comprehensive study Flashcards
1
Q
- A nurse is caring for an older adult client who has diabetes and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases?
a. cataracts
b. open angle glaucoma
c. macular degeneration
d. angle closure glaucoma
A
b ) open angle glaucoma
2
Q
- A nurse is caring for a client who has type 2 diabetes and will have excretory urography. prior to the procedure, which of the following actions should the nurse take? Select all that apply
a. Identify an allergy to seafood
b. withhold metformin for 24 hours
c. administer an enema
d. obtain a serum coagulations profile
e. check for asthma
A
A) identify seafood allergy
B) withhold metformin for 24 hrs
E) Check for asthma
3
Q
- a nurse is monitoring a client who had a kidney biopsy for postoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client?
a. Infection
b. hemorrhage
c. hematuria
d. pain
A
b. hemorrhage
4
Q
- A nurse is reinforcing teaching with a client who will have an X Ray of the kidneys, uterus, and bladder. Which of the following statements should the nurse include?
a. You will receive contrast die during the procedure
b. an enema is necessary before the procedure
c. you will need to lie in the prone position during the procedure
d. the procedure determines whether you have a kidney stone
A
d. the procedure determines whether you have a kidney stone
5
Q
- A nurse is reinforcing discharge teaching with a client who is postoperative following Fundoplication. Which of the following statements by the client indicates understanding?
a. When sitting in my lounge chair after a meal, I will lower the back of it
b. I will try to eat three large meals a day
c. I will elevate the head of my bed on blocks
d. when sleeping, I will lay on my left side
A
c. I will elevate the head of my bed on blocks
6
Q
- a nurse is reinforcing teaching with a client who has a hiatal hernia. Which of the following client statements indicates understanding?
a. I can take my medications with soda
b. peppermint tea will increase my indigestion
c. wearing an abdominal binder will limit my symptoms
d. I will drink hot chocolate at bedtime to help me sleep
A
b. peppermint tea will increase my indigestion
7
Q
- A nurse is collecting data from my client who has Gerd. Which of the following findings should the nurse expect?
a. Absence of saliva
b. loss of tooth enamel
c. sweet taste in mouth
d. absence of eructation
A
b. loss of tooth enamel
8
Q
- a nurse is caring for a client newly admitted with bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications?
a. Propranolol
b. metoclopramide
c. ranitidine
d. vasopressin
A
d. vasopressin
9
Q
- A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease. The nurse should anticipate prescriptions for which of the following medications? Select all that apply
a. antacids
b. histamine receptor antagonist
c. opioid analgesics
d. fiber laxatives
e. proton pump inhibitors
A
a. antacids
b. histamine receptor antagonist
e. proton pump inhibitors
10
Q
- a nurse is reinforcing discharge teaching with a client who is 3 days postoperative following a transverse: ostomy. Which of the following should the nurse include in the teaching?
a. Mucus will be present in stool for five to seven days after surgery
b. expect 500 to 1000ML semi liquid stool after 2 weeks
c. stoma should be moist and pink
d. empty the ostomy bag when it is 3/4 full
A
c. stoma should be moist and pink
11
Q
- a nurse is providing care to a client who is one day postoperative following in Pericentesis. The nurse observes clear, pale yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention?
a. Place a clean towel near the drainage site
b. apply a dry sterile dressing
c. apply direct pressure to the site
d. place the client in supine position
A
b. apply a dry sterile dressing
12
Q
- a nurse is caring for a group of clients. Which of the following client findings should the nurse identify as an indication to recommend enteral feedings?
a. Dysphasia secondary to Parkinson’s disease
b. gastric paresis
c. short bowel syndrome
d. paralytic ileus
A
a. Dysphasia secondary to Parkinson’s disease
13
Q
- a nurse is assisting with the plan of care for a client who has a prescription for total parenteral nutrition. which of the following interventions should the nurse include? Select all that apply
a. measure capillary blood glucose four times daily
b. administer medications through a secondary port on the TPN IV tubing
c. monitor vital signs three times during the 12 hour shift
d. change the TPN IV tubing every 24 hours
e. obtain a daily aPTT
A
c. monitor vital signs three times during the 12 hour shift
d. change the TPN IV tubing every 24 hours
14
Q
- A nurse is monitoring a client following a paracentesis. Which of the following findings indicates bowel perforation?
a. Report of upper chest pain
b. decreased urine output
c. pallor
d. temperature elevation
A
d. temperature elevation
15
Q
- a nurse is reviewing the health record of a client who might have a tumor of the jejunum. the nurse should anticipate a prescription for which of the following tests? Select all but apply
a. a serum Alpha fetoprotein
b. endoscopic retrograde cholangiopancreatography (ERCP)
c. GI x ray with contrast
d. Small bowel capsule endoscopy
e. Colonoscopy
A
c. GI x ray with contrast
d. Small bowel capsule endoscopy
16
Q
- a nurse is completing pre procedure instructions for a client who will undergo a sigmoidoscopy. Which of the following information should the nurse include? Select all that apply
a. Expect more flatulence following the procedure
b. consume no fluid or food before the procedure
c. you will receive moderate sedation for the procedure
d. you will need repositioning throughout the procedure
e. limit your fluid intake the day after the procedure
A
a. Expect more flatulence following the procedure
b. consume no fluid or food before the procedure
17
Q
- a nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following client statements indicates understanding of the instructions?
a. I will continue taking my warfarin while I complete these tests
b. I’m glad I don’t have to follow any special diet at this time
c. this test determines if I have parasites in my bowel
d. this is an easy way to screen for colon cancer
A
d. this is an easy way to screen for colon cancer
18
Q
- A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy. Which of the following actions is the nurses priority?
a. Check the clients airway
b. allow the client to sleep
c. prepare to administer an antidote to the sedative
d. evaluate pre procedure laboratory findings
A
a. Check the clients airway
19
Q
- A nurse is reinforcing teaching with a client about a bowel prep using polyethylene glycol who will undergo a colonoscopy. Which of the following instructions should the nurse reinforce?
a. check with the provider about taking current medications during the bowel prep
b. consume the usual dose until starting the bowel prep
c. expect a bowel prep to act the day after consuming it
d. stop the bowel prep as soon as fecal elimination begins
A
a. check with the provider about taking current medications during the bowel prep
20
Q
- a nurse is caring for a client who is at risk for increased intracranial pressure. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? Select all that apply
a. suction the client frequently
b. decrease the noise level in the client’s room
c. elevate the clients head on two pillows
d. administer a stool softener
e. keep the client well hydrated
A
b. decrease the noise level in the client’s room
d. administer a stool softener
21
Q
- a nurse is assisting with the care of a client following surgical evacuation of a subdural hematoma. Which of the following data is the priority to monitor?
a. Glasgow coma scale
b. cranial nerve function
c. oxygen saturation
d. pupillary response
A
c. oxygen saturation
22
Q
- a nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to check for this manifestation?
a. Stroke the lateral aspect of the sole of the foot
b. ask the client to blink his eyes
c. observe for facial drooping
d. have the client stand erect with eyes closed
A
d. have the client stand erect with eyes closed
23
Q
- a nurse is caring for a client who has a benign brain tumor. The client asked the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse?
a. It can spread to breasts and kidneys
b. it can develop in your gastrointestinal tract
c. it is limited to brain tissue
d. it probably started in another area of your body and spread to your brain
A
c. it is limited to brain tissue
24
Q
- a nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? Select all that apply
a. it is given to reduce swelling of the brain
b. you will need to monitor for low blood sugar
c. you may notice weight gain
d. tumor growth will be delayed
e. it can cause you to retain fluids
A
a. it is given to reduce swelling of the brain
c. you may notice weight gain
e. it can cause you to retain fluids
25
44. A nurse is collecting data from my client who has an increased intracranial pressure. Which of the following findings should the nurse expect? Select all that apply
a. disoriented to time and place
b. restlessness and irritability
c. unequal pupils
d. ICP 15 MM HG
e. headache
a. disoriented to time and place
b. restlessness and irritability
c. unequal pupils
e. headache
26
43. a nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for Baclofen. Which of the following statements should the nurse include in the teaching?
a. This medication will help you with your tremors
b. this medication will help you with your bladder function
c. this medication may cause your skin to bruise easily
d. this medication may cause your skin to appear yellow in color
d. this medication may cause your skin to appear yellow in color
27
42. a nurse is collecting data from my client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? Select all that apply
a. areas of paresthesia
b. involuntary eye movements
c. alopecia
d. increased salivation
e. ataxia
a. areas of paresthesia
b. involuntary eye movements
e. ataxia
28
41. A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?
a. Fluctuations in blood pressure
b. loss of cognitive function
c. ineffective cough
d. drooping eyelids
b. loss of cognitive function
29
40. a nurse is collecting data on a client who has experienced a left hemispheric stroke. Which of the following manifestations should the nurse expect?
a. Impulse control difficulty
b. poor judgment
c. frustrated about deficits
d. loss of depth perception
c. frustrated about deficits
30
39. a nurse is contributing to the plan of care for a client who has global aphasia. Which of the following interventions should the nurse include in the client's plan? Select all that apply
a. speak to the client at a slower rate
b. assist the client to use flash cards with pictures
c. speak to the client in a loud voice
d. complete sentence is that the client cannot finish
e. give instructions one step at a time
a. speak to the client at a slower rate
b. assist the client to use flash cards with pictures
e. give instructions one step at a time
31
38. a nurse is contributing to the plan of care for a client who has dysphasia and a new dietary prescription. Which of the following interventions should the nurse include in the plan? Select all that apply
a. have suction equipment available for use
b. feed the client thickened liquids
c. place food on the unaffected side of the client's mouth
d. assign assistive personnel to feed the client slowly
e. instruct the client to swallow with her neck flexed
a. have suction equipment available for use
b. feed the client thickened liquids
c. place food on the unaffected side of the client's mouth
e. instruct the client to swallow with her neck flexed
32
37. a nurse is caring for a client who has left homonymous hemianopsia. Which of the following interventions should the nurse implement?
a. Instruct the client to scan to the right to see objects on the right side of her body
b. place the bedside table on the right side of the bed
c. Orient the client to the food on her plate using the Clock method
d. place the wheelchair on the client's left side
b. place the bedside table on the right side of the bed
33
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36. A nurse is caring for a client who has experienced a right hemispheric stroke. Which of the following findings should the nurse expect? Select all that apply
A. impulse control difficulty
B. left hemiplegia
C. loss of depth perception
D. aphasia
E. lack of situational awareness
```
A. impulse control difficulty
B. left hemiplegia
C. loss of depth perception
E. lack of situational awareness
34
35. a nurse is caring for a client who has Alzheimer's disease. A family member of the client asked the nurse about risk factors for the disease. Which of the following information should the nurse include? Select all that apply
a. exposure to metal Waste products
b. long term estrogen therapy
c. sustained use of vitamin E
d. previous head injury
e. history of herpes infection
a. exposure to metal Waste products
d. previous head injury
e. history of herpes infection
35
34. a nurse is caring for a client who has Alzheimer's disease an falls frequently. Which of the following actions is the priority for the nurse to take to keep the client safe?
A. Keep the call light near the client
B. place the client in a room close to the nurses station
C. encourage the client to ask for assistance
D. remind the client to walk with someone for support
B. place the client in a room close to the nurses station
36
33. a nurse is making a home visit to a client who has Alzheimer's disease. The clients partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wondering. Which of the following safety measures should the nurse review with the partner? Select all that apply
a. remove floor rugs
b. have door locks that can be easily opened
c. provide increased lighting in stairwells
d. install hand rails in the bathroom
e. place the mattress on the floor
a. remove floor rugs
c. provide increased lighting in stairwells
d. install hand rails in the bathroom
e. place the mattress on the floor
37
32. A nurse working in a long term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take?
a. Allow the client to sleep whenever he chooses
b. avoid using gestures when communicating with the client
c. redirect the client when he talks about the past
d. provide finger foods for the clients snacks and meals
d. provide finger foods for the clients snacks and meals
38
31. A nurse is reinforcing teaching with the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective?
a. this medication should increase my partner's appetite
b. this medication should help my partner sleep better
c. this medication should help my partner's daily function
d. this medication should increase my partner's energy level
c. this medication should help my partner's daily function
39
30. a nurse is caring for a client who has Parkinson's disease and is starting to display Bradykinesia. Which of the actions should the nurse take?
a. Remind the client to walk more quickly when ambulating
b. complete passive range of motion exercises daily
c. place the client on a low protein, low calorie diet
d. give the client extra time to perform activities
d. give the client extra time to perform activities
40
29. A nurse is collecting data from my client who has Parkinson's disease. Which of the following findings should the nurse expect? Select all that apply
a. decreased vision
b. pill rolling tremor of the fingers
c. shuffling gait
d. drooling
e. bilateral ankle edema
f. lack of facial expression
b. pill rolling tremor of the fingers
c. shuffling gait
d. drooling
f. lack of facial expression
41
28. a nurse is reinforcing teaching with the family of a client who has Parkinson's disease and a new prescription for bromocriptine. which of the following statements by family member should the nurse identify as understanding of the teaching?
a. This medication can cause dizziness
b. this medication turns into dopamine once in the brain
c. we should see improved mobility in two to three days
d. we should avoid dopaminergics while taking this medication
a. This medication can cause dizziness
42
27. a nurse is contributing to the plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include in the plan of care? Select all that apply
a. provide three large balanced meals daily
b. record diet and fluid intake daily
c. document weight every other week
d. place the client in fowlers position to eat
e. offer nutritional supplements between meals
b. record diet and fluid intake daily
| e. offer nutritional supplements between meals
43
26. A nurse is reviewing the plan of care for a client who has Parkinson's disease. Which of the following interventions should the nurse identify as the priority?
a. Recommend a community support group
b. integrate a daily exercise routine
c. provide a Walker for ambulation
d. schedule a swallowing evaluation
d. schedule a swallowing evaluation
44
25. a nurse is reinforcing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include?
a. I will have a sore throat after placement of the stimulator
b. this stimulator will stop my tonic/clonic seizures
c. I can expect to have a temporary voice change
d. the device is inserted under local anesthesia
c. I can expect to have a temporary voice change
45
24. a nurse is reinforcing education about trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? Select all that apply
a. avoid overwhelming fatigue
b. remove caffeinated products from the diet
c. limit looking at flashing lights
d. perform aerobic exercise
e. limit episodes of hypoventilation
f. use of aerosol Hairspray is recommended
a. avoid overwhelming fatigue
b. remove caffeinated products from the diet
c. limit looking at flashing lights
46
23. a nurse is reinforcing discharge instructions with a female client who has a prescription for phenytoin. which of the following information should the nurse include?
a. Consider taking oral contraceptives when on this medication
b. watch for receding gums when taking the medication
c. take the medication at the same time every day
d. provide a urine sample to determine therapeutic levels of the medication
c. take the medication at the same time every day
47
22. a nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
a. Keep the client in a sideline position
b. document the duration of the seizure
c. reorient the client to the environment
d. provide client hygiene
a. Keep the client in a sideline position
48
21. A nurse is collecting data from my client who has a seizure disorder. The client reports sensing an aura and is about to have a seizure. Which of the following actions should the nurse implement? Select all that apply
a. provide privacy
b. ease the client to the floor if standing
c. move furniture away from the client
d. loosen the client's clothing
e. protect the clients head with padding
f. restrain the client
a. provide privacy
b. ease the client to the floor if standing
c. move furniture away from the client
d. loosen the client's clothing
e. protect the clients head with padding
49
20. a nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the following interventions should the nurse include? Select all that apply
a. monitor for hypotension
b. administer antipyretic medication
c. provide an emesis basin at the bedside
d. perform my skin assessment
e. keep the head of the bed flat
b. administer antipyretic medication
c. provide an emesis basin at the bedside
d. perform my skin assessment
50
19. a health Department nurse is reviewing the use of the meningococcal vaccine for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include?
a. The vaccine reduces the risk of respiratory infection
b. administer this vaccine in a series of four doses
c. recommend this vaccine for adolescents before starting college
d. The vaccine series begins at two months of age
c. recommend this vaccine for adolescents before starting college
51
18. A nurse is contributing to the plan of care for a client who has meningitis an is at risk for increased intracranial pressure. which of the following interventions should the nurse recommend? Select all that apply
a. implement seizure precautions
b. perform neurological checks four times a day
c. administer morphine for the report of neck and generalized pain
d. turn off room lights and television
e. monitor for impaired extraocular movements
f. encourage the client to cough frequently
a. implement seizure precautions
d. turn off room lights and television
e. monitor for impaired extraocular movements
52
17. a nurse is checking for the presence of Brudzinski’s signs in a client who has suspected meningitis. Which of the following actions should the nurse take? Select all that apply
a. place client in supine position
b. flex client’s hip and knee
c. place hands behind the client's neck
d. bend clients head toward chest
e. straighten the clients flexed leg at the knee
a. place client in supine position
c. place hands behind the client's neck
d. bend clients head toward chest
53
16. A nurse is collecting data from a client who reports severe headache and a stiff neck. Data collection reveals positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform first?
a. Administer antibiotics
b. implement droplet precautions
c. obtain an IV access
d. decrease bright lights
b. implement droplet precautions
54
15. a nurse is reinforcing teaching with a client who is to undergo an EEG the next day. which of the following information should the nurse include in the teaching?
a. Do not wash your hair the morning of the procedure
b. try to stay awake most of the night prior to the procedure
c. the procedure will take approximately 15 minutes
d. you will need to lie flat for four hours after the procedure
b. try to stay awake most of the night prior to the procedure
55
14. A nurse is reviewing the plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? Select all that apply
a. I think I might be pregnant
b. I take warfarin
c. i take antihypertensive medication
d. i am allergic to shrimp
e. i ate a light breakfast this morning
a. I think I might be pregnant
b. I take warfarin
d. i am allergic to shrimp
e. i ate a light breakfast this morning
56
13. a nurse is using the Glasgow coma scale to check a client for changes in the level of consciousness. The client opens his eyes when spoken to, speaks incoherently, and move his extremities when pain is applied. Which of the following GCS scores should the nurse document?
a. E2 + V3 + M 5 = 10
b. E3 + V4 + M4 = 11
c. E4 + V5 + M6 = 15
d. E2 + V2 + M4 = 8
b. E3 + V4 + M4 = 11
57
12. a nurse is reinforcing teaching with a client who is scheduled for a cerebral computed tomography CT scan with contrast. Which of the following statements by the client indicates understanding of the teaching?
a. I should not have caffeine 48 hours before the procedure
b. I will have my kidney function checked before the test
c. I should take my wedding band in place before the procedure
d. I will have my brain activity monitored during the test
b. I will have my kidney function checked before the test
58
11. A nurse is caring for a client who is post procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? Select all that apply
a. use the Glasgow coma scale to evaluate the client
b. assist the client to a supine position
c. administer an opioid medication
d. encourage the client to increase fluid intake
e. remove the bandage on the client's puncture site
b. assist the client to a supine position
c. administer an opioid medication
d. encourage the client to increase fluid intake
59
2. a nurse is reinforcing post-operative teaching with a client following cataract surgery. Which of the following statements should the nurse include in the teaching?
a. You can resume playing golf in two days
b. you need to tilt your head back when you wash your hair
c. you can get water in your eyes in one day
d. you need to limit your housekeeping activities
d. you need to limit your housekeeping activities
60
3. a nurse is collecting data on a male older adult client who has a new diagnosis of glaucoma. Which of the following findings should the nurse recognize as risk factors associated with this disease? Select all that apply
a. gender
b. genetic predisposition
c. eye trauma
d. age
e. diabetes
b. genetic predisposition
c. eye trauma
d. age
e. diabetes
61
4. a nurse is collecting data on a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? Select all that apply
a. eye pain
b. floating spots
c. blurred vision
d. white pupils
e. bilateral red reflexes
c. blurred vision
| d. white pupils
62
5. A nurse is reinforcing teaching with a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching?
a. Increase intake of deep yellow and orange vegetables
b. administer eye drops twice daily
c. avoid bending at the waist
d. wear an eye Patch at night
a. Increase intake of deep yellow and orange vegetables
63
6. A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding?
a. Pearly, gray tympanic membrane
b. malleus visible behind the tympanic membrane
c. presence of a soft cerumen in the external canal
d. fluid bubble seen behind the tympanic membrane
d. fluid bubble seen behind the tympanic membrane
64
7. A nurse is reviewing the health record I have a client who has severe otitis media which of the following are expected findings? Select all that apply
a. enlarged adenoids
b. report of recent colds
c. client prescription for daily furosemide
d. light reflex visible on otoscopic exam in the affected ear
e. air pain relieved by meclizine
a. enlarged adenoids
b. report of recent colds
e. air pain relieved by meclizine (debateable as meclizine helps with vertigo, yet does not relieve pain as per ATI page 91 in the answer rationale)
65
8. a nurse in a clinic is caring for a client who has been experiencing mild to moderate Vertigo due to benign paroxysmal Vertigo for several weeks. Which of the following actions should the nurse recommend to help control the Vertigo? Select all that apply
a. reduce exposure to bright lighting
b. move head slowly when changing positions
c. do not eat fruit high in potassium
d. plan evenly spaced daily fluid intake
e. avoid fluids containing caffeine
a. reduce exposure to bright lighting
b. move head slowly when changing positions
d. plan evenly spaced daily fluid intake
e. avoid fluids containing caffeine
66
9. A nurse is caring for a client who has suspected Meniere’s disease. Which of the following is an expected finding?
a. Purulent lesion in the external ear canal
b. feeling of pressure in the ear
c. bulging red bilateral tympanic membranes
d. unilateral hearing loss
d. unilateral hearing loss
67
10. A nurse is reinforcing discharge teaching with a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching?
a. I should restrict rapid movements and avoid bending from the waist for several weeks
b. I should wait until the day after surgery to wash my hair
c. I will remove the dressing behind my ear in seven days
d. my hearing should be back to normal right after my surgery
a. I should restrict rapid movements and avoid bending from the waist for several weeks
68
1. A nurse is caring for an older adult client who has diabetes and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases?
a. cataracts
b. open angle glaucoma
c. macular degeneration
d. angle closure glaucoma
b. open angle glaucoma
69
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THE NURSE WOULD RECOGNIZE WHICH OF THESE CONDITIONS AS THE CAUSE FOR DECREASED LEVEL OF CONSCIOUSNESS, WHICH IS COMMONLY FOUND IN PATIENTS EXPERIENCING SHOCK?
1 SEVERE PAIN
2 ENDOTOXINS
3 CEREBRAL EDEMA
4 CEREBRAL HYPOXIA
```
4 CEREBRAL HYPOXIA
70
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WHICH PH VALUE REPRESENTS ACIDOSIS?
1 7.26
2 7.35
3 7.4
4 7.49
```
1 7.26
71
WHICH OF THE FOLLOWING NURSING ACTIONS WILL BEST HELP THE PATIENT WITH CANCER TO CONTROL PAIN?
1 ASSESS THE PATIENT’S ANXIETY LEVEL.
2 ASSESS THE PATIENT’S UNDERSTANDING OF THE SIDE EFFECTS OF PAIN MEDICATION.
3 ENCOURAGE USE NONPHARMACOLOGICAL METHODS FOR PAIN.
4 TEACH THE USE OF A RELAXATION.
4 TEACH THE USE OF A RELAXATION.
72
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THE NURSE CHECKS CAPILLARY REFILL ON A PATIENT AND FINDS IT IS 4 SECONDS. THE NURSE WOULD INFORM THE HEALTH CARE PROVIDER SINCE WHICH OF THE FOLLOWING COULD BE INDICATED?
1 DECREASED ARTERIAL FLOW
2 INCREASED ARTERIAL FLOW
3 DECREASED VENOUS FLOW
4 INCREASED VENOUS FLOW
```
1 DECREASED ARTERIAL FLOW
73
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WHICH OF THE FOLLOWING WOULD THE NURSE REINFORCE AS THE MOST IMPORTANT LIFESTYLE MODIFICATION FOR THE PATIENT WITH HYPERTENSION WHO IS AGE 59, 71 INCHES TALL, 127 KILOGRAMS, AND EATS A VEGETARIAN DIET?
1 REDUCE WEIGHT.
2 RESTRICT SALT INTAKE.
3 INCREASE POTASSIUM INTAKE
4 AVOID USE OF ALCOHOL
```
1 REDUCE WEIGHT.
74
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PLACE THE FOLLOWING IN THE CORRECT SEQUENCE FOR NORMAL ELECTRICAL IMPULSE MOVEMENT THROUGH THE CARDIAC CONDUCTION SYSTEM.
1 ATRIOVENTRICULAR NODE
2 BUNDLE OF HIS
3 INTERNODAL TRACTS
4 PURKINJE FIBERS
5 SINOATRIAL NODE
```
5, 3, 1, 2, 4
75
THE NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A PATIENT EXPERIENCING SHOCK. WHICH OF THE FOLLOWING NURSING DIAGNOSES IS MOST APPROPRIATE TO INCLUDE IN THIS PLAN OF CARE?
1 FATIGUE
2 RISK FOR INEFFECTIVE TISSUE PERFUSION (CEREBRAL, PERIPHERAL)
3 INEFFECTIVE HEALTH MAINTENANCE
4 HOPELESSNESS
2 RISK FOR INEFFECTIVE TISSUE PERFUSION (CEREBRAL, PERIPHERAL)
76
WHICH PATIENT IS AT RISK FOR RESPIRATORY ACIDOSIS?
1 THE PATIENT WITH UNCONTROLLED DIABETES MELLITUS
2 THE PATIENT WITH CHRONIC PULMONARY DISEASE 3 THE PATIENT WHO IS VERY ANXIOUS
4 THE PATIENT WHO OVERUSES ANTACIDS
2 THE PATIENT WITH CHRONIC PULMONARY DISEASE
77
WHICH OF THE FOLLOWING PATIENTS WILL BENEFIT FROM HOSPICE CARE?
1 A PATIENT WHO HAS LIVER CANCER AND IS EXPECTED TO LIVE 4 TO 6 WEEKS
2 A PATIENT WHO IS HAVING MULTIPLE SIDE EFFECTS FROM CHEMOTHERAPY
3 A PATIENT WHO IS MAKING A DECISION ABOUT CANCER TREATMENT
4 A PATIENT WITH UNCONTROLLED PAIN
1 A PATIENT WHO HAS LIVER CANCER AND IS EXPECTED TO LIVE 4 TO 6 WEEKS
78
```
A PATIENT IS SCHEDULED FOR VASCULAR SURGERY. THE PATIENT IS TAKING THE FOLLOWING MEDICATIONS. WHICH MEDICATION WOULD THE NURSE QUESTION THE POSSIBLE NEED TO STOP SEVERAL DAYS BEFORE SURGERY?
1 DIGOXIN (LANOXIN)
2 FUROSEMIDE (LASIX)
3 WARFARIN (COUMADIN)
4. FAMOTIDINE (PEPCID)
```
3 WARFARIN (COUMADIN)
79
AT A FOLLOW-UP VISIT, WHICH OF THE FOLLOWING DATA WOULD BEST INDICATE THE PATIENT’S BLOOD PRESSURE THERAPY HAS BEEN SUCCESSFUL?
1 WEIGHT DECREASED BY 3 POUNDS.
2 DIARY OF DIETARY INTAKE IS WITHIN SUGGESTED DIET.
3 BLOOD PRESSURE IS 118/74 MM HG.
4 PATIENT REPORTS WALKING 30 TO 40 MINUTES DAILY
3 BLOOD PRESSURE IS 118/74 MM HG.
80
```
A PATIENT HAS A RADIAL PULSE OF 58 BEATS PER MINUTE. WHICH OF THE FOLLOWING SHOULD THE NURSE USE TO DOCUMENT THIS FINDING?
1 NORMAL
2 ASYSTOLE
3 BRADYCARDIA
4 TACHYCARDIA
```
3 BRADYCARDIA
81
```
A PATIENT WHO IS HEMORRHAGING FROM A LEG INCISION IS CONFUSED. THE NURSE APPLIES PRESSURE TO THE INCISION AND CALLS FOR HELP. WHICH OF THE FOLLOWING TREATMENTS FOR SHOCK WOULD THE NURSE ANTICIPATE BEING ORDERED FIRST?
1 CRYSTALLOID INTRAVENOUS FLUIDS
2 OXYGEN
3 VASOPRESSOR MEDICATION
4 PRBC
```
2. OXYGEN
82
```
A PATIENT IS BEING TREATED FOR HYPOKALEMIA. WHEN EVALUATING RESPONSE TO POTASSIUM REPLACEMENT THERAPY, WHICH OF THE FOLLOWING ASSESSMENT FINDINGS SHOULD THE NURSE OBSERVE FOR?
1 IMPROVING VISUAL ACUITY
2 WORSENING CONSTIPATION
3 DECREASING SERUM GLUCOSE
4 INCREASING MUSCLE STRENGTH
```
4 INCREASING MUSCLE STRENGTH
83
```
THE NURSE NOTES THAT A PATIENT UNDERGOING TREATMENT FOR BONE CANCER IS HAVING TROUBLE WALKING. FOR WHICH ONCOLOGICAL EMERGENCY SHOULD THE PATIENT BE ASSESSED?
1 TUMOR LYSIS SYNDROME
2 HYPERCALCEMIA
3 SPINAL CORD COMPRESSION
4 THROMBOCYTOPENIA
```
3 SPINAL CORD COMPRESSION
84
THE PATIENT ASKS WHAT THE PURPOSE OF A HIGH FIBER DIET IS. WHICH OF THE FOLLOWING REPLIES BY THE NURSE WOULD BE APPROPRIATE?
1 “TO INCREASE ABSORPTION OF THE NUTRIENTS IN YOUR INTESTINE.”
2 “TO PREVENT STRAINING TO REDUCE YOUR HEART’S WORKLOAD.”
3 “TO PREVENT EDEMA.”
4 “TO REDUCE YOUR APPETITE."
2 “TO PREVENT STRAINING TO REDUCE YOUR HEART’S WORKLOAD.”
85
THE NURSE IS REINFORCING MEDICATION TEACHING FOR A PATIENT. THE NURSE WOULD INCLUDE WHICH OF THE FOLLOWING INSTRUCTIONS TO A PATIENT TAKING A DIURETIC?
1 CHANGE POSITION SLOWLY.
2 ELIMINATE SALT IN YOUR DIET.
3 TAKE YOUR MEDICATION BEFORE BED.
4 EMPTY YOUR BLADDER AFTER TAKING THE FIRST DOSE.
1 CHANGE POSITION SLOWLY.
86
```
THE NURSE RESPONDS TO A CALL FOR ASSISTANCE WITH A PATIENT IN PULSELESS VENTRICULAR TACHYCARDIA. THE NURSE SHOULD PREPARE FOR WHAT FIRST-LINE TREATMENT FOR THIS RHYTHM?
1 ANTIARRHYTHMIC MEDICATION
2 DEFIBRILLATION
3 PACEMAKER
4 SYNCHRONIZED CARDIOVERSION
```
2 DEFIBRILLATION
87
```
WHICH OF THESE OBJECTIVE DATA COLLECTION FINDINGS WOULD INDICATE TO THE NURSE THAT THE THERAPEUTIC MEASURES FOR A PATIENT EXPERIENCING SHOCK HAVE BEEN EFFECTIVE?
1 HEART RATE 110 BEATS PER MINUTE
2 SPO2 89%
3 SYSTOLIC BLOOD PRESSURE 118 MM HG
4 RESPIRATORY RATE 22 PER MINUTE
```
3. SYSTOLIC BLOOD PRESSURE 118 MM HG
88
```
A PATIENT GAINS 2 POUNDS IN 24 HOURS, WEIGHED ON THE SAME SCALE AT 7 A.M. APPROXIMATELY HOW MUCH WATER WEIGHT IS REPRESENTED BY THE 2 POUNDS?
1 8 OUNCES
2 16 OUNCES
3 24 OUNCES
4 32 OUNCES
```
4 32 OUNCES
89
A PATIENT IS RECEIVING INTERNAL RADIATION THERAPY EXPRESSES FEELINGS OF ISOLATION IN HER PRIVATE ROOM. WHAT SHOULD THE NURSE DO?
1 ENCOURAGE THE PATIENT’S FRIEND TO STAY OVERNIGHT.
2 MOVE THE PATIENT INTO A SEMIPRIVATE ROOM
3 TEACH ABOUT SAFETY OF RADIATION
4 SPEND MORE TIME WITH THE PATIENT
3 TEACH ABOUT SAFETY OF RADIATION
90
```
THE NURSE IS CARING FOR A PATIENT ON BEDREST AND ON DIURETIC THERAPY. WHAT SHOULD THE NURSE DO TO CHECK FOR THE PRESENCE OF EDEMA? SELECT ALL THAT APPLY.
1 PRESS ON STERNAL AREA
2 ASK PATIENT TO PERFORM ANKLE PUMPS
3 TURN PATIENT ONTO SIDE
4 INSPECT SACRUM
5 PERFORM STERNAL RUB
6 PRESS ON SACRUM
```
3 TURN PATIENT ONTO SIDE
4 INSPECT SACRUM
6 PRESS ON SACRUM
91
```
THE NURSE IS REINFORCING TEACHING ON HYPERTENSION FOR A PATIENT. WHICH OF THE FOLLOWING STATEMENTS MADE BY THE PATIENT WOULD INDICATE UNDERSTANDING OF WHAT IS OFTEN THE ONLY SIGN OF HYPERTENSION?
1 “SACRAL EDEMA.”
2 “ELEVATED BLOOD PRESSURE LEVEL.”
3 “TACHYCARDIA.”
4 “JUGULAR VENOUS DISTENTION."
```
2 “ELEVATED BLOOD PRESSURE LEVEL.”
92
THE NURSE PREPARES TO DOCUMENT A CARDIAC RHYTHM. THE NURSE USES A SYSTEMATIC METHOD FOR ANALYZING THE CARDIAC TRACING FOR WHICH OF THE FOLLOWING REASONS?
1 TO PREVENT ABNORMALITIES FROM BEING MISSED
2 TO SAVE TIME
3 TO DEVELOP A ROUTINE FOR EXAMINING TRACINGS
4 TO INCREASE MEMORY
1 TO PREVENT ABNORMALITIES FROM BEING MISSED
93
WHICH OF THESE FINDINGS DURING DATA COLLECTION WOULD THE NURSE SPECIFICALLY ANTICIPATE IN A PATIENT EXPERIENCING ANAPHYLACTIC SHOCK? SELECT ALL THAT APPLY.
1. WHEEZING
2. HYPERTENSION
3. TACHYCARDIA
4. OLIGURIA
5. URTICARIA
6. BRONCHOSPASM
1. . WHEEZING
5. URICARIA (HIVES)
6. BRONCHOSPASM
94
```
A PATIENT IS BEING PLACED ON A POTASSIUM-LOSING DIURETIC. WHICH FOODS ARE HIGH IN POTASSIUM AND SHOULD BE RECOMMENDED TO THE PATIENT BY THE NURSE? SELECT ALL THAT APPLY.
1 BREAD
2 POTATO
3 YOGURT
4 BANANA
5 GELATIN
```
2 POTATO
| 3 YOGURT
95
```
A PATIENT HAS RECEIVED VINORELBINE (NAVELBINE) ON DAY 1 OF TREATMENT. FOR WHICH COMPLICATION SHOULD THE NURSE BE VIGILANT AROUND DAY 10?
1 INFECTION
2 HAIR LOSS
3 DIARRHEA
4 MYALGIA
```
1 INFECTION
96
```
THE NURSE IS TO OBTAIN ORTHOSTATIC BLOOD PRESSURE MEASUREMENTS. WHICH OF THE FOLLOWING INTERVENTIONS SHOULD THE NURSE USE? SELECT ALL THAT APPLY
1 REALITY ORIENTATION
2 GAIT OR WALKING BELT
3 LIQUIDS AT BEDSIDE
4 STANDING PATIENT QUICKLY
5 ASKING WHETHER DIZZY BEFORE STANDING
6 STANDING NEAR PATIENT
```
2 GAIT OR WALKING BELT
5 ASKING WHETHER DIZZY BEFORE STANDING
6 STANDING NEAR PATIENT
97
```
A NURSE IS CARING FOR A CLIENT WHO EXPERIENCED DEFIBRILLATION. WHICH OF THE FOLLOWING SHOULD BE INCLUDED IN THE DOCUMENTATION OF THIS PROCEDURE? (SELECT ALL THAT APPLY.)
A. FOLLOW‑UP ECG
B. ENERGY SETTINGS USED
C. IV FLUID INTAKE
D. URINARY OUTPUT
E. SKIN CONDITION UNDER ELECTRODES
```
A. FOLLOW‑UP ECG
B. ENERGY SETTINGS USED
E. SKIN CONDITION UNDER ELECTRODES
98
THE NURSE IS TO GIVE A PATIENT AMIODARONE 800 MG/DAY BY MOUTH IN TWO DIVIDED DOSES. THE NURSE HAS AVAILABLE 200-MG TABLETS. HOW MANY TABLETS SHOULD THE NURSE GIVE FOR EACH DOSE? FILL IN THE BLANK. ANSWER: ______________ TABLETS
2
99
A 160-POUND PATIENT IS TO RECEIVE CYCLOSPORINE (NEORAL) 12.5 MG/KG DAILY IN TWO DIVIDED DOSES. HOW MANY MILLIGRAMS WILL THE PATIENT RECEIVE WITH EACH DOSE? FILL IN THE BLANK. ANSWER: ______________ MG
454.5 MG PER DOSE
| 160/2.2 = 72.72 × 12.5 = 909/2 = 454.5
100
WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE PRIORITIZE WHEN TAKING CARE OF A PATIENT WITH A PLATELET COUNT OF 23,000?
1 REQUEST AN ORDER FOR AN ANTICOAGULANT.
2 PROTECT THE PATIENT FROM INJURY.
3 ENCOURAGE THE PATIENT TO DRINK PLENTY OF FLUIDS.
4 NO ACTION IS NECESSARY. THIS IS A NORMAL LEVEL.
2 PROTECT THE PATIENT FROM INJURY.
101
```
WHICH TERM SHOULD BE USED TO DOCUMENT THE MUSICAL SOUNDS GENERATED BY AIRFLOW THROUGH NARROWED AIRWAYS?
1 CRACKLES
2 WHEEZES
3 FRICTION RUB
4 STRIDOR
```
2 WHEEZES
102
```
A NURSE IS REVIEWING THE HEALTH RECORD OF A CLIENT WHO IS TO UNDERGO TOTAL JOINT ARTHROPLASTY. THE NURSE SHOULD RECOGNIZE WHICH OF THE FOLLOWING FINDINGS AS A CONTRAINDICATION TO THIS PROCEDURE?
A. AGE 78 YEARS
B. HISTORY OF CANCER
C. PREVIOUS JOINT REPLACEMENT
D. BRONCHITIS 2 WEEKS AGO
```
D. BRONCHITIS 2 WEEKS AGO
103
```
A NURSE IS MONITORING A CLIENT FOLLOWING A PARACENTESIS. WHICH OF THE FOLLOWING FINDINGS INDICATE THE BOWEL WAS PERFORATED DURING THE PROCEDURE?
A. CLIENT REPORT OF UPPER CHEST PAIN
B. DECREASED URINE OUTPUT
C. PALLOR
D. TEMPERATURE ELEVATION
```
D. TEMPERATURE ELEVATION
104
```
A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO HAS INCREASED ICP. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE EXPECT?
A. DILATED PUPILS
B. HYPOTENSION
C. TACHYCARDIA
D. HYPERVENTILATION
```
A. DILATED PUPILS
105
```
A NURSE IS CARING FOR A CLIENT WHO HAS DIABETES INSIPIDUS. WHICH OF THE FOLLOWING URINALYSIS LABORATORY FINDINGS SHOULD THE NURSE EXPECT?
A. PRESENCE OF GLUCOSE
B. DECREASED SPECIFIC GRAVITY
C. PRESENCE OF KETONES
D. PRESENCE OF RED BLOOD CELLS
```
B. DECREASED SPECIFIC GRAVITY
106
```
A NURSE IS REVIEWING LABORATORY RESULTS OF A CLIENT WHO IS BEING EVALUATED FOR SECONDARY HYPOTHYROIDISM. WHICH OF THE FOLLOWING LABORATORY FINDINGS IS EXPECTED?
A. ELEVATED T4
B. DECREASED T3
C. ELEVATED THYROID STIMULATING HORMONE
D. DECREASED CHOLESTEROL
```
B. DECREASED T3
107
```
A NURSE IS MONITORING A CLIENT WHO REPORTS SEVERE HEADACHE AND A STIFF NECK. THE NURSE’S DATA COLLECTION REVEALS POSITIVE KERNIG’S SIGNS. WHICH ACTION SHOULD THE NURSE PERFORM FIRST?
A. ADMINISTER ANTIBIOTICS.
B. IMPLEMENT DROPLET PRECAUTIONS.
C. INITIATE IV ACCESS
D. DECREASE BRIGHT LIGHTS.
```
B. IMPLEMENT DROPLET PRECAUTIONS.
108
A NURSE IS PROVIDING CARE FOLLOWING A PARACENTESIS. THE NURSE OBSERVES CLEAR, YELLOW FLUID ON THE BANDAGE. WHICH OF THE FOLLOWING IS AN APPROPRIATE NURSING INTERVENTION?
A. PLACE A CLEAN TOWEL NEAR THE DRAINAGE SITE.
B. APPLY A DRY, STERILE DRESSING.
C. APPLY DIRECT PRESSURE
B. APPLY A DRY, STERILE DRESSING
109
A NURSE IS REINFORCING TEACHING ABOUT RESIDUAL LIMB CARE FOR A CLIENT WHO HAS A BELOW THE KNEE AMPUTATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE?
A. USE A MIRROR TO EXAMINE ALL AREAS OF THE RESIDUAL LIMB DAILY.
B. ADJUST THE PROSTHESIS TWICE A WEEK.
C. CHANGE BANDAGES DAILY
A. USE A MIRROR TO EXAMINE ALL AREAS OF THE RESIDUAL LIMB DAILY.
110
PLACE THE FOLLOWING STEPS IN THE CORRECT SEQUENTIAL ORDER FOR OBTAINING A SPUTUM SPECIMEN.
1 HAVE THE PATIENT COUGH DEEPLY FROM THE LUNGS.
2 TEACH THE PATIENT TO INHALE DEEPLY SEVERAL TIMES.
3 CHECK THE ORDER FOR THE TEST.
4 SEND THE SPECIMEN IMMEDIATELY TO THE LABORATORY.
5 OBTAIN THE CONTAINER.
3, 5, 2, 1, 4
111
A NURSE IS PREPARING A PATIENT FOR LYMPHANGIOGRAPHY. WHICH STATEMENT BY THE PATIENT SHOWS MORE TEACHING IS NEEDED?
1 “MY SKIN MIGHT TURN A BLUISH COLOR.”
2 “I WILL NEED A SANDBAG ON MY GROIN TO PREVENT BLEEDING.”
3 “MY NURSE WILL BE CHECKING MY CIRCULATION ROUTINELY.”
4 “I WILL NEED MORE X-RAYS."
2 “I WILL NEED A SANDBAG ON MY GROIN TO PREVENT BLEEDING.”
112
```
THE NURSE IS CARING FOR A PATIENT ADMITTED WITH PANCYTOPENIA WITH COMPLAINTS OF DYSPNEA UPON EXERTION. FOR WHICH CONDITION SHOULD THE NURSE ASSESS FURTHER?
1 PAIN
2 THROMBOCYTOPENIA
3 ANEMIA
4 NEUTROPENIA
```
3 ANEMIA
113
A NURSE IS CARING FOR A CLIENT WHO HAD AN ABOVE‑THE‑KNEE AMPUTATION. THE CLIENT REPORTS PHANTOM PAIN. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE?
A. REMOVE THE INITIAL PRESSURE DRESSING.
B. ENCOURAGE USE OF COLD THERAPY.
C. QUESTION WHETHER THE PAIN IS REAL.
D. ADMINISTER AN ANTIEPILEPTIC
D. ADMINISTER AN ANTIEPILEPTIC
114
```
A NURSE IS COLLECTING DATA ON A CLIENT WHO HAS GERD . WHICH OF THE FOLLOWING IS AN EXPECTED FINDING?
A. ABSENCE OF SALIVA
B. PAINFUL SWALLOWING
C. SWEET TASTE IN MOUTH
D. ABSENCE OF ERUCTATION
```
B. PAINFUL SWALLOWING
115
A NURSE IS CARING FOR A CLIENT WHO JUST EXPERIENCED A GENERALIZED SEIZURE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE PERFORM FIRST?
A. KEEP THE CLIENT IN A SIDE‑LYING POSITION.
B. DOCUMENT THE DURATION OF THE SEIZURE
. C. REORIENT THE CLIENT TO THE ENVIRONMENT.
D. PROVIDE CLIENT HYGIENE.
A. KEEP THE CLIENT IN A SIDE‑LYING POSITION.
116
```
A NURSE IS COLLECTING AN ADMISSION HISTORY FROM A CLIENT WHO HAS HYPOTHYROIDISM. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE EXPECT? (SELECT ALL THAT APPLY.)
A. DIARRHEA
B. MENORRHAGIA
C. DRY SKIN
D. INCREASED LIBIDO
E. HOARSENESS
```
B. MENORRHAGIA
C. DRY SKIN
E. HOARSENESS
117
```
WHAT ASSESSMENT DATA WILL BEST HELP THE NURSE DETERMINE WHETHER INTERVENTIONS FOR NEUTROPENIA HAVE BEEN EFFECTIVE?
1 TEMPERATURE
2 FATIGUE LEVEL
3 OXYGEN SATURATION
4 HEMOGLOBIN LEVEL
```
1 TEMPERATURE
118
WHICH OF THE FOLLOWING POSITIONS IS RECOMMENDED FOR A PATIENT EXPERIENCING A NOSEBLEED?
1 LYING DOWN WITH FEET ELEVATED
2 SITTING UP WITH NECK FULLY EXTENDED
3 LYING DOWN WITH A SMALL PILLOW UNDER THE HEAD
4 SITTING UP LEANING SLIGHTLY FORWARD
4 SITTING UP LEANING SLIGHTLY FORWARD
119
A NURSE IS PROVIDING CARE FOR A CLIENT WHO HAD A VERTEBROPLASTY OF THE THORACIC SPINE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE?
A. APPLY HEAT TO THE PUNCTURE SITE.
B. PLACE THE CLIENT IN A SUPINE POSITION.
C. TURN THE CLIENT EVERY 1 HR.
D. AMBULATE THE CLIENT WITHIN THE FIRST HOUR POST
B. PLACE THE CLIENT IN A SUPINE POSITION.
120
```
A NURSE IN A CLINIC IS REVIEWING THE LABORATORY REPORTS OF A CLIENT WHO HAS SUSPECTED CHOLELITHIASIS. WHICH OF THE FOLLOWING IS AN EXPECTED FINDING?
A. BLOOD AMYLASE 80 UNITS/L
B. WBC 9,000/MM3
C. DIRECT BILIRUBIN 2.1 MG/DL
D. ALKALINE PHOSPHATASE 25 UNITS/L
```
C. DIRECT BILIRUBIN 2.1 MG/DL
121
A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS PARKINSON’S DISEASE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE INCLUDE?
A. PROVIDE THREE LARGE BALANCED MEALS DAILY.
B. RECORD DIET AND FLUID INTAKE DAILY.
C. DOCUMENT WEIGHT EVERY OTHER WEEK.
D. OFFER LOW-PROTEIN FOOD CHOICES.
B. RECORD DIET AND FLUID INTAKE DAILY.
122
A NURSE IS CARING FOR A CLIENT WHO HAS A BLOOD GLUCOSE OF 52 MG/DL. THE CLIENT IS LETHARGIC &AROUSABLE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE PERFORM FIRST?
A. RECHECK BLOOD GLUCOSE IN 15 MIN.
B. PROVIDE A CARBOHYDRATE AND PROTEIN FOOD.
C. PROVIDE 15 G OF SIMPLE CARBOHYDRATES.
D. REPORT IT
C. PROVIDE 15 G OF SIMPLE CARBOHYDRATES
123
WHICH OF THE FOLLOWING INTERVENTIONS ARE APPROPRIATE FOR A PATIENT WITH THROMBOCYTOPENIA? SELECT ALL THAT APPLY.
1 AVOID INTRAMUSCULAR INJECTIONS.
2 KEEP VISITORS WHO ARE ILL AWAY FROM THE PATIENT.
3 ENCOURAGE 4 LITERS OF FLUID DAILY.
4 AVOID USE OF ASPIRIN AND NONSTEROIDAL ANTI-INFLAMMATORY DRUGS.
1. AVOID INTRAMUSCULAR INJECTIONS.
| 4 AVOID USE OF ASPIRIN AND NONSTEROIDAL ANTI-INFLAMMATORY DRUGS.
124
```
A PATIENT WITH SHORTNESS OF BREATH IS BEING TESTED FOR LUNG CANCER. WHICH DIAGNOSTIC TEST WILL BE MOST CONCLUSIVE?
1 CHEST X-RAY
2 MAGNETIC RESONANCE IMAGING
3 SPUTUM CULTURE
4 BIOPSY
```
4 BIOPSY
125
```
A NURSE IS REINFORCING DIETARY TEACHING ABOUT CALCIUM-RICH FOODS TO A CLIENT WHO HAS OSTEOPOROSIS. WHICH OF THE FOLLOWING FOODS SHOULD THE NURSE INCLUDE IN THE INSTRUCTIONS?
A. WHITE BREAD
B. KALE
C. APPLES
D. BROWN RICE
```
B. KALE
126
```
A NURSE IS REVIEWING RISK FACTORS WITH A CLIENT WHO HAS CHOLECYSTITIS. THE NURSE SHOULD IDENTIFY WHICH OF THE FOLLOWING AS A RISK FACTOR FOR CHOLECYSTITIS?
A. OBESITY
B. RAPID WEIGHT GAIN
C. DECREASED BLOOD TRIGLYCERIDE LEVEL
D. MALE SEX
```
A. OBESITY
127
```
A NURSE IS COLLECTING DATA ON A CLIENT FOR MANIFESTATIONS OF PARKINSON’S DISEASE. WHICH OF THE FOLLOWING ARE EXPECTED FINDINGS? (SELECT ALL THAT APPLY.)
A. DECREASED VISION
B. PILL‑ROLLING TREMOR OF THE FINGERS
C. SHUFFLING GAIT
D. DROOLING
E. BILATERAL ANKLE EDEMA
F. LACK OF FACIAL EXPRESSION
```
B. PILL‑ROLLING TREMOR OF THE FINGERS
C. SHUFFLING GAIT
D. DROOLING
F. LACK OF FACIAL EXPRESSION
128
```
A NURSE IS CARING FOR A CLIENT WHO HAS SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH). WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE EXPECT? (SELECT ALL THAT APPLY.)
A. DECREASED BLOOD SODIUM
B. URINE SPECIFIC GRAVITY 1.001
C. BLOOD OSMOLARITY 230 MOSM/L
D. POLYURIA
E. INCREASED THIRST
```
A. DECREASED BLOOD SODIUM
| C. BLOOD OSMOLARITY 230 MOSM/L
129
```
A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO HAS EXPERIENCED A RIGHT‑HEMISPHERIC STROKE. THE NURSE SHOULD EXPECT THE CLIENT TO HAVE DIFFICULTY WITH WHICH OF THE FOLLOWING? (SELECT ALL THAT APPLY.)
A. IMPULSE CONTROL
B. MOVING THE LEFT SIDE
C. DEPTH PERCEPTION
D. SPEAKING
E. WRITING
```
A. IMPULSE CONTROL
B. MOVING THE LEFT SIDE
C. DEPTH PERCEPTION
130
```
A 65-YEAR-OLD MAN ON THE MEDICAL UNIT IS DIAGNOSED WITH ADVANCED CIRRHOSIS OF THE LIVER. VITAL SIGNS: P 130, R 32, BP 110/60, T 100.4ºF.THE PHYSICIAN STATES THAT THE CLIENT IS IN SHOCK. WHAT TYPE OF SHOCK IS THIS CLIENT EXPERIENCING?
A. HYPOVOLEMIC
B. ANAPHYLACTIC
C. SEPTIC
D. CARDIOGENIC
```
A. HYPOVOLEMIC
RATIONALE: CIRRHOSIS OF THE LIVER RESULTS IN THE FLUID SHIFTING INTO THE INTERSTITIAL SPACES (ASCITES). THIS DECREASES THE AMOUNT OF FLUID CIRCULATING IN THE BLOODSTREAM, RESULTING IN HYPOVOLEMIC SHOCK.
131
```
A CLIENT IS ADMITTED WITH A DIAGNOSIS OF PERNICIOUS ANEMIA. PRIORITY NURSING CARE WOULD INCLUDE:
A. PREVENTION OF INFECTION
B. INCREASING IRON INTAKE
C. PROVIDING REST PERIODS
D. INCREASING FLUID INTAKE
```
PROVIDING REST PERIODS.
RATIONALE: LACK OF OXYGEN TO THE CELLS RESULTS IN HYPOXIA AND FATIGUE.
132
```
A CLIENT IS ADMITTED WITH STENOSIS OF THE CARDIAC SPHINCTER. THE NURSE KNOWS THAT THIS WILL AFFECT THE CLIENT’S:
A. ABILITY TO SWALLOW
B. CARDIAC OUTPUT
C. BLOOD PRESSURE
D. GASTRIC EMPTYING
```
ABILITY TO SWALLOW.
RATIONALE: THE CARDIAC, OR LOWER ESOPHAGEAL SPHINCTER, OPENS TO ALLOW FOOD INTO THE STOMACH, AND IS NORMALLY CLOSED AT OTHER TIMES.
133
A 79-YEAR-OLD CLIENT WITH BENIGN PROSTATIC HYPERTROPHY HAS NOT VOIDED IN THE PAST 8 HOURS. THE FIRST PRIORITY ACTION BY THE LPN/LVN WOULD BE TO:
A. PROVIDE 500 ML FLUIDS ORALLY
B. PERFORM A CATHETERIZATION WITH A 14-FR. STRAIGHT CATHETER
C. PALPATE THE LOWER ABDOMEN D. NOTIFY THE PHYSICIAN
PALPATE THE LOWER ABDOMEN.
| RATIONALE: ASSESSMENT TO DETERMINE WHETHER THE BLADDER IS DISTENDED IS NEEDED BEFORE FURTHER ACTION IS TAKEN.
134
WOMEN WHO EXPERIENCE BREAST TENDERNESS SHOULD AVOID WHICH OF THE FOLLOWING:
A. COFFEE, COLAS, AND CHOCOLATE
B. HIGH PROTEIN SOURCES SUCH AS RED MEAT
C. THE USE OF ASPIRIN AND IBUPROFEN
D. A DIET HIGH IN SUGAR
COFFEE, COLAS, AND CHOCOLATE OUTCOME 5. RATIONALE: THINGS THAT CONTAIN CAFFEINE ARE ATTRIBUTED TO BREAST TENDERNESS. RED MEATS, ASPIRIN AND IBUPROFEN DO NOT CAUSE BREAST TENDERNESS.
135
```
IN REVIEWING AN X-RAY REPORT THAT STATES “DISTAL EPIPHYSEAL FRACTURE OF THE RADIUS,” THE NURSE CORRECTLY INTERPRETS THIS AS MEANING A FRACTURE:
A. CLOSE TO THE ELBOW
B. OF THE SHAFT OF THE RADIUS
C. AT THE WRIST END OF THE BONE
D. THAT HAS BROKEN THE SKIN
```
AT THE WRIST END OF THE BONE.
| RATIONALE: THE EPIPHYSIS IS THE BROAD END OF THE BONE; DISTAL INDICATES THE END FURTHER AWAY FROM THE TRUNK OF THE BODY
136
WHICH OF THESE CLIENTS WOULD MOST LIKELY DEVELOP DEHYDRATION AFTER SURGERY?
A. 24-YEAR-OLD MALE DIAGNOSED WITH AN INGUINAL HERNIA
B. 70-YEAR-OLD FEMALE WITH OVARIAN CANCER
C. 65-YEAR-OLD MALE WITH PROSTATE CANCER
D. 19-YEAR-OLD FEMALE WITH A BADLY FRACTURED LEG
70-YEAR-OLD FEMALE WITH OVARIAN CANCER. RATIONALE: FEMALES, IN GENERAL, HAVE MORE BODY FAT AND LESS BODY WATER THAN MALES. THERE IS LESS WATER AVAILABLE IN CLIENTS WITH A HIGHER PERCENTAGE OF BODY FAT. INDIVIDUALS OVER THE AGE OF 65 ALSO HAVE DECREASED BODY WATER DUE TO HIGHER BODY FAT
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A 42-YEAR-OLD FEMALE CLIENT IS BEING SEEN IN THE PHYSICIAN’S OFFICE DUE TO A CHRONIC BLEEDING DISORDER. THE NURSE NOTES THAT THE CLIENT HAS A PURPLE RASH WHEN INSPECTING THE LEGS AND ABDOMEN OF THE CLIENT. THE NURSE NOTES THAT WHAT IS PRESENT?
A. CYANOSIS
B. PALLOR
C. MOTTLING
D. PURPURA
```
PURPURA
RATIONALE: PURPURA IS A PURPLE RASH CAUSED BY BLOOD LEAKING INTO THE SKIN. CYANOSIS IS A BLUE COLOR RELATED TO LACK OF OXYGEN PERFUSION. BRUISING IS A DISCOLORATION FROM TISSUE TRAUMA AND CAN BE A VARIETY OF COLORS AS HEALING TAKES PLACE.
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WHEN ASSESSING THE ABDOMEN OF A CLIENT, THE NURSE NOTES DULLNESS TO PERCUSSION IN THE LOWER LEFT QUADRANT. ONE POSSIBLE EXPLANATION FOR THIS FINDING IS:
A. ENLARGEMENT OF THE LIVER
B. A FULL BLADDER
C. AIR IN THE SMALL INTESTINE
D. A FECAL MASS IN THE SIGMOID COLON
```
A FECAL MASS IN THE SIGMOID COLON.
RATIONALE: DULLNESS TO PERCUSSION GENERALLY INDICATES SOLID TISSUE OR A MASS. THE SIGMOID COLON IS FOUND IN THE LEFT LOWER QUADRANT; THE LIVER IN THE RIGHT UPPER QUADRANT. A DULL PERCUSSION TONE DUE TO A FULL BLADDER IS USUALLY NOTED AT MIDLINE.
139
A 50-YEAR-OLD WOMAN EXPERIENCES STRESS INCONTINENCE. WHICH OF THE FOLLOWING ASSESSMENT FINDINGS INDICATES A RISK FACTOR FOR THIS CONDITION?
A. TOTAL ABDOMINAL HYSTERECTOMY 9 YEARS AGO
B. SMOKES ONE PACK OF CIGARETTES PER DAY
C. EXERCISES FOUR TIMES A WEEK
D. HISTORY OF TWO PREGNANCIES
TOTAL ABDOMINAL HYSTERECTOMY 9 YEARS AGO. RATIONALE: LACK OF ESTROGEN AFTER A TOTAL HYSTERECTOMY RESULTS IN DECREASED URETHRAL RESISTANCE, PLACING THE CLIENT AT RISK FOR STRESS INCONTINENCE.
140
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AFTER A TRANSURETHRAL PROSTATECTOMY (TURP), A CLIENT CONFESSES TO THE NURSE THAT ALTHOUGH HE IS ABLE TO MAINTAIN AN ERECTION, HE “CAN’T SEEM TO PRODUCE ANYTHING” ON ORGASM. THE NURSE RECOGNIZES THIS AS INDICATIVE OF:
A. NOCTURIA
B. IMPOTENCE
C. DECREASED LIBIDO
D. RETROGRADE EJACULATION
```
RETROGRADE EJACULATION. OUTCOME 1. RATIONALE: DISCHARGE OF SEMINAL FLUID INTO THE BLADDER INSTEAD OF THROUGH THE URETHRA (RETROGRADE EJACULATION) IS COMMON AFTER TURP.
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THE CLIENT HAS HAD A MOTOR VEHICLE ACCIDENT AND HAS AN INJURY TO THE SHOULDER. THE FIRST TEST THE PHYSICIAN WILL LIKELY ORDER FOR THIS CLIENT IS:
A. A MYELOGRAM
B. AN X-RAY OF THE SHOULDER
C. AN ARTHROSCOPY
D. A BONE SCAN
```
AN X-RAY OF THE SHOULDER. OUTCOME 5. RATIONALE: AN X-RAY OF THE SHOULDER WILL BE USED TO EVALUATE BONE DENSITY AND STRUCTURE AND JOINT STRUCTURE
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A CLIENT HAS BEEN DIAGNOSED WITH DEFICIENT ANTIDIURETIC HORMONE (ADH). WHICH ASSESSMENT FINDING SHOULD THE NURSE ANTICIPATE?
A. INCREASED SERUM OSMOLALITY
B. DILUTE URINE
C. DECREASED THIRST
D. NORMAL BLOOD PRESSURE
```
DILUTE URINE.
RATIONALE: ANTIDIURETIC HORMONE (ADH) REGULATES WATER EXCRETION IN THE KIDNEYS. THE KIDNEYS ARE LESS PERMEABLE TO WATER. COPIOUS AMOUNTS OF DILUTE URINE ARE PRODUCED. SERUM OSMOLALITY DECREASES, BLOOD PRESSURE FALLS SLIGHTLY, AND THE THIRST MECHANISM IN THE BRAIN IS ACTIVATED
143
THE PURPOSE OF THE LYMPHATIC SYSTEM IS TO:
A. REMOVE WASTE FROM THE CIRCULATORY SYSTEM
B. FILTER AND REMOVE DAMAGED AND ABNORMAL CELLS
C. MAINTAIN CELL PRODUCTION
D. MONITOR LYMPH NODE ACTIVITY
FILTER AND REMOVE DAMAGED AND ABNORMAL CELLS.
RATIONALE: THE TISSUES AND ORGANS OF THE LYMPHATIC SYSTEM PLAY AN IMPORTANT ROLE IN REMOVING DAMAGED AND ABNORMAL CELLS AND FOREIGN MATTER FROM THE BODY. IT DOES NOT MONITOR LYMPH NODES NOR DOES IT FILTER CIRCULATORY FLUIDS.
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A 58-YEAR-OLD MALE IS ADMITTED WITH THE DIAGNOSIS OF ESOPHAGEAL CANCER WITH EROSION TO THE MIDDLE PORTION OF THE ESOPHAGUS. WHICH OF THE FOLLOWING IS MOST IMPORTANT TO REPORT IMMEDIATELY?
A. ASPIRATION PNEUMONIA
B. BRIGHT BLEEDING FROM THE MOUTH
C. WEIGHT LOSS
D. DIFFICULTY SWALLOWING
BRIGHT BLEEDING FROM THE MOUTH.
| RATIONALE: CANCERS THAT ERODE THROUGH THE ESOPHAGEAL WALL MAY CAUSE SEVERE HEMORRHAGE.
145
AN LPN/LVN EVALUATES FOR RESIDUAL URINE ON A CLIENT; 30 ML OF CLEAR YELLOW URINE IS RETURNED. THE APPROPRIATE ACTION BY THE NURSE WOULD BE TO:
A. NOTIFY THE PHYSICIAN
B. DOCUMENT THE FINDING IN THE MEDICAL RECORD
C. IMPLEMENT MEASURES TO ASSIST THE CLIENT TO VOID
D. INCREASE CLIENT’S FLUID INTAKE
DOCUMENT THE FINDING IN THE MEDICAL RECORD. RATIONALE: RESIDUAL URINE OF 50 ML OR LESS IS WITHIN NORMAL LIMITS SO THE NURSE WOULD SIMPLY DOCUMENT THIS FINDING.
146
AFTER TURP SURGERY, THE NURSE IRRIGATES THE BLADDER:
A. ON AN EVERY-4-HOURS SCHEDULE
B. AS NEEDED TO CLEAR BLOOD CLOTS AND REDUCE SPASMS
C. TO REDUCE THE SENSATION TO VOID
D. TO PREVENT HYPONATREMIA
AS NEEDED TO CLEAR BLOOD CLOTS AND REDUCE SPASMS. OUTCOME 4. RATIONALE: BLOOD CLOTS PROMOTE BLADDER SPASMS AND MAY OBSTRUCT URINE FLOW.
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THE CLIENT IS SCHEDULED TO HAVE A PROCEDURE DONE ON THE KNEE. THE PHYSICIAN WILL PERFORM THIS TEST TO VIEW STRUCTURES AND TISSUES INSIDE THE KNEE. THE NURSE KNOWS THIS PROCEDURE IS CALLED A:
A. ARTHROCENTESIS
B. ARTHROSCOPY
C. SURGICAL ENDOSCOPY
D. PARACENTESIS
```
ARTHROSCOPY. OUTCOME 5.
| RATIONALE: ARTHROSCOPY USES A FLEXIBLE FIBEROPTIC ENDOSCOPE TO VIEW JOINT STRUCTURES AND TISSUES.
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THE NURSE ASSESSING A CLIENT IN THE EMERGENCY DEPARTMENT NOTES DRY, STICKY MUCOUS MEMBRANES; WEAK PERIPHERAL PULSES; AND TACHYCARDIA. THE PRIMARY NURSING DIAGNOSIS SHOULD BE:
A. FLUID VOLUME DEFICIT
B. IMPAIRED SKIN INTEGRITY
C. RISK FOR INJURY.
D. DECREASED CARDIAC OUTPUT
```
FLUID VOLUME DEFICIT.
RATIONALE: DRY, STICKY MUCOUS MEMBRANES; WEAK PERIPHERAL PULSES; AND TACHYCARDIA INDICATE A DECREASE IN FLUID VOLUME, SUCH AS DEHYDRATION.
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THE NURSE CARING FOR A CLIENT WITH A DIAGNOSIS OF THROMBOCYTOPENIA (LOW THROMBOCYTE LEVELS) KNOWS THAT THIS DISORDER WILL AFFECT THE CLIENT’S:
A. ABILITY TO FORM BLOOD CLOTS
B. ABILITY TO FIGHT INFECTION
C. ENERGY LEVEL
D. NUTRITIONAL STATUS
```
ABILITY TO FORM BLOOD CLOTS.
RATIONALE: THROMBOCYTES (PLATELETS) ARE AN IMPORTANT PART OF THE COAGULATION SYSTEM, NECESSARY TO FORM STABLE BLOOD CLOTS. THE WBCS FIGHT INFECTION. ENERGY LEVEL IS RELATED TO H&H, NOT THROMBOCYTES. THROMBOCYTOPENIA AFFECTS CLOTTING, NOT NUTRITION.
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THE CLIENT IS RECEIVING ENTERAL FEEDINGS OF ENSURE (240 ML/CAN) AT A RATE OF 60 ML/HR. THE NURSE ANTICIPATES THAT EACH CAN OF THE FORMULA WILL RUN FOR __________ HOURS.
A. 4
B. 5
C. 2
D. 3
```
A. 4.
| RATIONALE: DIVIDE 60 ML INTO 240 ML TO CALCULATE THE NUMBER OF HOURS THAT IT WILL TAKE FOR THE FEEDING TO RUN (4 HRS).
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A 19-YEAR-OLD IS ADMITTED WITH ACUTE GLOMERULONEPHRITIS. THE NURSE EXPECTS TO OBTAIN WHICH OF THE FOLLOWING ASSESSMENT FINDINGS?
A. “STREP THROAT” 2 WEEKS AGO
B. PNEUMONIA 1 WEEK AGO
C. GASTROENTERITIS
D. INFLUENZA 3 WEEKS AGO
```
A. “STREP THROAT” 2 WEEKS AGO
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WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE WHEN TEACHING A CLIENT WITH NONBACTERIAL PROSTATITIS?
A. RESTRICT FLUIDS TO AVOID PAINFUL VOIDING
B. HAVE FREQUENT SEX
C. WEAR A CONDOM TO AVOID INFECTING THEIR PARTNER
D. FINISH THE ANTIBIOTIC THERAPY
HAVE FREQUENT SEX. OUTCOME 2.
| RATIONALE: FREQUENT EJACULATION IS THOUGHT TO RELIEVE CONGESTION IN THE PROSTATE.
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WHEN ASSESSING RANGE OF MOTION OF THE CLIENT’S KNEE, THE NURSE NOTES A GRATING SOUND. THIS IS APPROPRIATELY CHARTED AS:
A. CREPITUS
B. SYNOVITIS
C. ERYTHEMA
D. INFLAMMATION
```
CREPITUS.
OUTCOME 4.
RATIONALE: CREPITUS IS A GRATING SENSATION OR SOUND. SYNOVITIS IS INFLAMMATION, NOT A SOUND. ERYTHEMA IS REDNESS, NOT A NOISE. INFLAMMATION IS NOT A GRATING SOUND; CREPITUS IS.
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WHEN ASSESSING A CLIENT WHO HAS SUFFERED A HEAT STROKE, WHAT CLINICAL MANIFESTATION SHOULD THE NURSE EXPECT TO FIND? SELECT ALL THAT APPLY.
A. COOL SKIN
B. RAPID RESPIRATIONS
C. NAUSEA AND VOMITING
D. SEVERELY ELEVATED TEMPERATURE
E. RAPID PULSE
F. PROFUSE SWEATING
```
SEVERELY ELEVATED TEMPERATURE.
RAPID RESPIRATIONS.
RAPID PULSE.
RATIONALE: HEAT STROKE IS CHARACTERIZED BY AN EXTREMELY HIGH TEMPERATURE (AS HIGH AS 106º F), TACHYPNEA, AND TACHYCARDIA. COOL SKIN, PROFUSE SWEATING, AND NAUSEA AND VOMITING ARE SEEN IN HEAT EXHAUSTION
155
A CLIENT WITH RENAL FAILURE HAS LOW ERYTHROPOIETIN LEVELS. AS A RESULT, THE NURSE WOULD EXPECT WHICH OF THE FOLLOWING IN THE CBC? SELECT ALL THAT APPLY.
A. A LOW RBC COUNT
B. A HIGH HEMOGLOBIN LEVEL
C. A LOW HEMATOCRIT
D. A HIGH WBC COUNT
E. INCREASED NUMBERS OF IMMATURE RBCS IN THE BLOOD
A LOW RBC COUNT.
A LOW HEMATOCRIT.
RATIONALE: ERYTHROPOIETIN IS A HORMONE PRODUCED BY THE KIDNEYS THAT STIMULATES THE PRODUCTION OF RBCS IN THE BONE MARROW.
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WHEN DEVELOPING A TEACHING PLAN FOR A CLIENT WHO HAS UNDERGONE A PARTIAL GASTRECTOMY, WHICH WOULD THE NURSE INCLUDE RELATED TO PREVENTING DUMPING SYNDROME?
A. DIET LOW IN PROTEIN AND FATS
B. TAKING A WALK BEFORE EACH MEAL
C. EATING THREE MEALS A DAY
D. RESTING IN A SEMI-RECUMBENT POSITION
```
. RESTING IN A SEMI-RECUMBENT POSITION AFTER EATING.
| RATIONALE: DUMPING SYNDROME IS CHARACTERIZED BY STOMACH CONTENTS THAT RAPIDLY FLOOD THE SMALL INTESTINE AFTER A MEAL.
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FOR A CLIENT WITH A URETERAL CALCULUS (STONE), A PRIORITY NURSING ACTION IS TO:
A. WASH HANDS
B. RESTRICT FLUIDS
C. STRAIN ALL URINE
D. COLLECT A STERILE URINE SPECIMEN
```
STRAIN ALL URINE.
RATIONALE: ALL URINE OF CLIENTS WITH URINARY CALCULI SHOULD BE STRAINED FOR PRESENCE OF STONES. STONES SHOULD BE SENT TO THE LAB FOR ANALYSIS.
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WHICH OF THE FOLLOWING IS AN ACCURATE STATEMENT REGARDING SILDENAFIL (VIAGRA)?
A. SILDENAFIL IS HELPFUL IN CLIENTS WHO HAVE CARDIOVASCULAR DISEASE
B. SILDENAFIL WORKS BETTER WHEN COMBINED WITH A NITRATE DRUG
C. SILDENAFIL MAY CAUSE PRIAPISM
D. SILDENAFIL IS TAKEN B.I.D. ON AN EMPTY STOMACH
SILDENAFIL MAY CAUSE PRIAPISM.
OUTCOME 2
. RATIONALE: CLIENTS SHOULD BE ADVISED TO REPORT AN ERECTION THAT LASTS MORE THAN 4 HOURS (PRIAPISM).
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WHICH OF THE FOLLOWING INSTRUCTIONS ARE APPROPRIATE TO PROVIDE WHEN ASSESSING HAND STRENGTH? SELECT ALL THAT APPLY.
A. SHAKE HANDS
B. MOVE THE HAND UP (EXTENDED)
C. SPREAD THE FINGERS AGAINST RESISTANCE
D. MAKE A FIST
E. FLEX THE HAND AGAINST RESISTANCE
SHAKE HANDS.
SPREAD THE FINGERS AGAINST RESISTANCE.
MAKE A FIST.
. RATIONALE: FLEXION AND EXTENSION OF THE WRIST ARE USED TO ASSESS WRIST AND FOREARM MUSCLE STRENGTH.
160
WHAT IS 104.2 DEGREES F TO C?
40.1 C
| SUBTRACT 32. DIVIDE BY 1.8
161
68. A nurse is preparing to begin a 24 hour urine collection for a client. Which of the following actions should the nurse take?
a. Store collected urine in a designated container at room temperature
b. discard the first voiding when beginning the test
c. post I notice on the client's door regarding the testing
d. document any urine collection that was missed during the 24 hour of the testing
b. discard the first voiding when beginning the test
162
69. a nurse is collecting data from my client who has returned to the Med surg unit following a CT scan of the kidneys with IV contrast. Which of the following findings should the nurse identify as an indication the client is experiencing an allergic reaction to the contrast material?
a. Brady cardia
b. pink tinged urine
c. hyperpyrexia
d. pruritis
d. pruritis
163
70. A nurse is reinforcing teaching with a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include?
a. Hemodialysis restores kidney function
b. hemodialysis replaces hormonal function of the renal system
c. hemodialysis allows an unrestricted diet
d. hemodialysis returns a balance to the serum electrolytes
d. hemodialysis returns a balance to the serum electrolytes
164
71. a nurse is caring for a client who has acute kidney injury and is scheduled for hemodialysis. Which of the following actions should the nurse take? Select all that apply
a. review the medications the client currently takes
b. check the AV fistula for a bruit
c. calculate the clients hourly urine output
d. measure the clients weight
e. check serum electrolytes
f. use the access site area for venipuncture
a. review the medications the client currently takes
b. check the AV fistula for a bruit
d. measure the clients weight
e. check serum electrolytes
165
72. a nurse is contributing to the plan of care for a client who received hemodialysis. Which of the following interventions should the nurse recommend? Select all that apply
a. check BUN and serum creatinine
b. administer medications the nurse withheld prior to dialysis
c. observe for manifestations of hypovolemia
d. monitor the access site for bleeding
e. measure blood pressure on the extremity with AV access
a. check BUN and serum creatinine
b. administer medications the nurse withheld prior to dialysis
c. observe for manifestations of hypovolemia
d. monitor the access site for bleeding
166
73. A nurse is caring for a client who develops dis equilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take?
a. Administer an opioid medication
b. monitor for hypertension
c. check level of consciousness
d. recommend an increase in the dialysis exchange rate
c. check level of consciousness
167
74. a nurse is caring for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse plan to take? Select all that apply
a. monitor serum glucose levels
b. report cloudy dialysate return
c. warm the dialysate in a microwave oven
d. monitor for shortness of breath
e. check the access site dressing for wetness
f. maintain medical asepsis when accessing the catheter insertion site
a. monitor serum glucose levels
b. report cloudy dialysate return
d. monitor for shortness of breath
e. check the access site dressing for wetness
168
75. A nurse is contributing to the plan of care for a client who has prerenal acute kidney injury following abdominal aortic aneurysm repair. Urinary output is 60ML in the past two hours, an blood pressure is 92 / 58. The nurse should anticipate which of the following interventions?
a. prepare the client for a CT scan with contrast dye
b. administer ketorolac for pain
c. administer a fluid challenge
d. position the client in reverse Trendelenburg
c. administer a fluid challenge
169
76. a nurse is contributing to the plan of care for a client who has post renal acute kidney injury due to metastatic cancer. The client has a serum creatinine of 5mg/dL Which of the following interventions should the nurse recommend? Select all that apply
a. provide a high protein diet
b. check the urine for blood
c. monitor for intermittent anuria
d. weigh the client once per week
e. provide NSAIDS for pain
a. provide a high protein diet
b. check the urine for blood
c. monitor for intermittent anuria
170
77. A nurse is assisting in the planning of care for a client who has chronic kidney disease. Which of the following actions should the nurse include in the plan of care? Select all that apply
a. auscultate lungs for pulmonary edema
b. provide frequent mouth rinses
c. restrict fluids based on urinary output
d. provide a high sodium diet
e. monitor for weight gain trends
a. auscultate lungs for pulmonary edema
b. provide frequent mouth rinses (due to uremic halitosis)
c. restrict fluids based on urinary output
e. monitor for weight gain trends
171
78. a nurse is checking a client's laboratory findings. Which of the following findings is expected for a client who has stage three chronic kidney disease?
a. BUN 15
b. hemoglobin 14.4
c. serum creatinine 1.1
d. serum potassium 6.0
d. serum potassium 6.0
the client in stage 3 kidney disease can have a serum potassium level greater than 5
172
79. a nurse is reviewing the medical record of a client who has intrarenal acute kidney injury. Which of the following factors should the nurse identify as the cause of this form of AKI?
a. Shock
b. prostate hyperplasia
c. cocaine use disorder
d. liver failure
c. cocaine use disorder
cocaine is nephrotoxic, and is a causative factor of intrarenal AKI
173
80. A nurse is contributing to The plan of care for a client who has chronic pyelonephritis. Which of the following actions should the nurse recommend? Select all that apply
a. assist with a referral for nutrition counseling
b. encourage daily fluid intake of one liter
c. palpate the costovertebral angle
d. monitor urinary output
e. administer antibiotics
a. assist with a referral for nutrition counseling
c. palpate the costovertebral angle
d. monitor urinary output
e. administer antibiotics
174
81. a nurse is caring for a client who has a urinary tract infection. Which of the following is the priority interventions by the nurse?
a. offer a warm sitz bath
b. recommend drinking cranberry juice
c. encourage increased fluids
d. administer an antibiotic
d. administer an antibiotic
175
Which of the following information should the nurse include? Select all that apply
a. avoid sitting in a wet bathing suit
b. wipe the perineal area back to front following elimination
c. empty the bladder when there is an urge to void
d. wear synthetic fabric underwear
e. take a shower daily
a. avoid sitting in a wet bathing suit
c. empty the bladder when there is an urge to void
e. take a shower daily
176
83. a nurse is caring for several clients. Which of the following clients are at risk for developing pyelonephritis? Select all that apply
a. a client who is at 32 weeks of gestation
b. a client who has kidney calculi
c. a client who has a urine pH of 4.2
d. a client who has a neurogenic bladder
e. a client who has diabetes
a. a client who is at 32 weeks of gestation
b. a client who has kidney calculi
d. a client who has a neurogenic bladder
e. a client who has diabetes
177
84. a nurse is checking your analysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection?
a. Positive for hyaline casts
b. positive for leukocyte esterase
c. positive for ketones
d. positive for crystals
b. positive for leukocyte esterase
178
85. A nurse is assisting with the admission assessment of a client who has renal calculi. Which of the following findings should the nurse expect?
a. Bradycardia
b. diaphoresis
c. nocturia
d. Bradypnea
b. diaphoresis
179
86. A nurse is reinforcing discharge instructions with a client who had spontaneous passage of a calcium phosphate renal calculus. Which of the following instructions should the nurse include in the teaching? Select all that apply
a. limit intake of food high in animal protein
b. reduce sodium intake
c. strain urine for 48 hours
d. report burning with urination to the provider
e. increase fluid intake to 3 liters per day
a. limit intake of food high and animal protein
b. reduce sodium intake
d. report burning with urination to the provider
e. increase fluid intake to 3 liters per day
180
87. a nurse is reinforcing teaching with a client who is scheduled for extra Corporal shockwave lithotripsy. Which of the following statements by the client indicates understanding of the teaching?
a. I will be fully awake during the procedure
b. lithotripsy will reduce my chances of having stones in the future
c. I will report any bruising that occurs to my doctor
d. straining my urine following the procedure is important
d. straining my urine following the procedure is important
181
88. a nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following findings is the priority for the nurse to report to the provider?
a. Flank pain that radiates to the lower abdomen
b. client report of nausea
c. absent urine output for one hour
d. serum white blood count of 15,000
c. absent urine output for one hour
182
89. A nurse reinforcing discharge teaching with a client who has spontaneously passed a calcium oxalate calculus. To decrease the chance of reoccurrence, the client should avoid which of the following foods? Select all that apply
a. red meat
b. black tea
c. cheese
d. peanuts
e. spinach
b. black tea
d. peanuts
e. spinach
183
90. A nurse is reviewing the facilities testing process and procedures for human immune deficiency virus HIV with a new employee. Which of the following information should the nurse include in the review?
a. The enzyme immunoassay EIA test is typically reactive within 72 hours after the client is infected with HIV
b. the western blot assay is used to confirm diagnosis of HIV
c. the polymerase chain reaction PRC test is used to confirm diagnosis of HIV
d. CD4+ cell counts are elevated in a client who is infected with HIV
b. the western blot assay is used to confirm diagnosis of HIV
184
91. A nurse is reinforcing teaching with a client prior to her first mammogram. Which of the following statements should the nurse include in the teaching?
a. You should not take any aspirin products prior to the mammogram
b. do not apply any deodorant the day of the exam
c. you will need to avoid sexual intercourse the day before the mammogram
d. you should avoid exercise prior to the exam
b. do not apply any deodorant the day of the exam
185
92. a nurse is preparing a client for her first Pap test. Which of the following statements should the nurse make?
a. You should urinate immediately after the procedure is over
b. you will not feel any discomfort
c. you may experience some bleeding after the procedure
d. you will need to hold your breath during the procedure
c. you may experience some bleeding after the procedure
186
93. a nurse in a providers office is reviewing a client's laboratory results, which shows a positive rapid plasma regain. The nurse should identify which of the following test will be administered to the client to confirm the diagnosis of syphilis?
a. Venereal disease research laboratory
b. D dimer
c. fluorescent treponemal anti body absorbed
d. pap test
c. fluorescent treponemal anti body absorbed
187
94. a nurse is reinforcing teaching with a client who is to undergo a cervical biopsy. Which of the following information should the nurse include in the instructions? Select all that apply
a. the procedure is painless
b. avoid heavy lifting for approximately two weeks after the procedure
c. heavy bleeding is common during the first 12 hours after the procedure
d. plan to rest for the first 72 hours after the procedure
e. avoid the use of tampons for two weeks after the procedure
b. avoid heavy lifting for approximately two weeks after the procedure
e. avoid the use of tampons for two weeks after the procedure
188
95. a nurse is reinforcing teaching about menistration with an adolescent female client. Which of the following statements should the nurse include? Select all that apply
a. the average age of onset of menstruation is 10
b. the range for a typical menstrual cycle is between 23 and 35 days
c. the first day of the menstrual cycle begins with the last day of the menstrual period
d. ovulation typically occurs around the 14th day of the menstrual cycle
e. a menstrual period Can last as long as nine days
b. the range for a typical menstrual cycle is between 23 and 35 days
d. ovulation typically occurs around the 14th day of the menstrual cycle
e. a menstrual period Can last as long as nine days
189
96. A nurse is reviewing the medical record of a client who has PMS. The nurse should identify with that which of the following medications are used to treat PMS? Select all that apply
a. fluoxetine
b. spironolactone
c. ethinyl estradiol/drospirenone
d. ferrous sulfate
e. methylergonovine
a. fluoxetine
b. spironolactone
c. ethinyl estradiol/drospirenone
190
97. A nurse in a providers office is providing information to a client who has dysfunctional uterine bleeding. Which of the following clients statements indicate understanding of the information? Select all that apply
a. my heavy bleeding can be due to a hormonal imbalance
b. if I experience menstrual pain, I should take aspirin
c. I can't take oral contraceptives, because I have heavy uterine bleeding
d. my doctor may perform a D&C to find out what's causing my abnormal bleeding
e. my condition is more common in people who are in their 30s
a. my heavy bleeding can be due to a hormonal imbalance
| d. my doctor may perform a D&C to find out what's causing my abnormal bleeding
191
98. A nurse is providing support to a client who has a new diagnosis of in endometriosis. The nurse should inform the client that which of the following conditions is a possible complication of endometriosis?
a. Insulin resistance
b. infertility
c. vaginitis
d. pelvic inflammatory disease
b. infertility
192
99. a nurse is reviewing the medical record of a client who is menopausal. Which of the following findings should the nurse expect? Select all that apply
a. increased vaginal secretions
b. decreased bone density
c. increased HDL level
d. decreased skin elasticity
e. increased pubic hair growth
f. decreased follicle stimulating hormone level
b. decreased bone density
| d. decreased skin elasticity
193
100. A nurse is reinforcing education with a client about how to perform kegel exercises. Which of the following instructions should the nurse include? Select all that apply
a. perform exercises about 50 times each day
b. contract the circumvaginal in perirectal muscles
c. Gradually increase the contraction period to 10 seconds
d. follow each contraction with at least a 10 second relaxation.
e. Perform while sitting, lying, and standing
f. tighten abdominal muscles during contractions
a. perform exercises about 50 times each day
b. contract the circumvaginal in perirectal muscles
c. Gradually increase the contraction period to 10 seconds
d. follow each contraction with at least a 10 second relaxation.
e. Perform while sitting, lying, and standing
194
101. a nurse is collecting data from my client who is scheduled for an anterior colporrhaphy. which of the following client statements should the nurse expect?
a. I have to push the feces out of a pouch in my vagina with my fingers
b. I have pain and bleeding when I have a bowel movement
c. I have had frequent urinary tract infections
d. I am embarrassed by uncontrollable flatus
c. I have had frequent urinary tract infections
195
102. a nurse is reviewing the medical record of a client who has a cystocele. which of the following findings is a risk factor for development of this disorder?
a. BMI 18
b. Nulliparity
c. chronic Constipation
d. post menopause
d. post menopause
196
103. a nurse is assisting with the discharge of a client following in interior and posterior colporrhaphy. Which of the following instructions should the nurse provide?
a. Do not bend over for at least six weeks
b. you can lift objects as heavy as 10 pounds
c. do not engage in intercourse for at least six weeks
d. you might have foul smelling drainage for the first week after surgery
c. do not engage in intercourse for at least six weeks
197
104. a nurse in a providers office is reviewing the medical record of a client who has fibrocystic breast changes. Which of the following findings should the nurse expect?
a. Palpable rubberlike lump in the upper outer quadrant
b. BRC A1 gene mutation
c. elevated CA 125
d. peau d’oange dimpling of the breast
a. Palpable rubberlike lump in the upper outer quadrant
198
105. A nurse in a providers office is collecting history data from my client who is undergoing an evaluation for benign prostatic hyperplasia. The nurse should identify that which of the following findings are indicated of this condition? Select all that apply
a. Backache
b. frequent urinary tract infections
c. weight loss
d. hematuria
e. urinary incontinence
b. frequent urinary tract infections
d. hematuria
e. urinary incontinence
199
106. a nurse is caring for a client who has a new diagnosis of benign prostatic hyperplasia. The nurse should anticipate a prescription for which of the following medications?
a. Oxybutynin
b. diphenhydramine
c. ipratropium
d. tamsulosin
d. tamsulosin
200
107. A nurse is reinforcing instructions with the client who is scheduled for a transurethral Resection of the prostate, turp, about his post-operative care. which of the following information should the nurse include in the teaching?
a. You may have a continuous sensation of needing to avoid even though you have a catheter
b. You will be on bed rest for the first two days after procedure
c. you will be instructed to limit your fluid intake after the procedure
d. your urine should be clear yellow the evening after the surgery
a. You may have a continuous sensation of needing to avoid even though you have a catheter
201
108. a nurse is reinforcing discharge instructions with a client who is post-operative following a turp. Which of the following instructions should the nurse include? Select all that apply
a. Avoid sexual intercourse for three months after the surgery
b. If urine appears bloody, stop activity and rest
c. avoid drinking caffeinated beverages
d. take a stool softener once a day
e. treat pain with ibuprofen
b. If urine appears bloody, stop activity and rest
c. avoid drinking caffeinated beverages
d. take a stool softener once a day
202
109. a nurse is caring for an older adult client who is having an annual physical exam. Which of the following findings indicates additional follow-up is needed in regard to the prostate gland? Select all that apply
a. prostate specific antigen is 7.1
b. a digital rectal exam reveals an enlarged a nodular prostate
c. the client reports a weak urine stream
d. the client reports urinating once during the night
e. smegma is present below the glands of the penis
a. prostate specific antigen is 7.1
b. a digital rectal exam reveals an enlarged a nodular prostate
c. the client reports a weak urine stream
203
110. a nurse is reinforcing teaching with a client who is scheduled for a transrectal ultrasound . Which of the following information should the nurse include?
a. This procedure will determine whether you have prostate cancer
b. the procedure is contraindicated if you have an allergy to eggs
c. sound waves will be used to create a picture of your prostate
d. you should avoid having a bowel movement for one hour prior to the procedure
c. sound waves will be used to create a picture of your prostate
204
111. A nurse is reinforcing postoperative teaching with a client who is to undergo an Arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? Select all that apply
a. avoid damage or moisture to the cast on your arm
b. inspect incision daily for indications of infection
c. apply ice packs to the area for the first 24 hours
d. keep your arm a dependent position
e. perform isometric exercises
b. inspector incision daily for indications of infection
c. apply ice packs to the area for the first 24 hours
e. perform isometric exercises
205
112. a nurse is contributing to the plan of care for a client who is post-operative following an Arthroscopy of the knee. Which of the following actions should the nurse take? Select all that apply
a. inspect color and temperature of the extremity
b. apply warm compresses to incision site
c. place pillows under the extremity
d. administer analgesic medication
e. check pulse and sensation in the foot
a. inspect color and temperature of the extremity
c. place pillows under the extremity
d. administer analgesic medication
e. check pulse and sensation in the foot
206
113. a nurse is reinforcing teaching with a client who is to have a bone scan. Which of the following statements should the nurse include?
a. You will receive an injection of the radioactive isotope when the scanning procedures begins
b. you will be inside a tube-like structure during the procedure
c. you will need to take radioactive precautions with your urine for 24 hours after the procedure
d. you will have to urinate just before the procedure
d. you will have to urinate just before the procedure
207
114. A nurse is reinforcing teaching with clients at a health fair about dual energy X Ray absorptiometry scans. Which of the following information should the nurse include in the teaching? Select all that apply
a. The test requires the use of contrast material
b. the hip and spine are the usual areas the device scans
c. the scan detects osteoarthritis
d. bone pain can indicate a need for a scan
e at age 40, you should have a baseline scan
b. the hip and spine are the usual areas the device scans
d. bone pain can indicate a need for a scan
e at age 40, you should have a baseline scan
208
115. a nurse is contributing to the plan of care for a client who will undergo an Electromyography. Which of the following actions should the nurse include in the plan of care? Select all that apply
a. check for bruising
b. apply ice to insertion sites
c. determine whether the client takes a muscle relaxant
d. instruct the client to flex her muscles during needle insertion
e. expect swelling, redness, and tenderness at the insertion sites
a. check for bruising
b. apply ice to insertion sites
c. determine whether the client takes a muscle relaxant
d. instruct the client to flex her muscles during needle insertion
209
116. A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?
a. age 78 years
b. History of cancer
c. previous joint replacement
d. bronchitis two weeks ago
d. bronchitis two weeks ago
210
117. a nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions should the nurse take? Select all that apply
a. check continuous passive motion device settings
b. palpate dorsal pedal pulses
c. place a pillow under the knees
d. elevate heels off the bed
e. apply heat therapy to the incision
a. check continuous passive motion device settings
b. palpate dorsal pedal pulses
d. elevate heels off the bed
211
118. a nurse is assisting with planning discharge teaching for a client who had a total hip arthroplasty. Which of the following instructions should the nurse include? Select all that apply
a. clean the incision daily with soap and water
b. turn the toes inward when sitting or lying
c. sit in a straight backed armchair
d. bend at the waist when putting on socks
e. use a raised toilet seat
a. clean the incision daily with soap and water
c. sit in a straight backed armchair
e. use a raised toilet seat
212
119. a nurse is collecting data on a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? Select all that apply
a. skin reddened over the joint
b. pain when bearing weight
c. joint crepitus
d. swelling of the affected joint
e. limited joint motion
b. pain when bearing weight
c. joint crepitus
d. swelling of the affected joint
213
120. a nurse is assisting with a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? Select all that apply
a. complete autologous blood donation
b. sit in a low reclining chair
c. cross legs when in bed
d. use an abductor pillow when turning
e. perform isometric exercises
a. complete autologous blood donation
d. use an abductor pillow when turning
e. perform isometric exercises
214
121. A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide? Select all that apply
a. clients who smoke should consider smoking cessation programs
b. clients who have diabetes mellitus should maintain blood glucose within the expected reference range
c. unplug electrical equipment when performing repairs
d. clients who have vascular disease should maintain good foot care
e. wait two hours after taking pain medication before driving
a. clients who smoke should consider smoking cessation programs
b. clients who have diabetes mellitus should maintain blood glucose within the expected reference range
c. unplug electrical equipment when performing repairs
d. clients who have vascular disease should maintain good foot care
215
122. a nurse is collecting data from an older adult client who has arteriosclerosis and is scheduled for a right lower extremity amputation. Which of the following are expected findings in the affected extremity? Select all that apply
a. Skin cool to touch from mid calf to the toes
b. lower leg appearing dusky when client is sitting
c. palpable pounding pedal pulse
d. lack of hair on lower leg
e. blackened areas on several toes
a. Scan cool to touch from mid calf to the toes
b. lower leg appearing dusky when client is sitting
d. lack of hair on lower leg
e. blackened areas on several toes
216
123. a nurse is caring for a client following a below the elbow amputation. Which of the following actions should the nurse take? Select all that apply
a. encourage dependent positioning of the residual limb
b. inspect for presence an amount of drainage on the dressing
c. implement shrinkage intervention of the residual limb
d. wrap the residual limb in a circular manner using gauze
e. observe for body image changes
a. encourage dependent positioning of the residual limb
b. inspect for presence an amount of drainage on the dressing
c. implement shrinkage intervention of the residual limb
e. observe for body image changes
217
124. a nurse is caring for a client who had an above the knee amputation. The client reports a sharp, stabbing type of Phantom pain. Which of the following actions should the nurse take?
a. Remove the initial pressure dressing
b. encourage use of cold therapy
c. question whether the pain is real
d. administer an antiepileptic medication
d. administer an antiepileptic medication
218
125. a nurse is assisting with preparing a plan of care to prevent a client from developing flexion contractures following a below the knee amputation 24 hours ago. Which of the following actions should the nurse include in the plan of care?
a. Limit any type of exercise to the residual limb for the first 48 hours after surgery
b. position the client prone several times each day
c. wrap the stump in a Figure 8 pattern
d. encourage sitting in a chair during the day
b. position the client prone several times each day
219
126. a nurse is assisting in the admission of an older adult client who has suspected osteoporosis. Which of the following findings should the nurse expect? Select all that apply
a. history of consuming one glass of wine daily
b. loss in height of 5.1 centimeters (2inches)
c. body mass index 21
d. kyphotic curve at upper thoracic spine
e. history of lactose intolerance
b. loss in height of 5.1 centimeters (2 inches)
c. body mass index 21
d. kyphotic curve at upper thoracic spine
e. history of lactose intolerance
220
127. a nurse is assisting in the care of a client immediately following vertebroplasty of the thoracic spine. Which of the following actions should the nurse take?
a. Apply heat to the puncture site
b. place the client in a supine position
c. turn the client every hour
d. ambulate the client within the first hour post procedure
b. place the client in a supine position
221
128. a nurse is reinforcing dietary teaching about calcium rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?
a. White bread
b white beans
c. white meat of chicken
d. white rice
b white beans
222
129. a nurse is assisting with health screenings at a health fair. The nurse should identify that which of the following clients are at risk for osteoporosis? Select all that apply
a. 40 year old client who takes Prednisone for asthma
b. 30 year old client who jogs 3 miles daily
c. 45 year old client who takes phenytoin for seizures
d. 65 year old client who has a sedentary lifestyle
e. 70 year old client who has smoked for 50 years
a. 40 year old client who takes Prednisone for asthma
c. 45 year old client who takes phenytoin for seizures
d. 65 year old client who has a sedentary lifestyle
e. 70 year old client who has smoked for 50 years
223
130. A nurse is reinforcing discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include? Select all that apply
a. remove throw rugs in walk ways
b. use prescribed assistive devices
c. remove clutter from the environment
d. walk with caution on icy surfaces
e. maintain lighting in doorway areas
a. remove throw rugs in walk ways
b. use prescribed assistive devices
c. remove clutter from the environment
e. maintain lighting in doorway areas
224
131. A nurse is reinforcing teaching with the client about how to manage an external fixation device upon discharge. Which of the following clients statements indicate understanding? Select all that apply
a. I will clean the pins twice a day
b. I will use a separate cotton swab for each pin
c. I will report loosening of the pins to my doctor
d. I will clean the pins with tap water an anti bacterial soap
e. I will report increased redness at the pen site
a. I will clean the pins twice a day
b. I will use a separate cotton swab for each pin
c. I will report loosening of the pins to my doctor
e. I will report increased redness at the pen site
225
132. A nurse is collecting data from my client who has a casted compound fracture of the femur. The nurse should identify which of the following findings as a manifestation of fat emboli?
a. Altered mental status
b. reduced bowel sounds
c. swelling of the toes distal to the injury
d. pain with passive movement of the foot distal to the injury
a. Altered mental status
226
133. a nurse is collecting data from a client who had an external fixation device applied 2 hours ago for a fracture of the left tibia and fibula. The nurse should identify which of the following findings as manifestations of compartment syndrome? Select all that apply
a. intense pain when the left foot is passively moved
b. capillary refill of three seconds on the left toes
c. hard, swollen muscles in the left leg
d. burning and tingling of the left foot
e. client reported minimal pain relief following a second dose of opioid medication
a. intense pain when the left foot is passively moved
c. hard, swollen muscles in the left leg
d. burning and tingling of the left foot
e. client reported minimal pain relief following a second dose of opioid medication
227
134. a nurse is reinforcing discharge teaching with a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include?
a. Antibiotic therapy should continue for three months
b. relief of pain indicates the infection is eradicated
c. airborne precautions are used during wound care
d. expect paresthesia distal to the wound
a. Antibiotic therapy should continue for three months
228
135. a nurse is caring for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate?
a. Skeletal traction
b. bucks traction
c. Halo traction
d. bryant's traction
b. bucks traction
229
136. a nurse is collecting data from my client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? Select all that apply
a. heburdens nodes
b. swelling of all joints
c. small body frame
d. enlarged joint size
e. limp when walking
a. heburdens nodes
d. enlarged joint size
e. limp when walking
230
137. A nurse is reviewing information with a client who has osteoarthritis of the hip and knee. Which of the following instructions should the nurse reinforce? Select all that apply
a. Apply heat to joints to alleviate pain
b. ice inflamed joints following activity
c. install an elevated toilet seat
d. take tub baths
e. complete high energy activities in the morning
a. Apply heat to joints to alleviate pain
b. ice inflamed joints following activity
c. install an elevated toilet seat
e. complete high energy activities in the morning
231
138. a nurse is reviewing information about capsaicin cream with a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse reinforce?
a. Continuous pain relief is provided
b. inspect for skin irritation an cuts prior to application
c. cover the area with tight bandages after application
d. apply the medication every two hours during the day
b. inspect for skin irritation an cuts prior to application
232
139. a nurse is caring for a client who injured her lower back during a fall and described sharp pain in her back and down her left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease her pain?
a. Prone without use of pillows
b. semi fowlers with a pillow under the knees
c. how fallers with the knees flat on the bed
d. supine with the head flat
b. semi fowlers with a pillow under the knees
233
140. a nurse is reinforcing teaching with a client who has a history of low back injury. Which of the following instructions should the nurse reinforce with the client to prevent low back pain? Select all that apply
a. engage in regular exercise including walking
b. set for 10 hours each day to rest the back
c. maintain weight within 25% of ideal body weight
d. create a smoking cessation plan
e. wear low heeled shoes
a. engage in regular exercise including walking
d. create a smoking cessation plan
e. wear low heeled shoes
