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A 20-year-old female client calls the nurse to report a lump she

found in her breast. Which response is the best for the nurse to
provide?
A) Check it again in one month, and if it is still there schedule an
appointment.
B) Most lumps are benign, but it is always best to come in for an
examination.
C) Try not to worry too much about it, because usually, most lumps
are benign.
D) If you are in your menstrual period it is not a good time to check
for lumps.

A 32-year-old female client complains of severe


abdominal pain each month before her menstrual
period, painful intercourse, and painful defecation.
Which additional history should the nurse obtain
that is consistent with the client's complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
C) Premenstrual syndrome.
D) Chronic use of laxatives.

A 46-year-old female client is admitted for acute


renal failure secondary to diabetes and hypertension.
Which test is the best indicator of adequate
glomerular filtration?
A) Serum creatinine.
B) Blood Urea Nitrogen (BUN).
C) Sedimentation rate.
D) Urine specific gravity.

B) Most lumps are benign, but it is always best to come in


for an examination.
(B) provides the best response because it addresses the
client's anxiety most effectively and encourages prompt
and immediate action for a potential problem. (A)
postpones treatment if the lump is malignant, and does
not relieve the client's anxiety. (C and D) provide false
reassurance and do not help relieve anxiety.

B) Inability to get pregnant.


Dysmenorrhea, dyspareunia, and difficulty or painful defecation
are common symptoms of endometriosis, which is the abnormal
displacement of endometrial tissue in the dependent areas of the
pelvic peritoneum. A history of infertility (B) is another common
finding associated with endometriosis. Although (A, C, and D) are
common, nonspecific gynecological complaints, the most common
complaints of the client with endometriosis are pain and infertility.

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

B) Discuss perimenopause and related comfort measures.


A 49-year-old female client arrives at the clinic for an annual exam
and asks the nurse why she becomes excessively diaphoretic and
feels warm during nighttime. What is the nurse's best response?
A) Explain the effect of the follicle-stimulating and luteinizing
hormones.
B) Discuss perimenopause and related comfort measures.
C) Assess lung fields and for a cough productive of blood-tinged
mucous.
D) Ask if a fever above 101 F has occurred in the last 24 hours.

A 51-year-old truck driver who smokes two packs of


cigarettes a day and is 30 pounds overweight is
diagnosed with having a gastric ulcer. What content
is most important for the nurse to include in the
discharge teaching for this client?
A) Information about smoking cessation.
B) Diet instructions for a low-residue diet.
C) Instructions on a weight-loss program.
D) The importance of increasing milk in the diet.

The perimenopausal period begins about 10 years before


menopause with the cessation of menstruation at the average ages
of 52 to 54. Lower estrogen levels causes FSH and LH secretion in
bursts (surges), which triggers vasomotor instability, night sweats,
and hot flashes, so discussions about the perimenopausal body's
changes, comfort measures (B), and treatment options should be
provided. In-depth pathophysiology of the symptoms (A) may only
confuse the client. There is no indication that the client has
tuberculosis and an infection, so (C and D) are not indicated.

A) Information about smoking cessation.


Smoking has been associated with ulcer formation, and stopping
or decreasing the number of cigarettes smoked per day is an
important aspect of ulcer management (A). Diet management
includes a reduction in high-fiber/high-roughage foods as well as
spicy foods. (B) would be indicated for inflammatory bowel disease.
Sodium and caloric intake are not the key elements in an ulcer diet.
Although this client does need (C), the management of his ulcer is
the key factor at this point. (D) would actually increase gastric acid
production.

A 57-year-old male client is scheduled to have a stress-thallium test the


following morning and is NPO after midnight. At 0130, he is agitated
because he cannot eat and is demanding food. Which response is best
for the nurse to provide to this client?
A) I'm sorry sir, you have a prescription for nothing by mouth from
midnight tonight.
B) I will let you have one cracker, but that is all you can have for the rest
of tonight.
C) What did the healthcare provider tell you about the test you are
having tomorrow?
D) The test you are having tomorrow requires that you have nothing by
mouth tonight.

D) The test you are having tomorrow requires that you have nothing by
mouth tonight.
(D) is the most therapeutic statement because the nurse is responding
to the client's question. (A) is not an explanation and the nurse should
teach the client why eating is prohibited after midnight, rather than
enforcing this requirement without an explanation for it. (B) may result
in an inaccurate test result, or may cause the test to be cancelled, which
could also delay diagnosis and treatment. (C) defers the responsibility
for answering the client's question to the healthcare provider, when the
nurse could address the situation through client teaching.

A 58-year-old client who has been post-menopausal for five years


is concerned about the risk for osteoporosis because her mother
has the condition. Which information should the nurse offer?
A) Osteoporosis is a progressive genetic disease with no effective
treatment.
B) Calcium loss from bones can be slowed by increasing calcium
intake and exercise.
C) Estrogen replacement therapy should be started to prevent the
progression osteoporosis.
D) Low-dose corticosteroid treatment effectively halts the course of
osteoporosis.

B) Calcium loss from bones can be slowed by increasing calcium intake and
exercise.

A 58-year-old client, who has no health problems, asks the nurse


about the Pneumovax vaccine. The nurse's response to the client
should be based on which information?
A) The vaccine is given annually before the flu season to those over
50 years of age.
B) The immunization is administered once to older adults or
persons with a history of chronic illness.
C) The vaccine is for all ages and is given primarily to those
persons traveling overseas to areas of infection.
D) The vaccine will prevent the occurrence of pneumococcal
pneumonia for up to five years.

B) The immunization is administered once to older adults or persons


with a history of chronic illness.

A 67-year-old woman who lives alone is admitted after


tripping on a rug in her home and fractures her hip.
Which predisposing factor probably led to the fracture in
the proximal end of her femur?
A) Failing eyesight resulting in an unsafe environment.
B) Renal osteodystrophy resulting from chronic renal
failure.
C) Osteoporosis resulting from hormonal changes.
D) Cardiovascular changes resulting in small strokes
which impair mental acuity.
A 77-year-old female client is admitted to the hospital.
She is confused, has no appetite, is nauseated and
vomiting, and is complaining of a headache. Her pulse
rate is 43 beats per minute. Which question is a priority
for the nurse to ask this client or her family on
admission? "Does the client
A) have her own teeth or dentures?"
B) take aspirin and if so, how much?"
C) take nitroglycerin?"
D) take digitalis?"

Post-menopausal females are at risk for osteoporosis due to the cessation of


estrogen secretion, but a regimen including calcium, vitamin D, and weightbearing exercise can prevent further bone loss (B). Osteoporosis can be
managed with conservative therapy, such as bone metabolism regulators and
estrogen replacement therapy (ERT) to improve bone density, but it is not a
genetic disease (A). Although ERT is effective in managing osteoporosis, an
increased risk for cancer and heart disease should be considered for individual
clients. Corticosteroid therapy promotes bone resorption and is
counterproductive in maintaining or increasing bone density (D).

It is usually recommended that persons over 65 years of age and those


with a history of chronic illness receive the vaccine once in a lifetime
(B). (Some resources recommend obtaining the vaccine at 50 years of
age.) The influenza vaccine is given once a year, not the Pneumovax (A).
Although the vaccine might be given to a person traveling overseas, that
is not the main rationale for administering the vaccine (C). It is usually
given once in a lifetime (D), but with immunosuppressed clients or
clients with a history of pneumonia re-vaccination is sometimes
required.

C) Osteoporosis resulting from hormonal changes.


The most common cause of a fractured hip in elderly women is
osteoporosis, resulting from reduced calcium in the bones as a
result of hormonal changes in later life (C). (A) may or may not
have contributed to the accident, but it had nothing to do with the
hip being involved. (B) is not a common condition of the elderly; it
is common in chronic renal failure. (D) may occur in some people,
but does not affect the fragility of the bones as osteoporosis does.

D) take digitalis?"
Elderly persons are particularly susceptible to digitalis
intoxication (D) which manifests itself in such symptoms
as anorexia, nausea, vomiting, diarrhea, headache, and
fatigue. Although it is important to obtain a complete
medication history (B and C), the symptoms described
are classic for digitalis toxicity, and assessment of this
problem should be made promptly. (A) is irrelevant.

An 81-year-old male client has emphysema. He lives at home with his


cat and manages self-care with no difficulty. When making a home visit,
the nurse notices that his tongue is somewhat cracked and his eyeballs
are sunken into his head. What nursing intervention is indicated?
A) Help the client to determine ways to increase his fluid intake.
B) Obtain an appointment for the client to see an ear, nose, and throat
specialist.
C) Schedule an appointment with an allergist to determine if the client
is allergic to the cat.
D) Encourage the client to slightly increase his use of oxygen at night
and to always use humidified oxygen.

An adult client is admitted to the hospital burn unit with partialthickness and full-thickness burns over 40% of the body surface area. In
assessing the potential for skin regeneration, what should the nurse
remember about full-thickness burns?
A) Regenerative function of the skin is absent because the dermal layer
has been destroyed.
B) Tissue regeneration will begin several days following return of
normal circulation.
C) Debridement of eschar will delay the body's ability to regenerate
normal tissue.
D) Normal tissue formation will be preceded by scar formation for the
first year.

A) Help the client to determine ways to increase his fluid intake.


The nurse should suggest creative methods to increase the intake of
fluids (A), such as having disposable fruit juices readily available.
Clients with COPD should have at least three liters of fluids a day.
These clients often reduce fluid intake because of shortness of
breath. (B) is not indicated. These symptoms are not indicative of
an allergy (C). Many elderly depend on their pets for socialization
and self-esteem. Humidified oxygen will not relieve these
symptoms and increased oxygen levels will stifle the COPD client's
trigger to breathe (D).

A) Regenerative function of the skin is absent because


the dermal layer has been destroyed.
Full-thickness burns destroy the entire dermal layer.
Included in this destruction is the regenerative tissue.
For this reason, tissue regeneration does not occur,
and skin grafting is necessary (A). (B, C, and D) are
simply false.

After checking the urinary drainage system for kinks in


the tubing, the nurse determines that a client who has
returned from the post-anesthesia care has a dark,
concentrated urinary output of 54 ml for the last 2 hours.
What priority nursing action should be implemented?
A) Report the findings to the surgeon.
B) Irrigate the indwelling urinary catheter.
C) Apply manual pressure to the bladder.
D) Increase the IV flow rate for 15 minutes.

A) Report the findings to the surgeon.

After the fourth dose of gentamicin sulfate (Garamycin)


IV, the nurse plans to draw blood samples to determine
peak and trough levels. When are the best times to draw
these samples?
A) 15 minutes before and 15 minutes after the next dose.
B) One hour before and one hour after the next dose.
C) 5 minutes before and 30 minutes after the next dose.
D) 30 minutes before and 30 minutes after the next dose.

C) 5 minutes before and 30 minutes after the next dose.

Based on the analysis of the client's atrial


fibrillation, the nurse should prepare the
client for which treatment protocol?
A) Diuretic therapy.
B) Pacemaker implantation.
C) Anticoagulation therapy.
D) Cardiac catheterization.

An adult who weighs 132 pounds (60 kg) should


produce about 60 ml of urine hourly (1 ml/kg/hour).
Dark, concentrated, and low volume of urine output
should be reported to the surgeon. Although other
actions (B, C, and D) may be indicated, the
assessment findings should be reported to the
healthcare provider.

Peak drug serum levels are achieved 30 minutes after IV


administration of aminoglycosides. The best time to draw
a trough is the closest time to the next administration (C).
(A, B, and D) are not as good a time to draw the trough
as (C). (B and D) are not the best times to draw the peak
of an aminoglycoside that has been administered IV.

C) Anticoagulation therapy.
The client is experiencing atrial fibrillation, and the
nurse should prepare the client for anticoagulation
therapy (C) which should be prescribed before
rhythm control therapies to prevent cardioembolic
events which result from blood pooling in the
fibrillating atria. (A, B, and D) are not indicated.

A client experiencing uncontrolled atrial fibrillation


is admitted to the telemetry unit. What initial
medication should the nurse anticipate administering
to the client?
A) Xylocaine (Lidocaine).
B) Procainamide (Pronestyl).
C) Phenytoin (Dilantin).
D) Digoxin (Lanoxin).

A client has a staging procedure for cancer of the


breast and ask the nurse which type of breast cancer
has the poorest prognosis. Which information should
the nurse offer the client?
A) Stage II.
B) Invasive infiltrating ductal carcinoma.
C) T1N0M0.
D) Inflammatory with peau d'orange.

A client has been taking oral corticosteroids for the


past five days because of seasonal allergies. Which
assessment finding is of most concern to the nurse?
A) White blood count of 10,000 mm3.
B) Serum glucose of 115 mg/dl.
C) Purulent sputum.
D) Excessive hunger.

A client has taken steroids for 12 years to help


manage chronic obstructive pulmonary disease
(COPD). When making a home visit, which nursing
function is of greatest importance to this client?
Assess the client's
A) pulse rate, both apically and radially.
B) blood pressure, both standing and sitting.
C) temperature.
D) skin color and turgor.
A client has undergone insertion of a permanent
pacemaker. When developing a discharge teaching
plan, the nurse writes a goal of, "The client will
verbalize symptoms of pacemaker failure." Which
symptoms are most important to teach the client?
A) Facial flushing.
B) Fever.
C) Pounding headache.
D) Feelings of dizziness.

D) Digoxin (Lanoxin).
Digoxin (Lanoxin) (D) is administered for uncontrolled,
symptomatic atrial fibrillation resulting in a decreased
cardiac output. Digoxin slows the rate of conduction by
prolonging the refractory period of the AV node, thus
slowing the ventricular response, decreasing the heart
rate, and effecting cardiac output. (A, B, and C) are not
indicated in the initial treatment of uncontrolled atrial
fibrillation.

D) Inflammatory with peau d'orange.


Inflammatory breast cancer, which has a thickened appearance like an
orange peel (peau d'orange), is the most aggressive form of breast
malignancies (D). Staging classifies cancer by the extension or spread of
the disease, and (A) indicates limited local spread. (B) indicates cancer
cells have spread from the ducts into the surrounding breast tissue only.
TNM classification is used to indicate the extent of the disease process
according to tumor size, regional spread lymph nodes involvement, and
metastasis, and (C) indicates early cancer with small in situ
involvement, no lymph node involvement, and no distant metastases.

C) Purulent sputum.
Steroids cause immunosuppression, and a purulent
sputum (C) is an indication of infection, so this
symptom is of greatest concern. Oral steroids may
increase (A) and often cause (D). (B) may remain
normal, borderline, or increase while taking oral
steroids.

C) temperature.
It is very important to check the client's temperature (C). Infection
is the most common factor precipitating respiratory distress.
Clients with COPD who are on maintenance doses of
corticosteroids are particularly predisposed to infection. (A and B)
are important data for baseline and ongoing assessment, but they
are not as important as temperature measurement for this client
who is taking steroids. Assessment of skin color and turgor is less
important (D).

D) Feelings of dizziness.
Feelings of dizziness may occur as the result of a
decreased heart rate, leading to decreased cardiac
output (D). (A and C) will not occur as the result of
pacemaker failure. (B) may be an indication of
infection postoperatively, but is not an indication of
pacemaker failure.

A client is admitted for further testing to confirm


sarcoidosis. Which diagnostic test provides definitive
information that the nurse should report to the
healthcare provider?
A) Lung tissue biopsy.
B) Positive blood cultures.
C) Magnetic resonance imaging (MRI).
D) Computerized tomography (CT) of the thorax.

A client is admitted to the hospital with a diagnosis


of severe acute diverticulitis. Which assessment
finding should the nurse expect this client to exhibit?
A) Lower left quadrant pain and a low-grade fever.
B) Severe pain at McBurney's point and nausea.
C) Abdominal pain and intermittent tenesmus.
D) Exacerbations of severe diarrhea.

A client is admitted to the hospital with a medical diagnosis of


pneumococcal pneumonia. The nurse knows that the prognosis for
gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas,
and Proteus) is very poor because
A) they occur in the lower lobe alveoli which are more sensitive to
infection.
B) gram-negative organisms are more resistant to antibiotic therapy.
C) they occur in healthy young adults who have recently been
debilitated by an upper respiratory infection.
D) gram-negative pneumonias usually affect infants and small children.

A client is admitted to the medical intensive care unit


with a diagnosis of myocardial infarction. The client's
history indicates the infarction occurred ten hours
ago. Which laboratory test result should the nurse
expect this client to exhibit?
A) Elevated LDH.
B) Elevated serum amylase.
C) Elevated CK-MB.
D) Elevated hematocrit.

A) Lung tissue biopsy.


Sarcoidosis is an inflammatory condition that is characterized by
the formation of widespread granulomatous lesions involving a
pulmonary primary site. Although chest radiography identifies
sarcoidosis, lung tissue biopsy (A) obtained by bronchoscopy or
bronchoalveolar lavage provides definitive confirmation. (B) does
not provide results for sarcoidosis. Although MRI and CT identify
pulmonary lesions, the (C and D) are not necessary and do not
provide definitive confirmation.

A) Lower left quadrant pain and a low-grade fever.


Left lower quadrant pain occurs with diverticulitis
because the sigmoid colon is the most common area
for diverticula, and the inflammation of diverticula
causes a low-grade fever (A). (B) would be indicative
of appendicitis. (C and D) are symptoms exhibited
with ulcerative colitis.

B) gram-negative organisms are more resistant to


antibiotic therapy.
The gram-negative organisms are resistant to drug
therapy (B) which makes recovery very difficult. Gramnegative pneumonias affect all lobes of the lung (A). The
mean age for contracting this type of pneumonia is 50
years (C and D), and it usually strikes debilitated persons
such as alcoholics, diabetics, and those with chronic lung
diseases.
C) Elevated CK-MB.
The cardiac isoenzyme CK-MB (C) is the most sensitive
and most reliable indicator of myocardial damage of all
the cardiac enzymes. It peaks within 12 to 20 hours after
myocardial infarction (MI). (A) is a cardiac enzyme that
peaks around 48 hours after an MI. (B) is expected with
acute pancreatitis. (D) would be expected in a client with
a fluid volume deficit, which is not a typical finding in
MI.

A) Review the electrocardiogram tracing.


A client is brought to the Emergency Center after a
snow-skiing accident. Which intervention is most
important for the nurse to implement?
A) Review the electrocardiogram tracing.
B) Obtain blood for coagulation studies.
C) Apply a warming blanket.
D) Provide heated PO fluids.

Airway, breathing, and circulation are priorities in


client assessment and treatment. Continuous cardiac
monitoring is indicated (A) because hypothermic
clients have an increased risk for dysrhythmias.
Coagulations studies (A) and re-warming procedures
(C and D) can be initiated after a review of the ECG
tracing (A).

A client is placed on a respirator following a cerebral hemorrhage,


and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is
prescribed. Which nursing diagnosis is the priority for this client?
A) Impaired communication related to paralysis of skeletal
muscles.
B) High risk for infection related to increased intracranial
pressure.
C) Potential for injury related to impaired lung expansion.
D) Social isolation related to inability to communicate.

A client receiving cholestyramine


(Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
A) K.
B) B12.
C) B6.
D) C.
A client reports unprotected sexual intercourse one week ago and is
worried about HIV exposure. An initial HIV antibody screen
(ELISA) is obtained. The nurse teaches the client that
seroconversion to HIV positive relies on antibody production by B
lymphocytes after exposure to the virus. When should the nurse
recommend the client return for repeat blood testing?
A) 6 to 18 months.
B) 1 to 12 months.
C) 1 to 18 weeks.
D) 6 to 12 weeks.

A client taking a thiazide diuretic for the past six


months has a serum potassium level of 3. The nurse
anticipates which change in prescription for the
client?
A) The dosage of the diuretic will be decreased.
B) The diuretic will be discontinued.
C) A potassium supplement will be prescribed.
D) The dosage of the diuretic will be increased.

A) Impaired communication related to paralysis of skeletal


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

A) K.
Clients should be monitored for an increased
prothrombin time and prolonged bleeding times
which would alert the nurse to a vitamin K deficiency
(A). These drugs reduce absorption of the fat soluble
(lipid) vitamins A, D, E, and K. (B, C, and D) are not
fat soluble vitamins.

D) 6 to 12 weeks.
Although the HIV antigen is detectable approximately 2
weeks after exposure, seroconversion to HIV positive may
take up to 6 to 12 weeks (D) after exposure, so the client
should return to repeat the serum screen for the presence
of HIV antibodies during that time frame. (A) will delay
treatment if the client tests positive. (B and C) may
provide inaccurate results because the time frame maybe
too early to reevaluate the client.

C) A potassium supplement will be prescribed.


This client's potassium level is too low (normal is 3.5
to 5). Taking a thiazide diuretic often results in a loss
of potassium, so a potassium supplement needs to be
prescribed to restore a normal serum potassium level
(C). (A, B, and D) are not recommended actions for
restoring a normal serum potassium level.

D) At what time do you take your medication?

A client taking furosemide (Lasix), reports difficulty


sleeping. What question is important for the nurse to
ask the client?
A) What dose of medication are you taking?
B) Are you eating foods rich in potassium?
C) Have you lost weight recently?
D) At what time do you take your medication?

The nurse needs to first determine at what time of day the


client takes the Lasix (D). Because of the diuretic effect of
Lasix, clients should take the medication in the morning
to prevent nocturia. The actual dose of medication (A) is
of less importance than the time taken. (B) is not related
to the insomnia. (C) is valuable information about the
effect of the diuretic, but is not likely to be related to
insomnia.

A client who has heart failure is admitted with a


serum potassium level of 2.9 mEq/L. Which action is
most important for the nurse to implement?
A) Give 20 mEq of potassium chloride.
B) Initiate continuous cardiac monitoring.
C) Arrange a consultation with the dietician.
D) Teach about the side effects of diuretics.

B) Initiate continuous cardiac monitoring.


Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in
myocardial irritability and ECG waveform, so it is most important
for the nurse to initiate continuous cardiac monitoring (B) to
identify ventricular ectopy or other life-threatening dysrhythmias.
Potassium chloride (A) should be given after cardiac monitoring is
initiated so that the effects of potassium replacement on the cardiac
rhythm can be monitored. (C and D) should be implemented when
the client is stable.

A client who is fully awake after a gastroscopy asks


the nurse for something to drink. After confirming
that liquids are allowed, which assessment action
should the nurse consider a priority?
A) Listen to bilateral lung and bowel sounds.
B) Obtain the client's pulse and blood pressure.
C) Assist the client to the bathroom to void.
D) Check the client's gag and swallow reflexes.

D) Check the client's gag and swallow reflexes.

A client who is HIV positive asks the nurse, "How will I know
when I have AIDS?" Which response is best for the nurse to
provide?
A) Diagnosis of AIDS is made when you have 2 positive ELISA test
results.
B) Diagnosis is made when both the ELISA and the Western Blot
tests are positive.
C) I can tell that you are afraid of being diagnosed with AIDS.
Would you like for me to call your minister?
D) AIDS is diagnosed when a specific opportunistic infection is
found in an otherwise healthy individual.

D) AIDS is diagnosed when a specific opportunistic infection is found in


an otherwise healthy individual.

A client who is receiving chemotherapy asks the nurse, "Why is so


much of my hair falling out each day?" Which response by the
nurse best explains the reason for alopecia?
A) Chemotherapy affects the cells of the body that grow rapidly,
both normal and malignant.
B) Alopecia is a common side effect you will experience during
long-term steroid therapy.
C) Your hair will grow back completely after your course of
chemotherapy is completed.
D) The chemotherapy causes permanent alterations in your hair
follicles that lead to hair loss.

A client who is sexually active with several partners requests an intrauterine


device (IUD) as a contraceptive method. Which information should the nurse
provide?
A) Using an IUD offers no protection against sexually transmitted diseases
(STD), which increase the risk for pelvic inflammatory disease (PID).
B) Getting pregnant while using an IUD is common and is not the best
contraceptive choice.
C) Relying on an IUD may be a safer choice for monogamous partners, but a
barrier method provides a better option in preventing STD transmission.
D) Selecting a contraceptive device should consider choosing a successful
method used in the past.

Following gastroscopy, a client should remain


nothing by mouth until the effects of local anesthesia
have dissipated and the airway's protective reflexes,
gag and swallow reflexes, have returned (D). (A, B,
and C) are not the priority before reintroducing oral
fluids after a gastroscopy.

AIDS is diagnosed when one of several processes defined by the CDC is


present in an individual who is not otherwise immunosuppressed (D)
(PCP, candidacies, crytpococcus, cryptosporidiosis, Kaposi's sarcoma,
CNS lymphomas). (A and B) identify the presence of HIV, indicating a
high probability that in time the individual will develop AIDS, but do
not necessarily denote the presence of AIDS. (C) is telling the client how
he/she feels (afraid) and is dismissing the situation to the minister.
This client is asking a question and specific medical information needs
to be provided.

A) Chemotherapy affects the cells of the body that grow


rapidly, both normal and malignant.
The common adverse effects of chemotherapy (nausea,
vomiting, alopecia, bone marrow depression) are due to
chemotherapy's effect on the rapidly reproducing cells,
both normal and malignant (A). (B and D) do not
provide correct information about chemotherapy-induced
alopecia. Although (D) is a true statement, it does not
effectively answer the client's question.

A) Using an IUD offers no protection against sexually transmitted


diseases (STD), which increase the risk for pelvic inflammatory
disease (PID).
The use of an IUD provides the client with no protection from STDs
(A). While pregnancy rates with the use of an IUD are somewhat
higher, (B) is not therapeutic, but judgmental. (C) is judgmental
and does not provide the client any information about use of an
IUD. While talking about contraceptives may include (D), it is does
not provide the best information to maintain the client's health.

A client who was in a motor vehicle collision was admitted to the


hospital and the right knee was placed in skeletal traction. The nurse has
documented this nursing diagnosis in the client's medical record:
"Potential for impairment of skin integrity related to immobility from
traction." Which nursing intervention is indicated based on this
diagnosis statement?
A) Release the traction q4h to provide skin care.
B) Turn the client for back care while suspending traction.
C) Provide back and skin care while maintaining the traction.
D) Give back care after the client is released from traction.

C) Provide back and skin care while maintaining the


traction.
(C) indicates that back care is performed while traction is
left intact, which is the correct intervention for
maintaining skin integrity. Maintaining skin integrity and
providing back care is difficult when a client is in traction,
but it cannot be delayed until the client is removed from
traction (D). The nurse should never release the traction
(A and B).

A client with a 16-year history of diabetes mellitus is


having renal function tests because of recent fatigue,
weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse
conclude as an early symptom of renal insufficiency?
A) Dyspnea.
B) Nocturia.
C) Confusion.
D) Stomatitis.

B) Nocturia

A client with a completed ischemic stroke


has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
A) Position the head of the bed (HOB) flat.
B) Withhold intravenous fluids.
C) Administer a bolus of IV fluids.
D) Give an antihypertensive medications.

D) Give an antihypertensive medications.

As the glomerular filtration rate decreases in early renal


insufficiency, metabolic waste products, including urea,
creatinine, and other substances, such phenols,
hormones, electrolytes, accumulate in the blood. In the
early stage of renal insufficiency, polyuria results from the
inability of the kidneys to concentrate urine and
contribute to nocturia (B). (A, C, and D) are more
common in the later stages of renal failure.

Most ischemic strokes occur during sleep when baseline blood


pressure declines or blood viscosity increases due to minimal fluid
intake. Completed strokes usually produce neurologic deficits
within an hour, the client's current elevated blood pressure requires
antihypertensive medication (D). Positioning the HOB flat (A)
decreases venous drainage and contributes to cerebral edema post
stroke. Increased blood viscosity during sleep may be related to
reduced fluids, so (B) is not indicated. Increasing the vascular fluid
volume increases the blood pressure, so (C) is not indicated.

D) Restrict salt and fluid intake.


A client with cirrhosis develops increasing pedal
edema and ascites. What dietary modification is most
important for the nurse to teach this client?
A) Avoid high carbohydrate foods.
B) Decrease intake of fat soluble vitamins.
C) Decrease caloric intake.
D) Restrict salt and fluid intake.

A client with diabetes mellitus is


experiencing polyphagia. Which outcome
statement is the priority for this client?
A) Fluid and electrolyte balance.
B) Prevention of water toxicity.
C) Reduced glucose in the urine.
D) Adequate cellular nourishment.

Salt and fluid restrictions are the first


dietary modifications for a client who is
retaining fluid as manifested by edema
and ascites (D). (A, B, and C) will not
impact fluid retention.
D) Adequate cellular nourishment.
Diabetes mellitus Type 1 is characterized by hyperglycemia that
precipitates glucosuria and polyuria (frequent urination),
polydipsia (excessive thirst), and polyphagia (excessive hunger).
Polyphagia is a consequence of cellular malnourishment when
insulin deficiency prevents utilization of glucose for energy, so the
outcome statement should include stabilization of adequate cellular
nutrition (D). (A, B, and C) relate to subsequent osmolar fluid
shifts related to glucosuria, polyuria, and polydipsia.

A client with early breast cancer receives the results of a


breast biopsy and asks the nurse to explain the meaning
of staging and the type of receptors found on the cancer
cells. Which explanation should the nurse provide?
A) Lymph node involvement is not significant.
B) Small tumors are aggressive and indicate poor
prognosis.
C) The tumor's estrogen receptor guides treatment
options.
D) Stage I indicates metastasis.

C) The tumor's estrogen receptor guides treatment options.


Treatment decisions (C) and prediction of prognosis are related to the
tumor's receptor status, such as estrogen and progesterone receptor
status which commonly are well-differentiated, have a lower chance of
recurrence, and are receptive to hormonal therapy. Tumor staging
designates tumor size and spread of breast cancer cells into axillary
lymph nodes, which is one of the most important prognostic factors in
early-stage breast cancer, not (A). Larger tumors are more likely to
indicate poor prognosis, not (B). Stage I indicates the cancer is localized
and has not spread systemically (D).

A client with gastroesophageal reflux disease (GERD)


has been experiencing severe reflux during sleep.
Which recommendation by the nurse is most
effective to assist the client?
A) Losing weight.
B) Decreasing caffeine intake.
C) Avoiding large meals.
D) Raising the head of the bed on blocks.

D) Raising the head of the bed on blocks.

A client with heart disease is on a continuous telemetry


monitor and has developed sinus bradycardia. In
determining the possible cause of the bradycardia, the
nurse assesses the client's medication record. Which
medication is most likely the cause of the bradycardia?
A) Propanolol (Inderal).
B) Captopril (Capoten).
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex).

A) Propanolol (Inderal).

A client with multiple sclerosis has experienced an


exacerbation of symptoms, including paresthesias,
diplopia, and nystagmus. Which instruction should
the nurse provide?
A) Stay out of direct sunlight.
B) Restrict intake of high protein foods.
C) Schedule extra rest periods.
D) Go to the emergency room immediately.

C) Schedule extra rest periods.

Despite several eye surgeries, a 78-year-old client


who lives alone has persistent vision problems. The
visiting nurse is discussing painting the house with
the client. The nurse suggests that the edge of the
steps should be painted which color?
A) Black.
B) White.
C) Light green.
D) Medium yellow.

D) Medium yellow.

Raising the head of the bed on blocks (D) (reverse


Trendelenburg position) to reduce reflux and subsequent
aspiration is the most effective recommendation for a
client experiencing severe gastroesophageal reflux during
sleep. (A, B and C) may be effective recommendations but
raising the head of the bed is more effective for relief
during sleep.

Inderal (A) is a beta adrenergic blocking agent, which


causes decreased heart rate and decreased
contractility. Neither (B), an ACE inhibitor, nor (C), a
loop diuretic, causes bradycardia. (D) is a
sympathomimetic, direct acting cardiac stimulant,
which would increase the heart rate.

Exacerbations of the symptoms of MS occur


most commonly as the result of fatigue and
stress. Extra rest periods should be
scheduled (C) to reduce the symptoms. (A, B,
and D) are not necessary.

Yellow is the easiest for a person with failing vision to see


(D). (A) will be almost impossible to see at night because
the shadows of the steps will be too difficult to determine,
and would pose a safety hazard. (B) is very hard to see
with a glare from the sun and it could hurt the eyes in the
daytime to look at them. (C) is a pastel color and is
difficult for elderly clients to see.

During a health fair, a 72-year-old male client tells the


nurse that he is experiencing shortness of breath.
Auscultation reveals crackles and wheezing in both lungs.
Suspecting that the client might have chronic bronchitis,
which classic symptom should the nurse expect this client
to have?
A) Racing pulse with exertion.
B) Clubbing of the fingers.
C) An increased chest diameter.
D) Productive cough with grayish-white sputum.
During an interview with a client planning elective surgery, the
client asks the nurse, "What is the advantage of having a preferred
provider organization insurance plan?" Which response is best for
the nurse to provide?
A) Long-term relationships with healthcare providers are more
likely.
B) There are fewer healthcare providers to choose from than in an
HMO plan.
C) Insurance coverage of employees is less expensive to employers.
D) An individual can become a member of a PPO without
belonging to a group.

During assessment of a client with amyotrophic


lateral sclerosis (ALS), which finding should the
nurse identify when planning care for this client?
A) Muscle weakness.
B) Urinary frequency.
C) Abnormal involuntary movements.
D) A decline in cognitive function.

During CPR, when attempting to ventilate a client's lungs, the


nurse notes that the chest is not moving. What action should the
nurse take first?
A) Use a laryngoscope to check for a foreign body lodged in the
esophagus.
B) Reposition the head to validate that the head is in the proper
position to open the airway.
C) Turn the client to the side and administer three back blows.
D) Perform a finger sweep of the mouth to remove any vomitus.

During lung assessment, the nurse places a stethoscope


on a client's chest and instructs him/her to say "99" each
time the chest is touched with the stethoscope. What
should be the correct interpretation if the nurse hears the
spoken words "99" very clearly through the stethoscope?
A) This is a normal auscultatory finding.
B) May indicate pneumothorax.
C) May indicate pneumonia.
D) May indicate severe emphysema.

D) Productive cough with grayish-white sputum.


Chronic bronchitis, one of the diseases comprising the diagnosis of
COPD, is characterized by a productive cough with grayish-white
sputum (D), which usually occurs in the morning and is often
ignored by smokers. (A) is not related to chronic bronchitis;
however, it is indicative of other problems such as ventricular
tachycardia and should be explored. (B and C) are symptoms of
emphysema and are not consistent with the other symptoms. (C) is
usually referred to as a "barrel chest."

C) Insurance coverage of employees is less expensive to employers.


The financial advantage of (C) is the feature of a PPO that is most
relevant to the average consumer. The nurse must have knowledge
about PPOs, which provide discounted rates to large employers
who provide insurance coverage for their employees. In return, the
insurance company receives a large pool of clients for their
facilities. (A, B, and D) are not accurate representations of the
PPO.

A) Muscle weakness.
Amyotrophic lateral sclerosis (ALS) is characterized
by a degeneration of motor neurons in the brainstem
and spinal cord and are manifested by muscle
weakness (A) and wasting. ALS does not manifest (B
and C). In ALS, the client remains cognitively intact,
not (D), while the physical status deteriorates.

B) Reposition the head to validate that the head is in the


proper position to open the airway.
The most frequent cause of inadequate aeration of the
client's lungs during CPR is improper positioning of the
head resulting in occlusion of the airway (B). A foreign
body can occlude the airway, but this is not common
unless choking preceded the cardiac emergency, and (A,
C and D) should not be the nurse's first action.

C) May indicate pneumonia.


This test (whispered pectoriloquy) demonstrates hyperresonance and
helps determine the clarity with which spoken words are heard upon
auscultation. Normally, the spoken word is not well transmitted through
lung tissue, and is heard as a muffled or unclear transmission of the
spoken word. Increased clarity of a spoken word is indicative of some
sort of consolidation process (e.g., tumor, pneumonia) (C), and is not a
normal finding (A). When lung tissue is filled with more air than
normal, the voice sounds are absent or very diminished (e.g.,
pneumothorax, severe emphysema) (B and D).

During suctioning, a client with an uncuffed


tracheostomy tube begins to cough violently and
dislodges the tracheostomy tube. Which action should the
nurse implement first?
A) Notify the healthcare provider for reinsertion.
B) Attempt to reinsert the tracheostomy tube.
C) Position the client in a lateral position with the neck
extended.
D) Ventilate client's tracheostomy stoma with a manual
bag-mask.

Dysrhythmias are a concern for any client. However, the presence


of a dysrhythmia is more serious in an elderly person because
A) elderly persons usually live alone and cannot summon help
when symptoms appear.
B) elderly persons are more likely to eat high-fat diets which make
them susceptible to heart disease.
C) cardiac symptoms, such as confusion, are more difficult to
recognize in the elderly.
D) elderly persons are intolerant of decreased cardiac output which
may result in dizziness and falls.

B) Attempt to reinsert the tracheostomy tube.


The nurse should attempt to reinsert the tracheostomy
tube (B) by using a hemostat to open the tracheostomy or
by grasping the retention sutures (if present) to spread
the opening in insert a replacement tube (with its
obturator) into the stoma. Once in place, the obturator
should immediately be removed. (A, C, and D) place the
client at risk of airway obstruction.

D) elderly persons are intolerant of decreased cardiac output which may


result in dizziness and falls.
Cardiac output is decreased with aging (D). Because of loss of
contractility and elasticity, blood flow is decreased and tachycardia is
poorly tolerated. Therefore, if an elderly person experiences
dysrhythmia (tachycardia or bradycardia), further compromising their
cardiac output, they are more likely to experience syncope, falls,
transient ischemic attacks, and possibly dementia. Most elderly persons
do not eat high-fat diets (B) and most are not confused (C). Although
many elderly persons do live alone, inability to summon help (A) cannot
be assumed.

An elderly client is admitted with a diagnosis of


bacterial pneumonia. The nurse's assessment of the
client is most likely to reveal which sign/symptom?
A) Leukocytosis and febrile.
B) Polycythemia and crackles.
C) Pharyngitis and sputum production.
D) Confusion and tachycardia.

D) Confusion and tachycardia.

An elderly male client comes to the geriatric screening clinic


complaining of pain in his left calf. The nurse notices a reddened
area on the calf of his right leg which is warm to the touch and
suspects it might be thrombophlebitis. Which type of pain should
further confirm this suspicion?
A) Pain in the calf awakening him from a sound sleep.
B) Calf pain on exertion which stops when standing in one place.
C) Pain in the calf upon exertion which is relieved by rest and
elevating the extremity.
D) Pain upon arising in the morning which is relieved after some
stretching and exercise.

C) Pain in the calf upon exertion which is relieved by rest


and elevating the extremity.

A female client is brought to the clinic by her daughter for a flu


shot. She has lost significant weight since the last visit. She has
poor personal hygiene and inadequate clothing for the weather.
The client states that she lives alone and denies problems or
concerns. What action should the nurse implement?
A) Notify social services immediately of suspected elderly abuse.
B) Discuss the need for mental health counseling with the
daughter.
C) Explain to the client that she needs to take better care of herself.
D) Collect further data to determine whether self-neglect is
occurring.

D) Collect further data to determine whether selfneglect is occurring.

The onset of pneumonia in the elderly may be


signaled by general deterioration, confusion,
increased heart rate or increased respiratory rate
(D). (A, B, and C) are often absent in the elderly with
bacterial pneumonia.

Thrombophlebitis pain is relieved by rest and elevation of


the extremity (C). It typically occurs with exercise at the
site of the thrombus, and is aggravated by placing the
extremity in a dependent position, such as standing in
one place (B). (A and D) describe pain that is not
common with thrombophlebitis.

Changes in weight and hygiene may be indicators of


self-neglect or neglect by family members. Further
assessment is needed (D) before notifying social
services (A) or discussing a need for counseling (B).
Until further information is obtained, explanations
about the client's needs are premature (C).

A female client receiving IV vasopressin (Pitressin)


for esophageal varice rupture reports to the nurse
that she feels substernal tightness and pressure
across her chest. Which PRN protocol should the
nurse initiate?
A) Start an IV nitroglycerin infusion.
B) Nasogastric lavage with cool saline.
C) Increase the vasopressin infusion.
D) Prepare for endotracheal intubation.

A) Start an IV nitroglycerin infusion.


Vasopressin is used to promote vasoconstriction, thereby
reducing bleeding. Vasoconstriction of the coronary
arteries can lead to angina and myocardial infarction,
and should be counteracted by IV nitroglycerin per
prescribed protocol (A). (B) will not resolve the cardiac
problem. (C) will worsen the problem. Endotracheal
intubation may be needed if respiratory distress occurs
(D).
B) An accurate menstrual cycle diary for the past 6 to 12 months.

A female client requests information about using the calendar


method of contraception. Which assessment is most important for
the nurse to obtain?
A) Amount of weight gain or weight loss during the previous year.
B) An accurate menstrual cycle diary for the past 6 to 12 months.
C) Skin pigmentation and hair texture for evidence of hormonal
changes.
D) Previous birth-control methods and beliefs about the calendar
method.

A female client taking oral contraceptives reports to the nurse that


she is experiencing calf pain. What action should the nurse
implement?
A) Determine if the client has also experienced breast tenderness
and weight gain.
B) Encourage the client to begin a regular, daily program of
walking and exercise.
C) Advise the client to notify the healthcare provider for immediate
medical attention.
D) Tell the client to stop taking the medication for a week to see if
symptoms subside.

The fertile period, which occurs 2 weeks prior to the onset of


menses, is determined using an accurate record of the number of
days of the menstrual cycles for the past 6 months, so it is most
important to emphasize to the client that accuracy and compliancy
of a menstrual diary (B) is the basis of the calendar method. (A and
C) may be partially related to hormonal fluctuations but are not
indicators for using the calendar method. (D) may demonstrate
client understanding and compliancy but is not the most important
aspect.

C) Advise the client to notify the healthcare provider for immediate


medical attention.
Calf pain is indicative of thrombophlebitis, a serious, lifethreatening complication associated with the use of oral
contraceptives which requires further assessment and possibly
immediate medical intervention (C). (A) are symptoms of oral
contraceptive use, but are of less immediacy than (C). (B) may
cause an embolism if thrombophlebitis is present. By not seeking
immediate attention, (D) is potentially dangerous to the client.

The healthcare provider prescribes aluminum and


magnesium hydroxide (Maalox), 1 tablet PO PRN, for a
client with chronic renal failure who is complaining of
indigestion. What intervention should the nurse
implement?
A) Administer 30 minutes before eating.
B) Evaluate the effectiveness 1 hour after administration.
C) Instruct the client to swallow the tablet whole.
D) Question the healthcare provider's prescription.

D) Question the healthcare provider's prescription.

Healthcare workers must protect themselves against becoming


infected with HIV. The Center for Disease Control has issued
guidelines for healthcare workers in relation to protection from
HIV. These guidelines include which recommendation?
A) Place HIV positive clients in strict isolation and limit visitors.
B) Wear gloves when coming in contact with the blood or body
fluids of any client.
C) Conduct mandatory HIV testing of those who work with AIDS
clients.
D) Freeze HIV blood specimens at -70 F to kill the virus.

B) Wear gloves when coming in contact with the blood or body


fluids of any client.

Magnesium agents are not usually used for clients


with renal failure due to the risk of
hypermagnesemia, so this prescription should be
questioned by the nurse (D). (A, B, and C) are not
recommended nursing actions for the administration
of aluminum and magnesium hydroxide (Maalox).

The CDC guidelines recommend that healthcare workers use gloves


when coming in contact with blood or body fluids from ANY client
(B) since HIV is infectious before the client becomes aware of
symptoms. (A) is not recommended, nor is it necessary. (C) is very
controversial, difficult to enforce, and is not recommended by CDC.
(D) does not guarantee to kill the virus. Additionally, the purpose of
the blood specimen will determine how it is stored and handled.

How should the nurse position the electrodes for


modified chest lead one (MCL I) telemetry monitoring?
A) Positive polarity right shoulder, negative polarity left
shoulder, ground left chest nipple line.
B) Positive polarity left shoulder, negative polarity right
chest nipple line, ground left chest nipple line.
C) Positive polarity right chest nipple line, negative
polarity left chest nipple line, ground left shoulder.
D) Negative polarity left shoulder, positive polarity right
chest nipple line, ground left chest nipple line.

In assessing a client diagnosed with primary


hyperaldosteronism, the nurse expects the laboratory
test results to indicate a decreased serum level of
which substance?
A) Sodium.
B) Antidiuretic hormone.
C) Potassium.
D) Glucose.

In assessing cancer risk, the nurse identifies which


woman as being at greatest risk of developing breast
cancer?
A) A 35-year-old multipara who never breastfed.
B) A 50-year-old whose mother had unilateral breast
cancer.
C) A 55-year-old whose mother-in-law had bilateral
breast cancer.
D) A 20-year-old whose menarche occurred at age 9.

D) Negative polarity left shoulder, positive polarity right


chest nipple line, ground left chest nipple line.
In MCL I monitoring, the positive electrode is placed on
the client's mid-chest to the right of the sternum, and the
negative electrode is placed on the upper left part of the
chest (D). The ground may be placed anywhere, but is
usually placed on the lower left portion of the chest. (A,
B, and C) describe incorrect placement of electrodes for
telemetry monitoring.

C) Potassium.
Clients with primary aldosteronism exhibit a
profound decline in the serum levels of potassium (C)
(hypokalemia)--hypertension is the most prominent
and universal sign. (A) is normal or elevated,
depending on the amount of water reabsorbed with
the sodium. (B) is decreased with diabetes insipidus.
(D) is not affected by primary aldosteronism.

B) A 50-year-old whose mother had unilateral breast cancer.


The most predictive risk factors for development of breast cancer
are over 40 years of age and a positive family history (occurrence in
the immediate family, i.e., mother or sister). Other risk factors
include nulliparity, no history of breastfeeding, early menarche and
late menopause. Although all of the women described have one of
the risk factors for developing breast cancer, (B) has the greater
risk over (A, C, and D).

In preparing a discharge plan for a 22-year-old male


client diagnosed with Buerger's disease
(thromboangiitis obliterans), which referral is most
important?
A) Genetic counseling.
B) Twelve-step recovery program.
C) Clinical nutritionist.
D) Smoking cessation program.

D) Smoking cessation program.

In preparing to administer intravenous albumin to a client


following surgery, what is the priority nursing intervention? (Select
all that apply.)
A) Set the infusion pump to infuse the albumin within four hours.
B) Compare the client's blood type with the label on the albumin.
C) Assign a UAP to monitor blood pressure q15 minutes.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration.

A) Set the infusion pump to infuse the albumin within four hours.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration.

Buerger's disease is strongly related to smoking. The most effective


means of controlling symptoms and disease progression is through
smoking cessation (D). The cause of Buerger's disease is unknown;
a genetic predisposition is possible, but (A) will not be of value.
The client with Buerger's disease does not need referral to a 12-step
program any more than the general population (B). Diet is not a
significant factor in the disease, and general healthy diet
guidelines can be provided by the nurse (C).

(A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it
does not contain any preservatives. Any fluid remaining after four hours should be discarded (A).
Albumin administration does not require blood typing (B). Vital signs should be monitored
periodically to assess for fluid volume overload, but every 15 minutes is not necessary (C). This
frequency is often used during the first hour of a blood transfusion. A large gauge catheter (D)
allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin
and hematocrit levels (E), while increased blood volume and blood pressure may cause bleeding
(F).

B) Evaluate his blood pressure, pulse, and respiratory status.


A male client receives a local anesthetic during surgery. During the
post-operative assessment, the nurse notices the client is slurring
his speech. Which action should the nurse take?
A) Determine the client is anxious and allow him to sleep.
B) Evaluate his blood pressure, pulse, and respiratory status.
C) Review the client's pre-operative history for alcohol abuse.
D) Continue to monitor the client for reactivity to anesthesia.

A male client who has never smoked but has had


COPD for the past 5 years is now being assessed for
cancer of the lung. The nurse knows that he is most
likely to develop which type of lung cancer?
A) Adenocarcinoma.
B) Oat-cell carcinoma.
C) Malignant melanoma.
D) Squamous-cell carcinoma.

A middle-aged male client with diabetes continues to eat an abundance


of foods that are high in sugar and fat. According to the Health Belief
Model, which event is most likely to increase the client's willingness to
become compliant with the prescribed diet?
A) He visits his diabetic brother who just had surgery to amputate an
infected foot.
B) He is provided with the most current information about the dangers
of untreated diabetes.
C) He comments on the community service announcements about
preventing complications associated with diabetes.
D) His wife expresses a sincere willingness to prepare meals that are
within his prescribed diet.

The nurse assesses a client with advanced cirrhosis of


the liver for signs of hepatic encephalopathy. Which
finding should the nurse consider an indication of
progressive hepatic encephalopathy?
A) An increase in abdominal girth.
B) Hypertension and a bounding pulse.
C) Decreased bowel sounds.
D) Difficulty in handwriting.

The nurse formulates the nursing diagnosis of, Urinary retention


related to sensorimotor deficit for a client with multiple sclerosis.
Which nursing intervention should the nurse implement?
A) Teach the client techniques of intermittent self-catheterization.
B) Decrease fluid intake to prevent over distention of the bladder.
C) Use incontinence briefs to maintain hygiene with urinary
dribbling.
D) Explain that anticholinergic drugs will decrease muscle
spasticity.

Slurred speech in the post-operative client who received a local


anesthetic is an atypical finding and may indicate neurological
deficits that require further assessment, so obtaining the client's
vital signs (B) will provide information about possible
cardiovascular complications, such as stroke. The client's anxiety
(A), a history of alcohol abuse (D), or local anesthesia (D) are
unrelated to the client's sudden onset of slurred speech.

A) Adenocarcinoma.
Adenocarcinoma is the only lung cancer not related
to cigarette smoking (A). It has been found to be
directly related to lung scarring and fibrosis from
preexisting pulmonary disease such as TB or COPD.
Both (B and D) are malignant lung cancers related to
cigarette smoking. (C) is a skin cancer and is related
to exposure to sunlight, not to lung problems.

A) He visits his diabetic brother who just had surgery


to amputate an infected foot.
The loss of a limb by a family member (A) will be the
strongest event or "cue to action" and is most likely
to increase the perceived seriousness of the disease.
(B, C, and D) may influence his behavior but do not
have the personal impact of (A).

D) Difficulty in handwriting.
A daily record in handwriting may provide evidence
of progression or reversal of hepatic encephalopathy
leading to coma (D). (A) is a sign of ascites. (B) are
not seen with hepatic encephalopathy. (C) does not
indicate an increase in serum ammonia level which is
the primary cause of hepatic encephalopathy.

A) Teach the client techniques of intermittent self-catheterization.


Bladder control is a common problem for clients with multiple sclerosis.
A client with urinary retention should receive instructions about selfcatheterization (A) to prevent bladder distention. Adequate hydration,
not (B), is important to reduce the risk of urinary tract infections by
promoting elimination which reduces the time microorganisms spend
in the bladder and by diluting the number of microorganisms in the
bladder. Self-catheterization helps prevent dribbling, so (C) is
unnecessary. Cholinergic drugs improve bladder muscle tone and help
with bladder emptying, not (D).

The nurse is assessing a client who has a history of Parkinson's


disease for the past 5 years. What symptoms should this client
most likely exhibit?
A) Loss of short-term memory, facial tics and grimaces, and
constant writhing movements.
B) Shuffling gait, masklike facial expression, and tremors of the
head.
C) Extreme muscular weakness, easy fatigability, and ptosis.
D) Numbness of the extremities, loss of balance, and visual
disturbances.

B) Shuffling gait, masklike facial


expression, and tremors of the head.
(B) are common clinical features of
Parkinsonism. (A) are symptoms of
chorea, (C) of myasthenia gravis, and (D)
of multiple sclerosis.
C) Normal skin coloring.

The nurse is assessing a client who smokes cigarettes


and has been diagnosed with emphysema. Which
finding should the nurse expect this client to exhibit?
A) A decreased total lung capacity.
B) Normal arterial blood gases.
C) Normal skin coloring.
D) An absence of sputum.

The nurse is assessing a client with bacterial


meningitis. Which assessment finding indicates the
client may have developed septic emboli?
A) Cyanosis of the fingertips.
B) Bradycardia and bradypnea.
C) Presence of S3 and S4 heart sounds.
D) 3+ pitting edema of the lower extremities.

The nurse is assessing a client with chronic


renal failure (CRF). Which finding is most
important for the nurse to respond to first?
A) Potassium 6.0 mEq.
B) Daily urine output of 400 ml.
C) Peripheral neuropathy.
D) Uremic fetor.

The nurse is assessing a client's laboratory values


following administration of chemotherapy. Which lab
value leads the nurse to suspect that the client is
experiencing tumor lysis syndrome (TLS)?
A) Serum PTT of 10 seconds.
B) Serum calcium of 5 mg/dl.
C) Oxygen saturation of 90%.
D) Hemoglobin of 10 g/dl.

The differentiation between the "pink puffer" and the "blue bloater"
is a well-known method of differentiating clients exhibiting
symptoms of emphysema (normal color but puffing respirations)
from those exhibiting symptoms of chronic bronchitis (edematous,
cyanotic, shallow respirations) (C). Total lung capacity is
increased in emphysema since these clients have hyperinflated
lungs (A). Arterial blood gases are typically abnormal (B). (D) is
indicative of bronchitis, while clients with emphysema usually
have copious amounts of thick, white sputum.

A) Cyanosis of the fingertips.


Septic emboli secondary to meningitis commonly
lodge in the small arterioles of the extremities,
causing a decrease in circulation to the hands (A)
which may lead to gangrene. (B, C, and D) are
abnormal findings, but do not indicate the
development of septic emboli.

A) Potassium 6.0 mEq.


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

B) Serum calcium of 5 mg/dl.


TLS results in hyperkalemia, hypocalcemia,
hyperuricemia, and hyperphosphatemia. A serum
calcium level of 5 (B), which is low, is an indicator of
possible tumor lysis syndrome. (A, C, and D) are not
particularly related to TLS.

The nurse is assisting a client out of bed for the first


time after surgery. What action should the nurse do
first?
A) Place a chair at a right angle to the bedside.
B) Encourage deep breathing prior to standing.
C) Help the client to sit and dangle legs on the side of
the bed.
D) Allow the client to sit with the bed in a high
Fowler's position.
The nurse is caring for a client with a continuous feeding
through a percutaneous endoscopic gastrostomy (PEG)
tube. Which intervention should the nurse include in the
plan of care?
A) Flush the tube with 50 ml of water q 8 hours.
B) Check for tube placement and residual volume q4
hours.
C) Obtain a daily x- ray to verify tube placement.
D) Position on left side with head of bed elevated 45
degrees.
The nurse is caring for a client with a stroke resulting in right-sided paresis
and aphasia. The client attempts to use the left hand for feeding and other
self-care activities. The spouse becomes frustrated and insists on doing
everything for the client. Based on this data, which nursing diagnosis should
the nurse document for this client?
A) Situational low self-esteem related to functional impairment and change in
role function.
B) Disabled family coping related to dissonant coping style of significant
person.
C) Interrupted family processes related to shift in health status of family
member.
D) Risk for ineffective therapeutic regimen management related to complexity
of care.

D) Allow the client to sit with the bed in a high


Fowler's position.
The first step is to raise the head of the bed to a high
Fowler's position (D), which allow venous return to
compensate from lying flat and vasodilating effects of
perioperative drugs. (A, B, and C) are implemented
after (D).

B) Check for tube placement and residual volume q4 hours.


Tube placement and residual volume should be checked before each
feeding (B). Tube placement is checked by aspiration of stomach
contents and measurement of pH. It is important to check for
residual volume because gastric emptying is often delayed during
illness. There is an increased risk for aspiration of the feeding with
increased residual volume. (A, C, and D) are not correct procedures
to follow.

B) Disabled family coping related to dissonant coping style of


significant person.
A stroke affects the whole family and in this case the spouse
probably thinks that she is helping and needs to feel that she is
contributing to the client's care. Her help is noted as being
incongruent with attempts of self-care by the client thereby
disabling family coping (B). The scenario does not discuss the
client's self-esteem (A), interrupted family processes (C) or the risk
for ineffective therapeutic regimen (D).

A) Loss of thirst, weight gain.

The nurse is caring for a client with syndrome of


inappropriate antidiuretic hormone (SIADH), which
is manifested by which symptoms?
A) Loss of thirst, weight gain.
B) Dependent edema, fever.
C) Polydipsia, polyuria.
D) Hypernatremia, tachypnea.

The nurse is completing an admission interview and assessment


on a client with a history of Parkinson's disease. Which question
should provide information relevant to the client's plan of care?
A) Have you ever experienced any paralysis of your arms or legs?
B) Have you ever sustained a severe head injury?
C) Have you ever been 'frozen' in one spot, unable to move?
D) Do you have headaches, especially ones with throbbing pain?

SIADH occurs when the posterior pituitary gland releases too much
ADH, causing water retention, a urine output of less than 20 ml/hour,
and dilutional hyponatremia. Other indications of SIADH are loss of
thirst, weight gain (A), irritability, muscle weakness, and decreased
level of consciousness. (B) is not associated with SIADH. (C) is a finding
associated with diabetes insipidus (a water metabolism problem caused
by an ADH deficiency), not SIADH. The increase in plasma volume
causes an increase in the glomerular filtration rate that inhibits the
release of rennin and aldosterone, which results in an increased sodium
loss in urine, leading to greater hyponatremia, not (D).

C) Have you ever been 'frozen' in one spot, unable to


move?
Clients with Parkinson's disease frequently experience
difficulty in initiating, maintaining, and performing
motor activities. They may even experience being rooted
to the spot and unable to move (C). Parkinson's disease
does not cause (A). Parkinson's disease is not usually
associated with (B), nor does it typically cause (D).

The nurse is interviewing a male client with


hypertension. Which additional medical diagnosis in
the client's history presents the greatest risk for
developing a cerebral vascular accident (CVA)?
A) Diabetes mellitus.
B) Hypothyroidism.
C) Parkinson's disease.
D) Recurring pneumonia.

A) Diabetes mellitus.
A history of diabetes mellitus poses the
greatest risk for developing a CVA (A).
(B, C, and D) may place the client at
some risk due to immobility, but do not
present a risk as great as (A).
B) Risk for injury related to denial of deficits and impulsiveness.

The nurse is planning care for a client who has a right


hemispheric stroke. Which nursing diagnosis should the nurse
include in the plan of care?
A) Impaired physical mobility related to right-sided hemiplegia.
B) Risk for injury related to denial of deficits and impulsiveness.
C) Impaired verbal communication related to speech-language
deficits.
D) Ineffective coping related to depression and distress about
disability.

The nurse is planning care for a client with newly


diagnosed diabetes mellitus that requires insulin.
Which assessment should the nurse identify before
beginning the teaching session?
A) Present knowledge related to the skill of injection.
B) Intelligence and developmental level of the client.
C) Willingness of the client to learn the injection
sites.
D) Financial resources available for the equipment.

The nurse is planning care to prevent complication


for a client with multiple myeloma. Which
intervention is most important for the nurse to
include?
A) Safety precautions during activity.
B) Assess for changes in size of lymph nodes.
C) Maintain a fluid intake of 3 to 4 L per day.
D) Administer narcotic analgesic around the clock.

The nurse is planning to initiate a socialization group for


older residents of a long-term facility. Which information
is most useful to the nurse when planning activities for
the group?
A) The length of time each group member has resided at
the nursing home.
B) A brief description of each resident's family life.
C) The age of each group member.
D) The usual activity patterns of each member of the
group.

With right-brain damage, a client experience difficulty in judgment and


spatial perception and is more likely to be impulsive and move quickly,
which placing the client at risk for falls (B). Although clients with right
and left hemisphere damage may experience impaired physical
mobility, the client with right brain damage will manifest physical
impairments on the contralateral side of the body, not the same side
(A). The client with a left-brain injury may manifest right-sided
hemiplegia with speech or language deficits (C). A client with left-brain
damage is more likely to be aware of the deficits and experience grief
related to physical impairment and depression (D).

C) Willingness of the client to learn the injection sites.


If a client is incapable or does not want to learn, it is
unlikely that learning will occur, so motivation is the first
factor the nurse should assess before teaching (C). To
determine learning needs, the nurse should assess (A),
but this is not the most important factor for the nurse to
assess. (B and D) are factors to consider, but not as vital
as (C).

C) Maintain a fluid intake of 3 to 4 L per day.


Multiple myeloma is a malignancy of plasma cells that infiltrate bone
causing demineralization and hypercalcemia, so maintaining a urinary
output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote
excretion of serum calcium. Although the client is at risk for pathologic
fractures due to diffuse osteoporosis, mobilization and weight bearing
(A) should be encouraged to promote bone reabsorption of circulating
calcium, which can cause renal complications. (B) is a component of
ongoing assessment. Chronic pain management (D) should be included
in the plan of care, but prevention of complications related to
hypercalcemia is most important.

D) The usual activity patterns of each member of the


group.
An older person's level of activity (D) is a determining
factor in adjustment to aging as described by the Activity
Theory of Aging. All information described in the options
might be useful to the nurse, but the most useful
information initially would be an assessment of each
individual's adjustment to the aging process.

The nurse is preparing a teaching plan for a client


who is newly diagnosed with Type 1 diabetes
mellitus. Which signs and symptoms should the
nurse describe when teaching the client about
hypoglycemia?
A) Sweating, trembling, tachycardia.
B) Polyuria, polydipsia, polyphagia.
C) Nausea, vomiting, anorexia.
D) Fruity breath, tachypnea, chest pain.

A) Sweating, trembling, tachycardia.


Sweating, dizziness, and trembling are signs of
hypoglycemic reactions related to the release of
epinephrine as a compensatory response to the low
blood sugar (A). (B, C, and D) do not describe
common symptoms of hypoglycemia.

B) Increase intake of soluble fiber to 10 to 25 grams per


day.
The nurse is providing dietary instructions to a 68-year-old client
who is at high risk for development of coronary heart disease
(CHD). Which information should the nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day.
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake.

To reduce risk factors associated with coronary heart


disease, the daily intake of soluble fiber (B) should be
increased to between 10 and 25 gm. Cholesterol intake
(A) should be limited to 180 mg/day or less. Intake of
plant stanols and sterols is recommended at 2 g/day (C).
Saturated fat (D) intake should be limited to 7% of total
daily calories.
D) If the client's wound is infected.

The nurse is receiving report from surgery about a client with a


penrose drain who is to be admitted to the postoperative unit.
Before choosing a room for this client, which information is most
important for the nurse to obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac in place.
D) If the client's wound is infected.

The nurse is taking a history of a newly diagnosed


Type 2 diabetic who is beginning treatment. Which
subjective information is most important for the
nurse to note?
A) A history of obesity.
B) An allergy to sulfa drugs.
C) Cessation of smoking three years ago.
D) Numbness in the soles of the feet.

The nurse is teaching a client with maple syrup urine disease


(MSUD), an autosomal recessive disorder, about the inheritance
pattern. Which information should the nurse provide?
A) This recessive disorder is carried only on the X chromosome.
B) Occurrences mainly affect males and heterozygous females.
C) Both genes of a pair must be abnormal for the disorder to occur.
D) One copy of the abnormal gene is required for this disorder.

Penrose drains provide a sinus tract or opening and are often used
to provide drainage of an abscess. The fact that the client has a
penrose drain should alert the nurse to the possibility that the
client is infected. To avoid contamination of another postoperative
client, it is most important to place an infected client in a private
room (D). A penrose drain does not require (A). Although (B) is
information that should be considered, it does not have the priority
of (D). (C) is used to drain fluid from a dead space and is not
important in choosing a room.

B) An allergy to sulfa drugs.


An allergy to sulfa drugs may make the client unable to use some of
the most common antihyperglycemic agents (sulfonylureas). The
nurse needs to highlight this allergy for the healthcare provider.
(A) is common and warrants counseling, but does not have the
importance of (B). (C) does increase the risk for vascular disease,
but it is not as important to the treatment regimen as (B). Diabetic
neuropathy, as indicated by (D), is common with diabetics, but
when the serum glucose is decreased, new onset numbness can
possibly improve.

C) Both genes of a pair must be abnormal for the disorder


to occur.
Maple syrup urine disease (MSUD) is a type of autosomal
recessive inheritance disorder in which both genes of a
pair must be abnormal for the disorder to be expressed
(C). MSUD is not an x-linked (A and B) dominant or
recessive disorder or an autosomal dominant inheritance
disorder. Both genes of a pair, not (D), must be present.

The nurse is teaching a female client about the best


time to plan sexual intercourse in order to conceive.
Which information should the nurse provide?
A) Two weeks before menstruation.
B) Vaginal mucous discharge is thick.
C) Low basal temperature.
D) First thing in the morning.

The nurse is teaching a female client who uses a contraceptive


diaphragm about reducing the risk for toxic shock syndrome (TSS).
Which information should the nurse include? (Select all that apply.)
A) Remove the diaphragm immediately after intercourse.
B) Wash the diaphragm with an alcohol solution.
C) Use the diaphragm to prevent conception during the menstrual cycle.
D) Do not leave the diaphragm in place longer than 8 hours after
intercourse.
E) Contact a healthcare provider a sudden onset of fever grater than
101 F appears.
F) Replace the old diaphragm every 3 months.

The nurse is working with a 71-year-old obese client with


bilateral osteoarthritis (OA) of the hips. What
recommendation should the nurse make that is most
beneficial in protecting the client's joints?
A) Increase the amount of calcium intake in the diet.
B) Apply alternating heat and cold therapies.
C) Initiate a weight-reduction diet to achieve a healthy
body weight.
D) Use a walker for ambulation to lessen weight-bearing
on the hips.

The nurse knows that lab values sometimes vary for the older
client. Which data should the nurse expect to find when reviewing
laboratory values of an 80-year-old male?
A) Increased WBC, decreased RBC.
B) Increased serum bilirubin, slightly increased liver enzymes.
C) Increased protein in the urine, slightly increased serum glucose
levels.
D) Decreased serum sodium, an increased urine specific gravity.

The nurse notes that the only ECG for a 55-year-old male client
scheduled for surgery in two hours is dated two years ago. The
client reports that he has a history of "heart trouble," but has no
problems at present. Hospital protocol requires that those over 50
years of age have a recent ECG prior to surgery. What nursing
action is best for the nurse to implement?
A) Ask the client what he means by "heart trouble."
B) Call for an ECG to be performed immediately.
C) Notify surgery that the ECG is over two years old.
D) Notify the client's surgeon immediately.

A) Two weeks before menstruation.


Ovulation typically occurs 14 days before menstruation begins (A),
and sexual intercourse should occur within 24 hours of ovulation
for conception to occur. High estrogen levels occur during
ovulation and increase the vaginal mucous membrane
characteristics, which become more "slippery" and stretchy, not
(B). A rise in basal temperature, not (C), signals ovulation. The
timing during the day is not as significant in determining
conception as the day before and after ovulation (D).

D) Do not leave the diaphragm in place longer than 8 hours after intercourse.
E) Contact a healthcare provider a sudden onset of fever grater than 101 F
appears.
Correct selections are (D and E). The diaphragm needs to remain against the
cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer
than 8 hours (D) to avoid the risk of TSS. If a sudden fever occurs, the client
should notify the healthcare provider (E). (A) increases the risk of pregnancy,
and (B) can reduce the integrity of the barrier contraceptive but neither
prevents the risk of TSS. The diaphragm should not be used during menses (C)
because it obstructs the menstrual flow and is not indicated because
conception does not occur during this time. (F) is not necessary.

C) Initiate a weight-reduction diet to achieve a healthy body


weight.
Achieving a healthy weight (C) is critical to protect the joints of
clients with OA. Increasing the amount of calcium in the client's
diet (A) will not protect hip joints from the effects of OA. Thermal
therapies may lessen pain and stiffness from OA but are not
protective of the joints (B). Assistive devices such as a walker may
be beneficial to help avoid falls and assist in ambulation but are
not protective against OA's effects (D).

C) Increased protein in the urine, slightly increased


serum glucose levels.
In older adults, the protein found in urine slightly
rises probably as a result of kidney changes or
subclinical urinary tract infections. The serum
glucose increases slightly due to changes in the
kidney. The specific gravity declines by age 80 from
1.032 to 1.024.

B) Call for an ECG to be performed immediately.


Clients over the age of 40 and/or with a history of cardiovascular
disease, should receive ECG evaluation prior to surgery, generally 24
hours to two weeks before. (B) should be implemented to ensure that
the client's current cardiovascular status is stable. Additional data might
be valuable (A), but since time is limited, the priority is to obtain the
needed ECG. Documentation of vital signs is important, but does not
replace the need for the ECG (C). The surgeon only needs to be notified
if the ECG cannot be completed, or if there is a significant problem (D).

The nurse should be correct in withholding a dose of


digoxin in a client with congestive heart failure
without specific instruction from the healthcare
provider if the client's
A) serum digoxin level is 1.5.
B) blood pressure is 104/68.
C) serum potassium level is 3.
D) apical pulse is 68/min.

The nurse working in a postoperative surgical clinic is assessing a


woman who had a left radical mastectomy for breast cancer.
Which factor puts this client at greatest risk for developing
lymphedema?
A) She sustained an insect bite to her left arm yesterday.
B) She has lost twenty pounds since the surgery.
C) Her healthcare provider now prescribes a calcium channel
blocker for hypertension.
D) Her hobby is playing classical music on the piano.

The nurse working on a telemetry unit finds a client


unconscious and in pulseless ventricular tachycardia
(VT). The client has an implanted automatic defibrillator.
What action should the nurse implement?
A) Prepare the client for transcutaneous pacemaker.
B) Shock the client with 200 joules per hospital policy.
C) Use a magnet to deactivate the implanted pacemaker.
D) Observe the monitor until the onset of ventricular
fibrillation.

Physical examination of a comatose client reveals


decorticate posturing. Which statement is accurate
regarding this client's status based upon this finding?
A) A cerebral infectious process is causing the
posturing.
B) Severe dysfunction of the cerebral cortex has
occurred.
C) There is a probable dysfunction of the midbrain.
D) The client is exhibiting signs of a brain tumor.
A postmenopausal client asks the nurse why she is experiencing
discomfort during intercourse. What response is best for the nurse
to provide?
A) Estrogen deficiency causes the vaginal tissues to become dry
and thinner.
B) Infrequent intercourse results in the vaginal tissues losing their
elasticity.
C) Dehydration from inadequate fluid intake causes vulva tissue
dryness.
D) Lack of adequate stimulation is the most common reason for
dyspareunia.

C) serum potassium level is 3.


Hypokalemia (C) can precipitate digitalis toxicity in
persons receiving digoxin which will increase the chance
of dangerous dysrhythmias (normal potassium level is 3.5
to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to
2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range.
(B) would not warrant the nurse withholding the digoxin.
The nurse should withhold the digoxin if the apical pulse
is less than 60/min (D).
A) She sustained an insect bite to her left arm yesterday.
A radical mastectomy interrupts lymph flow, and the
increased lymph flow that occurs in response to the insect
bite increases the risk for the occurrence of lymphedema
(A). (B) is not a factor. Lymphedema is not significantly
related to vascular circulation (C). Only overuse of the
arm, such as weight-lifting, would cause lymphedema-(D) would not.

B) Shock the client with 200 joules per hospital policy.


The client must be externally shocked (B) to restore an
effective cardiac rhythm. The automatic defibrillator is
obviously malfunctioning. (A) will not be effective during
ventricular tachycardia, since it is used for asystole. Since
the defibrillator is not functioning, (C) is not warranted.
The client should be treated immediately to restore
cardiac output (D).

B) Severe dysfunction of the cerebral cortex has occurred.


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

A) Estrogen deficiency causes the vaginal tissues to


become dry and thinner.
Estrogen deprivation decreases the moisture-secreting
capacity of vaginal cells, so vaginal tissues tend to become
thinner, drier (A), and the rugae become smoother which
reduces vaginal stretching that contributes to
dyspareunia. Dyspareunia is not related to (B or C).
While (D) can contribute to discomfort during
intercourse, the primary cause is hormone-related.

Small bowel obstruction is a condition


characterized by which finding?
A) Severe fluid and electrolyte imbalances.
B) Metabolic acidosis.
C) Ribbon-like stools.
D) Intermittent lower abdominal cramping.

A splint is prescribed for nighttime use by a client


with rheumatoid arthritis. Which statement by the
nurse provides the most accurate explanation for use
of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength.

Two days postoperative, a male client reports aching pain


in his left leg. The nurse assesses redness and warmth on
the lower left calf. What intervention should be most
helpful to this client?
A) Apply sequential compression devices (SCDs)
bilaterally.
B) Assess for a positive Homan's sign in each leg.
C) Pad all bony prominences on the affected leg.
D) Advise the client to remain in bed with the leg
elevated.

A) Severe fluid and electrolyte imbalances.


Among the findings characteristic of a small
bowel obstruction is the presence of severe
fluid and electrolyte imbalances (A). (B, C,
and D) are findings associated with large
bowel obstruction.
A) Prevention of deformities.
Splints may be used at night by clients with
rheumatoid arthritis to prevent deformities (A)
caused by muscle spasms and contractures. Splints
are not used for (B). (C) is usually treated with
medications, particularly those classified as nonsteroidal antiinflammatory drugs (NSAIDs). For (D),
a prescribed exercise program is indicated.

D) Advise the client to remain in bed with the leg elevated.


The client is exhibiting symptoms of deep vein thrombosis (DVT),
a complication of immobility. The initial care includes bedrest and
elevation of the extremity (D). SCDs are used to prevent
thrombophlebitis, not for treatment, when a clot might be
dislodged (A). Once a client has thrombophlebitis, (B) is
contraindicated because of the possibility of dislodging a clot. (C)
is indicated to prevent pressure ulcers, but is not a therapeutic
action for thrombophlebitis.

C) Use daily reminders to take immunosuppressants.

What discharge instruction is most important for a


client after a kidney transplant?
A) Weigh weekly.
B) Report symptoms of secondary Candidiasis.
C) Use daily reminders to take immunosuppressants.
D) Stop cigarette smoking.

After renal transplantation, acute rejection is a risk for several months, so


immunosuppressive therapy, such as corticosteroids and azathioprine
(Imuran), is essential in preventing rejection, so the priority instruction
includes measures, such as daily reminders (C), to ensure the client takes these
medications regularly. Daily weights, not weekly (A), provides a better
indicator of weight gain related to rejection. Although fungal infections related
to the immunosuppression should be reported (B), it is more important to
ensure medication compliance to prevent rejection. Although smoking (D)
increases the risk of atherosclerotic vascular disease which is common in
clients with an organ transplant, (C) remains the priority.

D) Perform a breast self-exam (BSE) procedure monthly.

What instruction should the nurse give a client who is


diagnosed with fibrocystic changes of the breast?
A) Observe cyst size fluctuations as a sign of malignancy.
B) Use estrogen supplements to reduce breast discomfort.
C) Notify the healthcare provider if whitish nipple
discharge occurs.
D) Perform a breast self-exam (BSE) procedure monthly.

Fibrocystic changes in the breast are related to excess fibrous tissue,


proliferation of mammary ducts and cyst formation that cause edema and
nerve irritation. These changes obscure typical diagnostic tests, such as
mammography, due to an increased breast density. Women with fibrocystic
breasts should be instructed to carefully perform monthly BSE (D) and
consider changes in any previous "lumpiness." Fibrocystic disease does not
increase the risk of breast cancer (A). Cyst size fluctuates with the menstrual
cycle, and typically lessens after menopause, and responds with a heightened
sensitivity to circulating estrogen (B), which is not indicated. Nipple discharge
associated with fibrocystic breasts is often milky or watery-milky and is an
expected finding (C).

What is the correct procedure for performing an


ophthalmoscopic examination on a client's right retina?
A) Instruct the client to look at examiner's nose and not
move his/her eyes during the exam.
B) Set ophthalmoscope on the plus 2 to 3 lens and hold it
in front of the examiner's right eye.
C) From a distance of 8 to 12 inches and slightly to the
side, shine the light into the client's pupil.
D) For optimum visualization, keep the ophthalmoscope
at least 3 inches from the client's eye.

What types of medications should the nurse


expect to administer to a client during an
acute respiratory distress episode?
A) Vasodilators and hormones.
B) Analgesics and sedatives.
C) Anticoagulants and expectorants.
D) Bronchodilators and steroids.

When preparing a client who has had a total laryngectomy for


discharge, which instruction is most important for the nurse to
include in the discharge teaching?
A) Recommend that the client carry suction equipment at all times.
B) Instruct the client to have writing materials with him at all
times.
C) Tell the client to carry a medic alert card stating that he is a total
neck breather.
D) Tell the client not to travel alone.

When providing discharge teaching for a


client with osteoporosis, the nurse should
reinforce which home care activity?
A) A diet low in phosphates.
B) Skin inspection for bruising.
C) Exercise regimen, including swimming.
D) Elimination of hazards to home safety.
When teaching diaphragmatic breathing to a client with chronic
obstructive pulmonary disease (COPD), which information should
the nurse provide?
A) Place a small book or magazine on the abdomen and make it
rise while inhaling deeply.
B) Purse the lips while inhaling as deeply as possible and then
exhale through the nose.
C) Wrap a towel around the abdomen and push against the towel
while forcefully exhaling.
D) Place one hand on the chest, one hand the abdomen and make
both hands move outward.

D) For optimum visualization, keep the ophthalmoscope at least 3


inches from the client's eye.
The client should focus on a distant object in order to promote pupil
dilation. The ophthalmoscope should be set on the 0 lens to begin
(creates no correction at the beginning of the exam), and should be held
in front of the examiner's left eye when examining the client's right eye.
For optimum visualization, the ophthalmoscope should be kept within
one to three inches of the client's eye (D). (A and B) describe incorrect
methods for conducting an ophthalmoscopic examination. (C) should
illicit a red reflex as the light travels through the crystalline lens to the
retina.

D) Bronchodilators and steroids.


Besides supplemental oxygen, the ARDS client needs medications
to widen air passages, increase air space, and reduce alveolar
membrane inflammation, i.e., bronchodilators and steroids (D).
(A) would not help the condition. (B) would further depress the
client and compromise the ability to breathe. Anticoagulants would
be contraindicated since clotting of the blood is not yet a problem,
and expectorants are not appropriate for this critically ill client (C).

C) Tell the client to carry a medic alert card stating that he is a total
neck breather.
It is imperative that total neck breathers carry a medic alert notice
(C) so that if they have a cardiac arrest, mouth-to-neck breathing
can be done. Mouth-to-mouth resuscitation will not help them.
They do not need to carry (A) nor refrain from (D). There are many
alternative means of communication for clients who have had a
laryngectomy; depending on (B) is probably the least effective. How
do you know he can read and write?

D) Elimination of hazards to home safety.


Discussion about fall prevention strategies is imperative
for the discharged client with osteoporosis so that advice
about safety measures can be given (D). A low
phosphorus diet is not recommended in the treatment of
osteoporosis (A). Bruising (B) is not a related symptom to
osteoporosis. Weight-bearing exercise is most beneficial
for clients with osteoporosis. Swimming (C) is not a
weight-bearing exercise.

A) Place a small book or magazine on the abdomen and make it


rise while inhaling deeply.
Diaphragmatic or abdominal breathing uses the diaphragm
instead of accessory muscles to achieve maximum inhalation and
to slow the respiratory rate. The client should protrude the
abdomen on inhalation and contract it with exhalation, so (A)
helps the client visualize the rise and fall of the abdomen. The
client should purse the lips while exhaling, not (B). (C and D) are
ineffective.

Which assessment finding by the nurse during a


client's clinical breast examination requires followup?
A) Newly retracted nipple.
B) A thickened area where the skin folds under the
breast.
C) Whitish nipple discharge.
D) Tender lumpiness noted bilaterally throughout
the breasts.

Which client should the nurse recognize as most


likely to experience sleep apnea?
A) Middle-aged female who takes a diuretic nightly.
B) Obese older male client with a short, thick neck.
C) Adolescent female with a history of tonsillectomy.
D) School-aged male with a history of hyperactivity
disorder.

Which description of symptoms is characteristic of a


client diagnosed with trigeminal neuralgia (tic
douloureux)?
A) Tinnitus, vertigo, and hearing difficulties.
B) Sudden, stabbing, severe pain over the lip and
chin.
C) Facial weakness and paralysis.
D) Difficulty in chewing, talking, and swallowing.

Which finding should the nurse identify


as most significant for a client diagnosed
with polycystic kidney disease (PKD)?
A) Hematuria.
B) 2 pounds weight gain.
C) 3+ bacteria in urine.
D) Steady, dull flank pain.

A) Newly retracted nipple.


A newly retracted nipple (A), compared to a life-long finding, may
be an indication of breast cancer and requires additional follow-up.
The inframammary ridge (B) is a normal anatomic finding. Up to
80% of women may experience an intermittent nipple discharge
(C), especially related to recent stimulation, and in most cases,
nipple discharge is not related to malignancy. (D) is a classic
finding for fibrocystic breast disease, a benign condition.

B) Obese older male client with a short, thick neck.


Sleep apnea is characterized by lack of respirations for 10
seconds or more during sleep and is due to the loss of
pharyngeal tone which allows the pharynx to collapse
during inspiration and obstructs air flow through the
nose and mouth. With obstructive sleep apnea, the client
is often obese or has a short, thick neck as in (B). (A, C,
and D) are not typically prone to sleep apnea.
B) Sudden, stabbing, severe pain over the lip and chin.
Trigeminal neuralgia is characterized by paroxysms of
pain, similar to an electric shock, in the area innervated
by one or more branches of the trigeminal nerve (5th
cranial) (B). (A) would be characteristic of Mnire's
disease (8th cranial nerve). (C) would be characteristic of
Bell's palsy (7th cranial nerve). (D) would be
characteristic of disorders of the hypoglossal cranial nerve
(12th).

C) 3+ bacteria in urine.
Urinary tract infections (UTI) for a client with PKD require prompt
antibiotic therapy to prevent renal damage and scarring which may
cause further progression of the disease, so bacteria in the urine (C) is
the most significant finding at this time. (A) is an expected finding from
the rupture of the cysts. (B) does not provide a time frame to determine
if the weight gain is a significant fluid fluctuation, which is determined
within a 24-hour time frame. Although kidney pain can also be abrupt,
episodic, and colicky related to bleeding into the cysts, (D) is more likely
an early symptom in PKD.

C) Consume adequate foods rich in calcium.

Which healthcare practice is most important for the


nurse to teach a postmenopausal client?
A) Wear layers of clothes if experiencing hot flashes.
B) Use a water-soluble lubricant for vaginal dryness.
C) Consume adequate foods rich in calcium.
D) Participate in stimulating mental exercises.

Bone density loss associated with osteoporosis increases at a more rapid


rate when estrogen levels begin to fall, so the most important healthcare
practice during menopause is ensuring an adequate calcium (C) intake
to help maintain bone density and prevent osteoporosis. Although
practices such as (A and B) may reduce some of the discomforts for a
postmenopausal female, calcium intake is more important than comfort
measures. Although social and mental exercises stimulate thought, there
is no scientific evidence that mental exercises (D) prevent dementia or
common forgetfulness associated with reduced hormonal levels.

Which information about mammograms is most


important to provide a post-menopausal female client?
A) Breast self-examinations are not needed if annual
mammograms are obtained.
B) Radiation exposure is minimized by shielding the
abdomen with a lead-lined apron.
C) Yearly mammograms should be done regardless of
previous normal x-rays.
D) Women at high risk should have annual routine and
ultrasound mammograms.

C) Yearly mammograms should be done regardless of previous normal x-rays.


The current breast screening recommendation is a yearly mammogram after
age 40 (C). Breast self-exam (A) continues to be a priority recommendation
for all women because a small lump (or tumor) is often first felt by a woman
before a mammogram is obtained. The radiation exposure from a
mammogram is low, so (B) is not normally provided. The frequency of using
routine and ultrasound mammograms (D) in women with high-risk variables,
such as a history of breast cancer, the presence of BRC1 and BRC2 genes, or 2
first-degree relatives with breast cancer, should be recommended and followed
closely by the healthcare provider.

Which intervention should the nurse implement for a


female client diagnosed with pelvic relaxation disorder?
A) Describe proper administration of vaginal
suppositories and cream.
B) Encourage the client to perform Kegel exercises 10
times daily.
C) Explain the importance of using condoms when
having sexual intercourse.
D) Discuss the importance of keeping a diary of daily
temperature and menstrual cycle events.

B) Encourage the client to perform Kegel exercises 10


times daily.

Which intervention should the nurse plan to implement


when caring for a client who has just undergone a right
above-the-knee amputation?
A) Maintain the residual limb on three pillows at all
times.
B) Place a large tourniquet at the client's bedside.
C) Apply constant, direct pressure to the residual limb.
D) Do not allow the client to lie in the prone position.

B) Place a large tourniquet at the client's bedside.

Which milestone indicates to the nurse successful


achievement of young adulthood?
A) Demonstrates a conceptualization of death and
dying.
B) Completes education and becomes self-supporting.
C) Creates a new definition of self and roles with
others.
D) Develops a strong need for parental support and
approval.

B) Completes education and becomes self-supporting.

Which postmenopausal client's


complaint should the nurse refer to the
healthcare provider?
A) Breasts feel lumpy when palpated.
B) History of white nipple discharge.
C) Episodes of vaginal bleeding.
D) Excessive diaphoresis occurs at night.

Pelvic relaxation disorders are structural disorders


resulting from weakening support tissues of the pelvis.
(B) helps strengthen the surrounding muscles.
Medication will not help correct a cystocele, rectocele, or
uterine prolapse (A). (C) will help prevent sexually
transmitted diseases. (D) is used to identify fertile times
during the woman's menstrual cycle.

A large tourniquet should be placed in plain sight at the client's


bedside (B). If severe bleeding occurs, the tourniquet should be
readily available and applied to the residual limb to control
hemorrhage. The residual limb should not be placed on a pillow
(A) because a flexion contracture of the hip may result. (C) should
be avoided because it may compromise wound healing. (D) should
be encouraged to stretch the flexor muscles and to prevent flexion
contracture of the hip.

Transitioning through young adulthood is characterized


by establishing independence as an adult, and includes
developmental tasks such as completing education,
beginning a career, and becoming self-supporting (B). (A
and C) are characteristic of adolescence. Although strong
bonds with parents are an expected finding for this age
group, the need for support and approval (D) indicates
dependency, which is a developmental delay.

C) Episodes of vaginal bleeding.


Postmenopausal vaginal bleeding (C) may be an indication of
endometrial cancer, which should be reported to the healthcare
provider. Compared to a new-onset of a single lump, breasts that feel
lumpy (A) overall may be a normal variant or a finding consistent with
nonmalignant fibrocystic disease. Up to 80% of women experience (B),
depending on sexual stimulation or hormonal levels, and is no longer
recommended as a reportable symptom when discovered during breast
self-exam (BSE). The client may need further teaching concerning (D), a
disturbing symptom, but it is not as important as (C).

Which reaction should the nurse identify in a client


who is responding to stimulation of the sympathetic
nervous system?
A) Pupil constriction.
B) Increased heart rate.
C) Bronchial constriction.
D) Decreased blood pressure.

Which symptoms should the nurse expect a client to


exhibit who is known to have a pheochromocytoma?
A) Numbness, tingling, and cramps in the
extremities.
B) Headache, diaphoresis, and palpitations.
C) Cyanosis, fever, and classic signs of shock.
D) Nausea, vomiting, and muscular weakness.

While working in the emergency room, the nurse is


exposed to a client with active tuberculosis. When
should the nurse plan to obtain a tuberculin skin
test?
A) Immediately after the exposure.
B) Within one week of the exposure.
C) Four to six weeks after the exposure.
D) Three months after the exposure.

B) Increased heart rate.


Any stressor that is perceived as threatening to
homeostasis acts to stimulate the sympathetic
nervous system and manifests as a flight-or-fight
response, which includes an increase in heart rate (B).
(A, C, and D) are responses of the parasympathetic
nervous system.

B) Headache, diaphoresis, and palpitations.


(B) is the typical triad of symptoms of tumors of the
adrenal medulla (symptoms depend on the relative
proportions of epinephrine and norepinephrine
secretion). (A) lists the signs of latent tetany, exhibited by
clients diagnosed with hypoparathyroidism. (C) lists the
signs of an Addisonian (adrenal) crisis. (D) lists the signs
of hyperparathyroidism.

C) Four to six weeks after the exposure.


A tuberculin skin test is effective 4 to 6
weeks after an exposure (C), so the
individual with a known exposure should
wait 4 to 6 weeks before having a
tuberculin skin test.