)Aspirin 325 mg a day per physician order.
280)The client has a pacemaker with one pacing spike seen on the ECG before every
QRS complex. There is no change in the pacemaker rhythm over time, with rest or
with activity. The nurse realizes that this means that the type of pacemaker is: 280)
_____
A)Atrial single-chamber pacing.
B)Asynchronous pacing.
C)Dual-chamber pacing.
D)Demand pacing.
281)Sinus bradycardia (rate 56) is identified in a sleeping client on telemetry. The
nurse realizes that the priority is to: 281) _____
A)Call for an immediate 12-lead EKG.
B)Call the physician and report the dysrhythmia.
C)Check the medication administration record to see if a drug is ordered prn that will
help slow the heart rate.
D)Awaken the client and see how the heart rate responds.
SHORT ANSWER. Write the word or phrase that best completes each statement or
answers the question.
282)The nurse is caring for a client who develops atrial fibrillation with a heart rate
above 100 beats per minute. Place the following nursing actions in sequence from the
highest priority to the lowest priority:
1. Check the patency of an intermittent IV.
2. Assess the client for comfort level and vital signs.
3. Call the physician to report the dysrhythmia.
4. Check the client's chart for lab results from today's tests. 282) ____________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement
or answers the question.
283)A client is in sinus tachycardia. The nurse realizes that the needed interventions
are to:
(Select all that apply.) 283) _____
A)Observe the client for effects on cardiac function.
B)Administer normal saline 0.9% IV at the ordered rate of 200 ml per hour if
hypovolemia is suspected as the cause.
C)Administer two tablets of acetaminophen (Tylenol) per physician order if an
elevated temperature is present.
D)Administer atropine (Atropair) IV push to halt the tachycardia.
284)When caring for a client who has experienced a massive trauma, the nurse
recognizes that the response of the autonomic nervous system to stress correlates with
the following assessment finding: 284) _____
A)increased peristalsis B) dilated pupils
C)urinary urgency D) decreased pulse
285)The nurse is explaining the preparation needed for a positive emission
tomography (PET) scan. The client is told he will: 285) _____
A)only be allowed to drink water the morning of the test.
B)have an intravenous line inserted just before the test.
C)be given a mild sedative 1 hour before the test.
D)need to drink several glasses of contrast media.
286)During a neurologic examination of the older client the nurse would expect to see
which of the following age-related findings? 286) _____
A)disorientation to person and place
B)an increase in deep tendon reflexes
C)a depressed mood
D)a decreased sense of touch and temperature
287)The nurse notes that a client was treated for labyrinthitis on previous admission.
To determine if the problem has resolved, the nurse asks the client: 287) _____
A)"Are you having difficulty with your balance?"
B)"Are you still having earaches?"
C)"Have you noticed any drainage from your ears?"
298)The nurse is planning a seminar about headaches for a local civic group. The type
of headache that has a strong familial connection, affects females three to one over
males, and results in lost productivity is: 298) _____
A)Cluster. B) Migraine.
C)Sinus. D) Stress.
299)After a fall, the client is brought to the emergency department. There was a brief
loss of consciousness, the client complains of headache, has vomited twice, has a
dilated pupil on the same side as a hematoma over the temporal area, and now is
having a seizure. The nurse anticipates that: 299) _____
A)This is an emergency situation that is likely an epidural hematoma and requires
surgery.
B)This is a controlled situation once the seizure stops.
C)This is a serious situation in which a subdural hematoma is developing and requires
surgery.
D)This is a typical situation seen with most clients who fall and will subside with
observation.
300)Brain death is the cessation of all brain functions. The criteria to establish brain
death varies from state to state but generally recognized criteria include: (Select all
that apply.) 300) _____
A)No spontaneous respiration.
B)Absent motor and reflex movements.
C)Flat electroencephalogram (EEG) on successive EEGs.
D)Pupils are equal and responsive to light.
301)The nurse is caring for a head-injured client with cerebral edema and increased
intracranial pressure (IICP). To prevent further transient increases from occurring, the
nurse should implement which of the following interventions? 301) _____
A)Position the client in the supine position with the head of the bed at 30 degrees.
B)Initiate and monitor an IV with normal saline.
C)Initiate oxygen administration.
D)Implement measures to help the client avoid coughing, sneezing, and straining.
302)When assessing an adult after a fall, the nurse in the emergency department notes
a dilated pupil on the right and a hematoma in the right temporal area. The nurse
realizes that this likely means that: 302) _____
A)The process affecting the pupil is occurring locally on the right side (ipsilateral
pupil dilation).
B)The process causing the right pupil to dilate is a result of a metabolic process.
C)The process affecting the pupil is occurring on the opposite side and is unrelated to
the right temporal hematoma.
D)The process affecting the right pupil is temporary and soon both pupils will be
equal in size.
303)A change in breathing pattern to alternating regular periods of deep, rapid
breathing followed by periods of apnea is called ________ and is related to damage in
the diencephalon region of the cerebrum. 303) _____
A)Neurogenic hyperventilation B) Cheyne-Stokes respirations
C)Ataxic respirations D) Apneustic respirations
SHORT ANSWER. Write the word or phrase that best completes each statement or
answers the question.
304)The nurse is caring for a client on a medical unit who begins a tonic-clonic
seizure. After a few minutes the seizure stops but repeats again after a minute. This
pattern continues in which the client is having repeated tonic-clonic seizures and has
lasted for more than 10 minutes. Place the following nursing actions into order from
highest priority to lowest:
1. Hang an IV of normal saline to keep vein open.
2. Call respiratory therapy stat.
3. Call the physician stat.
4. Initiate oxygen via the nasal cannula at the bedside. 304) ____________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement
or answers the question.
305)The client is hit by a swinging bat. This is an example of: 305) _____
A)An acceleration-deceleration injury.
B)An acceleration injury.
C)A deceleration injury.
D)A penetrating head injury.
306)In the client with altered level of consciousness (LOC), the most appropriate
intravenous fluid is: 306) _____
A)Dextrose 5% and .45 normal saline.
B)Isotonic or hypertonic.
C).45 normal saline.
D)Dextrose 5% in water.
307)A client is in the emergency department following a head injury. The most
accurate sign of developing increased intracranial pressure is: 307) _____
A)Decreasing respiratory rate.
B)Elevated diastolic blood pressure.
C)Decreasing level of consciousness.
D)Pupils that are equal.
308)The nurse is observing a client who is having a seizure that involves a blank stare,
unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a
minute. The nurse categorizes the seizure as: 308) _____
A)Partial. B) Absence.
C)Tonic-clonic. D) Status epilepticus.
309)The medication expected in the care of an Alzheimer's client is: 309) _____
A)Acetaminophen (Tylenol).
B)Adrenocorticotropic hormone (ACTH).
C)Rivastigmine tartrate (Exelon).
D)Meperidine (Demerol).
310)A client is admitted to the hospital with a suspected case of botulism. The nurse
realizes that the botulism infection was likely caused by which of the following
scenarios? 310) _____
A)The client was injected with the poison.
B)The client ate food contaminated with the toxin.
C)The client ate infected dirt.
D)The client had a dirty wound that developed this toxin.
311)An adult woman comes to the clinic complaining of repetitive episodes of sudden
severe pain on the right side of the face. The nurse expects that the diagnosis will be
________ and the medication treatment will be ________. 311) _____
A)Bell's palsy; penicillin
B)Myasthenia gravis; acetaminophen (Tylenol)
C)Trigeminal neuralgia; phenytoin (Dilantin)
D)Parkinson's disease; propranolol (Inderal)
312)An adult client has been diagnosed with Bell's palsy. The client asks if the facial
paralysis and distortion will go away. The nurse should answer: 312) _____
A)"Most people have permanent facial paralysis on both sides of the face."
B)"About 80% of people recover completely within a few weeks to a few months, but
there can be lasting effects."
C)"Everyone recovers from Bell's palsy in three to five weeks."
D)"Most people have permanent facial paralysis on one side of the face."
313)The nurse anticipates the following medication administration for a client with
multiple sclerosis (MS): 313) _____
A)Rivastigmine tartrate (Exelon).
B)Adrenocorticotropic hormone (ACTH).
C)Meperidine (Demerol).
D)MAO inhibitors.
314)The nurse is assessing a client who was just admitted with the diagnosis
Guillain-Barre syndrome. The nurse anticipates that the client will exhibit: 314)
_____
A)Increased leg pain.
B)Increased muscular weakness.
C)Increased intolerance to light.
D)Increased confusion.
315)Huntington's disease has no cure and causes progressive chorea, speech problems,
and dementia. When teaching the newly-diagnosed client about the disease, the client
asks the nurse whether it can be passed on to future children. The nurse's best
response is: 315) _____
A)"Each child will have a 50% chance of inheriting the gene."
B)"There may be genetic concerns that should be discussed with the physician."
C)"The disease is passed on genetically in 75% of offspring."
D)"Children will not be affected by the disease."
316)A client who was diagnosed with Parkinson's disease is demonstrating
bradykinesia. The nurse will likely observe the following actions in this client: 316)
_____
A)Very slow talk.
B)A loss of spontaneous movement.
C)An increase in spontaneous movements that occur more slowly.
D)Active exercise and high energy as required to perform activities of daily living.
317)A test that is used to diagnose myasthenia gravis (MG) is ordered by the
physician. Because the test involves an injection of a drug that makes muscle strength
improve for about five minutes the nurse realizes that this test likely is: 317) _____
A)A computed tomography (CT) scan of the legs.
B)A Tensilon test.
C)Analysis of antiacetylcholine receptor antibodies.
D)A nerve stimulation study.
318)The nurse understands that tetanus is completely preventable by: 318) _____
A)Debriding the bite wound.
B)Administering antibiotics immediately after a bite.
C)Passive immunization.
D)Active immunization.
319)The nurse is having a conversation with an older adult with Parkinson's disease.
Which of the following would this client most likely exhibit during conversation with
the nurse? 319) _____
A)Jumbled words that do not make sense
B)Angry, loud talk
C)A low-pitched monotone voice
D)Bubbly, spirited discussion
320)The nurse is caring for a client with amyotrophic lateral sclerosis (ALS). The
nurse realizes that the prognosis is: 320) _____
A)Good. The disease will progress over many years but the quality of life will be
good.
B)Good. The disease progresses rapidly but can be halted by drug therapy.
C)Excellent. The disease will progress slowly and can be controlled by medication.
D)Poor. The disease rapidly progresses and is fatal.
321)A surgical option for clients younger than 60 with myasthenia gravis (MG) is
thymectomy. The nurse anticipates that ________ will obtain remission with the
surgery. 321) _____
A)40% B) 60% C) 30% D) 10%
322)A 30-year-old nurse who works on a busy medical-surgical unit has been
diagnosed with multiple sclerosis (MS). The priority for this client is to: 322) _____
A)Negotiate a regular schedule of working 8-hour dayshifts and consider applying for
nursing positions that are less stressful and demanding.
B)Continue to work as scheduled without making changes.
C)Work as hard as possible now because later, it may not be possible.
D)Leave employment as a nurse due to the need for complete bed rest.
323)Medication does not stop all symptoms with Parkinson's disease. The nurse notes
tremors and muscle rigidity in an older adult client. Expected medication to combat
these symptoms includes: (Select all that apply.) 323) _____
A)Nitroglycerin (Nitrobid). B) Meperidine (Demerol).
C)Acetaminophen (Tylenol). D) Propranolol (Inderal).
324)The family of a client with Alzheimer's disease expresses concern that their
mother is becoming worse. The nurse identifies the following manifestations as
indicating the client is advancing to stage 2 of Alzheimer's disease: 324) _____
A)forgets the location and names of objects
B)short-term memory loss
C)has difficulty learning new information
D)has difficulty using objects
325)When planning to discharge a client with multiple sclerosis (MS), the nurse
should teach the client to: 325) _____
A)decrease medication as symptoms improve.
B)perform tasks in the morning.
C)take showers or tub baths in hot water.
D)increase exercises in the afternoon.
326)After administering diazepam (Valium) PO to a client who has a spinal cord
injury the nurse should expect to observe which of these client responses? 326)
_____
A)improved swallowing ability
B)improved motor coordination
C)a decrease in salivation and sweating
D)decrease in muscle spasm and pain
327)When doing a physical assessment of a client, the nurse should expect to find
which symptom related to a diagnosis of Parkinson's disease? 327) _____
A)dry skin B) elevated blood pressure
C)polyuria D) bradykinesia
328)When teaching the client and family about the disease myasthenia gravis, the
nurse should include which of the following? 328) _____
A)methods to increase fluid intake
B)signs and symptoms of fluid volume excess
C)signs and symptoms of cholinergic crisis
D)strategies to improve memory
329)A client diagnosed with Parkinson's disease is prescribed to take levodopa. The
nurse should instruct the client about possible side effects which include: 329)
_____
A)diarrhea.
B)bradycardia.
C)acute hypertension and glycosuria.
D)orthostatic hypotension and confusion.
330)When planning the care for a client who has a spinal cord injury, the nurse should
give priority to which of these treatment measures first? 330) _____
A)listening for bowel sounds
B)testing for motor strength
C)monitoring the client's blood pressure
D)palpating the client's bladder for fullness
331)When a client has trigeminal neuralgia, the client should be carefully assessed for:
331) _____
A)changes in the level of consciousness.
B)symptoms of acute respiratory distress.
C)signs and symptoms of acute cholinergic crisis.
D)trigger zones that cause pain when stimulated.
332)When caring for a client with herniated disk disease, the nurse's priority of focus
is to: 332) _____
A)take precautions to prevent further injury.
B)teach the client log-rolling techniques.
C)decrease intervertebral disk pressure.
D)assess the degree to which the disease affects daily activities.
333)A client is admitted with the following symptoms: visual changes, muscular
weakness, and numbness and tingling in the extremities. Based on theses findings, the
nurse should suspect the client of having which of the following diseases? 333)
_____
A)myasthenia gravis B) multiple sclerosis
C)amyotrophic lateral sclerosis D) Guillain-Barraccent(e) syndrome
334)A client is scheduled for diagnostic tests to determine the cause of his hearing
and balance disorder. The diagnostic tests that could be used to help this client include:
(Select all that apply.) 334) _____
A)Auditory brainstem response (ABR).
B)Tonometry.
C)Caloric test.
D)Computed tomography (CT) scan.
E)Auditory evoked potentials (AEP).
335)The nurse notes that a client's left eye deviates inward while focusing on an
object. This finding is consistent with: 335) _____
A)Strabismus. B) Presbyopia.
C)Myopia. D) Hyperopia.
336)The nurse notices that a client's pupils constrict when reading the consent form
for medical treatment. This observation is considered: 336) _____
A)Evidence that the client can read.
B)Evidence that the client needs reading glasses.
C)A normal pupillary response.
D)Evidence that the client has normal vision.
337)A client has sustained an injury to the inner layer of his left retina. The nurse
realizes that this client will have difficulty with: 337) _____
A)Peripheral vision and color perception.
B)Tear production.
C)Blinking.
D)Reading.
338)A client who is using atropine eye drops is found to have a poor consensual light
response. The nurse realizes that this finding is considered: 338) _____
A)Normal because of the eye drops.
350)During an assessment, a client without any health problems explains how his
"ears ring" periodically. The nurse realizes that this assessment finding most likely is:
350) _____
A)Aspirin overdose.
B)A preliminary symptom of a severe disease.
C)Nothing.
D)Pending drug toxicity.
351)A client experiences an increase in ear pain when the auricle is pulled up and
back. The nurse realizes that this client might be experiencing: 351) _____
A)Mastoiditis. B) Otitis interna.
C)Otitis externa. D) Otitis media.
352)A client is learning how to apply and care for a new set of contact lenses.
Instructions for this client should include: (Select all that apply.) 352) _____
A)Wash hands before and after applying the lenses.
B)Distilled water is the best solution for the lenses.
C)Once applied, only remove when cloudy.
D)Contact eye physician if eyes become red or tear.
E)Eye pain is a common complaint and should not be a concern.
353)A client is experiencing a severe episode of Meniere's disease. The medication to
help reduce the sensation of spinning and nausea is: 353) _____
A)Droperidol (Inapsine).
B)Hydrochlorothiazide (HydroDIURIL).
C)Diazepam (Valium).
D)Meclizine hydrochloride (Antivert).
354)An elderly client often responds incorrectly to questions or during general
conversation. The nurse realizes that this client should be assessed for: 354) _____
A)History of strokes. B) Hearing disorder.
C)Cognitive impairment. D) Level of education.
355)A client with COPD is being treated for glaucoma. The medication that will most
likely be prescribed for this client is a(an): 355) _____
A)Antibiotic. B) Adrenergic agonist.
C)Betablocker. D) Calcium channel blocker
356)An elderly client with a mobility disorder is being discharged after having a
cataract removed as an outpatient. The nurse should assess this client for their: 356)
_____
A)Ability to read discharge instructions.
B)Ability to provide eye drops postprocedure.
C)Ability to ambulate.
D)Ability to drive.
357)A client is seen for hearing loss and odd popping noises in his left ear after
"having a cold". This client is demonstrating signs of: 357) _____
A)Otitis interna. B) Acute otitis media.
C)Serous otitis media. D) Otitis externa.
358)A client with chronic acute otitis media infections is having tympanostomy tubes
placed. Post-tube placement instructions for this client should include: 358) _____
A)Avoid getting any water into the ears.
B)Wash hair only with warm water.
C)Make sure showers are completed within 10 minutes.
D)Avoid gum chewing.
359)The nurse is instructing a client who has a hearing and balance disorder. Which
of the following should be included in these instructions? (Select all that apply.) 359)
_____
A)Increase pace of ambulation.
B)Stand very still with the onset of vertigo.
C)Take antivertigo medication only when able to lie down.
D)Change positions slowly.
E)Turn the whole body, rather than just the head.
360)A teenage client is diagnosed with a corneal abrasion. Which of the following
should the nurse instruct this client? 360) _____
A)Do not share or use another person's eye makeup.
B)Use the prescribed eye drops until the symptoms disappear.
C)Gently rub the eyes when itchy.
D)Only share a towel with family members.
361)A client with chronic otitis media is diagnosed with a cholesteatoma. The nurse
realizes that the treatment of choice for this client will be: 361) _____
A)Surgery.
B)Nothing. It will resolve on its own.
C)Antibiotics.
D)Tympanostomy tubes.
362)A client who became blind in his left eye because of an industrial accident says,
"I still have one good eye and I can still do a lot." The nurse realizes that this client is
demonstrating signs of: 362) _____
A)Anticipatory grieving. B) Remorse.
C)Denial. D) Acceptance.
363)A client comes into the clinic complaining of "black spots and a curtain
dropping" in his right eye. The nurse realizes that this client is experiencing signs of:
363) _____
A)Conjunctivitis. B) Cataract.
C)Detached retina. D) Sty.
364)A client scheduled to have a urea breath test asks the nurse what the purpose of
the test is. The nurse explains: 364) _____
A)"It is done to determine the amount of hydrochloric acid secreted by your
stomach."
B)"It measures the acidity of your esophagus and gastric fluids."
C)"It identifies the pressure of the esophageal sphincter."
D)"It detects the presence of bacteria that contribute to formation of peptic ulcer
disease."
365)The nurse is caring for a client being treated for pancreatitis. Which of the
following laboratory studies would best indicate the treatment is being effective:
365) _____
A)normal liver function tests. B) normal lipase level.
C)elevated amylase level. D) decreased bilirubin level.
366)A client is scheduled to have esophageal manometry testing. Prior to the test
nursing responsibilities will include: 366) _____
A)ensure client has not smoked cigarettes in the past 24 hours.
B)keeping client NPO for 12 hours prior to the test.
C)restricting intake to clear liquids for 4 hours prior to the test.
200 mL of bright red blood in the nasogastric (NG) drainage container. What is the
most appropriate nursing action? 381) _____
A)Notify the physician. B) Assess the client's pain level.
C)Apply an abdominal binder. D) Irrigate the NG tube.
382)A client visits an urgent care center and tells the nurse he has had nausea and
vomiting for 3 days and thinks he has the flu. The nurse should assess the client for
symptoms of: 382) _____
A)adequate carbohydrate intake.
B)dehydration.
C)chronic fatigue.
D)vitamin C deficiency.
383)During assessment of the oral cavity, the nurse notes the presence of swollen
gums. The nurse teaches the client about proper oral hygiene in order to assist the
client in meeting which of the following outcomes? 383) _____
A)Maintain balanced nutritional intake.
B)Experience a decrease in dental caries.
C)Maintain healthy oral mucous membranes.
D)Reduce risk factors for periodontal disease.
384)A client who is experiencing difficulty swallowing is diagnosed with esophageal
cancer after having a barium swallow. The nurse realizes that the diagnostic test must
have displayed: 384) _____
A)Metastasis. B) A tumor.
C)A narrow esophageal lumen. D) Blood.
385)The nurse is assessing a client with gastrointestinal dysfunction who says, "I was
having chest pain so bad last week I thought I was having a heart attack!" The nurse
suspects that the client was experiencing: 385) _____
A)Hiatal hernia. B) Diverticulitis.
C)Constipation. D) Bowel obstruction.
386)A client with chronic gastritis says, "I've stopped taking the medication because I
feel so much better now that I drink ginger tea." The nurse realizes that this client:
386) _____
A)Needs to see the doctor immediately.
B)Is using a complementary therapy for the symptoms.
A)Ineffective coping.
B)Vitamin deficiency.
C)A return of the stomach cancer.
D)Metastasis.
392)A client with a long history of chewing tobacco says, "I've been chewing for
years. I'm not going to get cancer." Which of the following would be an appropriate
nursing response? 392) _____
A)"It's not my body."
B)"You are probably one of the lucky ones."
C)"I guess you're right."
D)"Use of smokeless tobacco has been linked to oral cancer."
393)A client who is in need of a radical neck dissection for cancer continues to delay
the surgery. Which of the following nursing diagnoses would best describe the reason
for this client's delay? 393) _____
A)Risk for Ineffective Airway Clearance
B)Imbalanced Nutrition: Less than Body Requirements
C)Disturbed Body Image
D)Impaired Verbal Communication
394)A client with peptic ulcer disease says, "I feel so much better now that I've
stopped eating." The nurse realizes that this client is at risk for: 394) _____
A)Pain.
B)Sleep Pattern Disturbance.
C)Imbalanced Nutrition: Less than Body Requirements.
D)Fluid Volume Overload.
395)The nurse learns that an elderly client with ill-fitting dentures has been using an
over-the-counter preparation for a gum sore over the last month. Which of the
following should the nurse instruct this client? 395) _____
A)Continue to use the preparation.
B)Change the preparation.
C)Stop wearing the dentures.
D)Make an appointment to see the physician.
396)A client with nausea says, "I'm tired of taking this medication. All it does is make
me nauseated." Which of the following could the nurse instruct this client? 396)
_____
A)Nothing.
B)Suggest that the client take the medication with a heavy meal.
C)Suggest eating a dry cracker to help with the nausea.
D)Encourage the client to stop taking the medication.
397)The nurse is preparing to instruct a client who is newly-diagnosed with
gastroesophageal reflux disease (GERD) about dietary considerations. Which of the
following should the nurse include in these instructions? (Select all that apply.) 397)
_____
A)"Be sure to eat at least one citrus fruit per day."
B)"Meals should be small and more frequent."
C)"Alcohol should be limited to two drinks per day."
D)"Avoid eating up to three hours before bedtime."
E)"Avoid peppermint."
398)A client who is in the post-gastric surgery stage for cancer is denying that he has
cancer. The nurse should: 398) _____
A)Do not argue with the client, but continue to provide emotional support as needed.
B)Remind the client of the diagnosis.
C)Explain how many people with cancer live long, productive lives.
D)Ask a clinical psychologist to talk with the client.
399)A client who is prescribed lactulose is complaining of "diarrhea with cramps"
throughout most of the day. The nurse realizes that this client is demonstrating: 399)
_____
A)An allergy to the medication.
B)An expected outcome from taking the medication.
C)The need to adjust the dose of the medication.
D)Intolerance of the medication and it should be discontinued.
400)A client tells the nurse that his bowel movements are "weird" in that they look
"soapy" and "smell really bad". The nurse realizes that this client might be
experiencing: 400) _____
A)An obstructed gallbladder. B) Cullen's sign.
C)Turner's sign. D) Steatorrhea.
401)A client is scheduled for extracorporeal shock wave lithotripsy for gallstones.
Which of the following should be included in the care of this client after the
procedure? 401) _____
A)Instruct about the potential for nausea, vomiting, and hematuria postprocedure.
B)Admit to the hospital until the stones have been passed.
C)Nothing.
D)Monitor vital signs for eight hours postprocedure.
402)The family and friends of a liver transplant client is concerned because they have
not been permitted to see the client after the surgery. The nurse realizes that this
means: 402) _____
A)The client is prone to developing an infection and is in isolation.
B)The client's condition is not stable.
C)Nothing. This is a common restriction.
D)The client's condition is critical.
403)The family of a client with acute pancreatitis arrives to the care area with a large
bag of personal items and food. What should the nurse instruct this family about the
care of the client? 403) _____
A)Avoid bringing food to the client.
B)Bring high-calorie foods to support the client's caloric needs.
C)Only bring foods the client requests.
D)Bring fresh fruits.
404)A client comes into the clinic complaining of "gaining weight only in the
stomach". The nurse realizes that this client is exhibiting signs of:
404) _____
A)Esophageal varices. B) Hepatic encephalopathy.
C)Portal hypertension. D) Splenomegaly.
405)The nurse is preparing to instruct a client with pruritis caused by jaundice about
the care of the skin. Which of the following should be included in these instructions?
(Select all that apply.) 405) _____
A)Apply lotion to keep the skin moist.
B)Take another antihistamine if the itching continues.
C)Bathe with hot water.
D)Alcohol-based products work the best.
E)Use soap when bathing.
F)Scratching is permitted.
406)A client who is being evaluated for liver trauma that was sustained in a motor
vehicle accident is found to have a negative peritoneal lavage. The nurse realizes that
this client is demonstrating: 406) _____
A)Clotting factor malfunction. B) No bleeding from the liver.
C)Severe liver lacerations. D) Hematoma formation.
407)During a physical assessment, the nurse learns that a client has pain in the right
shoulder and scapula most evenings after eating dinner. Which of the following
should the nurse ask to further assess these findings? 407) _____
A)"Have you been told you have high blood pressure?"
B)"Have you been restricting your diet?"
C)"Have you changed your exercise program?"
D)"How much water do you drink each day?"
408)A client who is admitted to the hospital with an acutely inflamed gallbladder says,
"I suddenly feel better. The pain was really bad but then it completely stopped." The
nurse should: 408) _____
A)See when the client last received pain medication.
B)Suggest that the client prepare to be discharged.
C)Contact the physician immediately.
D)Do nothing.
409)A client with hepatic cirrhosis begins to bleed. Which of the following should the
nurse anticipate being included in the physician's orders? 409) _____
A)Administer packed red blood cells (PRBCs).
B)Administer vitamin K.
C)Administer nadolol (Corgard).
D)Administer folic acid.
410)While providing care to a client with hepatitis B, the nurse is exposed to this
client's blood. What should the nurse do? 410) _____
A)Report the exposure and prepare to receive immune globulin (IG).
B)Prepare to be treated with interferon.
C)Report the exposure and prepare to receive hepatitis B immune globulin (HBIG).
D)Nothing.
411)A client with hepatitis is complaining of "itchy skin" and "odd colored bowel
movements". The nurse realizes that this client is in which phase of acute hepatitis?
411) _____
A)Posticteric. B) Icteric.
C)Prodromal. D) Preicteric.
412)A client with acute pancreatitis is uncomfortable in bed. Which of the following
positions might improve this client's comfort level? 412) _____
A)Lay on the stomach.
B)Lay flat in bed.
C)Elevate the head 45 degrees.
D)Assist to a standing position and ambulate.
413)A client with acute pancreatitis is being discharged. Which of the following
should the nurse include when providing discharge instructions to this client? 413)
_____
A)Limit smoking. B) A fever is common.
C)Avoid all alcohol. D) Resume a regular diet.
414)Following a motor vehicle accident, a client with injuries to the face is tested for
muscle strength. The nurse determines there is adequate strength of the eyes and
eyelids when the client is able to: 414) _____
A)blink rapidly.
B)follow the nurse's finger movements with eyes.
C)close eyes tightly.
D)keep eyelids closed for 30 seconds.
415)The nurse is preparing a client scheduled for an arthroscopy of the elbow. When
the client asks if there will be any restrictions after the procedure, the nurse explains:
415) _____
A)"You will need to limit range of motion in the joint until the sutures are removed."
B)"The elbow will be kept in a sling for two weeks."
C)"You will need to keep the elbow elevated for one to two days."
D)"There are no restrictions, unless you have a lot of pain."
416)When checking laboratory values on a client recovering from a fracture of the left
femur, the nurse would expect to find which of the following changes? 416) _____
A)a positive antinuclear antibody (ANA)
B)an increase in alkaline phosphatase
431)The nurse planning care for a client who was diagnosed with muscular dystrophy
(MD) needs to remember that: 431) _____
A)The pathophysiology of MD involves muscle degeneration, which affects activities
of daily living.
B)The treatment is daily electrical muscle stimulus.
C)The treatment of MD is aimed at eliminating the cause by identifyng the specific
organisms that cause the muscle infection.
D)The cause is related to a lack of blood supply to nerves.
432)The nurse expects to care for clients most often with which of the following types
of arthritis? 432) _____
A)Rheumatoid arthritis B) Osteoarthritis
C)Ankylosing spondylitis D) Gouty arthritis
433)A 52-year-old client is prescribed raloxifene (Evista) for the treatment of
osteoporosis. The nurse realizes that this drug is used with postmenopausal women,
and that it works by: 433) _____
A)Stimulating osteoblast activity and increasing bone formation.
B)Inhibiting bone breakdown.
C)Inhibiting bone loss.
D)Preventing bone loss by mimicking what estrogen does for bone density.
434)One of the first symptoms of osteoarthritis the nurse expects to note in the
assessment is: 434) _____
A)Crepitus in the joint with movement.
B)Inability to walk long distances due to fatigue.
C)Pain when at rest.
D)Pain and stiffness in one or more joints.
435)The nurse is teaching a 68-year-old female client information about dietary
calcium recommendations. Which dosage should be included in the nurse's teaching?
435) _____
A)750 mg per day B) 1500 mg per day
C)1000 mg per day D) 500 mg per day
436)The nurse is teaching a client who has gout. Which of the following should be
included in the teaching?
436) _____
457) _____
A)acute renal failure B) glomerulonephritis
C)chronic renal failure D) polycystic kidney disease
458)The nurse is giving discharge instructions to a client treated for renal calculi. The
nurse explains that the stones can be prevented in many cases by: 458) _____
A)drinking 8 to 10 glasses of water daily.
B)taking urinary antiseptic agents to prevent urinary tract infections.
C)engaging in frequent aerobic exercise.
D)restricting protein and acid foods in the diet.
459)A client is scheduled for an MRI (magnetic resonance imaging) of the head. Prior
to the procedure the nurse will need to determine if the client: 459) _____
A)has a history of seizures.
B)has had anything to eat in the past 8 hours.
C)has any metallic implants.
D)is allergic to iodine.
460)A client with type 1 diabetes mellitus has a glycosylated hemoglobin level of 8%.
The nurse recognizes that this indicates the client: 460) _____
A)is well controlled in his diet and insulin.
B)has a low hemoglobin level.
C)needs adjustment in diet and/or medication.
D)has not been taking his insulin.
461)When reading a client's history, the nurse notes the client has exopthalmos,
secondary to hyperthyroidism. An assessment finding the nurse expects to see is:
461) _____
A)ecchymotic areas on the trunk.
B)purple striae over the abdomen.
C)a bronze discoloration of the skin.
D)forward protrusion of the eyeballs.
462)A client seen in the clinic is scheduled to have a radioactive iodine (RAI) uptake
test. In preparation for the test, it is important for the nurse to instruct the client to:
462) _____
A)avoid drinking dairy products 24 hours prior to the test.
B)hold any thyroid medications for 2 weeks prior to the test.
B)"You will drink a glucose solution and not eat anything for two hours."
C)"You will have blood drawn two hours after eating a large meal."
D)"Blood is drawn two hours after eating a high carbohydrate meal."
469)A client with myxedema tells the nurse, "I watch what I eat but my cholesterol
continues to go up." An appropriate response for the nurse to make to this client
would be: 469) _____
A)"Maybe you don't realize how much fat is in the foods that you eat."
B)"What are you eating at bedtime?"
C)"It's a normal part of aging."
D)"The thyroid gland malfunction can affect your cholesterol level."
470)A client comes into the emergency department with Addisonian crisis. Which of
the following should the nurse be prepared to administer to assist this client? 470)
_____
A)Intravenous fluids
B)Blood transfusion
C)Warm blankets
D)Thyroid replacement hormone
471)A postoperative parathyroidectomy client has a temperature of 103 degrees F
with a rising systolic blood pressure. What should the nurse do for this client? 471)
_____
A)Apply a cooling blanket.
B)Administer aspirin as prescribed.
C)Nothing. These are normal postoperative findings.
D)Apply ice to the groin.
472)The family of an elderly client with hypothyroidism says, "I try to keep her clean
but she has all of these open areas on her legs and arms." Which of the following
would be appropriate for the nurse to instruct this family? 472) _____
A)"Follow the bath with a rubbing alcohol massage."
B)"Make sure she has a daily bath."
C)"Use firm consistent strokes when bathing."
D)"Use warm water."
473)A client with Cushing's syndrome tells the nurse, "I seem to catch a cold every
couple of weeks." Which of the following nursing interventions would be appropriate
488)The physician orders 10 units regular and 40 units NPH insulin subcutaneously.
The nurse prepares the injection by: 488) _____
A)injecting 40 units air into the NPH, 10 units air into the regular, aspirate 10 units of
regular, then aspirate 40 units NPH.
B)injecting air into the regular, air into the NPH, aspirating the NPH, then aspirating
the regular.
C)aspirating 10 units regular, then aspirating 40 units NPH.
D)injecting air into the regular, aspirating 10 units regular, injecting air into the NPH,
then aspirating 40 units NPH.
489)A diabetic client asks the nurse why it is so important to exercise several times a
week. Which of the following is the best response by the nurse? 489) _____
A)"Exercise helps to increase blood sugar levels, so the body needs less food."
B)"Exercise brings down high sugar levels, so the body needs less food."
C)"Exercise increases the use of insulin in the body, so it requires less insulin."
D)"Exercise helps reduce high ketone levels, so the body stays healthier."
490)A client was diagnosed as having type 2 diabetes and was treated with diet and
exercise. When assisting the client with diet planning, the nurse's instructions include:
490) _____
A)a consistent number of calories are needed each day.
B)no substitutes can be made if using the food exchange plan.
C)the greatest number of calories should be from the protein group.
D)the meal plan can be disregarded if "dietetic" foods are used.
491)A type 1 diabetic was admitted to the emergency room with an elevated
temperature and urinary tract infection. The findings were 31 acetone in the urine and
blood glucose of 654 mg/dL. The nurse recognizes the client is probably experiencing:
491) _____
A)a Somogyi reaction.
B)diabetic ketoacidosis.
C)nonketotic hyperosmolar syndrome.
D)hyperinsulinism.
492)The client who is self-injecting insulin was advised by the nurse to rotate
injection sites because: 492) _____
A)insulin can reach all parts of the body and be used more efficiently.
B)it reduces the danger of nerve damage and decreases absorption.
503)A female client complains about increasing premenstrual symptoms over the past
few years and thinks "something must be wrong". The nurse realizes that this client is
experiencing: 503) _____
A)Normal pattern of premenstrual syndrome.
B)Premenstrual dysphoric disorder.
C)Early menopausal symptoms.
D)Interpersonal relationship difficulties.
504)A female client is diagnosed with "chocolate" cysts. The nurse realizes that these
cysts are caused by: 504) _____
A)Use of oral contraceptives. B) Endometrial overgrowth.
C)Infection. D) Hormone imbalance.
505)A mass is found on a mammogram of a 42-year-old female client. The mass is
diagnosed as a cyst upon ultrasound. The nurse realizes that the best course of action
for this client is: 505) _____
A)Apply warm soaks to the cyst.
B)A surgical biopsy is needed to rule out cancer.
C)Suggest the "watch and wait" approach.
D)Reduce caffeine intake.
506)A 25-year-old female is diagnosed with endometriosis. The nurse should include
which of the following when teaching the client about this disorder? (select all that
apply) 506) _____
A)It can be treated without any long-term effects.
B)If children are desired, pregnancy should occur before the disease progresses.
C)Leaving it untreated will not result in any long-term health issues.
D)Laser ablation and birth control pills are the treatments for this condition.
507)The mother of a 16-year-old female child voices concern to the nurse. The parent
reports that the teen began menstruating at age 14 but has stopped for at least 5
months. Which of the following responses would be most appropriate for the nurse to
make to this mother? 507) _____
A)"Have you noticed any other changes in diet, activity, or weight loss?"
B)"That's normal."
C)"It's probably psychological."
D)"Have you thought about a pregnancy?"
508)A client who is recovering from a complete hysterectomy for endometrial cancer
is concerned that she will not be able to continue a sexual relationship with her
husband because of the related activity intolerance. Which of the following would
assist this client? 508) _____
A)Suggest that she discuss her fears with a marriage counselor.
B)Suggest that she and her husband coordinate sexual activity with rest periods and
pain-free periods.
C)Remind her that she has successfully survived cancer surgery.
D)Suggest other activities to participate with her spouse.
509)A client comes into the emergency department with complaints of an erection
that has lasted for more than four hours. Which of the following should the nurse
include in the client's assessment? 509) _____
A)Number of sexual partners
B)Use of medications for erectile dysfunction
C)Blood pressure
D)Substance abuse
510)A client who is complaining of heaviness in his scrotum has learned that his
serum lactic acid dehydrogenase level is normal. This information indicates that the
client: 510) _____
A)Needs more diagnostic tests for testicular cancer.
B)Has testicular cancer.
C)Does not have testicular cancer.
D)Has a spermatocele.
511)A 55-year-old client with a history of angina and is being treated with
nitroglycerin asks for a prescription to aid with erectile dysfunction. Which of the
following should be done to assist this client? 511) _____
A)Suggest a behavioral health consult to analyze the reason for the erectile
dysfunction.
B)Explain why the erectile dysfunction medication is not a good idea with the heart
medication.
C)Provide education about the medication once the prescription is provided.
D)Remind the client to stop taking the heart medication when planning to take the
erectile dysfunction medication.
512)A client was diagnosed with benign prostatic hypertrophy. The nurse realizes that
the blood pressure measurement of this client will be beneficial to determine: 512)
_____
A)The dose of finasteride (Proscar).
B)If the client can tolerate doxazosin mesylate (Cardura).
C)The volume of urine being retained in the bladder.
D)If surgery is indicated.
513)A client is recovering from a penile implant procedure. Which of the following
should be included in the care of, and teaching about, the implant? (Select all that
apply.) 513) _____
A)Suggest wearing snug-fitting underwear and loose-fitting trousers to conceal the
semi-erection.
B)Suggest wearing loose-fitting underwear.
C)Encourage the client to practice inflating and deflating the device during the
recovery period.
D)Remind the client to not inflate or deflate the device for at least 4 weeks.
E)Encourage the client to resume sexual activity within 3 weeks.
514)A male client is concerned about ongoing premature ejaculation. Which of the
following can the nurse do to assist this client? 514) _____
A)Review any newly-prescribed medications, and check for side effects.
B)Tell the client that the condition is temporary and will disappear in time.
C)Suggest that the client wear a condom with sexual activity.
D)Suggest that the client talk with the physician about medication choices.
515)The nurse is instructing a client with benign prostatic hypertrophy about
techniques to reduce urinary retention. These instructions should include: 515) _____
A)Urinate until all of the urine is drained from the bladder.
B)Over-the-counter cold remedies are permitted with other medications.
C)Avoid alcoholic beverages.
D)Encourage ingesting large amounts of fluids at one time.
516)A male client who presents with the complaint of a "swollen" scrotum is found to
have fluid within his scrotum. The nurse realizes that this finding is consistent with a:
516) _____
A)Variocele. B) Scrotal cancer.
C)Spermatocele. D) Hydrocele.
517)The nurse is planning instructions for a client diagnosed with prostatitis. Which
of the following should be included in these instructions? (Select all that apply.) 517)
_____
A)Adhere to a daily bowel movement regime.
B)Withhold voiding for as long as possible.
C)Only take antibiotics when symptoms are present.
D)Remind the client that the condition does not cause cancer.
E)Increase fluid intake up to 3 liters per day.
518)A client is diagnosed with asymptomatic inflammatory prostatitis. The nurse
realizes that this diagnosis was made: 518) _____
A)According to the client's symptoms.
B)After palpating the client's prostate gland.
C)After examining prostate tissue.
D)By testing the serum PSA (prostate-specific antigen) level.
519)A male client reports concern about his recent increase in breast tissue. The nurse
can best assist this client by: 519) _____
A)Recommending a breast biopsy to find out the reason for the increase in breast
tissue.
B)Suggesting that the client has a mammogram to ensure he does not have breast
cancer.
C)Telling him that it is self-limiting and will go away in time.
D)Reviewing the client's health history.
520)A male client is diagnosed with stage 1 testicular cancer. The nurse realizes that
the first step in the treatment for this client is: 520) _____
A)Surgical removal of the testicle.
B)Radiation.
C)Chemotherapy.
D)Aspiration of the enlarged testicle.
521)A male client with type I diabetes mellitus and coronary artery disease is able to
achieve an erection but cannot maintain it. Which of the following could be done to
assist this client? 521) _____
A)Provide tadalafil (Cialis) teaching material.
B)Suggest an "O" ring.
527)A male client is "relieved" to learn that he has a sexually transmitted disease and
is not HIV positive. Which of the following would be an appropriate response for the
nurse to make to this client? 527) _____
A)"I told you not to be concerned."
B)"You would know if you had HIV."
C)"Having a sexually transmitted disease does predispose the body to be infected with
HIV if exposed to the virus."
D)"You are lucky."
528)A female client is seen for a new onset of blisters on the labia majora. The nurse
realizes that this client is experiencing: 528) _____
A)A drug reaction.
B)Latency period of the herpes virus infection.
C)Prodromal symptoms of the herpes virus.
D)First episode of a herpes virus infection.
529)A female client is having difficulty accepting the diagnosis of a sexually
transmitted disease because she has "been on the pill" for years. Information the nurse
can provide to aid this client is that: 529) _____
A)She possibly needs to change the type of birth control pill being used.
B)Some diseases are virulent and the pill will not protect her.
C)Skipping doses could have caused the disease.
D)Oral contraceptives do not protect against sexually transmitted diseases.
530)A female client complains of a fever and foul-smelling vaginal discharge. Upon a
gynecological examination, the client has pain when the cervix is palpated. The nurse
realizes that this client should have a diagnostic test for: 530) _____
A)Syphilis.
B)Ectopic pregnancy.
C)Yeast infection.
D)Many sexually transmitted diseases.
531)A female client who was just diagnosed with a sexually transmitted disease is
beginning treatment. The nurse should remind the client to: 531) _____
A)Inform all sexual partners about the diagnosis so they can also be treated.
B)Be pleased that she was not diagnosed with HIV.
C)Avoid all sexual activity in the future.
C)Erythromycin (Erythrocin).
D)Amoxicillin (Amoxil).
538)A female client has the complaint of a 'weird rash" on her hands and feet. Which
of the following should the nurse include in the care of this client? (Select all that
apply.) 538) _____
A)Ask the client if she uses a public gym for working out.
B)Ask if the client has experienced a foul-smelling vaginal discharge.
C)Conduct a complete sexual history assessment.
D)Ask the client how long the rash has been present.
E)Find out if the client has experienced a chancre sore on her mouth or genital area.
539)A client is admitted with third-degree burns of the upper arms and chest. When
assessing the client, the nurse will expect the skin to be: 539) _____
A)bluish-purple with blisters.
B)reddened and covered with blisters.
C)diffusely bright red and swollen.
D)white with patches of blackened skin.
540)While bathing an elderly client, the nurse observes the presence of various
age-related skin changes. Which of the following skin changes should be of concern
to the nurse? 540) _____
A)seborrheic keratosis B) actinic keratosis
C)senile lentigines D) skin tags
541)A client has a patch test done to determine degree of allergic reaction to
suspected allergens. After the patches are applied the nurse instructs the client to:
541) _____
A)return in 1 week to have skin reactions assessed.
B)return in 48 hours to have the patches removed.
C)avoid contact with anyone else for 48 hours.
D)leave patches on until they fall off on their own.
542)When assessing a client of African American descent for jaundice, the nurse
should check the: 542) _____
A)sclera.
B)mucous membranes of the mouth.
C)palms of the hands.
D)abdomen.
543)A client seen in the clinic is being evaluated for a scabies infection. To confirm
the diagnosis, the nurse informs the client he will need to have which of the following
tests performed? 543) _____
A)skin scraping B) patch test
C)Tzank test D) Wood's light examination
544)The nurse observes that a client has a deep, irregularly shaped area of skin loss
extending into the dermis on the lower extremity. The nurse documents that the client
has: 544) _____
A)a fissure. B) a wheal.
C)a macule. D) an ulcer.
545)A client recently started on steroids has been reading about the medication and
asks the nurse: "The book says I could have hirsutism as a side effect. How will I
know if this happens?" The nurse explains: 545) _____
A)"You will notice a pinpoint red rash on your chest."
B)"Your breasts will become enlarged and swollen."
C)"Your hair will start to come out in clumps."
D)"You will notice excess facial and body hair."
546)When performing an assessment of the integumentary system on a client, the
nurse should: 546) _____
A)palpate for edema over the knee.
B)inspect inside of the mouth for skin tags.
C)check color, quantity, and distribution of hair.
D)check for skin turgor on the forearm.
547)Which of the following assessment findings on an African American client
should be reported to the primary nurse? 547) _____
A)a pustule on the right hand
B)red splinter hemorrhages on the nails
C)pigmented bands on the fingernails
D)keloid formation over an appendectomy scar
548)The nurse is assisting in the collection of fluid from a client's blister. The nurse
explains the specimen will be sent for a Tzanck test, which is done to: 548) _____
554)The nurse is preparing to cleanse a pressure ulcer over the sacrum of a client. The
nurse chooses which of the following solutions? 554) _____
A)normal saline solution B) povidone-iodine (Betadine)
C)Dakin's solution D) hydrogen peroxide
555)A dark-skinned client was admitted in respiratory distress. When planning to
assess for cyanosis the nurse recognizes that: 555) _____
A)cyanosis will blanch with direct pressure to the soles of the feet in dark-skinned
clients.
B)cyanosis in clients with dark skin will need to be checked.
C)it is not possible to assess color changes in clients with dark skin.
D)cyanosis can be seen on the lips and mucous membranes of clients with dark skin.
556)After turning a bedridden client from her side to her back, the nurse observes that
the area over the trochanter is red and does not blanch with finger pressure. The nurse
should document this observation as: 556) _____
A)ischemia. B) a stage I pressure ulcer.
C)eschar. D) hyperemia.
557)A female client with acne vulgaris is given a prescription for Retin-A. The client
should be instructed to: 557) _____
A)avoid chocolate, cola drinks, and peanuts.
B)increase intake of vitamin A and calcium.
C)do not take if pregnant and limit exposure to sunlight.
D)take larger doses if acne gets worse before menstrual periods.
558)A client has been treated for pediculosis capitis and is concerned about spreading
the infestation. The nurse explains that it can be spread: 558) _____
A)through sexual activity.
B)by sharing drinks and eating utensils.
C)by sharing personal hygiene items.
D)through your clothing and bed linens.
559)During the acute stage of burns, nursing interventions should focus on: 559)
_____
A)treatment of respiratory distress.
B)prevention of contractures.
C)application of topical antimicrobial agents.
D)assessment of shock.
560)The client told the nurse that he was thankful that the burns were not bad since
they did not hurt much. The best response by the nurse would be: 560) _____
A)"Your burns are pretty deep and have destroyed some of the pain receptors."
B)"Yes, you are fortunate not have a lot of pain"
C)"I'm glad you have such a positive attitude; it's going to be helpful during your
recovery."
D)"I'm afraid you are mistaken. These are severe burns."
561)A burn client experiences excessive fluid in the interstitial spaces causing edema.
Because the fluid accumulation impairs peripheral circulation, the nurse assesses the
client for which of the following complications? 561) _____
A)tissue necrosis B) increased diuresis
C)increase in cardiac output D) impaired mobility
562)Before applying mafenide acetate (Sulfamylon) to a client's burns, the nurse
should plan to: 562) _____
A)check client for allergies to codeine.
B)wear protective clothing to avoid staining.
C)premedicate client with pain medication.
D)have client wear a facial mask.
563)A 42-year-old client was admitted with second- and third-degree burns over 45%
of the body. The nurse identifies the initial goal in treatment for these burns as: 563)
_____
A)preventing scarring and infection.
B)preventing hemorrhage and shock.
C)preventing dehydration and infection.
D)combating shock and preventing infection.
564)A client with first- and second-degree burns of the cheek was very concerned
about permanent damage. The nurse might focus the client teaching on: 564) _____
A)prevention of infection to reduce scarring.
B)scrubbing the burned area daily to promote new skin growth.
C)use of plastic surgery to relieve scarring.
D)use of vitamin E to prevent scarring.
565)The nurse is observing a client with major burn injuries for signs of Curling's
ulcer, a common complication. The nurse should assess the client for: 565) _____
A)frequent headaches.
B)hypertension.
C)black, tarry stools.
D)purulent drainage from wound sites.
566)The nurse plans interventions knowing the client with first-degree burns over a
large part of her body surface may experience symptoms such as: 566) _____
A)dehydration and thirst.
B)headache, chills, nausea, and vomiting.
C)chest pain and dyspnea.
D)pain and temporary memory loss.
567)The nurse notices that the burn client develops a dysrhythmia. The nurse
recognizes that the probable cause of this complication is: 567) _____
A)increased cardiac output.
B)increase of intracellular magnesium ions.
C)loss of potassium ion related to cell injury.
D)decrease in sodium levels related to diuresis.
568)The nurse admits a severely burned client who is unconscious, dyspneic, and
cyanotic. The blood test shows decreased levels of oxyhemoglobin, which occur
secondary to: 568) _____
A)cardiac arrest. B) carbon monoxide poisoning.
C)pulmonary collapse. D) smoke inhalation.
569)A client is admitted with trauma to the integumentary system. Which of the
following are types of skin trauma? (Select all that apply.) 569) _____
A)Laceration B) Cutaneous
C)Contusion D) Abrasion
570)The nurse suspects that a client is a victim of abuse. Which of the following
would provide this indication to the nurse? 570) _____
A)Spontaneously moving all four extremities
B)Caring attitude between client and spouse
C)Evidence of adequate hydration
D)Injuries that do not correlate with the client's story of the injury
571)A client is going to be evaluated for brain death. Which of the following
diagnostic tests will need to be done to make this evaluation? 571) _____
A)Chest x-ray B) EKG
C)Serum carbon dioxide level D) EEG
572)A trauma client needs whole blood transfusions and has a blood type of AB+.
The nurse realizes that this client will need to receive which type of blood? 572)
_____
A)Any type. B) O+ only
C)AB+ only D) AB- only
573)A client is diagnosed as being in the warm phase of septic shock. The nurse will
expect to see which of the following signs and symptoms in this client? 573) _____
A)Hypotension
B)Tachycardia
C)Alert and anxious
D)Urine output less than 30 cc per hour
574)A trauma client has multiple injuries and has lost approximately 25% of
circulating blood volume. The nurse realizes that this client is in which stage of shock?
574) _____
A)Stage III B) Stage I C) Stage II D) Stage IV
575)A trauma client in Stage II shock is demonstrating signs of pulmonary edema.
The nurse realizes that this client is demonstrating: 575) _____
A)Heart failure. B) SARs.
C)ARDS. D) Respiratory acidosis.
576)A client is brought into the emergency department with multiple stab wounds.
The nurse realizes that these wounds can be classified as being: 576) _____
A)Intentional B) Related to disease process
C)Accidental D) Unintentional
577)The nurse is determining a client's cardiac output. Which of the following
equations can the nurse use to make this assessment? 577) _____
A)Systolic blood pressure x heart rate
I hope I don't faint this time." The nurse should take the following action: 592)
_____
A)Have another nurse present.
B)Be sure to have aromatic spirits available.
C)Ensure client is in a recumbent position.
D)Keep client distracted while drawing the blood.
593)The nurse initially employs which of the following nursing interventions to
reduce anxiety in a client demonstrating severe anxiety? 593) _____
A)Allow client to be alone in a quiet environment.
B)Ask the client to verbalize his feelings.
C)Instruct client to do deep-breathing exercises.
D)Encourage client to identify the source of the anxiety.
594)The nurse instructs a client being started on a SSRI for possible side effects. The
nurse explains that the most frequent side effects include: 594) _____
A)postural hypotension and diarrhea.
B)cardiac arrhythmias and postural hypotension.
C)headaches, nausea, and insomnia.
D)urinary retention, dry mouth, and drowsiness.
595)A client is seen in the emergency department complaining of sudden onset of a
throbbing headache. The client is taking a monoamine oxidase inhibitor (MAOI) and
admits to having eaten a lot of aged cheese recently. The nurse should assess the
client for which other symptoms? 595) _____
A)stiff neck B) diaphoresis
C)abdominal cramping D) hypotension
596)The nurse is caring for a client with bipolar disorder who is experiencing a manic
episode. To assist the client in reducing the hyperactive behavior, the nurse should
plan to do which of the following? 596) _____
A)Allow the client to set her own limits on behavior.
B)Engage the client in a quiet game of cards or puzzle solving.
C)Encourage the client to get involved in a game of volleyball.
D)Provide a calm, quiet area for client to sit or walk around in.
597)A client who was experiencing symptoms of early lithium toxicity has had the
dosage of medication reduced. The nurse determines the dosage reduction was
602)A client being treated for depression with a selective serotonin reuptake inhibitor
(SSRI) becomes agitated, diaphoretic, and complains of muscle spasms and tremors.
The client's sister confides to the nurse her sister has been taking St. John's wort daily
for the last 6 months. Which of the following actions should be taken by the nurse?
602) _____
A)Withhold any scheduled doses of the SSRI and notify the physician.
B)Have the laboratory draw blood work for a serotonin level.
C)Ask the client to give the St. John's wort tablets to the staff.
D)Discuss the dangers of taking over-the-counter herbal preparations with the client.
603)A client confides in the nurse that he is going to kill himself. Which of the
following questions should the nurse ask the client? 603) _____
A)"What has happened to make you feel this way?"
B)"Have you ever attempted suicide before?"
C)"How will you kill yourself?"
D)"Do you think this will solve your problems?"
604)In planning the care of a postoperative client who uses caffeine and nicotine in
large quantities, the nurse may want to observe for signs and symptoms of: 604)
_____
A)physical and psychological withdrawal.
B)lower pain threshold.
C)cardiac arrhythmias.
D)depression.
605)A client who has a history of amphetamine abuse comes to the clinic and informs
the nurse she has stopped taking all drugs. To ensure the client's safety, the nurse
informs her withdrawal from amphetamines can cause: 605) _____
A)nausea and vomiting.
B)lethargy and depression.
C)an extreme increase in appetite.
D)life-threatening respiratory depression.
606)The nurse working with clients who have a history of substance abuse
understands that a major reason they are not readily identified or do not seek help
from health professionals is: 606) _____
A)fear of health interventions against their will.
B)fear that family members will reject them.
_____
A)make a decision about their care.
B)be free from self-harm.
C)improve social skills.
D)refrain from harming others.
618)When caring for a client with a Dependent Personality Disorder, the nurse plans
nursing interventions based on the knowledge that the client: 618) _____
A)has an unrealistic fear of abandonment.
B)has an inflated sense of self-importance.
C)will frequently display attention-seeking behaviors.
D)often engages in self-harm activities.
619)A client admitted with Paranoid Personality Disorder insists the food is
contaminated with pesticides. Which of the following communication techniques
should the nurse plan to use to encourage the client to eat? 619) _____
A)Describe how the food is prepared at the institution.
B)Ask client open-ended questions and sit with client.
C)Encourage identification of foods preferred by the client.
D)Identify reasons why the client should eat.
620)A client with an obsessive compulsive personality tells the nurse, "I become so
anxious and stressed and then I start my compulsive ritual. I wish I could stop it." To
help the client reduce the anxiety, the nurse offers the following suggestions: 620)
_____
A)"Keep distracted by playing the television and radio loudly."
B)"Make a list of things that provoke anxiety for you."
C)"Set a rigid timetable of your daily schedule."
D)"Hold an ice cube in each hand for ten minutes when you are tempted to do a
ritual."
621)The nurse is doing group therapy with a group of clients on a mental health unit.
The nurse determines that a client with Schizotypal Personality Disorder is displaying
an inappropriate affect when the client: 621) _____
A)sits off to the side and refuses to participate.
B)cries when another client tells a silly joke.
C)rocks back and forth in the chair throughout the meeting.
D)sings loudly while the other clients are trying to talk.
622)A client with a Histrionic Personality Disorder is admitted to the mental health
unit. The nurse expects the client will display which of the following behaviors?
622) _____
A)being the center of attention
B)impulsive and frequently aggressive with others
C)hostile and suspicious of others
D)detachment from staff and other clients
623)When developing a plan of care for the client with Paranoid Personality Disorder,
the nurse recognizes that a hallmark of the disorder is the client's: 623) _____
A)difficulty with interpersonal relationships.
B)violation of the rights of others.
C)impulsive behavior.
D)preoccupation with delusions of persecution.
1)D
2)A
3)B
4)D
5)D
6)D
7)B
8)C
9)B
10)A
11)D
12)B
13)A
14)B
15)B
16)C
17)D
18)A
19)D
20)D
21)D
22)D
23)A, B, D
24)C
25)A
26)A
27)C
28)A
29)A
30)D
31)C
32)B
33)B
34)B
35)B
36)A
37)D
38)B
39)D
40)B
41)10 liters
42)D
43)D
44)D
45)B
46)A, B, C
47)A
48)C
49)A
50)C
51)C
52)A
53)C
54)B
55)D
56)B
57)B
58)D
59)A
60)B
61)A
62)A
63)A
64)B
65)D
66)B
67)D
68)A
69)D
70)C
71)B
72)C
73)A
74)B
75)D
76)D
77)C
78)A
79)C
80)B
81)C
82)A
83)B
84)A
85)B
86)A
87)C
88)B
89)C
90)C
91)A
92)A
93)B
94)C
95)D
96)B
97)C
98)C
99)D
100)A
101)A
102)C
103)B
104)D
105)D, E, F
106)A
107)A, C, D
108)B
109)D
110)C
111)B
112)C
113)D
114)C
115)A
116)B
117)D
118)B
119)A
120)A
121)D
122)A
123)D
124)A
125)C
126)B
127)A
128)D
129)D
130)A
131)D
132)C
133)C
134)A
135)D
136)D
137)D
138)A
139)D
140)A
141)A
142)D
143)B
144)D
145)A
146)A, B, C
147)D
148)D
149)B
150)C
151)C
152)D
153)A
154)B
155)B
156)D
157)A
158)C
159)B
160)A
161)A
162)B
163)D
164)B
165)A
166)A
167)B
168)B
169)B
170)B
171)A
172)C
173)D
174)B
175)C
176)C
177)C
178)D
179)B
180)B
181)B
182)C
183)A
184)B
185)C
186)A
187)D
188)C
189)D
190)D
191)D
192)D
193)A
194)B
195)A
196)B, C, D
197)C, D
198)D
199)D
200)A
201)D
202)D
203)A
204)C
205)A
206)C, D, E
207)D
208)C
209)A
210)A
211)A, B
212)C
213)A, C
214)A, B
215)C, D
216)C
217)D
218)D
219)C
220)C
221)D
222)B
223)B
224)B
225)B
226)C
227)A
228)C
229)C
230)D
231)B
232)C
233)C
234)B
235)B
236)D
237)D
238)A
239)D
240)C
241)B
242)B
243)C
244)A
245)A
246)D
247)D
248)A
249)C
250)A
251)B
252)A
253)A
254)A, B
255)B
256)A
257)A
258)C
259)B
260)B
261)D
262)A
263)B
264)B
265)A
266)D
267)A
268)A, B, D
269)C
270)D
271)B
272)A, B, C
273)A
274)A, B, D
275)D
276)D
277)A
278)A, C, D
279)D
280)B
281)D
282)2, 1, 4, 3
283)A, B, C
284)B
285)B
286)D
287)A
288)D
289)C
290)D
291)D
292)C
293)D
294)A
295)A
296)4, 2, 1, 3
297)B
298)B
299)A
300)A, B, C
301)D
302)A
303)B
304)4, 2, 3, 1
305)B
306)B
307)C
308)B
309)C
310)B
311)C
312)B
313)B
314)B
315)B
316)B
317)B
318)D
319)C
320)D
321)A
322)A
323)D
324)D
325)B
326)D
327)D
328)C
329)D
330)C
331)D
332)A
333)B
334)A, C, E
335)A
336)C
337)A
338)A
339)C
340)C
341)D
342)D
343)A, C
344)D
345)C
346)C
347)A
348)C
349)C
350)C
351)C
352)A, D
353)D
354)B
355)B
356)B
357)C
358)A
359)B, D
360)A
361)A
362)D
363)C
364)D
365)C
366)A
367)A
368)B
369)A
370)D
371)C
372)C
373)B
374)B
375)D
376)A
377)A
378)B
379)C
380)D
381)A
382)B
383)D
384)C
385)A
386)B
387)C
388)A
389)B
390)D
391)B
392)D
393)C
394)C
395)D
396)C
397)B, D, E
398)A
399)C
400)D
401)A
402)C
403)A
404)C
405)A
406)B
407)B
408)C
409)A
410)C
411)B
412)C
413)C
414)C
415)C
416)B
417)A
418)B
419)C
420)C
421)A
422)A
423)B
424)D
425)B
426)C
427)A
428)B
429)C
430)A
431)A
432)B
433)D
434)D
435)B
436)D
437)C
438)B
439)B
440)D
441)C
442)D
443)D
444)C
445)C
446)C
447)B
448)D
449)A
450)A
451)D
452)C
453)C
454)C
455)B
456)D
457)A
458)A
459)C
460)C
461)D
462)B
463)D
464)D
465)A
466)C
467)D
468)B
469)D
470)A
471)A
472)D
473)A
474)D
475)C
476)D
477)C
478)A, C, E, F
479)C
480)A
481)C
482)C
483)A
484)A
485)D
486)A
487)A
488)A
489)C
490)A
491)B
492)D
493)B
494)A
495)A
496)B, C, E
497)C
498)D
499)A
500)D
501)C
502)D
503)A
504)B
505)B
506)B, D
507)A
508)B
509)B
510)A
511)B
512)B
513)A, C
514)C
515)C
516)D
517)A, D, E
518)C
519)D
520)A
521)B
522)B
523)B
524)A
525)D
526)B
527)C
528)D
529)D
530)D
531)A
532)D
533)A
534)B
535)B
536)C
537)B
538)C, D, E
539)D
540)B
541)B
542)A
543)A
544)D
545)D
546)C
547)A
548)D
549)D
550)D
551)B
552)D
553)C
554)A
555)D
556)B
557)C
558)C
559)C
560)A
561)A
562)C
563)D
564)A
565)C
566)B
567)C
568)B
569)A, C, D
570)D
571)D
572)A
573)C
574)B
575)C
576)A
577)C
578)A
579)B
580)D
581)D
582)B, C, D
583)D
584)B
585)B
586)A
587)B
588)C
589)C
590)B
591)A
592)C
593)C
594)C
595)A
596)D
597)C
598)C
599)A
600)D
601)C
602)A
603)C
604)A
605)B
606)C
607)C
608)A
609)B
610)A
611)B
612)C
613)A
614)D
615)B
616)A
617)C
618)A
619)B
620)B
621)B
622)A
623)A