med surg nclex

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies showed a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?Rationale:Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature (B), because the fracture leaves the meninges open to bacterial invasion. Clients may experience (C and D), but these findings do not pose as great a life-threatening risk as infection. Jugular distention (A) is not a typical complication of basal skull fractures. A. Bilateral jugular venous distention

B. Oral temperature 102° F

C. Intermittent focal motor seizures

D. Intractable pain in the cervical regionSubmit

Incorrect | Correct Answer: BA home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?Rationale:Thin, nonelastic skin (C), is an important factor in decubitus formation. Proportion of body fat to lean mass increases with age (A), and might help decrease ulcer tendency. (B) results in gray hair. (D) can contribute to broken bones, but it is probably not a factor in decubitus formation. A. 16% increase in overall body fat

B. Reduced melanin production

C. Thinning of the skin with loss of elasticity

D. Calcium loss in the bonesSubmit

Incorrect | Correct Answer: CA home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?Rationale:Thin, nonelastic skin (C), is an important factor in decubitus formation. Proportion of body fat to lean mass increases with age (A), and might help decrease ulcer tendency. (B) results in gray hair. (D) can contribute to broken bones, but it is probably not a factor in decubitus formation. A. 16% increase in overall body fat

B. Reduced melanin production

C. Thinning of the skin with loss of elasticity

D. Calcium loss in the bonesSubmit

Incorrect | Correct Answer: C

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Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?Rationale:Microalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end stage renal disease caused by diabetic nephropathy. (C) may be elevated in end stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA). A. Hypokalemia

B. Microalbuminuria

C. Elevated serum lipids

D. KetonuriaSubmit

Incorrect | Correct Answer: B

When preparing a male client who has had a total laryngectomy for discharge, what instruction would be most important for the nurse to include in the discharge teaching?Rationale:It is imperative that total neck breathers carry a medical alert card (C) that notifies healthcare personnel of the need to use mouth-to-stoma breathing in the event of a cardiac arrest in this client. Mouth-to-mouth resuscitation will not establish a patent airway. (A and D) are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence upon writing messages (B) is probably the least effective. A. Recommend that the client carry suction equipment at all

times.

B. Instruct the client to have writing materials with him at all times.

C. Tell the client to carry a medic alert card that explains his condition.

D. Caution the client not to travel outside of the United States alone.

Submit Correct | Correct Answer: C

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?Rationale:Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing (A) includes the most weight-bearing, while (B, C, and D) involve less.

A. Cross-country skiing

B. Scuba diving

C. Horseback riding

D. KayakingSubmit

Incorrect | Correct Answer: A

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An antacid (Maalox) is prescribed for a client with peptic ulcer disease. What is the therapeutic action of this medication which is effective in treating the client's ulcer?Rationale:The objective of antacids is to neutralize gastric acids and keep a pH of 3.5 or above (C) which is necessary for pepsinogen inactivity. (A) is the therapeutic effect of H2 receptor antagonists, such as ranitidine (Zantac). (B) is the therapeutic effect of sucralfate (Carafate). (D) is the therapeutic effect of anticholinergic drugs such as propantheline bromide (Pro-Banthine) used as adjunctive therapy with antacids. A. Decrease in the production of gastric secretions

B. Production of an adherent barrier over the ulcer

C. Maintenance of a gastric pH of 3.5 or above

D. Decrease in the gastric motor activitySubmit

Correct | Correct Answer: CA nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection?Rationale:(A) is at greatest risk for developing sexually transmitted diseases, including HIV, because the greater the number of sexual partners one has, the greater the risk for contracting STDs. (B) comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. (C), who free-bases, would not be sharing needles, so contracting STDs is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV, as long as both partners are monogamous and neither is infected (D). A. A 17-year-old who is sexually active with numerous

partners

B. A 45-year-old lesbian who has been sexually active with two partners in the past year

C. A 30-year-old cocaine user who inhales the drug and works in a topless bar

D. A 34-year-old male homosexual who is in a monogamous relationship

Submit Incorrect | Correct Answer: A

A female practical nurse (PN) who is a valued employee tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?Rationale:Temporary reassignment (D) is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. (A) is not the best option, because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination (B). Implying that the PN is somehow creating the situation is inappropriate until further evaluation is conducted (C). A. Notify the family that the resident will have to be

discharged if his behavior does not improve.

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B. Notify administration of the PN's insubordination and need for counseling about her statements.

C. Ask the PN what she has done to encourage the resident to believe that she is his daughter.

D. Reassign the PN until the resident can be assessed more completely for reality orientation.

Submit Incorrect | Correct Answer: D

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?Rationale:A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are 2 to 5 times higher than the normal value (A). Severe, boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the immediate importance that a positive Trousseau sign has. A. The client's amylase level is three times higher than the

normal level.

B. While the nurse is taking the client's blood pressure, he has a carpal spasm.

C. On a 1 to 10 scale the client tells the nurse that his epigastric pain is at 7.

D. The client states that he will continue to drink alcohol after going home.

Submit Incorrect | Correct Answer: B

The nurse is receiving report from PACU about a client with a Penrose drain who is to be admitted to the surgical nursing unit. Before choosing a room for this client, which information is most important for the nurse to obtain?Rationale:The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected (D). Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require (A). Although (B) is helpful information, it does not have the priority of (D). A Hemovac® (C) is used to drain fluid from a dead space and is not a determinant for the room assignment. A. If suctioning will be needed for drainage of the wound

B. If the family would prefer a private or semiprivate room

C. If the client also has a Hemovac® in place

D. If the client's wound is infectedSubmit

Correct | Correct Answer: D

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A client with non–insulin-dependent diabetes mellitus (NIDDM) takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates the use of which approach to best manage the client's diabetes while the client is NPO during the perioperative period?Rationale:Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO but coping with the major stress of surgery (D). (A) increases the risk of vomiting and aspiration. (B and C) provide less precise control of the blood glucose. A. NPO except for metformin and regular snacks

B. NPO except for oral antidiabetic agent

C. Novolin-N insulin subcutaneously twice daily

D. Regular insulin subcutaneously per sliding scaleSubmit

Incorrect | Correct Answer: DTwelve hours after chest tube insertion for hemothorax, the nurse notes that the client's drainage has decreased from 50 ml/hr to 5 ml/hr. What is the best initial action for the nurse to take?Rationale:The least "invasive" nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops. A. Document this expected decrease in drainage.

B. Clamp the chest tube while assessing for air leaks.

C. Milk the tube to remove any excessive blood clot build-up.

D. Assess for kinks or dependent loops in the tubing.Submit

Correct | Correct Answer: Dincluded in this client's plan of care?Rationale:The prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Since tissue death has already occurred, (A and C) are unattainable goals. (D) is important, but of less priority than (B). A. Restore skin integrity.

B. Prevent infection.

C. Promote healing.

D. Improve nutrition.Submit

Incorrect | Correct Answer: BThe nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants the most immediate intervention by the nurse?

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Rationale:Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the healthcare provider immediately (A). (B) is a normal response to being awakened. (C and D) are common manifestations of head injury and are of less immediacy than (A). A. A unilateral pupil that is dilated and nonreactive to light

B. Client cries out when awakened by a verbal stimulus

C. Client demonstrates a loss of memory of the events leading up to the injury

D. Onset of nausea, headache, and vertigoSubmit

Incorrect | Correct Answer: AThe nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations the client is likely to experience?Rationale:Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson disease does not typically cause (A, B, or D). A. "Have you ever experienced any paralysis of your arms or

legs?"

B. "Do you have frequent blackout spells?"

C. "Have you ever been 'frozen' in one spot, unable to move?"

D. "Do you have headaches, especially ones with throbbing pain?"


The nurse assesses a postoperative client. Oxygen is being administered at 2 L/min and a saline lock is in place. Assessment shows cool, pale, moist skin. The client is very restless and has scant urine in the urinary drainage bag. What intervention should the nurse implement first?Rationale:The client is at risk for hypovolemic shock due to the postoperative status, and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B). A. Measure urine specific gravity.

B. Obtain IV fluids for infusion per protocol.

C. Prepare for insertion of a central venous catheter.

D. Auscultate the client's breath sounds.Submit

Incorrect | Correct Answer: BThe nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention?

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Rationale:Compartment syndrome is a condition involving increased pressure and constriction of nerves and vessels within an anatomic compartment (causing pain uncontrolled by narcotics) and neurovascular compromise (B). (A) is an expected finding. (C) related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. (D) is an expected finding. A. Ecchymosis over the right elbow area

B. Deep, unrelenting pain in the right arm

C. An edematous right elbow

D. The presence of crepitus in the right elbowSubmit

Incorrect | Correct Answer: BA postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?Rationale:Administration of a Schedule II opioid analgesic can result in respiratory depression (C), which requires immediate intervention by the nurse to prevent respiratory arrest. (A, B, and D) require action by the nurse, but are of less priority than (C). A. Hypoactive bowel sounds with abdominal distention

B. Client reports continued pain of 8 on a 10-point scale

C. Respiratory rate of 12 per minute with O2 saturation of 85%

D. Client reports nausea after receiving the medicationSubmit

Incorrect | Correct Answer: CWhich change in lab values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy?Rationale:Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in hemoglobin (B). (A) indicates disease progression, but is not a side effect of the medication. (C) is not related to methotrexate. (D) indicates that inflammation associated with the disease has diminished. A. Increase in rheumatoid factor

B. Decrease in hemoglobin

C. Increase in blood glucose

D. Decrease in ESR (sed rate)Submit

Correct | Correct Answer: BWhich assessment finding in a client with an acute small bowel obstruction requires the most immediate intervention by the nurse?Rationale:A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the healthcare provider immediately (A). (B, C, and D) are also findings which require intervention by the nurse, but are of less priority than (A). (B) may indicate a hypertensive condition, but is not as acute a condition as peritonitis. (C) is an

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expected finding in clients with a small bowel obstruction and may require medication. (D) indicates probable fluid volume deficit which requires fluid volume replacement. A. Fever of 102° F

B. Blood pressure of 150/90

C. Abdominal cramping

D. Dry mucus membranesSubmit

Incorrect | Correct Answer: AThe nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately?Rationale:The level of consciousness (LOC) should be established immediately when a head injury has occurred. Spontaneous eye opening (D) is a simple measure of alertness which indicates that arousal mechanisms are intact. (A) is not the best indicator of LOC. While (B) is important, vital signs are not the best indicators of LOC, and can be evaluated after the client's LOC has been determined. (C) can be assessed after LOC has been established by assessing eye opening. A. Reactivity of deep tendon reflexes, comparing upper to

lower extremities

B. Vital sign readings, excluding blood pressure if needed equipment is unavailable

C. Memory of events that occurred before and after the blow to the head

D. Ability to spontaneously open the eyes before any tactile stimuli are given


An adult resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?Rationale:Hepatitis B vaccine should be administered to all healthcare providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal/oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to client blood/body fluids; therefore (C) is false. There is no need to wear gloves and gowns except with blood/body fluid contact (D). A. Discuss the importance of all employees starting the

hepatitis B vaccine series.

B. Explain that this type of hepatitis can be transmitted when feeding the client.

C. Assure the employees that they cannot contract hepatitis B when providing direct care to this client.

D. Tell the employees that wearing gloves and a gown are required any time care is provided for this client.


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The nurse is observing an unlicensed assistive personnel (UAP) who is performing morning care for a bedfast client with Huntington disease. Which care measure is most important for the nurse to supervise?Rationale:The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely (A). (B, C, and D) do not necessarily require RN supervision because they do not ordinarily pose life-threatening consequences. A. Oral care

B. Bathing

C. Foot care

D. Catheter careSubmit

Incorrect | Correct Answer: AIn assessing an older client with dementia for sundowning syndrome, what assessment technique is best for the nurse to use?Rationale:Sundowning syndrome is a pattern of agitated behavior in the evening, believed to be associated with tiredness at the end of the day combined with fewer orienting stimuli, such as activities and interactions (A). (B, C, and D) will not provide information about this syndrome. A. Observe for tiredness at the end of the day.

B. Perform a neurologic exam and mental status exam.

C. Monitor for medication side effects.

D. Assess for decreased gross motor movement.Submit

Incorrect | Correct Answer: ASeconal 0.1 gram PRN at bedtime is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?Rationale:15 gr = 1 g. Converting the prescribed dose of 0.1 g to grains requires multiplying 0.1 x 15 = 1.5 grains. The tablets come in 1.5 grains; therefore, the nurse should plan to administer 1 tablet (B). (A, C, and D) are incorrect. A. ½ tablet

B. 1 tablet

C. 1½ tablets

D. 2 tabletsSubmit

Correct | Correct Answer: BA severe thunderstorm has moved into a small community, and the tornado warning alarm has been activated at the local hospital. Which action should the charge nurse in the surgical department implement first?Rationale:In the event of a tornado, all persons should be moved into hallways away from windows to prevent flying debris from causing injury (B). Although (A) may help decrease the amount of flying debris, it is not safe to leave clients in rooms with

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closed blinds; (B) is a higher priority at this time. Hospital staff should stay away from windows to avoid injury, and should focus on client evacuation into hallways rather than (C). (D) is not the first action that should be taken. A. Instruct nursing staff to close all window blinds and

curtains in client rooms.

B. Move clients and visitors into the hallways and close all doors to client rooms.

C. Visually confirm the location of the tornado by checking windows on the unit.

D. Assist all visitors with evacuation down the stairs in a calm and orderly manner.

Submit Correct | Correct Answer: B

The nurse observes ventricular fibrillation on telemetry and upon entering the client's bathroom finds the client unconscious on the floor. What intervention should the nurse implement first?Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately (B). (A and C) are appropriate, but CPR is the priority action. The client is dying, and (D) does not address the seriousness of this situation. A. Administer an antidysrhythmic medication.

B. Start cardiopulmonary resuscitation.

C. Defibrillate the client at 200 joules.

D. Assess the client's pulse oximetry.Submit

Incorrect | Correct Answer: BA male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the unlicensed assistive personnel (UAP) to quickly relieve the client's pain?Rationale:The client who has arterial PVD may benefit from dependent positioning and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bedrest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain. A. Help the client to dangle his legs.

B. Apply compression stockings.

C. Assist with passive leg exercises.

D. Ambulate three times a day.Submit

Incorrect | Correct Answer: AA client with cirrhosis states that his disease was caused by a blood transfusion. What information should the nurse obtain first to provide effective client teaching?Rationale:The nurse should first verify the client's explanation (A), since it may be accurate. In the United States, the blood supply was not screened effectively for the hepatitis C virus prior to 1990, so the client may have contracted hepatitis C through that route.

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Hepatitis C can cause cirrhosis. Not all cirrhosis is caused by alcoholism (B). (C and D) provide useful but less relevant information to respond to the client's statement. A. The year the blood transfusion was received

B. The amount of alcohol the client drinks

C. How long the client has had cirrhosis

D. The client's normal coping mechanismsSubmit

Incorrect | Correct Answer: AA client with Parkinson disease is taking carbidopa-levodopa (Sinemet). Which observation by the nurse would indicate that the desired outcome of the medication is being achieved?Rationale:Sinemet increases the amount of levodopa to the CNS (dopamine to the brain). Increased amounts of dopamine improve the symptoms of Parkinson (B), such as involuntary movements, resting tremors, shuffling gait, etc. Orthostatic hypotension is a side effect of Sinemet (A). Decreased drooling would be a desired effect, not (C). Sinemet does not affect (D). A. Decreased blood pressure

B. Lessening of tremors

C. Increased salivation

D. Increased attention spanSubmit

Incorrect | Correct Answer: BAn older female client with dementia is transferred from a long-term care unit to an acute care unit. The client's children express concern that their mother's confusion is worsening. How should the nurse respond?Rationale:Relocation (B) often results in confusion among older clients, and is stressful for clients of all ages. (A) is an inaccurate statement, and is the basis of stereotypical perceptions about the older. It is important to reassure the family that their mother will be kept safe, but (C) is most likely a false statement, since many factors may be the cause of a temporary increase in confusion. (D) may be true, but does not provide the family with a sense of security about the care of their mother. A. "It is to be expected that older people will experience

progressive confusion."

B. "Confusion in an older person often follows relocation to new surroundings."

C. "The dementia is progressing rapidly, but we will do everything we can to keep your mother safe."

D. "The acute care staff is not as experienced as the long-term care staff at dealing with dementia."


A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse question as possibly inappropriate for this client?

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Rationale:Sedatives, such as Nembutal (D), are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed since the normal clotting mechanism is damaged. (B) is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted (C) to decrease ascites which often accompanies cirrhosis, particularly in the later stages of the disease. A. Vitamin K1 (AquaMEPHYTON) 5 mg IM daily

B. High-calorie, low-sodium diet

C. Fluid restriction to 1500 ml/day

D. Pentobarbital (Nembutal sodium) 50 mg at bedtime for rest


The nurse is giving preoperative instructions to a 14-year-old female client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates learning has taken place?Rationale:Outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration (D). A 14-year-old may or may not follow through with (A), and there is no measurement of learning. (B) may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In (C), the client may be saying what the nurse wants to hear, without expressing any real understanding of what to do after surgery. A. "I will read all the teaching booklets you gave me before

surgery."

B. "I have had surgery before, so I know what to expect afterward."

C. "All the things people have told me will help me take care of my back."

D. "Let me show you the method of turning I will use after surgery."


During change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?Rationale:All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first. (A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Though (D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as (C). A. A continuous IV infusion of magnesium

B. A one-time infusion of albumin

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C. A continuous epidural infusion of morphine

D. An intermittent infusion of IV vancomycinSubmit

Incorrect | Correct Answer: CThe nurse is caring for a client who is 1 day post acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight PVCs per minute. Which intervention should the nurse implement first?Rationale:Increasing the flow rate (B) provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. (A) can be delegated and is a lower priority action than (B). Defibrillation may eventually be necessary, but (C) is not the immediate treatment for frequent PVCs. (D) may become necessary if the client stops breathing, but it is not indicated at this time. A. Obtain an IV pump for antiarrhythmic infusion.

B. Increase the client's oxygen flow rate.

C. Prepare for immediate countershock.

D. Gather equipment for endotracheal intubation.Submit

Incorrect | Correct Answer: BThe nurse plans to help an 18-year-old developmentally disabled female client ambulate on the first postoperative day. When the nurse tells her it is time to get out of bed, the client becomes angry and yells at the nurse, "Get out of here! I'll get up when I'm ready." Which response should the nurse provide?Rationale:Returning within 30 minutes (D) provides a "cooling off" period, is firm, direct, nonthreatening, and avoids arguing with the client. (A) avoids the nurse's responsibility in ambulating the client. (B) invokes a threatening posture with a developmentally disabled client. (C) is an assumption by the nurse that disregards the client's actual feelings that only the client can know and interpret for herself. A. "Your healthcare provider has prescribed ambulation on

the first postoperative day."

B. "You must ambulate to avoid serious complications that are much more painful."

C. "I know how you feel; you're angry about having to do this, but it is required."

D. "I'll be back in 30 minutes to help you get out of bed and walk around the room."


In assessing a client for complications of total parenteral nutrition, it is most important for the nurse to monitor which lab value regularly?Rationale:TPN solutions contain high concentrations of glucose, so blood glucose is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically, since an increase in albumin, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not

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generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration. A. Albumin

B. Calcium

C. Glucose

D. Alkaline phosphataseSubmit

Correct | Correct Answer: CCushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome?Rationale:Those with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels (A) assesses for the occurrence of this process so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, and not by offering potassium-enhanced fluids (B), which are contraindicated for clients with edema. There is no need to emphasize the need for rest because fatigue is usually not an overwhelming factor in Cushing syndrome (C). A low-calorie, low-carbohydrate, low-sodium diet is recommended, not (D). A. Monitor blood glucose levels daily.

B. Increase intake of fluids high in potassium.

C. Encourage adequate rest between activities.

D. Offer the client a sodium-enriched menu.Submit

Incorrect | Correct Answer: ADebilitating anginal pain can be decreased in some clients by the administration of beta-blocking agents such as nadolol (Corgard). Which client requires the nurse to use extreme caution when administering Corgard?Rationale:The client with asthma must be carefully monitored (B) because nadolol (Corgard) blocks beta-adrenergic receptors within the heart, decreasing sympathetic stimulation in the myocardium, which decreases excitability and cardiac output. It must be used with extreme caution in clients who have congestive heart failure or respiratory problems because it can induce cardiogenic shock and reduce bronchodilation efforts. Corgard is indicated in the management of clients with symptoms as identified in (A and D), and is not contraindicated for clients with symptoms as identified in (C). A. A 56-year-old air traffic controller who had bypass

surgery 2 years ago

B. A 47-year-old kindergarten teacher diagnosed with asthma 40 years ago

C. A 52-year-old unemployed stock broker who refuses treatment for alcoholism

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D. A 60-year-old retired librarian who takes a diuretic daily for hypertension


A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority?Rationale:The client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO (A), to reduce risk of intestinal rupture. (B, C, and D) are important, but of less priority than (A), which is implemented to prevent a severe complication. A. Place the client on NPO status.

B. Assess the client's temperature.

C. Obtain a stool specimen.

D. Administer IV fluids.Submit

Incorrect | Correct Answer: AA client with hypertension has been receiving ramipril (Altace) 5 mg PO daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830 the client's blood pressure is 120/70. What action should the nurse take?Rationale:The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered (A). (B and C) would be appropriate if the client's blood pressure was excessively low (less than 100 systolic), or the client was exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore (D) is not necessary. A. Administer the dose as prescribed.

B. Hold the dose and contact the healthcare provider.

C. Hold the dose and recheck the blood pressure in 1 hour.

D. Check the healthcare provider's prescription to clarify the dose.


A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD). What is the nurse's rationale for keeping the client's oxygen administration level at 3 L/min or less?Rationale:Because of chronic irritation of the medulla from elevated carbon dioxide levels, the response of the chemoreceptors in the medulla to hypercapnia diminishes and hypoxemia becomes the primary drive for breathing (D). (A) are symptoms of cerebral hypoxia, not hyperoxygenation. COPD damages the alveoli (B), but this phenomenon interferes with oxygen absorption. The client does not develop (C). A. Hyperoxygenation causes agitation and restlessness.

B. Damaged alveoli absorb oxygen more rapidly than normal.

C. COPD causes oxygen sensitivity, which reduces oxygen

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needs.

D. Chronic hypoxemia creates the urge to breathe in COPD.Submit

Incorrect | Correct Answer: DThe home health nurse is assessing a male client being treated for Parkinson disease with levodopa-carbidopa (Sinemet). The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement?Rationale:A mask-like expression and infrequent blinking are common clinical features of Parkinsonism. The nurse should document these expected findings (C). (A and D) are not necessary. Signs of toxicity (B) of levodopa-carbidopa (Sinemet) include dyskinesia, hallucinations, and psychosis. A. Perform a complete cranial nerve assessment.

B. Instruct the client that he may be experiencing medication toxicity.

C. Document the presence of these assessment findings.

D. Advise the client to seek immediate medical evaluation.Submit

Correct | Correct Answer: CA male client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? The clientRationale:Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be due to a decreased heart rate, leading to decreased cardiac output (D). The rate of a pacemaker is not changed by a client, though the client may be familiar with this procedure as explained by his healthcare provider (A). (B) is an important step in preparing the client for discharge, but does not demonstrate knowledge of the symptoms of pacer failure. (C) are symptoms of possible incisional infection or irritation, but do not indicate pacer failure. A. demonstrates the procedures to change the rate of the

pacemaker using a magnet.

B. carries a card in his wallet stating the type and serial number of the pacemaker.

C. tells the nurse that it is important to report redness and tenderness at the insertion site.

D. states that changes in the pulse and feelings of dizziness are significant changes.


The nurse is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication?Rationale:Mycostatin is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes, then swallow (A). (B) does not affect

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administration of this medication. The medication should not be diluted, since this will reduce its effectiveness (C). (D) is not necessary. A. Hold the medication in the mouth for a few minutes before

swallowing it.

B. Do not drink or eat milk products for 1 hour prior to taking this medication.

C. Dilute the medication with juice to reduce the unpleasant taste and odor.

D. Take the medication before meals to promote increased absorption.


The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit are decreased. What additional change in lab data should the nurse expect?Rationale:The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increases ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia (C). (A, B, and D) will not be significantly impacted by the removal of blood. A. Increased serum albumin

B. Decreased serum creatinine

C. Decreased serum ammonia

D. Increased liver function testsSubmit

Incorrect | Correct Answer: CThe nurse is providing care for a client who has had a cervical cord injury. Following reduction of the cervical fracture, a halo vest is placed to maintain realignment of the spinal canal. What intervention is needed to ensure client safety while the halo vest is in place?Rationale:A wrench (B) must be available so that the anterior portion can be removed quickly to give access to the chest should CPR be necessary. A halo vest allows for mobilization of the client following reduction of the cervical spinal cord injury, so that (A) is not necessary. (C) should never be implemented. (D) can be painful for the client. These pins should be tightened by the healthcare provider if found to be loose. A. Teach the client that bedrest will need to be maintained.

B. Ensure that a set of wrenches are kept in close proximity.

C. Use halo bars when moving the client to maintain immobilization.

D. Release the skull pins every 4 hours to relieve pressure.Submit

Correct | Correct Answer: B

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When assigning clients on a medical-surgical floor to a registered nurse (RN) and a practical nurse (PN), it is best for the charge nurse to assign which client to the PN?Rationale:The most stable client is (B). (A, C, and D) are all at high risk for increasing intracranial pressure, and require the expertise of the RN for assessment and management of care. A. A child with bacterial meningitis with recent seizures

B. An older adult client with pneumonia and viral meningitis

C. A female client in isolation with meningococcal meningitis

D. A male client 1 day postoperative after drainage of a brain abscess


A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer?Rationale:Adenocarcinoma is the only lung cancer not related to cigarette smoking (A). It has been found to be directly related to lung scarring and fibrosis from preexisting pulmonary diseases such as TB or COPD. (B and D) are malignant lung cancers related to cigarette smoking. (C) is a skin cancer and is related to exposure to sunlight, not to lung problems. A. Adenocarcinoma

B. Oat-cell carcinoma

C. Malignant melanoma

D. Squamous-cell carcinomaSubmit

Incorrect | Correct Answer: AClient census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns?Rationale:Average daily census (C) is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. (A and B) provide data at a certain point in time and that data could change quickly. It is unrealistic to expect to obtain an hourly census (D), and such data would only provide information about a certain point in time. A. Midnight census

B. Oncoming shift census

C. Average daily census

D. Hourly censusSubmit

Incorrect | Correct Answer: CA female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. What action should the nurse take first?

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Rationale:The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require (D). A. Irrigate the nasogastric tube with sterile normal saline.

B. Reposition the client on her side.

C. Advance the nasogastric tube 5 cm.

D. Administer an intravenous antiemetic as prescribed.Submit

Incorrect | Correct Answer: Bpostoperatively, when should the nurse inflate the cuff?Rationale:The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis. A. Immediately after feeding

B. Just prior to tube feeding

C. Continuous inflation is required

D. Inflation is not requiredSubmit

Incorrect | Correct Answer: BA central venous catheter has been inserted via a jugular vein and a radiograph has confirmed placement of the catheter. A prescription has been received for a stat medication, but IV fluids have not yet been started. What action should the nurse take prior to administering the prescribed medication?Rationale:A medication can be administered via a central line without IV fluids. The line should first be flushed with normal saline solution (C) to remove any heparin in the line which may be incompatible with the medication. Heparin is used following medication administration and a second saline bolus (D). (A) will not impact the decision to administer the medication, and is not a priority. Administration of the stat medication is of greater priority than (B). A. Assess for signs of jugular venous distention.

B. Obtain the needed intravenous solution.

C. Administer a bolus of normal saline solution.

D. Flush the line with heparinized saline.Submit

Correct | Correct Answer: CA 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with conventional wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?

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Rationale:Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses (A). The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited (C), depending on the degree of damage, this is not always the case. (B and D) are signs of adequate perfusion of the foot, which would not be expected in this client. A. Pedal pulses will be weak or absent in the left foot.

B. The client will state that the left foot is usually warm.

C. Flexion and extension of the left foot will be limited.

D. Capillary refill of the client's left toes will be brisk.Submit

Incorrect | Correct Answer: AOne day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed at blood pressure 100/80, pulse 110 beats/min, and respirations 36 breaths/min. What action is most important for the nurse to take?Rationale:Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment (D). A rapid respiratory rate should not be treated as hyperventilation (A). (B) should not be administered until more ominous etiologies are ruled out or treated. There is no evidence that the client is hypoglycemic (C). A. Provide a paper bag for his hyperventilation.

B. Administer a prescribed PRN analgesic.

C. Have the client drink a glass of sweetened fruit juice.

D. Apply oxygen at 2 L per nasal cannula.Submit

Correct | Correct Answer: DThe nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed?Rationale:Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the healthcare provider before the chest tube is removed (A) to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae due to abnormally wide changes in negative intrathoracic pressure. (B) may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. (C) usually indicates an infection, which may not be related to the chest tube. (D) is an expected finding. A. Tidaling of water in water seal chamber

B. Bilateral muffled breath sounds at bases

C. Temperature of 101° F

D. Absence of chest tube drainage for 2 daysSubmit

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Incorrect | Correct Answer: ADuring report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?Rationale:Clients with tumor lysis syndrome may experience hyperkalemia requiring the addition of insulin to the IV solution to reduce the serum potassium. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data, but are of less priority than (C). A. Review the client's history for diabetes mellitus.

B. Observe the extremity distal to the IV site.

C. Monitor the client's serum potassium and blood glucose.

D. Evaluate the client's oxygen saturation and breath sounds.Submit

Incorrect | Correct Answer: CREVIEW MODE: Medical-Surgical

Question 58 of 120

HomeCalculatorHelp BackNext In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?Rationale:Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (C) (hypokalemia); hypertension is the most prominent and universal sign. Serum sodium level is normal or elevated, depending on the amount of water reabsorbed with the sodium (A). (B) is influenced by parathyroid hormone (PTH). (D) is not affected by primary aldosteronism. A. Sodium

B. Phosphate

C. Potassium

D. GlucoseSubmit

Correct | Correct Answer: CAn older client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?Rationale:The onset of pneumonia in the older may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the older with bacterial pneumonia. A. Leukocytosis and febrile

B. Polycythemia and crackles

C. Pharyngitis and sputum production

D. Confusion and tachycardiaSubmit

Correct | Correct Answer: DThe nurse is reviewing the routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question?

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Rationale:Clients with angle closure glaucoma should not take medications that dilate the pupil (B), because this can precipitate acute and severely increased intraocular pressure. (A, C, and D) do not cause increased intracranial pressure, which is the primary concern with angle closure glaucoma. A. An antianginal with a therapeutic effect of vasodilation

B. An anticholinergic with a side effect of pupillary dilation

C. An antihistamine with a side effect of sedation

D. A corticosteroid with a side effect of hyperglycemiaSubmit

Incorrect | Correct Answer: BDuring a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?Rationale:Manifestations of emphysema include an increase in AP diameter (referred to as a "barrel chest"), nailbed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods (A). (B) may result in decreased drive to breathe. The client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A). A. "Pace your activities and schedule rest periods."

B. "Increase the amount of oxygen you use at night."

C. "Obtain medical evaluation for antibiotic therapy."

D. "Reduce your intake of fluids containing caffeine."Submit

Incorrect | Correct Answer: AWhich description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial) (B). (A) would be characteristic of Ménière syndrome (8th cranial nerve). (C) would be characteristic of Bell palsy (7th cranial nerve). (D) would be characteristic of disorders of the hypoglossal (12th cranial nerve). A. Tinnitus, vertigo, and hearing difficulties

B. Sudden, stabbing, severe pain over the lip and chin

C. Unilateral facial weakness and paralysis

D. Difficulty in chewing, talking, and swallowingSubmit

Incorrect | Correct Answer: BThe nurse is preparing a 45-year-old female client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan?Rationale:Attending a support group (D) will be beneficial to the client and should be encouraged, since adaptation to the ostomy can be difficult. This goal is attainable

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and is measurable. (A) is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish (B). (C) is not necessary. A. Reduce daily intake of animal fat to 10% of diet within 6

weeks.

B. Exhibit regular soft-formed bowel movements within one month.

C. Demonstrate irrigation procedure correctly within 1 week.

D. Attend an ostomy support group within 2 weeks.Submit

Incorrect | Correct Answer: DDuring the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being "floated" to the other unit. What is the best immediate action for the charge nurse to take?Rationale:Continuing with shift report (A) is the best immediate action because it allows the nurse who was floated some "cool off" time. At a later time (after the nurse has "cooled off") the charge nurse should discuss with the nurse in private her inappropriate conduct. (B) encourages the nurse to shirk the float assignment. (C) is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private (D). A. Continue with shift report and talk to the nurse about the

incident at a later time.

B. Ask the nurse to call the house supervisor to see if she must be reassigned.

C. Stop the shift report and remind the nurse that all staff are floated equally.

D. Inform the nurse that her behavior is disruptive to the rest of the staff.


The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in 2 hours is dated 2 years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action would be best for the nurse to implement?Rationale:Clients over the age of 40 and/or with a history of cardiovascular disease should receive ECG evaluation prior to surgery, generally 24 hours to 2 weeks prior to surgery; thus (B) should be implemented to rule out cardiac problems. (A) might be valuable, but since time is limited, the priority is to obtain the needed ECG. (C) does not solve the problem. Surgery would not usually be delayed (D) unless the ECG reveals further complications that might cause the surgeon to cancel the procedure and reevaluate the client. A. Ask the client what he means by "heart trouble."

B. Call for an ECG to be performed immediately.

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C. Notify surgery that the ECG is over 2 years old.

D. Delay the client's surgery until the late afternoon.Submit

Incorrect | Correct Answer: Bcough and produces a moderate amount of white sputum. Which action should the nurse take first?Rationale:A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding (B) to prevent further aspiration. (A, C, and D) should all be performed before restarting the tube feeding, if no evidence of aspiration is present and the tube is in place. A. Auscultate the client's breath sounds.

B. Turn off the continuous feeding pump.

C. Check placement of the nasogastric tube.

D. Measure the amount of residual feeding.Submit

Incorrect | Correct Answer: BThe nurse is assessing a client who presents with jaundice. Which assessment finding is the most significant indication that further follow-up is needed?Rationale:Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and an elevated serum amylase and lipase (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected findings related to jaundice. A. Urine specific gravity of 1.03 with a urine output of 500

ml in 8 hours

B. Frothy, tea-colored urine

C. Clay-colored stools and complaints of pruritus

D. Serum amylase and lipase levels are twice their normal values


What is the correct procedure for performing an ophthalmoscopic examination on a client's right eye?Rationale:The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lens to begin (creates no correction at the beginning of the exam), and should be held in front of the examiner's left eye when examining the client's right eye. For optimum visualization, the ophthalmoscope should be kept within one inch of the client's eye (C). (A, B, and D) describe incorrect methods for conducting an ophthalmoscopic examination. A. Instruct the client to look at examiner's nose and not move

his/her eyes during the exam.

B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.

C. From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil.

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D. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

Submit Incorrect | Correct Answer: C

The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?Rationale:The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection (C), since these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. While oral care will be of benefit to the client who may also be experiencing (A, B, or D), these problems are not the primary reason for the provision of frequent oral care. A. Fluid volume deficit

B. Self-care deficit

C. Risk for infection

D. Impaired nutritionSubmit

Incorrect | Correct Answer: CA 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD?Rationale:Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD (C). The exact mechanism of genetic and hereditary implications (A) for development of COPD is still under investigation, although exposure to similar predisposing factors (such as smoking or inhaling second-hand smoke) may increase the likelihood of COPD incidence among family members. (B and D) do not exceed the risks associated with cigarette smoking in the development of COPD. A. The client's father was diagnosed with COPD in his 50s.

B. A close family member contracted tuberculosis last year.

C. The client smokes 1 to 2 packs of cigarettes per day.

D. The client has been 40 pounds overweight for 15 years.Submit

Incorrect | Correct Answer: CWhat is the most important nursing priority for a client who has been admitted for a possible kidney stone?Rationale:Straining all urine (B) is the most important nursing action to take in this instance. Encouraging fluid intake (D) is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. (C) is not the highest priority action. (A) is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

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A. Reducing dairy products in the diet

B. Straining all urine

C. Measuring intake and output

D. Increasing fluid intakeSubmit

Incorrect | Correct Answer: BWhich assessment finding would confirm the specific location of an enteral feeding tube?Rationale:Viewing the tube placement by chest radiograph (C) will confirm the specific location of an enteral feeding tube. (A and B) are methods used to check the general location of an enteral feeding tube, but they are not considered to be a reliable indicator of the tube's specific location within the small intestine. (D) is not an indicator of proper tube placement. A. Aspiration of gastric contents followed by testing for pH

level of 4

B. Auscultation of air injected into the tube that is heard over the stomach

C. Examination of portable radiograph taken after the tube was inserted

D. Visual inspection of the tube after placement to determine actual length inserted


After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices, and makes what additional recommendation?Rationale:Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. (A) promotes reduced fat consumption. Orange slices provide more fiber than orange juice (B). (C and D) are not standard recommendations for reducing cancer risk. A. Switch to skim milk.

B. Switch to orange juice.

C. Add a source of protein.

D. Add herbal tea.Submit

Incorrect | Correct Answer: AA 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?Rationale:The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years (C). (A) may or may not have contributed to the accident, but

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eye changes were not involved in promoting the hip fracture. (B) is not a common condition of the older, but is associated with CKD. While (D) may result in transient ischemic attacks (TIAs) or stroke, it will not create fragility of the bones as osteoporosis does. A. Failing eyesight resulting in an unsafe environment

B. Renal osteodystrophy resulting from chronic kidney disease (CKD)

C. Osteoporosis resulting from declining hormone levels

D. Cerebral vessel changes causing transient ischemic attacksSubmit

Correct | Correct Answer: CThe nurse initiates neuro checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neuro function?Rationale:A decrease or change in the level of consciousness (A) is usually the first indication of neurologic deterioration. (B and C) may also occur but are much less likely to be the first sign of neuro compromise. (D) is often a sign of meningitis. A. Change in level of consciousness

B. Increasing muscular weakness

C. Changes in pupil size bilaterally

D. Progressive nuchal rigiditySubmit

Incorrect | Correct Answer: AWhich statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia?Rationale:The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardiac or bradycardiac dysrhythmia, cardiac output is compromised further, placing the client at risk of syncope and falling, as well as confusion (D). (A) is of high priority, but less so than maintaining client safety. Clients may experience (B) as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the priority of (D). (C) also does not have the priority of (D). A. Diarrhea related to medication side effects

B. Anxiety related to fear of recurrent anginal episodes

C. Altered nutrition related to high serum lipid levels

D. Risk for injury related to syncope and confusionSubmit

Incorrect | Correct Answer: DThe nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which client condition is most likely to have contributed to this finding?Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased BUN (B). (A) would affect serum enzyme levels, not BUN. (C) would primarily affect the blood glucose level; renal failure that could increase

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the BUN would be unlikely in a newly diagnosed client with type 2 diabetes. Effects of (D) might impact the CBC, but would not directly increase the BUN. A. Myocardial infarction 2 months ago

B. Anorexia and vomiting for the past 2 days

C. Recently diagnosed type 2 diabetes mellitus

D. Skeletal traction for a right hip fractureSubmit

Incorrect | Correct Answer: BAn 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. What nursing intervention is indicated?Rationale:Clients with COPD should ingest 3 liters of fluids daily, but may experience a fluid deficit due to shortness of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having fruit juices in disposable containers readily available. (B) is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night (C). These symptoms are not indicative of (D), and may unnecessarily upset the client who depends on his pet for socialization. A. Help the client to determine ways to increase his fluid

intake.

B. Obtain an appointment for the client to have an eye examination.

C. Instruct the client to use oxygen at night and increase the humidification.

D. Schedule the client for tests to determine his sensitivity to cat hair.


The nurse knows that normal lab values expected for an adult may vary in an older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall?Rationale:In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying (C). Laboratory findings in (A, B, and D) are not considered to be normal findings in an older adult. A. Complete blood count reveals increased WBC and

decreased RBC counts.

B. Chemistries reveal an increased serum bilirubin with slightly increased liver enzymes.

C. Urinalysis reveals slight protein in the urine and bacteriuria with pyuria.

D. Serum electrolytes reveal a decreased sodium level with

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an increased potassium level.Submit

Correct | Correct Answer: Ccancer?Rationale:Cancer of the larynx would be the greatest risk for (A). The most common risk factors for throat cancer are tobacco use, alcohol abuse, and voice abuse. Abuse in conjunction with a carcinogenic irritant, such as smoking or chewing tobacco, makes the person more susceptible to cancer. (B) is not thought to be a risk factor; and opera singers (D), as well as others who may abuse their vocal cords, would probably not be as susceptible as someone who smokes or chews tobacco. Although research continues to indicate greater health risks for those who are exposed to passive smoke (C and D), (A) would have the greatest risk for cancer of the larynx. A. An alcoholic, tobacco-chewing auctioneer

B. An ex-smoker who jogs 2 miles a day

C. A nonsmoker exposed to second-hand smoke in childhood

D. A smoker's wife who sings soprano in the operaSubmit

Incorrect | Correct Answer: AREVIEW MODE: Medical-Surgical

Question 81 of 120

HomeCalculatorHelp BackNext A 58-year-old client, who has no health problems, asks the nurse about taking the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine?Rationale:It is usually recommended that persons over 65 years of age and those with a history of chronic illness should receive the vaccine once in a lifetime (B). (Some resources recommend obtaining the vaccine at 50 years of age). The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but with immunosuppressed clients, or clients with a history of pneumonia, revaccination is sometimes required. A. "The vaccine is given annually before the flu season to

those over 50 years of age."

B. "The immunization is administered once to older adults or persons with a history of chronic illness."

C. "The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection."

D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years."


A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite for several days. She has been nauseated and vomited several times prior to admission. She is currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to what medication?

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Rationale:Elderly persons are particularly susceptible to the build-up of cardiac glycosides such as digoxin (Lanoxin) or digitoxin (medications derived from digitalis) (D) to a toxic level within their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. The other medications (A, B, and C) are unlikely to result in the symptoms described. A. Warfarin (Coumadin)

B. Ibuprofen (Motrin)

C. Nitroglycerine (Nitrostat)

D. Digitalis (Lanoxin)Submit

Correct | Correct Answer: Dcalf of his right leg that is warm to the touch and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?Rationale:All of these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds (B), since the client may have a pulmonary embolus secondary to the thrombophlebitis. (A) may provide data which supports the nurse's suspicion of thrombophlebitis. (C) is the least helpful assessment, since bruising is not a typical finding associated with thrombophlebitis. (D) is always useful to evaluate the client's response to a problem, but is of less immediate priority than breath sound auscultation. A. Measure the client's calf circumference.

B. Auscultate the client's breath sounds.

C. Observe for ecchymosis and petechiae.

D. Obtain the client's blood pressure.Submit

Incorrect | Correct Answer: Bthis client?Rationale:Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not impact fluid retention. A. Avoid high-carbohydrate foods.

B. Decrease intake of fat-soluble vitamins.

C. Decrease caloric intake.

D. Restrict salt and fluid intake.Submit

Incorrect | Correct Answer: DA nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. What area contains the older person's center of gravity?Rationale:Stooped posture results in the upper torso (B) becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common, because of the changes from osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and

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elbows flex. The head and neck (A) and feet and legs (D) are not the center of gravity in the older adult. Although arms (C) comprise a part of the upper torso, they do not reflect the best and most complete answer. A. Head and neck

B. Upper torso

C. Bilateral arms

D. Feet and legsSubmit

Incorrect | Correct Answer: BIn assessing a client with an arteriovenous shunt who is scheduled for dialysis today, the nurse notes the absence of either a thrill or a bruit at the shunt site. What action should the nurse take?Rationale:Absence of either a thrill or a bruit indicates that the shunt may be obstructed. The nurse should notify the healthcare provider (C), so intervention can be initiated to restore function of the shunt. (A) is incorrect. (B) will not resolve the obstruction. An AV shunt is internal, and cannot be flushed (D) without access using special needles. A. Advise the client that the shunt is intact and ready for

dialysis as scheduled.

B. Encourage the client to keep the shunt site elevated above the level of the heart.

C. Notify the healthcare provider of the findings.

D. Flush the site with a heparinized saline solution.Submit

Incorrect | Correct Answer: CWhich condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?Rationale:Infection (B) is the major complication resulting from stasis of urine and subsequent catheterization. (A) is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure. (C) is the most common symptom of bladder cancer. (D) is the most common and serious complication of peritoneal dialysis. A. Stress incontinence

B. Infection

C. Painless, gross hematuria

D. PeritonitisSubmit

Incorrect | Correct Answer: BIn caring for a client with acute diverticulitis, which assessment data warrant immediate nursing intervention? The clientRationale:A hard, rigid abdomen and elevated WBC is indicative of peritonitis (A), which is a medical emergency and should be reported to the healthcare provider immediately. (B and C) are expected clinical manifestations of diverticulitis. (D) does not warrant immediate intervention.

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A. has a rigid hard abdomen and elevated white blood cell count (WBC).

B. has left lower quadrant pain and an elevated temperature.

C. is refusing to eat any of the meal and is complaining of nausea.

D. has not had a bowel movement in 2 days and has a soft abdomen.


A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?Rationale:The nurse should safely assist the client to a resting position (A), then administer (C and D). The client must cease all activity immediately, which will decrease the oxygen need to the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher (B). A. Support the client to a sitting position.

B. Ask the client to walk slowly back to the room.

C. Administer a sublingual nitroglycerin tablet.

D. Provide oxygen via nasal cannula.Submit

Incorrect | Correct Answer: ADuring assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear upon auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?Rationale:The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output—that is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap (A). IV Lasix is not indicated for treatment of the pericarditis (B). Since the client's breath sounds are clear, (C) is not a priority. Fluids are frequently increased (D) in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the priority as is (A). A. Prepare the client for a pericardial tap.

B. Administer intravenous furosemide (Lasix).

C. Assist the client to cough and deep breathe.

D. Instruct the client to restrict oral fluid intake.Submit

Incorrect | Correct Answer: AThe nurse is assessing a 75-year-old male client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?Rationale:Signs and symptoms of hyperglycemia in older adults may include fatigue, infection (D), and evidence of neuropathy (such as sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as (A, B, and C) and polyphagia may be absent in older adults.

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A. Polyuria

B. Polydipsia

C. Weight loss

D. InfectionSubmit

Incorrect | Correct Answer: DAn emaciated homeless client presents to the emergency department complaining of a productive cough with blood-tinged sputum and night sweats. What action is most important for the emergency department triage nurse to implement for this client?Rationale:This client is exhibiting classic symptoms of tuberculosis (TB) and the client is from a high-risk population for TB. Therefore, until proved otherwise, airborne infection precautions (A), which are indicated for TB, should be used with this client. (B) is used with droplet precautions. There is no evidence that (C or D) would be warranted at this time. A. Initiate airborne infection precautions.

B. Place a surgical mask on the client.

C. Don an isolation gown and latex gloves.

D. Start protective (reverse) isolation precautions.Submit

Incorrect | Correct Answer: AWhat nursing action is necessary for the client with a flail chest?Rationale:Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied, since the fractures are clearly visible on chest radiograph. A. Withhold prescribed analgesic medications.

B. Percuss the fractured rib area with light taps.

C. Avoid implementing pulmonary suctioning.

D. Encourage coughing and deep breathing.Submit

Incorrect | Correct Answer: DIn evaluating the effects of lactulose (Cephulac), which outcome would indicate that the drug is performing as intended?Rationale:Two to three stools a day indicate that lactulose is performing as intended (B). Lactulose is administered to reduce blood ammonia by excretion of ammonia through the stool. (A) would be expected if the client received a diuretic. (C) would be expected if the client received an antiemetic. Lactulose does not affect (D). A. An increase in urine output

B. Two or three soft stools per day

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C. Absence of nausea

D. Decreased serum potassiumSubmit

Incorrect | Correct Answer: BA client who is receiving an ACE inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. What action should the nurse implement?Rationale:Cough is a common side effect of ACE inhibitors and is not an indication to discontinue the medication (D). Immediate evaluation is not needed (A). Antihypertensive medications should not be stopped abruptly (B), since rebound hypertension may occur. (C) is demeaning, since the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect. A. Advise the client to come to the clinic immediately for

further assessment.

B. Instruct the client to discontinue use of the drug, and make an appointment at the clinic.

C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription.

D. Encourage the client to keep taking the drug until seen by the healthcare provider.


The nurse knows that clients taking diuretics must be assessed for the development of hypokalemia, and that hypokalemia will create changes in the client's normal ECG tracing. Which ECG change would be an expected finding in the client with hypokalemia?Rationale:A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium). (A, B, and C) are all signs of hyperkalemia. A. Tall, spiked T waves

B. A prolonged QT interval

C. A widening QRS complex

D. Presence of a U waveSubmit

Correct | Correct Answer: DA client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?Rationale:Placing the client in a supine position (C) reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. (A) compromises diaphragmatic expansion and inhibits pressoreceptor activity. (B) places the client at risk of evisceration of the abdominal wound and increased bleeding. (D) will not stop internal bleeding in the liver and spleen caused by the gunshot wound.

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A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.

B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding.

C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.

D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.


What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client?Rationale:The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum (C). (A) is placed too high. (B) would not compress the heart. (D) would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions. A. Just above the xiphoid process on the upper third of the

sternum

B. Below the xiphoid process midway between the sternum and the umbilicus

C. Just above the xiphoid process on the lower third of the sternum

D. Below the xiphoid process midway between the sternum and the first rib


Which content about self-care should the nurse include in the teaching plan of a client who has genital herpes? (Select all that apply.)Rationale:The nurse should include (A, B, C, and D) in the teaching plan of a client with genital herpes. (E) is specific for Candida infections, and (F) is used to treat Trichomonas. A. Encourage annual physical and Pap smear.

B. Take antiviral medication as prescribed.

C. Use condoms to avoid transmission to others.

D. Warm sitz baths may relieve itching.

E. Use Nystatin suppositories to control itching.

F. Douche with weak vinegar solution to decrease itching.Submit

Incorrect | Correct Answer: A,B,C,DA family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?Rationale:(B) indicates correct technique for performing suctioning. Suction pressure should be

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between -80 and -120 mm Hg, not -190 mm Hg (A). The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction (C). (D) introduces pathogens unnecessarily into the tracheobronchial tree. A. Turns on the continuous wall suction to -190 mm Hg

B. Inserts the catheter until resistance or coughing occurs

C. Withdraws the catheter while maintaining suctioning

D. Re-clears the tracheostomy after suctioning the mouthSubmit

Incorrect | Correct Answer: BA client with chronic asthma is admitted to postanesthesia complaining of pain at a level of 8 of 10, with a blood pressure of 124/78, pulse of 88 beats/min, and respirations of 20 breaths/min. The postanesthesia recovery prescription is, "Morphine 2 to 4 mg IV push while in recovery for pain level over 5." What intervention should the nurse implement?Rationale:The nurse should call the provider for a different medication (B) because morphine and meperidine (Demerol) are both histamine-releasing narcotics and should be avoided when the client has asthma. (A) is unsafe as it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, (C and D) both disregard the prescription and the client's need for pain relief in the immediate postoperative period. A. Give the medication as prescribed to decrease the client's

pain.

B. Call the anesthesia provider for a different medication for pain.

C. Use nonpharmacologic techniques before giving the medication.

D. Reassess pain level in 30 minutes and medicate if it remains elevated.


A 74-year-old male client is admitted to the ICU with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent with settings of tidal volume (VT) 750 ml and intermittent mandatory ventilation (IMV) rate of 10. ABG results are pH 7.48; PaCO2 30; PaO2 64; HCO3 25; and FiO2 0.80. Which intervention should the nurse implement first?Rationale:Adding PEEP (D) helps to improve oxygenation while reducing FiO2 to a less toxic level. (A, B, and C) will not result in improved oxygenation, and could cause further complications for this client experiencing respiratory failure. A. Increase the ventilator VT to 850 ml.

B. Decrease the ventilator IMV to a rate of 8.

C. Reduce the FiO2 to 0.70 and redraw ABGs.

D. Add 5 cm positive end-expiratory pressure (PEEP).Submit

Incorrect | Correct Answer: D

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A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information for the nurse to provide this client's family?Rationale:Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure (A) that would pose a hazard to others. (B) is a good suggestion to promote adequate nutrition, but is not as important as (A). (C) is unnecessary. Contact with the client (D) is permitted, but should be brief to limit radiation exposure. A. Follow exposure precautions.

B. Encourage regular meals.

C. Collect all urine.

D. Avoid touching the client.Submit

Incorrect | Correct Answer: AThe nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. What action should the nurse implement first?Rationale:Alpha-interferon and ribavirin combination therapy can cause severe depression (B), therefore it is most important for the nurse to review the medication effects, and report these to the healthcare provider. (A, C, and D) might be implemented after the physiologic aspects of the situation are assessed. A. Recommend mental health counseling.

B. Review the medication actions and interactions.

C. Assess for the client's daily activity level.

D. Provide information regarding a support group.Submit

Correct | Correct Answer: BA 55-year-old male client is admitted to the coronary care unit having suffered an acute myocardial infarction (MI). Within 24 hours of the occurrence, the nurse can expect to find which systemic sign?Rationale:Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. An elevated CM-MB is a recognized indicator of MI (B). It peaks in 12 to 20 hours post-MI, and returns to normal within 48 to 72 hours. (A) would be an indication of pancreatitis or a gastric disorder. Although an elevated BUN (D) might be related to an acute MI, it is usually associated with dehydration, high protein intake, or gastrointestinal bleeding. An increased creatinine level indicates renal damage. While (C) may be an indicator of effective anticoagulation therapy, it is not usually a result of an MI. A. Elevated serum amylase level

B. Elevated CM-MB level

C. Prolonged prothrombin time (PT)

D. Elevated serum BUN and creatinineSubmit

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Incorrect | Correct Answer: Bclient is ready for discharge following creation of an ileostomy. Which instruction should the nurse include in discharge teaching?Rationale:A seal must be maintained to prevent leakage of irritating liquid stool onto the skin (C). (A) is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, therefore (B) is not necessary. (D) is not needed. A. Replace the stoma appliance every day.

B. Use warm tap water to irrigate the ileostomy.

C. Change the bag when the seal is broken.

D. Measure and record the ileostomy output.Submit

Incorrect | Correct Answer: CWhich assessment finding indicates that the expected outcome of administering donepezil (Aricept) to a client with Alzheimer disease has been accomplished?Rationale:Aricept is used to improve cognitive functioning in those suffering from Alzheimer disease. Improvement in cognitive functioning is most clearly assessed when the client exhibits increased memory, attention, reasoning, and problem solving (C). (A, B, and D) are not useful outcome criteria for determining levels of cognitive functioning. A. Increased muscle strength and tone

B. Fewer episodes of urinary incontinence

C. Increased ability to solve simple problems

D. Increased feelings of well-beingSubmit

Correct | Correct Answer: CWhich consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)?Rationale:Raynaud phenomenon is precipitated by exposure to cold (A) in clients with scleroderma. (B) is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to (C), which is often very noisy. (D) is not necessary. A. Provide a room that can be kept warm.

B. Make sure the room can be kept dark.

C. Keep the client close to the nursing unit.

D. Select a room that can be visually monitored from the nurses' desk.


A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. In assessing the client before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?Rationale:Hypocalcemia (B) develops in CKD due to chronic hyperphosphatemia, not (A). Increased phosphate levels cause peripheral deposition of calcium and resistance to

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vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with (C or D). A. Hypophosphatemia

B. Hypocalcemia

C. Hyponatremia

D. HypokalemiaSubmit

Incorrect | Correct Answer: BA 58-year-old female client tells the nurse that she feels a sense of loss since she has stopped having menstrual periods. She then states, "At least I will no longer have to suffer through those horrible Pap smear tests every year." Which action should the nurse implement?Rationale:A Pap smear tests for possible vaginal or cervical cancer, and should be continued postmenopause, so it is important for the nurse to correct the client's misconception (D). (A) may be useful, but is not the best intervention at this time. (B) is belittling the client's sense of loss. (C) is also important, but is not directed at the client's current comment regarding Pap smears. A. Reinforce additional positive aspects of menopause.

B. Offer reassurance that her feelings of loss are temporary.

C. Remind the client that she still needs annual mammograms.

D. Advise the client that Pap smear tests should be continued.Submit

Incorrect | Correct Answer: DA client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. What action should the nurse take based on this observation?Rationale:This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium (B). Ventricular ectopy, characterized by multiple premature ventricular contractions (PVCs), is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of (A), which does not exacerbate the ectopy. (C) could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of (D). A. Assess for bilateral jugular vein distention.

B. Increase oxygen flow via nasal cannula.

C. Administer PRN furosemide (Lasix).

D. Auscultate for a pleural friction rub.Submit

Incorrect | Correct Answer: BA female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. The nurse should explain which pathophysiologic consequence that supports the need for temporary dialysis until acute tubular necrosis subsides?

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Rationale:Chronic kidney disease (CKD) is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that slough or become edematous. The obstruction of urine flow will resolve (D) with the return of an adequate glomerular filtration rate, and when it does dialysis will no longer be needed. (A, B, and C) are manifestations seen in both acute and chronic kidney disease. A. Azotemia

B. Oliguria

C. Hyperkalemia

D. Nephron obstructionSubmit

Incorrect | Correct Answer: DA client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg every 12 hours IV is prescribed. What is the priority nursing diagnosis for this client?Rationale:To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. (A) is a serious outcome because the client cannot communicate his/her needs. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The respirator will ensure that the lungs are expanded, so (C) is incorrect. A. Impaired communication related to paralysis of skeletal

muscles

B. High risk for infection related to increased intracranial pressure

C. Potential for injury related to impaired lung expansion

D. Social isolation related to inability to communicateSubmit

Incorrect | Correct Answer: AThe nurse is planning the care for a client who is admitted with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.)Rationale:Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic change when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation that can lead to periods of disorientation, assess deep tendon reflexes (C) and neurologic checks (D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload: 1 kg weight gain equals 1 L of fluid retention, which further dilutes serum sodium levels. (A and F) contribute to dilutional hyponatremia. A. Salt-free diet

B. Quiet environment

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C. Deep tendon reflex assessments

D. Neurologic checks

E. Daily weights

F. Unrestricted intake of free waterSubmit

Incorrect | Correct Answer: B,C,D,EWhich instruction should the nurse teach a female client about the prevention of toxic shock syndrome?Rationale:Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently (B) reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. (A) helps prevent cervical cancer, not toxic shock syndrome. (C) can lessen the incidence of urinary tract infection. (D) can help prevent contracting the flu and pneumonia in some individuals, but no relationship to toxic shock syndrome has been proven. A. "Get immunization against the HPV virus."

B. "Change your tampon frequently."

C. "Empty your bladder after intercourse."

D. "Obtain a yearly flu vaccination." Submit

Incorrect | Correct Answer: BThe nurse receives the client's next scheduled bag of total parental nutrition (TPN) labeled with the additive NPH insulin. What action should the nurse implement?Rationale:Only regular insulin is administered by IV, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered. A. Hang the solution at the current rate.

B. Refrigerate the solution until needed.

C. Prepare the solution with new tubing.

D. Return the solution to the pharmacy.Submit

Incorrect | Correct Answer: DA 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54. Based on these findings, which IV medication should the nurse administer?Rationale:Because the client has chronic alcoholism, she is likely to have hypomagnesemia. (B) is the recommended drug for torsades de pointes (AHA, 2005), which is a form of polymorphic ventricular tachycardia (VT), usually associated with a prolonged QT interval that occurs with hypomagnesemia. (A and D) increase the QT interval, which can cause the torsades to worsen. (C) is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades. A. Amiodarone (Cordarone)

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B. Magnesium sulfate

C. Lidocaine (Xylocaine)

D. Procainamide (Pronestyl)Submit

Incorrect | Correct Answer: BA client who is being monitored with telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates administering which treatment?Rationale:With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion (B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation. A. Administer lidocaine 75 mg IVP.

B. Perform synchronized cardioversion.

C. Defibrillate the client as soon as possible.

D. Administer atropine 0.4 mg IVP.Submit

Incorrect | Correct Answer: BThe nurse is preparing a teaching plan for healthy adults. Which individual is most likely to maintain optimum health?Rationale:The diabetic teacher (A) has assumed responsibility for self-care, so consequently, among those listed, is the most likely to maintain his/her health. (B) has expressed a lack of interest in health promotion. (C) continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis (D) make this individual a health risk despite the fact that he/she is in recovery. A. A teacher whose blood glucose levels average 126 daily

with oral antidiabetic drugs

B. An accountant whose blood pressure averages 140/96 and states he does not have time to exercise

C. A stock broker whose total serum cholesterol dropped to 290 with diet modifications

D. A recovering IV heroin user who contracted hepatitis 10 years ago


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