322 - EXAM 4 Practice

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? 1- Increased tearing 2- Itching of the eye 3- Reduction in vision 4- Swollen eyelid

3 A reduction in vision after cataract surgery indicates a problem, and the client should notify the provider immediately. Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? 1- "I will get some books on tape for entertainment." 2- "I will be sure to pick up all clutter and loose carpets from the floor." 3- "I will rearrange the furniture for better flow before my spouse gets home." 4- "I will place a nonslip mat in the bathtub."

3 Changes in item location should not be made without input from the client with reduced vision. Books on tape are a good diversion for recuperating clients with reduced vision. Any objects that may present a tripping hazard should be removed at once. A nonslip mat may be used to prevent falls in the bathtub.

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? 1- Urine output of 20 mL over 2 hours 2- Blood pressure of 106/58 mm Hg 3- Absent bowel sounds 4- +3 pedal pulses

1 Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria. Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output (think ABCs). +3 pedal pulses is a normal physical assessment finding.

Which risk factor is shared by clients who have osteoporosis or osteomalacia? 1- High alcohol intake 2- A history of smoking 3- Inadequate exposure to sunlight 4- Homelessness

1 High alcohol intake is a risk factor for both osteoporosis and osteomalacia. A history of smoking is a risk factor for osteoporosis only. Inadequate exposure to sunlight and homelessness are risk factors for osteomalacia only.

Which statement reflects correct cardiac physical assessment technique? 1- Auscultate the aortic valve in the second intercostal space at the right sternal border. 2- Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. 3- Palpate the apical pulse over the third intercostal space in the midclavicular line. 4- Assess for carotid bruit by auscultating over the anterior neck.

1 The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor will be the priority for client teaching? 1- Low calcium intake 2- Postmenopausal status 3- Positive family history 4- Previous use of steroids

1 The client's calcium intake is the only risk factor that the client can change. The nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake. Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the client can change. These risk factors should be discussed, but are not the priority for this client.

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? 1- Urine output of 1500 mL on the preceding day 2- Crackles in the lung fields 3- Pedal edema 4- Expectoration of yellow sputum

2 Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

Prompt pain management with myocardial infarction is essential for which reason? 1- The discomfort will increase client anxiety and reduce coping. 2- Pain relief improves oxygen supply and decreases oxygen demand. 3- Relief of pain indicates that the MI is resolving. 4- Pain medication should not be used until a definitive diagnosis has been established.

2 The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although it used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? 1- "Avoid contact sports." 2- "Avoid rigorous exercise." 3- "Wear helmets when riding a motorcycle." 4- "Avoid driving in inclement weather."

2 Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what many health care professionals recommend to maintain health.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? 1- Serum potassium level of 3.2 mEq/L 2- Ejection fraction of 60% 3- B-type natriuretic peptide (BNP) of 760 ng/dL 4- Chest x-ray report showing right middle lobe consolidation

3 BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for HF, but may also occur with other conditions; it is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

Which nursing action may be delegated to a nursing assistant working on the medical unit? 1- Determine the usual alcohol intake for a client with cardiomyopathy. 2- Monitor the pain level for a client with acute pericarditis. 3- Obtain daily weights for several clients with class IV heart failure. 4- Check for peripheral edema in a client with endocarditis.

3 Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; determining alcohol intake, monitoring pain level, and assessing for peripheral edema should not be delegated.

A mother who is a carrier of muscular dystrophy (MD) has a daughter. The client asks the nurse what the daughter's genetic risk is for having MD. What is the nurse's best response? 1- "Because you are a carrier of the MD gene, your daughter will develop MD." 2- "She will not have MD nor will she be a carrier." 3- "There is a 50% chance that your daughter may carry the gene." 4- "Your daughter is X-linked dominant for the MD gene."

3 MD is an X-linked recessive disorder, so the daughter of a mother who is a carrier has a 50% chance of carrying the gene. The daughter would only be a carrier of the disease; she would not have MD.

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? 1- The need to increase activities slowly at home 2- Planning and participating in a walking program 3- Placing a chair in the shower for independent hygiene 4- Consultation with social worker for disability planning

3 Phase 1 begins with the acute illness and ends with discharge from the hospital; it focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities. Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning; it consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? 1- Friction rub auscultated at the left lower sternal border 2- Pain aggravated by breathing, coughing, and swallowing 3- Splinter hemorrhages 4- Thickening of the endocardium

3 Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

An older adult client reports nausea during removal of impacted cerumen from the ear canal. What does the nurse do next? 1- Administer an antiemetic. 2- Call the health care provider. 3- Stop irrigation immediately. 4- Use less water to irrigate.

3 The client's nausea may be a sign of vertigo. If nausea, vomiting, or dizziness develop in the client, irrigation should be stopped immediately. Antiemetics should not be administered immediately in this case. The client's nausea may be a symptom of vertigo, and further assessment is required first. The health care provider should not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client's nausea.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? 1- Surgical repair of the rotator cuff 2- Prescribed exercises of the affected arm 3- Immobilizer for the affected arm 4- Patient-controlled analgesia with morphine

3 The conservative treatment for this client is to place the injured arm in an immobilizer. Surgical intervention is not considered conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? 1- "Consume foods high in potassium." 2- "Monitor for irregular pulse." 3- "Monitor for muscle cramping." 4- "Avoid grapefruit juice."

4 Grapefruit juice should be avoided with verapamil because it can enhance the action of the drug. Foods high in potassium should be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.

A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon? 1- Swelling of the right lower extremity 2- 1+ to 2+ bilateral palpable pedal pulses 3- Pain of right lower extremity on movement 4- Paresis of right lower extremity

4 Paresis indicates a neurovascular compromise that must be reported immediately to the surgeon. The client undergoing a sequestrectomy experiences increased swelling after the procedure; the affected extremity should be elevated to increase venous return and thus control swelling. Palpable pulses of 1+ to 2+ bilaterally are a sign of adequate blood flow. Pain on movement of the right lower extremity is an expected finding.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? 1- Determines the client's physical limitations 2- Encourages alternate rest and activity periods 3- Monitors and documents heart rate, rhythm, and pulses 4- Positions the client to alleviate dyspnea 19.

4 Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

An older adult client reports ear pain. Otoscopic examination by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? 1- Continues further assessment 2- Irrigates the ear 3- Prescribes antibiotics for probable otitis media 4- Tests hearing acuity

1 A dull and retracted membrane should not be the only indication of otitis media for the older adult client. This finding may be a normal age-related change, so further assessment is continued. Irrigating the ear is not indicated for this client. Further assessment is needed to determine whether the client has otitis media; therefore, antibiotics should not be prescribed. Auditory assessment is the last part of an ear examination after the otoscopic examination.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? 1- Observation of a large amount of serosanguineous or bloody drainage 2- Mild to moderate pain controlled with prescribed analgesics 3- Absence of erythema and tenderness at the surgical site 4- Ability to flex and extend the right knee

1 A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client should be able to flex and extend the right knee (limb) after surgery.

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? 1- Fatigue 2- Swelling of one leg 3- Slow heart rate 4- Brown discoloration of lower extremities

1 Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? 1- "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." 2- "Angina is just a temporary interruption of blood flow to my heart." 3- "I need to tell my wife I've had a heart attack." 4- "Because this was temporary, I will not need to take any medications for my heart."

1 Among people who have unstable angina, 10% to 30% have a myocardial infarction within 1 year. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, anti-anginals, or antihypertensives.

Which test best determines hearing acuity? 1- Audioscopy 2- Electronystagmography 3- Otoscope 4- Snellen test

1 Audioscopy involves the use of a handheld device to generate tones of varying intensity to test hearing. Electronystagmography is a test that is sensitive for detecting central and peripheral disease of the vestibular system in the ear. An otoscope is used to inspect the ear canal. The Snellen test is a vision acuity test.

A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? 1- Magnetic resonance imaging (MRI) 2- Ophthalmoscopy 3- Radioisotope scanning 4- Snellen chart

1 Because the client has metal in the eye, MRI is an absolute contraindication. Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? 1- Keep the client's heels off the bed at all times. 2- Re-position the client every 3 to 4 hours. 3- Administer preventive pain medication before deep-breathing exercises. 4- Prohibit the use of antiembolic stockings.

1 Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Re-positioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings are not contraindicated for older adults; rather, they help prevent deep vein thrombosis.

The nurse is instructing a client who has been prescribed calcium citrate (Citracal). Which instruction does the nurse include? 1- "Take Citracal with food." 2- "For best absorption, take Citracal with a carbonated beverage." 3- "One third of the daily dose is best taken during the day." 4- "Milk of Magnesia (MOM) should be taken with Citracal."

1 Calcium supplements can cause gastric upset; taking Citracal with food can minimize gastric upset. Calcium citrate should be taken with 6 to 8 ounces of water, not carbonated beverages. One third of the daily dose is best taken at bedtime. MOM is not indicated and actually may lead to decreased absorption of calcium citrate.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? 1- Reproducible leg pain with exercise 2- Unilateral swelling of affected leg 3- Decreased pain when legs are elevated 4- Pulse oximetry reading of 90%

1 Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the provider immediately? 1- Swelling and tenseness in the affected area 2- Incisional pain and tenderness at the surgical site 3- Pink, mobile fingers 4- An order for heparin infusion

1 Compartment syndrome may develop after an embolectomy; swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb. Incisional pain is expected. Pink fingers and mobility are normal physical assessment findings. Heparin may be prescribed to maintain patency of the vessel after clot removal.

The nurse is performing an otoscopic examination of a client's ear and sees a greenish-white drainage. What does the nurse do next? 1- Disposes of the otoscope tip and washes the hands before examining the other ear 2- Reports the finding to the health care provider immediately 3- Sends a specimen for culture 4- Suctions out the drainage

1 Contact Precautions must be used with any client who has drainage from the ear canal. To prevent cross-contamination, the nurse should dispose of the otoscope tip and wash the hands before examining the opposite ear. The health care provider will be notified after the ear examination is complete. After an otoscopic examination, the nurse must perform an auditory assessment. A specimen is obtained only if the nurse is examining the external meatus region, but this is not the first step. The nurse must assess the second ear and compare. Suctioning the ear that is infected causes trauma to the tissue.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? 1- "I will call the provider if I have a cough lasting 3 or more days." 2- "I will report to the provider weight loss of 2 to 3 pounds in a day." 3- "I will try walking for 1 hour each day." 4- "I should expect occasional chest pain."

1 Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? 1- "I should avoid eating hamburgers." 2- "I must cut out bacon and canned foods." 3- "I shouldn't put the salt shaker on the table anymore." 4- "I should avoid lunchmeats but may cook my own turkey."

1 Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention; these are to be avoided. The client correctly understands that adding salt to food should be avoided.

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? 1- The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea 2- The client with percutaneous coronary angioplasty who has a dose of heparin scheduled 3- The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min 4- A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

1 Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate; the client with dyspnea should be seen first.

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? 1- "I always wear earplugs when I swim." 2- "It is noisy where I work, so I listen to music with ear buds." 3- "My ears ring after attending a rock concert, but it goes away." 4- "The machinery is loud at work, but I get used to it."

1 Earplugs worn during swimming protect against potential ear infection. If the client's work environment is noisy, the client will have to turn up the volume significantly of music played through ear buds. A ringing in the ears (tinnitus) may be a sign of injury. Clients should wear earplugs in environments with loud music. Not wearing ear protection around noisy machinery will cause damage to the ear. "Getting used to" the noise is a sign that damage has occurred.

A client has a purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? 1- Administer a Snellen test. 2- Obtain an informed consent. 3- Instill antibiotic drops. 4- Put on gloves.

1 Gloves should be worn in the presence of drainage and should be put on before examining the eye. Administering a Snellen test or instilling antibiotic eyedrops is not the first thing that the nurse should do before examining the client's eye. Obtaining informed consent is not necessary for an eye examination.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? 1- "How does this make you feel?" 2- "This can be caused by taking performance-enhancing drugs." 3- "This may be caused by a genetic trait." 4- "Just imagine how bad it would be if you weren't in good shape."

1 Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

A client has a bilateral corneal disorder and must instill anti-infective eyedrops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? 1- "I have two bottles of eyedrops because I will require a lot of medication." 2- "I won't be able to wear my contacts for a while." 3- "I must apply the drops throughout the night." 4- "I must wash my hands before and between eye applications and after putting the drops in."

1 If both eyes are infected, separate bottles of drugs are needed for each eye. The client should be taught to clearly label the bottles "right eye" and "left eye" and to not switch the drugs from eye to eye. The client should not wear contact lenses during the entire time that these drugs are being used because the eye then has fewer protections against infection or injury. In addition, the drugs can cloud or damage contact lenses. If the drugs are to be instilled every hour for the first 24 hours, the client will have to wake up every hour during the night to apply the drops. The client should completely care for one eye, wash the hands, and by using the drugs for the remaining eye, care for that eye. As always, handwashing should be done before and after eye care.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? 1- Ibuprofen (Motrin) 2- Hydrochlorothiazide (HydroDIURIL) 3- NPH insulin 4- Levothyroxine (Synthroid)

1 Long-term use of NSAIDs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF. A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause HF.

Which intervention does the nurse suggest to a client with a leg amputation to help cope with loss of the limb? 1- Talking with an amputee close to the client's age who has had the same type of amputation 2- Drawing a picture of how the client sees him- or herself 3- Talking with a psychiatrist about the amputation 4- Engaging in diversional activities to avoid focusing on the amputation

1 Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist should not be necessary. Diversional activities do not help the client deal with loss of the limb.

The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? 1- "I'll have to wear a bandage over my eye after the test." 2- "I will be awake during this test." 3- "I won't hear the high-frequency sound waves." 4- "This test will help determine whether my retina is detached."

1 No special follow-up care is needed after an ultrasonography of the eye, so the client does not have to wear a bandage after the test. However, the client should be reminded not to rub or touch the eye until the effects of the anesthetic drops have worn off. The test is noninvasive and painless, and the client remains awake during the test. The high-frequency sound waves that are bounced through the eye cannot be heard. Ultrasonography aids in the diagnosis of trauma, intraorbital tumor, proptosis, and choroidal or retinal detachment.

Which is a priority problem for the older adult client diagnosed with bone cancer? 1- Potential for injury related to weakness and drug therapy 2- Altered self-esteem related to fear of death and dying 3- Reduced mobility related to weakness and fatigue 4- Pain of a chronic nature related to tumor invasion of other organs

1 Older adult clients are more likely to fall and injure themselves because of weakness and the medications that they are prescribed, especially analgesics. Client problems of altered self-esteem, reduced mobility, and chronic pain are relevant, but are not the priority. The client's safety comes first.

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? "My leg might turn very white after the surgery." "I should be concerned if my foot turns blue." "I should report a fever or any drainage." "Warmness, redness, and swelling are expected."

1 Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis. The foot turning blue is a sign of poor perfusion. Fever or drainage would indicate an infection. Warmness, redness, and swelling indicate reperfusion, which is a good sign.

A client with bone cancer is scheduled for a right upper extremity amputation. Which statement by the client's husband indicates an effective coping strategy? 1- "I'll have to find ways to help my wife focus on positive aspects of her body." 2- "The family will avoid direct discussion of my wife's amputation." 3- "I'll try to limit her visitors." 4- "My family will use diversional methods to help her not focus on the amputation."

1 Planning to help the client focus on positive aspects of her body illustrates that the husband is coping with the change in his wife's body image in a positive way. Planning to have the family avoid direct discussion of the amputation does not allow the client the opportunity to discuss her feelings about the loss of a limb. Visitors could be a source of comfort and may provide a way for the client to express her feelings, so visitors should not be limited. Using diversional methods to help the client not focus on the amputation is not an effective coping strategy; it limits the chance for the client to discuss feelings about the amputation.

Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis? 1- Instructing the client to brush teeth after every meal 2- Maintaining clean dressing change technique for long-term IV catheters 3- Using clean technique 4- Using Standard Precautions

1 Proper dental hygiene helps prevent periodontal infection, which can be a causative factor in osteomyelitis of the facial bone. Long-term IV catheters can be a primary source of infection, so dressing changes are done using sterile technique. All clients undergoing hemodialysis require careful sterile technique before needle cannulation. Standard Precautions should be used for all clients.

Which client has the highest risk for cardiovascular disease? 1- Man who smokes and whose father died at 49 of myocardial infarction (MI) 2- Woman with abdominal obesity who exercises three times per week 3- Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL 4- Man who is sedentary and reports four episodes of strep throat

1 Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? 1- A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions 2- A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% 3- A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths 4- A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

1 The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.

A client's left arm is placed in a plaster cast. Which assessment does the nurse perform before the client is discharged? 1- Assess that the cast is dry. 2- Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. 3- Check the fit of the cast by inserting a tongue blade between the cast and the skin. 4- Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.

1 The cast must be dry and free of cracking and crumbling before the client is discharged. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. Capillary refill longer than 3 seconds indicates impairment of the circulation in the extremity and requires the health care provider's immediate attention.

The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective? 1- "I can't drink caffeine 24 to 48 hours before the test." 2- "I should drink more fluids 4 hours before the test." 3- "I'll be placed in a soundproof booth for the test." 4- "I'll be sedated for the test."

1 The client must fast for several hours before electronystagmography and avoid caffeine-containing beverages for 24 to 48 hours before the test. Fluids are carefully introduced after the test is completed to prevent nausea and vomiting. The client is placed in a soundproof booth for an audiometry test. The examiners will ask the client to name names or do simple math problems during the test to ensure that he or she stays alert.

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? 1- "Use pain medication as prescribed to control pain." 2- "Clean the pin site when any drainage is noticed." 3- "Wear the same clothing that is normally worn." 4- "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

1 The client should be taught the correct use of prescribed pain medication to control pain adequately. Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.

The nurse is assigned to all of these clients. Which client should be assessed first? 1- The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago 2- The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg 3- The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid 4- The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

1 The client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure. The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment; he can be assessed after the PTA client is seen

A 65-year-old female client has chronic hip pain and muscle atrophy from an arthritic disorder. Which musculoskeletal assessment finding does the nurse expect to see in the client? 1- Antalgic gait 2- Midswing gait 3- Narrow-based stance 4- No lurch in gait

1 The client with chronic hip pain and muscle atrophy from an arthritic disorder would likely have a lurch in the gait (antalgic gait). Midswing gait is not a term used to assess a client's gait. This client would likely have a wide-based stance because of the musculoskeletal disorder.

Which client is best to assign to an LPN/LVN working on the telemetry unit? 1- Client with heart failure who is receiving dobutamine (Dobutrex) 2- Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea 3- Client with pericarditis who has a paradoxical pulse and distended jugular veins 4- Client with rheumatic fever who has a new systolic murmur

1 The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.

A diabetic older adult client who had arthroscopic surgery on the right knee the previous day has a red, swollen, and painful right knee. The nurse anticipates that the health care provider will request which medication? 1- Levofloxacin (Levaquin) 2- Enoxaparin (Lovenox) 3- Oxycodone (Roxicodone) 4- Prednisone (Deltasone)

1 The client's symptoms indicate a possible right knee infection, so the first action will be to start antibiotic therapy, especially because the client is diabetic and is at greater risk for infection. Enoxaparin is an anticoagulant that can increase the risk for postoperative bleeding; the health care provider usually requests an opioid analgesic combination following arthroscopic surgery. Oxycodone is used for more invasive surgical procedures and is not indicated for this client. Prednisone is a glucocorticoid used to treat inflammation; it increases blood sugar and increases susceptibility to infection. Prednisone is not indicated for this client because the client is diabetic and is susceptible to infection.

A client recently had an amputation of the right hand. Which statement by the client, who was right-handed, indicates that he or she is coping effectively? 1- "I can learn to write with my left hand." 2- "I'll need help with all of my personal care." 3- "Clothing will cover my missing hand." 4- "People will look at me differently."

1 The client's willingness to learn to write with his or her left hand indicates that the client is coping effectively by planning to adapt to the loss of the right hand. The client can adapt to the use of assistive devices to be independent in personal care. The client's desire for help with all personal care indicates lack of willingness or information or both. Wanting to cover the missing hand with clothing indicates that the client is not adjusting to the loss of the hand. Concern over people looking at him or her differently is a realistic concern for the client, but it also indicates that the client is not coping effectively regarding the amputated limb.

A client with a compound fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? 1- Check the dorsalis pedis pulses. 2- Immobilize the left leg with a splint. 3- Administer the prescribed analgesic. 4- Place a dressing on the affected area.

1 The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area should both be done after the nurse has assessed the client.

Which aspect of a musculoskeletal assessment will the physical therapist and the nurse plan to collaborate on? 1- The need for ambulatory devices 2- Medication that the client is currently taking 3- Nutritional intake of the client before admission 4- Current list of the client's medical conditions

1 The nurse and the physical therapist assess and collaborate on the need for ambulatory devices. It is the nurse's responsibility to assess which medications the client is currently taking. Nutritional assessment is performed by the nurse, but this might also involve a dietitian if special needs exist. The nurse assesses the client for all present medical conditions.

An older adult client comes in for a routine visit. During the assessment, he irritably exclaims, "Speak up and quit mumbling!" How does the nurse respond? 1- Apologizes and speaks louder and clearer 2- Asks whether the client has a hearing loss 3- Offers the client a stethoscope to use 4- Suggests that the client move to a soundproof examination room to improve his hearing

1 The nurse should speak more clearly first, and then determine whether further assessment is needed. It should not be assumed that the client has a hearing loss; this suggestion may make the client more irritable, especially if the client is in denial. Using a stethoscope will be effective only once a hearing loss diagnosis has been established. Soundproof rooms are used for hearing tests, not to improve hearing.

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? 1- Building on the remaining vision 2- Keeping the floor free of clutter 3- Suggesting a seeing-eye animal companion 4- Teaching Braille

1 Using large-print books, talking clocks, and telephones with large, raised block numbers are examples of building on the client's remaining vision, which best facilitates the client's independent self-care. Keeping the floor free of clutter is important but is too specific. A seeing-eye animal companion may be assigned to those who are legally blind, not to those with diminished vision. Braille is used by clients who are legally blind; this client will still be able to read using a magnification device such as a visualizer.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (SATA) 1- Troponin 3.2 ng/mL 2- Myoglobin 234 mcg/L 3- C-reactive protein 13 mg/dL 4- Triglycerides 400 mg/dL 5- Lipoprotein-a 18 mg/dL

1,2 Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction? (SATA) 1- Morphine sulfate 2- Oxygen 3- Nitroglycerin 4- Naloxone 5- Acetaminophen 6- Verapamil (Calan, Isoptin)

1,2,3 Morphine is needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain. Administering oxygen will increase available oxygen for the ischemic myocardium. Naloxone is a narcotic antagonist that is used for overdosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (SATA) 1- Occupational therapist 2- Physical therapist 3- Psychologist 4- Respiratory therapist 5- Speech therapist

1,2,3 An occupational therapist and a physical therapist will help to enable the client to become more independent in performing activities of daily living. An amputation can be traumatic to the client; loss of a body part should not be underestimated because the client may experience an altered self-concept, so counseling support with a psychologist should be made available to the client. The client does not have a respiratory condition that warrants collaborative care with a respiratory therapist. A speech therapist is not indicated because the client does not have speech impairment.

Which clients are at high risk for developing hearing problems? (SATA) 1- Airline mechanic 2- Client with Down syndrome 3- Drummer in a rock band 4- Teenager listening to music using ear buds 5- Telephone operator

1,2,3,4 An airline mechanic is exposed to excessive noise and is at risk for hearing damage. A client with Down syndrome is at risk for hearing problems because this genetic condition is associated with frequent hearing problems. A drummer in a rock band is at risk for hearing problems due to exposure to loud noise. A teenager listening to music using ear buds is at high risk because ear buds are known risk factors for increasing potential hearing loss among people who use them on a regular basis with elevated noise levels. A telephone operator is not at risk for hearing problems simply because he or she may wear headphones or audio equipment.

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? (SATA) 1- Announce name and purpose when entering the client's room. 2- Explain food positions on the tray using a clock face as the example. 3- Orient the client to the location of the call light, and keep it in that place. 4- Orient the client to the room surroundings and equipment. 5- Speak in a loud, clear voice.

1,2,3,4 Staff should always introduce themselves to clients, with or without visual issues. Using a standard clock face to explain food locations on the tray will assist the client with self-feeding. Providing room orientation to the client is important to improve his or her ability for self-care. Orienting the client to the room and equipment in the room will allow him or her to have increased comfort with surroundings. This client has visual issues, not hearing issues, so speaking louder is not necessary.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (SATA) 1- Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL 2- Smoking 3- Aspirin (acetylsalicylic acid [ASA]) consumption 4- Type 2 diabetes 5- Vegetarian diet

1,2,4 Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease. ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? (SATA) 1- Truncal obesity 2- Hypercholesterolemia 3- Elevated homocysteine levels 4- Glucose intolerance 5- Client taking losartan (Cozaar)

1,2,4,5 A large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome. Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (SATA) 1- Acute compartment syndrome (ACS) 2- Fat embolism syndrome (FES) 3- Congestive heart failure 4- Urinary tract infection (UTI) 5- Osteomyelitis

1,2,5 ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair, but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (SATA) 1- Has maintained a low-sodium, no-added-salt diet 2- Has lost 3 pounds since last seen in the clinic 3- Cooks food in palm oil to save money 4- Exercises once weekly 5- Has cut down on caffeine

1,2,5 Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure. Although palm oil may be cost-saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. The goal is to exercise three times weekly.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (SATA) 1- Chest discomfort or pain 2- Tachycardia 3- Expectorating thick, yellow sputum 4- Sleeping on back without a pillow 5- Fatigue

1,2,5 Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom; Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (SATA) 1- Bending over to tie shoes 2- Sitting with legs elevated 3- Sleeping on more than two pillows 4- Blowing the nose frequently 5- Lifting objects weighing more than 10 pounds

1,4,5 Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? 1- Less than 30% of the daily caloric intake should be derived from proteins. 2- Use canola oil rather than palm oil. 3- Consume 10 mg of fiber daily. 4- Work toward lowering your high-density lipoprotein (HDL) cholesterol levels. 2.

2 Palm oil is higher in saturated fats and should be avoided. Less than 30% of daily calories should come from fats. Clients should be encouraged to consume 30 g of dietary fiber daily. A higher HDL cholesterol level (good cholesterol) is more desirable; clients should strive to reduce low-density lipoprotein cholesterol (bad cholesterol) when elevated.

Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast? 1- Arthroscopy 2- Computed tomography (CT) 3- Electromyography (EMG) 4- Tomography

2 A CT scan creates three-dimensional images and may be done with iodine-based contrast. Arthroscopy involves inserting a fiberoptic tube into a joint for direct visualization of ligaments, menisci, and articular surfaces of the joint. An EMG evaluates diffuse or localized muscle weakness by testing nerve conduction. Tomography identifies locations, or "slices", for focus and blurs the images of other structures.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? 1- "I don't know how I am going to change my lifestyle." 2- "I don't need to change. It hasn't killed me yet." 3- "I don't think it is as bad as the doctors say." 4- "I will have to change my diet and exercise more."

2 A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? 1- Administers oxygen therapy 2- Obtains the client's description of the chest discomfort 3- Provides pain relief medication 4- Remains calm and stays with the client

2 A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.

The nurse plans to use which tool to measure joint range of motion (ROM)? 1- Doppler device 2- Goniometer 3- Reflex hammer 4- Tonometer

2 A goniometer provides an exact measurement of flexion and extension or joint ROM. A Doppler device is used to check and find pulses. A reflex hammer is used to test and elicit reflexes and is used in neurologic examinations. A tonometer is used to measure tension or pressure in the eye.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? 1- No intervention is needed; this is a normal reading. 2- Collaborate with the health care provider to administer a positive inotropic agent. 3- Administer a STAT dose of metoprolol (Lopressor). 4- Ask the client to perform the Valsalva maneuver.

2 A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? 1- Assess leg ulcers for evidence of infection. 2- Administer a clonidine patch for hypertension. 3- Obtain a request from the health care provider for a dietary consult. 4- Develop a plan for discharge, and assess home care needs.

2 Administering medication is within the scope of practice for the LPN/LVN. The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction? 1- "My child should look down at the floor during instillation." 2- "I will place the ointment in the lower lid." 3- "My child should rub the eye gently after instillation to increase absorption." 4- "I will press gently on the inner canthus for 1 minute."

2 After the lower lid is gently pulled down to form a small pocket, eye ointment should be placed in the lower lid. For instillation of eye ointment, the client should tilt the head backward and look up at the ceiling. After closing the eye, the client may gently wipe away any excess ointment with a tissue, but the eye should never be rubbed. Pressing on the inner canthus is a technique reserved for the instillation of glaucoma drops.

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? 1- Allowing the client's seeing-eye dog in the unit 2- Making all health care team members aware of the client's visual limitations 3- Keeping the client bedridden for safety 4- Addressing the client in a loud, clear voice

2 All health care team members must be made aware of the client's visual limitations and need for assistance. Seeing-eye dogs are not usually allowed in the ICU. It is not necessary to keep the client bedridden. The client should be addressed in a normal tone of voice; the client's hearing is not affected.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? 1- The client's ability to understand medication teaching 2- The risk for hypotension 3- The potential for bradycardia 4- Liver function tests

2 Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? 1- Assess the client for peripheral edema. 2- Auscultate the client's posterior breath sounds. 3- Notify the health care provider about the client's weight gain. 4- Remind the client about dietary sodium restrictions.

2 Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse should notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

A client has recently been diagnosed with 20/200 vision bilaterally. How does the nurse best offer increased support? 1- Provides instructions in a loud, clear voice 2- Refers the family to local services for the blind 3- Tells the client to find a support group 4- Writes instructions down in very large print

2 Because the client is considered legally blind, referring the family to local services for the blind is the best way for the nurse to offer increased support. Talking in a loud, clear voice demonstrates insensitivity on the part of the nurse because speaking louder does not have any impact on vision. The client needs more specific assistance than just being told to find a support group. The client with 20/200 vision will not be able to distinguish large print.

Which medication, when given in heart failure, may improve morbidity and mortality? 1- Dobutamine (Dobutrex) 2- Carvedilol (Coreg) 3- Digoxin (Lanoxin) 4- Bumetanide (Bumex)

2 Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? 1- Balanced skin traction 2- Buck's traction 3- Overhead traction 4- Plaster traction

2 Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? 1- Serum sodium level of 135 mEq/L 2- Serum potassium level of 2.8 mEq/L 3- Serum creatinine of 1.0 mg/dL 4- Serum magnesium level of 1.9 mEq/L

2 Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.

Care of the older adult may be affected by which physiologic change in the musculoskeletal system? 1- Regeneration of cartilage 2- Decreased range of motion (ROM) 3- Increased bone density 4- Narrower gait

2 Decreased ROM occurs in older adults, and they may need assistance with self-care skills. Cartilage degeneration is an age-related change that occurs in the musculoskeletal system. Decreased bone density occurs with musculoskeletal system aging, and porous bones are more likely to fracture. The older adult experiences kyphotic posture, widened gait, and a shift in the center of gravity.

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? 1- Inferior wall 2- Anterior wall 3- Lateral wall 4- Posterior wall

2 Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure. The client with an inferior wall MI is more likely to develop right ventricular heart failure. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? 1- A 1-inch backup of blood in the IV tubing 2- Facial drooping 3- Partial thromboplastin time (PTT) 68 seconds 4- Report of chest pressure during dye injection

2 During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding. A 1-inch backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? 1- Heart rate 52 beats/min 2- Blood pressure 192/102 mm Hg 3- Report of constipation 4- Anxiety

2 Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture. The nurse must consider the client's usual pulse; however, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection; however, a potential problem should not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious; however, the elevated blood pressure is an immediate risk.

Which eye procedure requires informed consent from the client? 1- Eyedrop instillation 2- Fluorescein angiography 3- Ophthalmoscopy 4- Snellen test

2 Fluorescein angiography is an invasive test and requires informed consent from the client. Eyedrop instillation, ophthalmoscopy, and the Snellen test are not invasive procedures and do not require informed consent from the client.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? 1- Ejection fraction is 25%. 2- Client states that she is able to sleep on one pillow. 3- Client was hospitalized five times last year with pulmonary edema. 4- Client reports that she experiences palpitations.

2 Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? 1- "A callus is quickly deposited and transformed into bone." 2- "A hematoma forms at the site of the fracture." 3- "Calcium and vascular proliferation surround the fracture site." 4- "Granulation tissue reabsorbs the hematoma and deposits new bone."

2 In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

Which statement about diagnostic cardiovascular testing is correct? 1- Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. 2- An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. 3- Holter monitoring allows periodic recording of cardiac activity during an extended period of time. 4- The left side of the heart is catheterized first and may be the only side examined.

2 Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

What is the primary role of the nurse when caring for an adult client with muscular dystrophy (MD)? 1- Pain management 2- Supportive care 3- Teaching the importance of keeping appointments 4- Advocating for the client and the family

2 Management of the client with MD is supportive and involves the entire health care team. Coordinating pain management is not the nurse's primary role for the adult client with MD. The nurse's role does not focus on whether the client keeps appointments; this would be more important for clients who, for example, are receiving intermittent chemotherapy. The nurse is always an advocate for all clients and families, but this is not the nurse's primary role when caring for the client with MD.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? 1- Increase red meat in the diet. 2- Consume melons and baked potatoes. 3- Add several portions of dairy products each day. 4- Try replacing your usual breakfast with oatmeal or Cream of Wheat.

2 Melons and baked potatoes contain potassium. Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron; oatmeal contains fiber but not potassium.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? 1- Calcium 8.5 mEq/L 2- Potassium 3.0 mEq/L 3- Magnesium 2.1 mEq/L 4- International normalized ratio (INR) of 1.0

2 Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the health care provider will request which medication? 1- Ascorbic acid (vitamin C) 2- Ergocalciferol (Calciferol) 3- Phenytoin (Dilantin) 4- Prednisone (Deltasone)

2 Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol. Ascorbic acid (vitamin C) is not indicated for treatment of osteomalacia, which is related to vitamin D deficiency. Phenytoin interferes with the metabolism of vitamin D. Prednisone is a glucocorticoid for treatment of inflammatory disorders and is not indicated in the treatment of osteomalacia.

The nurse is teaching a client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? 1- "I must wait 10 to 15 minutes between different eyedrop medications." 2- "I must press on the inside of my eye to prevent washout." 3- "It is important to not skip a dose." 4- "These eyedrops will not cure my glaucoma."

2 Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug. To avoid washout, the client should wait 10 to 15 minutes between eyedrop medications. Skipping a dose will not exacerbate the client's glaucoma. Medication will not cure glaucoma, but it will control its progression.

The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis? 1- Consuming 12 ounces of carbonated beverages daily 2- Working at a desk and playing the piano for a hobby 3- Having a hysterectomy and taking estrogen replacement therapy 4- Consuming one alcoholic drink per week

2 Sedentary lifestyle and prolonged immobility produce rapid bone loss. The client would have to consume large amounts of carbonated beverages daily (over 40 ounces) for this to be a risk factor for osteoporosis. Maintaining estrogen levels reduces the risk for osteoporosis. Alcohol has a direct toxic effect on bone tissue, resulting in decreased bone formation and increased bone resorption. For those who have excessive alcohol intake, alcohol calories decrease hunger and the need to take in adequate quantities of nutrients. This client's alcoholic intake is not high, so it is not a risk factor.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I feel my heart beating in my abdominal area." "I just started to feel a tearing pain in my belly." "I have a headache. May I have some acetaminophen?" "I have had hoarseness for a few weeks."

2 Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA. The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? 1- Temperature 98.2° F 2- Chest tube drainage 175 mL last hour 3- Serum potassium 3.9 mEq/L 4- Incisional pain 6 on a scale of 0 to 10

2 Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL/hr to the surgeon. Although hypothermia is a common problem after surgery, a temperature of 98.2° F is a normal finding. Serum potassium of 3.9 mEq/L is a normal finding. Incisional pain of 6 on a scale of 0 to 10 is expected immediately after major surgery; the nurse should administer prescribed analgesics.

The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider? 1- Knee pain at a level of 9 (0-to-10 scale) 2- Warm, red, and swollen knee 3- Allergy to shellfish and iodine 4- Previous surgery on the other knee

2 Swelling, heat, and redness may indicate infection in the knee joint, which would indicate a need to cancel the procedure. Having knee pain before surgery is not unexpected but will not affect whether the client will have surgery. Allergy to shellfish and iodine will need to be reported, but also will not affect whether the client will have surgery. Having previous surgery on the other knee does not preclude the client from having this surgery.

Which client is most in need of immediate examination by an ophthalmologist? 1- A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged 2- A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights 3- A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes 4- A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes

2 The 40-year-old client with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights is exhibiting signs and symptoms of increased intraocular pressure (IOP). This is a priority because the optic nerve can be damaged, which can cause possible blindness. Acute angle-closure glaucoma can occur in those 40 years of age and older. The 58-year-old client reporting an inability to see colors well is exhibiting early signs of cataracts and will need to be seen, but this is not the priority. The 76-year-old with seborrhea of the eyebrows and eyelids is exhibiting signs and symptoms of blepharitis and will need to be seen, but this is also not the priority. The 39-year-old with contacts is exhibiting signs and symptoms of corneal abrasion, possibly from cataracts, and will need to be seen soon, but the client exhibiting increased IOP is still the priority.

The nurse refers a client with an amputation and the client's family to which community resource? 1- American Amputee Society (AAS) 2- Amputee Coalition of America (ACA) 3- Community Workers for Amputees (CWA) 4- National Amputee of America Society (NAAS)

2 The ACA is an available resource for clients with amputations and supports them and their families. The AAS, CWA, and NAAS do not exist.

A client is suspected of having muscular dystrophy (MD). Which laboratory test result does the nurse anticipate with this disease? 1- Decreased serum creatine kinase (CK) level 2- Moderately elevated aspartate aminotransferase (AST) 3- Decreased alkaline phosphatase (ALP) 4- Decreased skeletal muscle creatine kinase (CK-MM) level

2 The AST level is moderately elevated (three to five times normal) in certain musculoskeletal diseases, such as MD. The CK level is elevated in musculoskeletal diseases such as MD. ALP is an enzyme normally present in blood, and the concentration of ALP increases with bone or liver damage; it is not associated with MD. A decreased CK-MM level is not associated with MD.

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? 1- Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted 2- Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes 3- Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain 4- Client who has many questions about the electrophysiology studies (EPS) scheduled for today

2 The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? 1- "Monitor the pulses in your feet when you get home." 2- "Keep your affected leg straight for 2 to 6 hours." 3- "Do not take your blood pressure medications on the day of the procedure." 4- "Take your oral hypoglycemic with a sip of water on the morning of the procedure.

2 The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? 1- The client has had intermittent substernal chest pain for 6 months. 2- The client develops wheezes and dyspnea after eating crab or lobster. 3- The client reports that a previous arteriogram was negative for coronary artery disease. 4- The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

2 The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? 1- NPO status will cause the client to be thirsty. 2- The dye causes an osmotic diuresis. 3- The dye contains a heavy sodium load. 4- The pedal pulses will be more easily palpable.

2 The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodine-based. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.

Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the health care provider? 1- Thighs have multiple oozing abrasions. 2- Serum potassium level is 7 mEq/L. 3- The client is describing pain as level 4 (0-to-10 scale). 4- Hemoglobin level is 12.0 g/dL.

2 The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further kidney damage or cardiac dysrhythmias. Thighs having multiple oozing abrasions with a pain level of 4 are not unusual for a client with this type of injury. A hemoglobin level of 12.0 g/dL is a normal finding.

A client has sustained damage to cranial nerve II after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? 1- Artificial tears 2- Identifying food on the client's plate using the clock method 3- Daily eye assessment using the six cardinal positions of gaze 4- Ensuring that the client wears sunglasses when the curtains are open or when the room light is on

2 The optic nerve (cranial nerve [CN] II) controls sight. Using the clock method helps the client with impaired vision or loss of vision locate food on his or her plate. Artificial tears are used when tear production is decreased due to the aging process. The six cardinal positions of gaze assess CN III, IV, and VI. Sunglasses are used when the pupils are artificially dilated for assessment purposes, or when medications are used that cause dilation of the pupil.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? 1- A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures 2- A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index 3- A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging 4- A client with acute coronary syndrome who has just been admitted and needs an admission assessment

2 The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.

The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first? 1- Client with dyspnea on exertion when ambulating to the bathroom 2- Client with third-degree heart block on the monitor 3- Client with normal sinus rhythm and PR interval of 0.28 second 4- Client who refuses to take heparin or nitroglycerin

2 Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the client with the third-degree heart block should be seen first. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? 1- Calls the family to lift the client's spirits 2- Considers further assessment for depression 3- Sedates the client to decrease myocardial oxygen demand 4- Tells the client that things will get better

2 This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

Which technique is the correct way to instill eardrops? 1- Maintain the head in the same position for 2 minutes after instillation. 2- Place the medication bottle in a bowl of warm water before instillation. 3- Rinse the ear canal with hydrogen peroxide before instillation. 4- Check to see whether the eardrum is intact before instillation.

2 To instill eardrops, place the bottle (with the top on tightly) in a bowl of warm water for 5 minutes. This warms the medication and makes instillation more comfortable for the client. The head should be gently moved back and forth five times after instillation to ensure proper distribution. It is not necessary to rinse the ear canal with hydrogen peroxide or check to see whether the eardrum is intact before instillation.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? 1- Right atrial pressure is 4 mm Hg. 2- Mean arterial pressure (MAP) is 58 mm Hg. 3- Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. 4- PO2 is reported as 78 mm Hg.

2 To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? 1- Client with abdominal pain and belching 2- Client with pressure in the mid-abdomen and profound diaphoresis 3- Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows 4- Client with claudication and fatigue

2 Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the provider? 1- Partial thromboplastin time (PTT) 60 seconds 2- Platelets 32,000/mm3 3- White blood cells 11,000/mm3 4- Hemoglobin 12.2 g/dL

2 UFH can also decrease platelet counts. Notify the provider if the platelet count is below 100,000 to 120,000/mm3. Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm3. A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL reflects a normal reading.

A client has a grade III compound fracture of the right tibia. To prevent infection, which intervention does the nurse implement? 1- Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. 2- Use strict aseptic technique when cleaning the site. 3- Leave the site open to the air to keep it dry. 4- Assist the client to shower daily and pat the wound site dry.

2 Using aseptic technique is the best way to prevent infection. Chlorhexidine (Hibiclens), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. A wound of this type should be kept covered, not left open to the air. The wound site of a compound fracture must not be exposed to a shower; this practice violates maintaining aseptic technique.

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? 1- "I can use an electric razor or a regular razor." 2- "Eating foods like green beans won't interfere with my Coumadin therapy." 3- "If I notice I am bleeding a lot, I should stop taking Coumadin right away." 4- "When taking Coumadin, I may notice some blood in my urine."

2 Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin. Warfarin "thins" the blood; the risk for cutting oneself and bleeding is very high with the use of a regular razor, so the client should use an electric razor. Clients should apply pressure to bleeding wounds and should seek medical assistance immediately, but they should not discontinue warfarin therapy. Blood in the urine of a client taking warfarin therapy is not a side effect; the client should notify the health care provider immediately if this occurs.

An older adult client is discharged from the hospital for treatment of osteoporosis. What does the nurse include in client teaching related to the client's home safety? 1- "Use area rugs on tile floors." 2- "Keep walkways free of clutter." 3- "Walk slowly on wet floor areas after mopping." 4- "Keep light low to prevent glare."

2 Walkways in the home must be clear of clutter and obstacles to help prevent falls. Clients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling. Clients with metabolic bone problems must not walk on wet floors because the potential for falling is too great. Keeping the lights low would not allow the client to see adequately to walk safely or avoid an object on the floor.

Which characteristics place women at high risk for myocardial infarction (MI)? (SATA) 1- Premenopausal 2- Increasing age 3- Family history 4- Abdominal obesity 5- Breast cancer

2,3,4 Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. A large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI. Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (SATA) 1- Sharp, inspiratory chest pain 2- Dyspnea 3- Dizziness 4- Extreme fatigue 5- Anorexia

2,3,4 Many women who experience an MI present with dyspnea, light-headedness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (SATA) 1- "You will need to wear a patch on your eye for several weeks after the surgery." 2- "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." 3- "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." 4- "Bring sunglasses with you on the day of your procedure." 5- "You might experience a lot of bruising and swelling around the eye."

2,3,4 The client will have multiple eyedrops to use after surgery and should be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eyedrops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure. A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling post-surgery.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (SATA) 1- Hypokalemia 2- Sinus bradycardia 3- Fatigue 4- Serum digoxin level of 1.5 5- Anorexia

2,3,5 Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity. Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. A serum digoxin level between 0.8 and 2.0 is considered normal and is not a symptom.

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (SATA) 1- Bradycardia 2- Cool, diaphoretic skin 3- Crackles in the lung fields 4- Respiratory rate of 12 breaths/min 5- Anxiety and restlessness 6- Temperature of 100.4° F

2,3,5 The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Because of poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.

Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? (SATA) 1- Anemia 2- Diabetes mellitus 3- Hepatitis 4- Hypertension 5- Multiple sclerosis (MS)

2,4,5 Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity. Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

Which signs and symptoms are seen with suspected pericarditis? (SATA) 1- Squeezing, vise-like chest pain 2- Chest pain relieved by sitting upright 3- Chest and abdominal pain relieved by antacids 4- Sudden-onset chest pain relieved by anti-inflammatory agents 5- Pain in the chest described as sharp or stabbing

2,4,5 The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

Which of these factors contribute to the risk for cardiovascular disease? (SATA) 1- Consuming a diet rich in fiber 2- Elevated C-reactive protein levels 3- Low blood pressure 4- Elevated high-density lipoprotein (HDL) cholesterol level 5- Smoking

2,5 Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? 1- This blood pressure is good because it is a normal reading. 2- This blood pressure indicates that the client has hypertension or high blood pressure. 3- This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. 4- This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

3 A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.

the nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? 1- The eardrum is red, thick-appearing, and immobile. 2- The lymph nodes are swollen and painful to touch. 3- The client reports a headache and a stiff neck. 4- The client's oral temperature is 100.1° F (37.8° C).

3 A headache and a stiff neck may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention. The eardrum being red, thick-appearing, and immobile is an expected finding for a client with an ear infection. Lymph nodes that are swollen and painful to touch are an expected finding for a client with an active infection of the mastoid area. An oral temperature of 100.1° F (37.8° C) is also an expected finding for a client with an active infection.

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? 1- Dietary consult 2- Sodium restriction 3- Daily weight monitoring 4- Restricted activity

3 A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? 1- Administer a Snellen test. 2- Obtain an informed consent. 3- Wash the hands. 4- Put on sterile gloves.

3 Always wash hands before touching the external eye structures to prevent infection. A Snellen test may be done, but is not the first thing that should be done by the nurse. An informed consent or sterile gloves are not needed for the nurse to examine the client's eye.

The nurse admits a client diagnosed with Paget's disease. The nurse anticipates that the client will have which condition? 1- Progressive muscle weakness 2- Low body weight, thin build 3- Enlarged, thick skull 4- Bone infection

3 An enlarged thick skull is a feature of Paget's disease. Progressive muscle weakness is a feature of muscular dystrophy. Low body weight with a thin build is a feature of osteoporosis. Bone infection is a feature of osteomyelitis.

The nurse is providing postmortem care to a client who has donated a cornea. Which action is appropriate for the nurse to implement? 1- Apply a warm pack to the eyes. 2- Elevate the lower extremities. 3- Instill antibiotic drops into the eyes. 4- Contact the recipient family.

3 Antibiotic eyedrops, such as Neosporin (polymyxin B, neomycin, bacitracin) or tobramycin, should be instilled into the corneal donor's eyes to prevent infection. Small cold packs should be applied to the donor's closed eyes. Raising the head of the bed 30 degrees prevents blood from pooling in the eye region of the deceased client. The nurse is not the person to contact the recipient family; the donor organization will complete all the communication to the parties involved.

A client experiencing kyphosis appears withdrawn and does not initiate any conversation with the nurse when medications are given each day. Which statement by the nurse is most supportive of this client? 1- "It is normal to feel depressed at times about your condition. You have my support." 2- "You could exercise more often to build up your strength and endurance." 3- "How do you feel about the pain in your spine? I am here if you want to talk." 4- "What does your family say to you? Try talking to them."

3 Asking the client about his or her pain and offering to listen is most supportive because it allows the client to discuss his or her feelings and informs the client that the nurse is available to listen.

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? 1- Maintains NPO (nothing by mouth) until this resolves 2- Calls in another nurse for a second opinion 3- Performs a complete neurologic assessment and notifies the health care provider 4- Explains to the client and family that this is expected after sedation

3 Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation.

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon? 1- Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. 2- The client's extremity became white, then red temporarily. 3- The affected extremity becomes purple and cold. 4- The client states that the digits are painful when they are white.

3 Cold, mottled extremities are indicative of occlusion, which could lead to gangrene. Vasodilating drugs are administered as treatment and may lower the blood pressure; this is not a significant drop. In severe cases, the attack lasts longer, and gangrene of the digits can occur. Pain, numbness, and cold are typical findings in Raynaud's phenomenon.

An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? 1- No action is required; low blood pressure is normal for older adults. 2- No action is required for postsurgical CABG clients. 3- Assess pulmonary artery wedge pressure (PAWP). 4- Give ordered loop diuretics.

3 Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation; hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative clients. The cause of hypotension must be found and treated; further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia; giving loop diuretics increases hypovolemia.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? 1- Enalapril (Vasotec) 2- Sodium nitroprusside (Nipride) 3- Dopamine (Intropin) 4- Clevidipine (Butyrate)

3 Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure; it should not be used in hypertensive emergency. Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Clevidipine, an intravenous calcium channel blocker, is used in hypertensive emergencies when oral therapy is not feasible.

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first? 1- Assess coping skills. 2- Assess for postoperative pain at the client's incision site. 3- Monitor for dysrhythmias. 4- Monitor mental status.

3 Dysrhythmias are the leading cause of prehospital death; the nurse should monitor the client's heart rhythm. Assessing mental status, coping skills, or postoperative pain is not the priority for this client.

The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? 1- Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic 2- Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side 3- Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache 4- Client who has acute otitis media and is reporting drainage from the affected ear

3 Elevated temperature and headache with labyrinthitis may indicate that the client has developed meningitis and requires further immediate assessment and intervention. Severe nausea is an expected finding with Ménière's disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? 1- White blood cell count 2- Low-density lipoproteins 3- Serum troponin I level 4- C-reactive protein

3 Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? 1- Bilateral eye patches 2- Contact lenses 3- Nothing; this is normal 4- Reading glasses

3 Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment. Bilateral eye patches inhibit the client's vision. Contact lenses are used to correct underrefraction of the eye. Reading glasses are used to correct overrefraction of the eye.

The nurse is assessing a client with Ewing's sarcoma. Which finding does the nurse expect to observe? 1- Bradycardia 2- High fever 3- Leukocytosis 4- Migraine headaches

3 Ewing's sarcoma is a malignant tumor, and the client may experience systemic manifestations, including leukocytosis, anemia, and low-grade fever. Bradycardia and migraine headache are not symptoms of Ewing's sarcoma. A low-grade fever is a systemic manifestation of Ewing's sarcoma.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? 1- "Elevate your legs above heart level to prevent swelling." 2- "Inspect your legs daily for brownish discoloration around the ankles." 3- "Walk to the point of leg pain, then rest, resuming when pain stops." 4- "Apply a heating pad to the legs if they feel cold."

3 Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther. Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous occlusive disease. Application of heat should be avoided in clients with PAD owing to lack of sensation and possible burns.

Which client information is most essential for the nurse to report to the health care provider before a client with knee pain undergoes magnetic resonance imaging (MRI)? 1- Daily use of aspirin 2- Swollen and tender knee 3- Presence of a permanent pacemaker 4- History of claustrophobia

3 Having a permanent pacemaker is a contraindication for MRI because metallic implants are present within the client. Taking a daily dose of aspirin does not affect or interact with the MRI test. A swollen and tender knee does not warrant cancellation of an MRI. A history of claustrophobia should be reported, but does not indicate that cancellation of the MRI is necessary because sedatives can be given to manage claustrophobia.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? 1- Monitor pulse oximetry and cardiac rate and rhythm. 2- Reassure the client that his distress can be relieved with proper intervention. 3- Place the client in high-Fowler's position with the legs down. 4- Ask a family member to remain with the client.

3 High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? 1- "Are you afraid you will not be able to work?" 2- "If you control your diabetes, you can avoid amputation." 3- "Your concerns are valid; we can review some steps to limit disease progression." 4- "What about the situation concerns you most?"

3 It is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern. Controlling diabetes may help prevent amputation, but the nurse cannot state this with certainty. Asking the client about what concerns him the most is not as open-ended a question as the others; plus, the client has already stated his concern.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? 1- The client ambulates around the nursing unit with a walker. 2- The nurse monitors the client's pulse and blood pressure frequently. 3- The nurse obtains a bedside commode before administering furosemide. 4- The nurse returns the client to bed when he becomes tachycardic.

3 Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? 1- "This way you will not need to have a leg incision." 2- "The surgeon prefers this approach because it is easier." 3- "These arteries remain open longer." 4- "The surgeon has chosen this approach because of your age."

3 Mammary arteries remain patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? 1- Antihistamines 2- Antipyretics 3- Diuretics 4- Nicotinic acid

3 Mild diuretics are prescribed to decrease endolymph volume. Antihistamines help reduce the severity of or stop an acute attack, and antipyretics control fever and pain, but they do not decrease endolymph volume. Nicotinic acid has been found to be useful because of its vasodilatory effect, but it does not decrease endolymph volume.

The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the health care provider will prescribe which medication? 1- Calcitonin (Calcimar) 2- Medroxyprogesterone (Prempro) 3- Pamidronate (Aredia) 4- Tamsulosin hydrochloride (Flomax)

3 Pamidronate is a bisphosphonate that is available intravenously and is approved for bone metastasis from the breast, lung, and prostate. Pamidronate protects bones and prevents fractures. Calcitonin is used for the treatment of postmenopausal osteoporosis, Paget's disease, and hypercalcemia associated with cancer. Medroxyprogesterone is indicated for treating menopausal symptoms and preventing osteoporosis. Tamsulosin hydrochloride is an alpha-adrenergic blocking agent used for the treatment of benign prostatic hyperplasia.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? 1- Ankle-brachial index 2- Dye allergy 3- Pedal pulses 4- Gag reflex

3 Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses). Ankle-brachial index is a diagnostic study used to detect the presence of PAD; this is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy); the femoral artery is generally the access site for PTA.

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding? 1- Lateral deviation of the great toe; first metatarsal head becomes enlarged 2- Dorsiflexion of any metatarsophalangeal (MTP) joint, with plantar flexion of the adjacent proximal interphalangeal (PIP) joint 3- Severe pain in the arch of the foot, especially when getting out of bed 4- A small tumor in a digital nerve of the foot

3 Severe pain in the arch of the foot, especially when getting out of bed, is a description of plantar fasciitis. Lateral deviation of the great toe with an enlarged first metatarsal head describes a bunion of the foot. Dorsiflexion of any MTP joint with plantar flexion of the adjacent PIP joint is a description of a hallux valgus and hammertoe of the foot. A small tumor in a digital nerve of the foot describes Morton's neuroma of the foot.

Which symptom reported by a client who has had a total hip replacement requires emergency action? 1- Localized swelling of one of the lower extremities 2- Positive Homans' sign 3- Shortness of breath and chest pain 4- Tenderness and redness at the IV site

3 Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE. Although localized swelling is a symptom of DVT, it is not emergent. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common; therefore, assessing for Homans' sign is not advised. Tenderness and redness at the IV site indicate phlebitis and are not emergent, but should be attended to after the emergency.

The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? 1- "Here is a picture of how the test is done. See how your bad ear will be tested first? You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." 2- "Here is a video of the procedure. Please watch and feel free to ask me any questions." 3- "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." 4- "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."

3 Sitting in front of the hearing-impaired client while providing instructions allows the client to read lips. Pictures help the client with impaired hearing, but the good ear is tested first. The client wears earphones and listens for sounds, not flashing lights. Showing a hearing-impaired client a video is ineffective because of tone and frequency differences in the video, which make it difficult to read lips and understand the instructions. During the test, earphones are placed on the client. The client will raise her or his hand up when hearing the first sound and will lower the hand when the sound first disappears.

An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? 1- A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain 2- A 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C 3- A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today 4- A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia

3 The LPN/LVN scope of practice includes administration of medications to stable clients. Third-degree heart block is characterized by a very low heart rate and usually by required pacemaker insertion; the skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability; he will need medications and monitoring beyond the scope of practice of the LPN/LVN.

The nurse is caring for a client with bone cancer of the right hip who has undergone radical resection of the tumor and has received a prosthetic implant. Which client statement indicates effective coping after the procedure? 1- "After I recover, I'll be just as strong as I was before the surgery." 2- "I won't be able to go out in public like I did before." 3- "Physical therapy and counseling will help me adjust to my prosthesis." 4- "I'll be able to return to work and drive without assistance."

3 The client stating that physical therapy and counseling will help him or her to adjust to the prosthesis illustrates effective coping and acceptance. The client expecting to be just as strong as before the surgery or expecting to return to work and drive without assistance reveals that the client is in denial of how surgery will affect his or her prognosis and activity. Avoiding going out in public suggests that the client is having difficulty coping and adjusting to his or her changed body image.

The nurse is using a common scale to grade a client's muscle strength. The client is able to complete range of motion (ROM) with gravity eliminated. Which grade does the nurse document in this client's record? 1- 0 2- 1 3- 2 4- 3

3 This client should be given a grade of 2. Two indicates poor muscle strength; the client can complete ROM with gravity eliminated. Zero indicates no evidence of muscle contractility. One indicates trace muscle strength; the client has no joint motion and slight evidence of muscle contractility. Three indicates fair muscle strength; the client can complete ROM against gravity.

Which proper technique does the nurse use for eyedrop instillation? 1- Instilling the drops into the inner canthus 2- Opening the eye by raising the upper eyelid 3- Placing the eyedrop in the lower lid pocket 4- Touching the bottle tip to the eyeball

3 To instill eyedrops, the lower eyelid is gently pulled down against the cheek to form a pocket, and the medication is instilled. Instilling drops into the inner canthus causes the medication to enter the punctum and be absorbed systemically. The upper eyelid is larger than the lower eyelid and is used to protect the eye and keep the cornea moist; it should not be used to create a pocket to instill medication. Touching the bottle tip to any part of the eye could potentially contaminate the eye.

The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? 1- Reduce abdominal fat. 2- Avoid stress. 3- Do not smoke or chew tobacco. 4- Avoid alcoholic beverages.

3 Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity, but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.

Which finding does the nurse expect to observe in a client with suspected common chronic osteomyelitis? 1- Erythema of the affected area 2- Fever; temperature usually above 101° F (38° C) 3- Ulceration of the skin 4- Constant, localized, and pulsating bone pain

3 Ulceration of the skin is a feature of chronic osteomyelitis. Erythema of the affected area; fever; and constant, localized, pulsating bone pain are features of acute osteomyelitis.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? 1- Auscultation of crackles 2- Pedal edema 3- Weight loss of 6 pounds since the last visit 4- Reports sucking on ice chips all day for dry mouth

3 Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

The nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include? 1- "It may take your eyes longer to adjust in a darkened room." 2- "Most visual changes occur before age 40." 3- "When the sclera starts to turn yellow, this means you might have problems with your liver." 4- "You probably will have to move reading materials closer to your eyes."

3 With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments. Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia also commonly begins in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? 1- Ensure that weights are attached to the bed frame or placed on the floor. 2- Ensure that pins are not loose, and tighten as needed. 3- Inspect the skin at least every 8 hours. 4- Remove the traction weights only for bathing.

3 he client's skin should be inspected every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights are not allowed to be placed on the floor; weights should hang freely at all times. Pin sites should be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Weights must never be removed without a request from the health care provider.

The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? (SATA) 1- Cab driver 2- College student 3- Lifeguard 4- Racquetball player 5- Registered nurse

3,4 Lifeguards are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play racquetball need to wear protective eyewear to prevent possible eye injury. Cab drivers may require eyewear for corrective purposes, but are not at high risk and in need of protective eyewear. College students are generally not at high risk. Although an RN would need eye protection at times, RNs do not routinely require protective eyewear for general work.

The nurse is assessing a client with osteomalacia. Which findings does the nurse expect to observe? (SATA) 1- Hyperparathyroidism 2- Hyperuricemia 3- Hypophosphatemia 4- Looser's lines or zones 5- Unsteady gait

3,4,5 Osteomalacia is loss of bone related to vitamin D deficiency, which can lead to bone softening and inadequate deposits of calcium and phosphorus in the bone matrix; this may cause hypophosphatemia. Looser's lines or zones (radiolucent bands) represent stress fractures and are a classic diagnostic finding of osteomalacia. Muscle weakness in the lower extremities may cause waddling and an unsteady gait. Hyperparathyroidism and hyperuricemia may be observed in Paget's disease.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? (SATA) 1- Acetaminophen (Tylenol) 2- Beta blockers 3- Erythromycin 4- Ibuprofen (Advil) 5- Insulin 6- Furosemide (Lasix)

3,4,6 Erythromycin, ibuprofen, and furosemide (Lasix) are medications known to increase the risk for ototoxicity and hearing problems. Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? 1- "Simple fracture involves a break in the bone, with skin contusions." 2- "Compound fracture does not extend through the skin." 3- "Simple fracture is accompanied by damage to the blood vessels." 4- "Compound fracture involves a break in the bone, with damage to the skin."

4 A compound fracture involves a break in the bone with damage to the skin. A simple fracture does not extend through the skin. A compound fracture is accompanied by damage to blood vessels.

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? 1- "My spouse will be the only person to change my dressing." 2- "I can't believe that this has happened to me. I can't stand to look at it." 3- "I do not want any visitors while I'm in the hospital." 4- "It will take me some time to get used to this."

4 Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping. Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

The ambulatory surgery postanesthesia care unit (PACU) nurse has just received report about clients who had arthroscopic surgery. Which client will the nurse plan to assess first? 1- Young adult client who has been in the PACU for 30 minutes after left knee arthroscopy under local anesthesia 2- Adult client who had a synovial biopsy of the right knee under local anesthesia and has been in the PACU for 20 minutes 3- Adult client who has multiple right knee incisions for repair of torn cartilage and arrived in the PACU an hour ago 4- Middle-aged adult client who returned to the PACU 25 minutes ago after left knee arthroscopic surgery under epidural anesthesia

4 After epidural anesthesia, frequent assessments for the return of sensation and movement of the leg will be important. The client who had knee arthroscopic surgery under epidural anesthesia is at greatest risk for complications and should be assessed first. The clients who had local anesthesia for knee arthroscopy, the client who had a synovial biopsy of the right knee, and the client who had multiple right knee incisions are all at less risk for developing complications.

The charge nurse in the hospital-based day surgery center is making client assignments for the staff. Which client is most appropriate to assign to a nurse who has floated from the general surgical unit? 1- Young adult who has just been admitted for surgery after sustaining an ankle fracture 2- Adult who needs teaching about quadriceps-setting exercises after knee arthroscopy 3- Middle-aged adult who will require a pneumatic tourniquet applied before knee surgery 4- Older adult who has undergone arthroscopic surgery of the shoulder under local anesthesia

4 Arthroscopic surgery and local anesthesia have low complication rates and could be monitored by the float nurse, who would be expected to know how to assess neurovascular status. The young, newly admitted client requires assessment that will be best performed by nurses with more experience in day surgery. Client teaching for the adult client who has had arthroscopic knee surgery is best completed by nurses with more experience in day surgery. The middle-aged adult who needs a pneumatic tourniquet requires an intervention that is best performed by nurses with more experience in day surgery.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? "You are right. Work on your diet then." "You must find someplace to walk." "Walk around the edge of your apartment complex." "Where might you be able to walk?"

4 Asking the client where he or she might be able to walk calls for cooperation and participation from the client; increased activity is imperative for this client. Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.

The nurse prepares to perform a neurovascular assessment on a client with closed multiple fractures of the right humerus. Which technique does the nurse use? 1- Inspect the abdomen for tenderness and bowel sounds. 2- Auscultate lung sounds. 3- Assess the level of consciousness and ability to follow commands. 4- Assess sensation of the right upper extremity.

4 Assessing sensation of the right upper extremity is part of a focused neurovascular assessment for the client with multiple fractures of the right humerus. Inspecting the abdomen and auscultating lung sounds of the client with multiple fractures are not part of a focused neurovascular assessment. Because the client does not have a head injury, assessing the client's level of consciousness and ability to follow commands is not part of a focused neurovascular assessment.

An older adult client expresses concern about the ability to instill over-the-counter eyedrops, saying, "My vision is getting so bad, I can't even see my own eyes." What is the nurse's best response? 1- "Don't worry about the eyedrops." 2- "Getting old isn't fun, is it?" 3- "Can your daughter help you do it?" 4- "Let's find a way that will work for you."

4 Assessing the client's ability to self-perform and adjusting the steps of eyedrop instillation to accommodate the client's change in vision promote independence. Telling the client not to worry about the eyedrops falsely reassures the client and blocks communication. Diverting the client's concern over the inability to instill eyedrops with a comment about getting old blocks communication. Suggesting that the client's daughter help does not promote client independence.

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? 1- Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase 2- Homocysteine and C-reactive protein 3- Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol 4- CK-MB and troponin

4 CK-MB and troponin are the cardiac markers used to determine whether MI has occurred. Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

Which vascular assessment by the student nurse requires intervention by the supervising nurse? 1- Measuring capillary refill in the fingertips 2- Assessing pedal pulses by Doppler 3- Measuring blood pressure in both arms 4- Simultaneously palpating the bilateral carotids

4 Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion. Prolonged capillary filling generally indicates poor circulation; this is an appropriate assessment. Many clients with vascular disease have poor blood flow, and pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.

The nurse plans to refer a client diagnosed with osteoporosis to which community resource? 1- American Bone Society 2- CanSurmount 3- I Can Cope 4- National Osteoporosis Foundation

4 Clients with musculoskeletal problems should be referred to appropriate community resources, such as the National Osteoporosis Foundation, for help and support for their diagnosis. There is no organization known as the American Bone Society. CanSurmount is a cancer support group geared toward client and family education. I Can Cope is also a support group for clients with cancer.

Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? 1- Snellen eye examination result is 20/50 for a client who normally wears corrective lenses, but does not have them at the time of the examination. 2- When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. 3- The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. 4- When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.

4 Cloudiness in the cornea and pain from a light shined into the pupil is an abnormal finding that requires further assessment and possible intervention/referral. A Snellen eye examination result of 20/50 for the client who normally wears corrective lenses but does not have them at the time of the examination is normal given the client's baseline and considering that he or she wears corrective lenses. It can be a normal finding for the client to exhibit nystagmus when looking to the left lower and upper fields during assessment of the six cardinal positions of gaze of the left eye. It is normal for the pupil to exhibit miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? 1- Give the digoxin; reassess the heart rate in 30 minutes. 2- Give the digoxin; document assessment findings in the medical record. 3- Hold the digoxin, and obtain a prescription for an additional dose of furosemide. 4- Hold the digoxin, and obtain a prescription for a potassium supplement.

4 Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? 1- "This is a noninvasive test performed to assess your heart rhythm." 2- "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." 3- "This is a painless test that is done to assess the structure of your heart using sound waves." 4- "This test evaluates you for potentially fatal cardiac rhythms."

4 EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? 1- Anisocoria 2- Presbyopia 3- Diabetic retinopathy 4- Glaucoma

4 Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year. Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population; this condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects; increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? 1- Burning in the eye 2- Inability to differentiate colors 3- Increased sensitivity to light 4- Gradual vision changes

4 Gradual vision changes are an indication of increased intraocular pressure. A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? 1- "I may have problems with vertigo after the surgery." 2- "I should not drink from a straw for several weeks." 3- "I will have to take antibiotics after the surgery." 4- "I will be able to hear as soon as my dressing is removed."

4 Hearing is initially worse after a stapedectomy. The client should be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing. Swelling in the ear after surgery reduces hearing, but this condition is temporary. Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. Clients should not drink through a straw for 2 to 3 weeks after surgery. Antibiotics are used to reduce the risk for infection.

A nursing student is studying the skeletal system. Which statement indicates to the nursing instructor that the student understands a normal physiologic function of the skeletal system? 1- "Volkmann's canals connect osteoblasts and osteoclasts." 2- "In the deepest layer of the periosteum is the cortex, which consists of dense, compact bone tissue." 3- "The matrix of the bone is where deposits of calcium and magnesium are present." 4- "Hematopoiesis occurs in the red marrow, which is where blood cells are produced."

4 Hematopoiesis is the production of blood cells in the red marrow and is the correct statement. Volkmann's canals connect bone marrow vessels with the haversian system. In the deepest layer of the periosteum are osteogenic cells that differentiate into osteoblasts and osteoclasts. The cortex is the outer layer of the bone that consists of dense, compact bone tissue. Deposits of inorganic calcium salts (carbonate and phosphate) in the matrix of the bone are what provide the hardness of bone.

What is the proper technique for assessing an adult client's ear with an otoscope? 1- Hold the otoscope right side up when inserting it into the ear canal. 2- Maintain distance between the otoscope and the client's head. 3- Place the otoscope in the nondominant hand. 4- Pull the pinna up and back with the nondominant hand

4 In the adult, pulling the pinna up and back allows the ear canal to straighten. The otoscope should be held upside down, like a large pen. The distance between the otoscope and the client's head is very short. The otoscope should be held in the dominant hand.

A client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? 1- On the affected side 2- Supine, with eyes toward the ceiling 3- With the head elevated 60 degrees 4- With the affected ear facing up

4 Keep the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery. Raising the head places undue pressure on the surgical site.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? 1- Psychiatric disturbance 2- High sodium intake 3- Physical inactivity 4- Kidney disease

4 Kidney disease is one of the most common causes of secondary hypertension. Psychiatric disturbance can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

The nurse is conducting a musculoskeletal history in an older adult client who requires a caregiver to perform all activities of daily living (ADLs). Which level of functioning does the nurse record in the client's history using Gordon's Functional Health Patterns? 1- Level 0 2- Level II 3- Level III 4- Level IV

4 Level IV indicates that the client is dependent and does not participate in ADLs such as dressing him- or herself. Level 0 indicates a client who is able to perform full self-care. Level II indicates a client who requires assistance or supervision of another person without assistive equipment or devices. Level III indicates that the client requires the assistance or supervision of another person, as well as assistive equipment or devices.

The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? 1- "Background noises will be difficult for me to hear." 2- "I should wear my hearing aid only to work at first." 3- "I should just get a smaller hearing aid because I don't have much money." 4- "Listening to the radio and television will help me get used to new sounds."

4 Listening to television and the radio and reading aloud can help the client get used to new sounds. With hearing aids, background noises are amplified so the client must learn to concentrate and filter out background noises. + The client should start using the hearing aid slowly, at first wearing it only at home and only during part of the day. The cost of smaller hearing aids is actually greater than for larger ones.

The nurse is reviewing the medication history for a client scheduled for a left total hip replacement. The nurse plans to contact the health care provider if the client is taking which medication? 1- Acetaminophen (Tylenol) for pain relief 2- Bupropion (Wellbutrin) for smoking cessation 3- Magnesium hydroxide (Milk of Magnesia) to treat heartburn 4- Prednisone (Deltasone) to treat asthma

4 Long-term steroid use is strongly associated with osteoporosis and will increase the risk for poor wound healing and prolonged recovery after the hip replacement. Taking acetaminophen for pain relief, bupropion for smoking cessation, or magnesium hydroxide to treat heartburn will not influence the potential success of the surgery.

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? 1- Peptic ulcer disease 2- Deep vein thrombosis (DVT) 3- Osteoarthritis 4- Marfan syndrome

4 Marfan syndrome is a risk factor for cardiovascular disorders. Peptic ulcer disease is not a risk factor for AAA formation. AAA is an arterial problem; thus, DVT is not a related risk. Osteoarthritis is related to overuse of joints; it does not present a risk for AAA.

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? 1- "I may need to use a cane." 2- "I should keep my grandkids' toys out of the hallway." 3- "Moving more slowly may help the vertigo subside." 4- "Taking my medication will allow me to drive my car again."

4 Medications for vertigo may cause drowsiness, so the client should not drive or operate machinery while taking these drugs. The client with vertigo may need to use a cane for balance. Clients should maintain a safe, uncluttered environment to prevent accidents during periods of vertigo. Restricting head motion and moving more slowly may help clients reduce occurrences of vertigo.

An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? 1- Cyclobenzaprine (Flexeril) 2- Ibuprofen (Advil) 3- Meperidine (Demerol) 4- Patient-controlled analgesia (PCA) with morphine

4 Morphine is an opioid narcotic analgesic; given through PCA, it is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries. Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory drug that is used to treat mild to moderate pain; bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? 1- Saline infusion 2- Morphine sulfate 3- No treatment, continue monitoring 4- Intravenous furosemide

4 Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure.

The nurse is talking to a client about ear hygiene safety. Which statement by the client indicates a need for further teaching? 1- "After I shower, I dry my ears using my fingertip and a towel." 2- "I irrigate my ears with tap water." 3- "I never clean my ears with a cotton swab." 4- "I use a bobby pin to remove earwax."

4 Nothing smaller than the client's own fingertip should be inserted into the ear canal. Use of a bobby pin or cotton swab can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum. Using the fingertip and a towel and irrigating the ear canal with tap water are acceptable.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? 1- Auscultate the client's precordium for murmurs. 2- Teach the client about the reason for the TEE. 3- Reassure the client that the test is painless. 4- Validate that the client has remained NPO.

4 Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? 1- "I will be awake during this procedure." 2- "I will have a balloon in my artery to widen it." 3- "I must lie still after the procedure." 4- "My angina will be gone for good."

4 Reocclusion is possible after PTCA. The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? 1- Chest pain brought on by exertion or stress 2- Substernal chest discomfort occurring at rest 3- Substernal chest discomfort relieved by nitroglycerin or rest 4- Substernal chest pressure relieved only by opioids

4 Substernal chest pressure relieved only by opioids is typically indicative of MI . Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? 1- Pulse 60 beats/min and regular 2- Urinary frequency 3- Incisional discomfort 4- Respiratory rate 28 breaths/min

4 Tachypnea and tachycardia reflect activity intolerance; activity should be terminated. Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Pain with activity after surgery is anticipated; pain medication should be available.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? 1- A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness 2- A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) 3- A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness 4- A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

4 The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery. The 64-year-old is most stable and can be seen last. The 60-year-old and the 69-year-old should both be seen soon, but the 70-year-old client must be seen first.

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? 1- Provide further assessment. 2- Suggest a quiet environment. 3- Suggest temporary removal of a hearing aid. 4- Refer the client to the American Tinnitus Association.

4 The American Tinnitus Association assists clients in coping with tinnitus when other therapy is unsuccessful. Reassessment of the client's diagnosis is not needed; this will only waste the client's and the nurse's time. Background noise masks the tinnitus while quiet conditions exacerbate it; ear-mold hearing aids can amplify sounds to drown out tinnitus during the day.

An older adult client with a new diagnosis of hearing loss is deeply concerned about not being able to hear at the neighborhood council meetings. Which nursing intervention best addresses the client's concern? 1- Suggest that the client discuss with the chairperson about asking everyone speaking at the meeting to speak louder. 2- Refer the client to the Center for the Visually Impaired for support. 3- Arrange for a sign language specialist to attend the meetings to teach everyone how to communicate with the hearing-impaired member. 4- Refer the client to the Hearing Loss Association of America.

4 The Hearing Loss Association of America can inform the client about support groups in the area, along with interventions to help improve hearing. Speaking louder raises the frequency of the sound, making it more difficult to hear. The Center for the Visually Impaired is useful for people with vision problems, not hearing problems. The client and members of the neighborhood council must first express an interest in learning sign language before arrangements are made with a sign language specialist.

A client says, "I have problems reading the signs when I am driving." Which test does the nurse use to assess this client's problem? 1- Confrontation test 2- Ishihara chart 3- Rosenbaum Pocket Vision Screener or a Jaeger card 4- Snellen chart

4 The Snellen chart assesses the client's distance vision, which is the type of vision used while driving. The confrontation test assesses the client's visual field. The Ishihara chart assesses the client's color vision. The Rosenbaum Pocket Vision Screener or Jaeger card assess the client's near vision.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? 1- The client has diuresis of 400 mL in 24 hours. 2- The client's blood pressure is 122/84 mm Hg. 3- The client has an apical pulse of 82 beats/min. 4- The client's weight decreases by 2.5 kg.

4 The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

A client is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the client before the test? 1- "It will be important to lie still in a reclined position for 20 minutes." 2- "Do not eat or drink for 8 hours before the test." 3- "You can have the MRI if you have an internal pacemaker." 4- "All jewelry and clothing with zippers or metal fasteners must be removed."

4 The client must remove all metal objects on clothing and all jewelry before undergoing MRI. The client having a closed MRI will lie still in a supine position for 45 to 60 minutes, not 20 minutes, and may require sedation. It is not necessary for the client to be NPO before an MRI. The client cannot undergo MRI when an internal pacemaker or any other metal object is present in the body.

A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? 1- Bleeding 2- Head injury 3- Pain 4- Respiratory distress

4 The client should first be assessed for respiratory distress, and any oxygen interventions instituted accordingly. Bleeding is the second assessment priority, head injury is the third assessment priority, and pain is the fourth assessment priority in this case.

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? 1- "One eye is green and the other eye is blue." 2- "My eyes are red and itchy." 3- "My vision has been getting worse gradually." 4- "Something hit my eye while I was cutting grass."

4 The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist. Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color; this is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects, but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes, but does not require immediate care by an ophthalmologist.

All of these client assignments have been made by the charge nurse. Which assignment is questionable? 1- The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy 2- The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement 3- The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL 4- The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg

4 The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. The client should be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications. (A better assignment would be to assign the client with a headache to an RN and the client with PAD to the LPN/LVN.) The RN with 3 years of experience has sufficient experience to provide care for a client with PE. The LPN/LVN can provide care for the client with leg ulcers, including dressing changes, if needed. The RN with 8 years of experience has sufficient knowledge to provide care for the client with PAD.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? 1- Small amount of blood at the IV insertion site 2- Heavy menstrual bleeding 3- +1 pitting edema of the affected extremity 4- Client stating that the year is 1967

4 The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness. Thrombolytics such as t-PA dissolve clots; even without this medication, a small amount of blood at the insertion site is not abnormal. Anticoagulants and thrombolytics may cause heavier-than-usual menstrual bleeding. Swelling is expected in the extremity with deep vein thrombosis.

When preparing to examine an ear with drainage, what does the nurse do first? 1- Begins testing at 1000 Hz 2- Reassures the client that the ear drainage is normal 3- Tilts the client's head away slightly 4- Dons clean gloves

4 The nurse should always use Contact Precautions, which include wearing clean gloves, with any client who has drainage from the ear canal to prevent infection. Testing for hearing loss (1000 Hz) is not used when examining an ear for drainage. Ear drainage is not normal and must be investigated. Tilting the client's head is not the first action among the options given that the nurse should do.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? 1- C-reactive protein of 1 mg/dL 2- Homocysteine level of 13 mmol/L 3- Creatine kinase (CK) of 125 mg/dL 4- Troponin of 5.2 ng/mL

4 The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? 1- Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. 2- Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. 3- Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. 4- Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

4 Vital sign assessment is a skill that is within the role of the UAP. Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? 1- Assess preprocedure medications the client took that day. 2- Have the client sign the consent form before the procedure is performed. 3- Educate the client about the need to remain on bedrest after the procedure. 4- Obtain client vital signs and a resting electrocardiogram (ECG).

4 Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.

Which is the best way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? 1- Increase nutritional intake of calcium. 2- Engage in high-impact exercise, such as running. 3- Increase nutritional intake of phosphorus. 4- Walk for 30 minutes three times a week.

4 Walking for 30 minutes three to five times a week is the single most effective exercise for osteoporosis prevention. Walking is a safe way to promote weight bearing and muscle strength. A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis. High-impact exercise and overtraining, such as running, may cause vertebral compression fractures and should be avoided. Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day (over 40 ounces) are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender.

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? 1- "I must stop taking my birth control pills." 2- "I should drink lots of water so I don't get dehydrated." 3- "I should exercise my legs when I have been sitting or standing for a long time." 4- "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

4 Wearing the graduated compression stockings is a prevention specific to the hospital setting; they are designed to prevent blood clots, unlike regular pantyhose. Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? 1- Dry, flaky cerumen 2- Pain on movement of the tragus 3- Ringing in the ears 4- Vertigo

4 With otitis media, as pressure on the middle ear pushes against the inner ear, the client may develop dizziness or vertigo. Dry, flaky cerumen is normal with aging. Pain on movement of the tragus is indicative of external otitis. Ringing in the ears is more likely with Ménière's disease.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? 1- Men do not tend to report chest pain. 2- Men are more likely than women to die after MI. 3- Men more than women tend to deny the importance of symptoms. 4- Women may experience extreme fatigue and dizziness as sole symptoms.

4 Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.

A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? 1- Gesturing 2- Sign language 3- Speaking 4- Writing

4 Writing is the most effective way to communicate with the client who has undergone a stapedectomy. Gesturing can be vague and imprecise. Sign language requires training. It is hoped that the client will not be hearing-impaired long enough for this to be a viable option. The client will not be able to hear for the first 6 weeks after surgery.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (SATA) 1- Hypertension 2- Tachycardia 3- Bounding right pedal pulses 4- Cold right foot 5- Numbness and tingling of right foot 6- Mottling of right foot and lower leg

4,5,6 Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. A- 2, 4, 3, 1 B- 3, 4, 1, 2 C- 1, 4, 3, 2 D- 4, 1, 2, 3

B First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.

What is the action of miotics in the client with glaucoma? 1- Decrease the inflammatory process 2- Enhance aqueous outflow 3- Increase the production of vitreous humor 4- Vasoconstrict the blood vessels in the eye

Miotics are used to improve the flow of fluid (aqueous humor) and decrease intraocular pressure in clients with glaucoma. Steroid drops, not miotics, decrease the inflammatory process. Vitreous humor fills the space between the lens and the retina, is stagnant, and is not replenished as the aqueous humor is. Miotics make the pupil smaller, which creates more room between the iris and the lens.