Adult Health Final Exam Questions

118. Drug calculations: A client is prescribed 0.25 mg digoxin po daily. Digoxin is available at 0.5 mg per mL. How many mL does the nurse administer to the client?

0.5 mL

117. Drug calculations: A client has a prescription for IV fluids. Administer D5 0.9 NS 1000 mL over 8 hours. The drop factor on the infusion set is 60 drops/mL. Which is the correct drip rate calculated by the nurse?

125 drops/minute

41. Musculoskeletal: A nurse is caring for a client who had a BKA for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the absent right foot. Which of the following statements should the nurse make? A) "This type of pain usually decreases over time as the limb becomes less sensitive." B) "Try to look at the surgical wound as a reminder the limb is gone." C) "Use a cold compress intermittently to decrease these pain sensations." D) "Grief over the lost limb can sometimes cause denial that the limb is really gone."

A) "This type of pain usually decreases over time as the limb becomes less sensitive." Rationale: The nurse should recognize that the client has phantom limb pain. The sensation should decrease over time. The nurse should recognize the pain, provide treatment and handle the limb gently.

18. Musculoskeletal: The nurse provides education about using crutches to a client diagnosed with a fractured left ankle. The client has a short leg cast. Which are appropriate instructions for using crutches? A) 3-point gait requires you to place weight on your good foot B) Crutches are never used on stairs. You'll always have to take elevators C) You will be using the swing-through gait with weight-supporting braces. D) Make sure you lean on your armpits when using ancillary crutches

A) 3-point gait requires you to place weight on your good foot Rationale: Weight is placed on unaffected leg and crutches

90. Cardiovascular: The nurse provides care for a client diagnosed with a MI. The client's adult child asks the nurse, "What is a realistic goal for my cardiovascular health?" Which is the best response by the nurse? A) A total blood cholesterol level of less than 200 mg/dL B) A body mass index between 25 and 30 C) A waist circumference of 41 D) A blood pressure of 90 mmHg diastolic

A) A total blood cholesterol level of less than 200 mg/dL Rationale: Total blood cholesterol of less than 200 is the acceptable level.

77. Medications: A client diagnosed with type 2 diabetes asks the nurse, "Are the pills I am taking to control my blood sugar a form of insulin?" Which statement best describes the action of oral hypoglycemic agents? A) Act to stimulate beta cells in the pancreas to release endogenous insulin B) Supply exogenous insulin, which enhances the transfer of glucose into the cells C) Increase the release of insulin in the liver, which restores efficient glucose and fat utilization D) Stimulate adipose tissue to release endogenous insulin

A) Act to stimulate beta cells in the pancreas to release endogenous insulin Rationale: Some oral hypoglycemic agents act by stimulating beta cells in the pancreas to release endogenous insulin.

114. Blood transfusions: A nurse is caring for a client who has an upper GI bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells, which of the following actions should the nurse take? (Select all that apply) A) Asses and document vital signs B) Restart the IV with a 22-gauge needle C) Verify with another nurse the blood type and Rh of the packed RBCs D) Hang a bag of LR IV solution E) Change IV tubing to a set that has a filter

A) Asses and document vital signs C) Verify with another nurse the blood type and Rh of the packed RBCs E) Change IV tubing to a set that has a filter

69. Infectious Disease: A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include? (Select all that apply) A) Avoid large gatherings of people B) Clean toothbrush by running through the dishwasher C) Change pet litter boxes with disposable gloves D) Consume fresh fruit and raw vegetables E) Avoid digging in the garden

A) Avoid large gatherings of people B) Clean toothbrush by running through the dishwasher E) Avoid digging in the garden Rationale: The nurse should instruct the client to avoid large crowds or gatherings of people. The client should clean the toothbrush by running it through the dishwasher. The client should avoid digging in the garden because of exposure to the dirt which contains bacteria and organisms.

66. Infectious Disease: A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care?

A) Avoid salty foods Rationale: Stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations. Foods that are spicy, acidic or salty should be avoided to prevent further irritation and damage to the oral mucosa.

97. Cardiovascular: The nurse expects which laboratory test results to be elevated for a client following an acute myocardial infarction? A) CK, Troponin, Myoglobin B) BUN, Creatinine, Protein-bound iodine C) AST, RBC, Platelets D) LDH, thyroxin, endorphin

A) CK, Troponin, Myoglobin Rationale: These are the cardiac enzymes that increase after an MI.

38. Musculoskeletal: A nurse is assessing a client who is 24 hours postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? A) Client report of muscle spasms B) Inability to get dressed without assistance C) Client report of feelings of anger D) Refusal to look at the affected limb

A) Client report of muscle spasms Rationale: Maslow's hierarchy of needs, physiological need

50. Infectious Disease: The nurse provides care for a client diagnosed with AIDS. The client is reporting diarrhea. It is most important for the nurse to include which intervention in the client's plan of care? A) Decrease roughage in the diet B) Eat three meals per day C) Increase intake of milk and cheese D) Decrease intake of fluids

A) Decrease roughage in the diet Rationale: The client should avoid foods that stimulate intestinal motility, such as vegetables and fruits, fatty, spicy and sweet foods, alcohol and caffeine.

24. Musculoskeletal: The nurse evaluates care given to a client after a left BKA. The nurse intervenes if which observation is made? A) Dressing to the surgical site is dated two days prior B) A surgical tourniquet is readily available to client and staff C) Nurse uses a transfer belt to transfer client from bed to chair D) Client sits in a chair frequently for short periods of time

A) Dressing to the surgical site is dated two days prior Rationale: Dressing change should occur at least every 24 hours.

88. Cardiovascular: The nurse caring for Mr. Smith knows that adequate glucose control is essential for CAD management because: A) Hyperglycemia is a modifiable risk factor for CAD B) Uncontrolled hyperglycemia can lead to ketoacidosis C) Hyperglycemia stimulates insulin resistance D) Hyperglycemia increases susceptibility to infection

A) Hyperglycemia is a modifiable risk factor for CAD

95. Cardiovascular: A client experiences anginal chest pain on and off for 3 days before admission. The nurse completes discharge medication, activity, and follow-up teaching. Which client statement indicates the client requires further teaching about angina-related activity instructions? A) I should not engage in sexual activity for 6 weeks B) I can return to my usual activities, but should not rest if the pain comes back C) I should not use nitroglycerin as a substitute for rest if I have chest pain D) I should take a nitroglycerin tablet before activities that usually give me chest pain

A) I should not engage in sexual activity for 6 weeks Rationale: The client may resume sexual activity in 1 weeks or less, if feeling well.

30. Musculoskeletal: A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicated that the client understands the teaching? A) I'll call the doctor's office if my fingers get colder on the arm with the cast B) If I have any itching under the cast, I'll try to reach the area with a cotton swab C) If my fingers swell, I should put a heating pad on them and rest D) If I have any tingling under my cast, I'll know I need to move my fingers more

A) I'll call the doctor's office if my fingers get colder on the arm with the cast Rationale: Temperature variances are an unexpected finding which require HCP notification.

35. Musculoskeletal: A nurse is providing teaching for a client following a BKA. Which of the following pieces of information should the nurse include in the teaching? A) Instruct the client to lie prone while in bed B) Ensure the client sleeps on a soft mattress C) Pull up the residual limb while in bed D) Keep the residual limb exposed to air to heal

A) Instruct the client to lie prone while in bed Rationale: The nurse should instruct the client to lie in a prone position for 20-30 minutes every 3 to 4 hours. This prevents the client from developing contractures while in bed.

100. Cardiovascular: The nurse understands that the pain of angina is caused by which mechanism? A) Insufficient oxygen to the heart muscles B) Inflammation of the pericardium C) Ineffective contractions of the heart muscle D) Severe cardiac arrhythmias

A) Insufficient oxygen to the heart muscles Rationale: Angina is caused by myocardial ischemia.

61. Infectious Disease: A client has just been diagnosed with HIV virus. The nurse provides information on the transmission of the virus. Which client statement indicates the best understanding of the information provided by the nurse? A) It is OK for someone to share food with me B) I am really contagious only for the next 6 months C) It is possible that an insect that bites me can transmit the virus to someone else D) When I am not having an outbreak , I don't have to worry about giving the virus to anyone.

A) It is OK for someone to share food with me

47. Musculoskeletal: A nurse caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement? (Select all that apply) A) Monitor the client's vital signs q4hr. B) Monitor the client's pin sites for loosening. C) Hold the halo device when turning the client. D) Check the clients skin to ensure the jacket is not applying pressure. E) Adjust the screws holding the client's halo device in place to ensure a proper fit.

A) Monitor the client's vital signs q4hr. B) Monitor the client's pin sites for loosening. D) Check the clients skin to ensure the jacket is not applying pressure. Rationale: VS and neurological status should be monitored q4hr. Check pin sites for loosening... risk integrity of the cervical or thoracic traction. Check skin for redness to ensure vest is not rubbing against the skin... risk for pressure ulcer and skin breakdown.

44. Musculoskeletal: A nurse is preparing to care for a client who is balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? A) Offering the client a diet high in fluid and fiber B) Encourage active range of motion of the affected leg C) Removing the weights prior to repositioning the client D)Inspecting pin sites every 24 hr for drainage

A) Offering the client a diet high in fluid and fiber Rationale: A client who is immobilized is at risk for constipation, administering a diet high in fluid and fiber will promote GI function.

87. Cardiovascular: While educating a patient about AF, the nurse informs the patient that which of the following can be symptoms of AF? (Select all that apply) A) Shortness of breath B) Hypotension C) Weight loss D) Dizziness E) Sweating

A) Shortness of breath B) Hypotension D) Dizziness E) Sweating Rationale: Shortness of breath, diaphoresis, hypotension, and dizziness are all signs of decreased cardiac output associated with AF.

23. Musculoskeletal: The nurse instructs a client diagnosed with a fractured and casted left ankle how to use crutches. Which action by the client indicates the client understands the correct technique for using crutches? A) The client moves the crutches and the left leg forward while standing on the right leg. Then, the client moves the right leg forward while balancing on the crutches. Rationale: This is the correct technique for 3-point gait. B) The client moves the left crutch and the left foot forward while balancing on the right leg. Then, the client moves the right crutch and right foot forward while balancing on the left leg. C) The client moves the right crutch and left foot, then the left crutch and the right foot D) The client bears partial weight on the left foot and moves the crutches forward. Then, the client moves the left foot forward while balancing on the crutches.

A) The client moves the crutches and the left leg forward while standing on the right leg. Then, the client moves the right leg forward while balancing on the crutches. Rationale: This is the correct technique for 3-point gait.

20. Musculoskeletal: The nurse provides care for a client diagnosed with a fractured left tibia. The nurse teaches the client how to ambulate on crutches using a 3-point gait. Which observation indicated to the nurse the client will be able to safely manage crutches? A) The client stands on the right leg and sways from side to side on the crutches before ambulating B) The client tolerates partial weight bearing on the left leg C) The client supports full body weight on the axilla while using crutches D) The client advances both crutches and the left leg, then brings the right leg to the crutches

A) The client stands on the right leg and sways from side to side on the crutches before ambulating Rationale: This shows that the client can balance on one leg, if the client can not sway while balancing on one leg will have difficulty safely managing crutches

19. Musculoskeletal: The nurse teaches a client to use a 3-point gait that does not permit weight bearing on the affected right extremity. Which pattern best represents this type of crutch walking? A) The crutches and the affected leg are advanced simultaneously followed by the left foot Rationale: Both crutches and affected leg move in unison then unaffected leg B) The right crutch and the right foot are advanced, followed by the left crutch, and then the left foot C) Both crutches are advanced simultaneously, followed by the left foot, and then the right foot D) The right crutch is advanced, then the left crutch, followed by both extremities simultaneously

A) The crutches and the affected leg are advanced simultaneously followed by the left foot Rationale: Both crutches and affected leg move in unison then unaffected leg

86. Cardiovascular: The nurse cares for the client diagnosed with myocardial infarction (MI). Which is the correct rationale for the nurse administering a stool softener to the client? A) To avoid straining, which may exacerbate the cardiac condition B) As a substitute for coffee to facilitate evacuation C) To avoid constipation, which is an added annoyance D) Allows the nurses to more accurately keep track of output

A) To avoid straining, which may exacerbate the cardiac condition

46. Musculoskeletal: A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider? A) Toes that are cold to the touch B) Serous drainage from the pin sites C) Blanching of the toenail beds with pressure D) Pink tissue around the fixator insertion sites

A) Toes that are cold to the touch Rationale: Nurse should monitor and report S/S of compartment syndrome.

39. Musculoskeletal: A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? A) Use a hair dryer on cool B) Ask provider to bivalve the cast C) Provide the client with a sterile cotton swab to rub the affected skin D)Wrap the extremity with a dry heating pad

A) Use a hair dryer on cool Rationale: treatment for itching inside of the cast

65. Infectious Disease: A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A) Wash your genitalia using an antimicrobial soap B) Rinse your dishes with cold water C) Clean your toothbrush once per months D) Incorporate raw fruits and vegetables into your diet

A) Wash your genitalia using an antimicrobial soap Rationale: should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection

64. Infectious Disease: A nurse is teaching a client who has HIV about the early manifestations of AIDS. Which of the following statements should the nurse include in the teaching? A) You can expect a persistent fever and swollen glands B) You can expect an elevated WBC C) You can expect increased BP and edema D) You can expect weight gain

A) You can expect a persistent fever and swollen glands Rationale: S/S of AIDS include persistent fever, swollen glands, diarrhea, weight loss, fatigue

67. Infectious Disease: A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? A) You can suck on popsicles to numb your mouth B) Season food with spices instead of salt C) Avoid the use of a straw to drink liquids D) Eat foods at hot temperatures

A) You can suck on popsicles to numb your mouth Rationale: The nurse should instruct the client to suck on popsicles or ice chips, which can numb the mouth.

76. Medications: The nurse instructs a client about insulin self-administration. It is most important for the nurse to make which statement? A) You should rotate the injection sites B) Wipe the needle prior to the injection C) Insert the needle at a 90 degree angle D) Cool the insulin prior to injecting it

A) You should rotate the injection sites Rationale: The site of the injection must be rotated in order to promote proper absorption. Lipodystrophy can occur with repeated injections at the same site and can use poor absorption of the insulin.

45. Musculoskeletal: A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply) A) You'll have considerably less pain with traction in place B) You'll have the traction in place for a week or so C) The traction will help decreased muscle spasms D) The weights act as pulling force to keep your leg and hip still E) We have to make sure the weights are just barely touching the floor

A) You'll have considerably less pain with traction in place C) The traction will help decreased muscle spasms D) The weights act as pulling force to keep your leg and hip still Rationale: Goals of traction stated. Weight helps to stabilize the hip and leg.

4. Musculoskeletal: The nurse teaches a client about proper body mechanics. Which client statement indicates to the nurse that the teaching has been successful? A) "It is normal to experience joint degeneration after age 40, and lower back pain will probably happen even if I lift heavy objects the right way." B) "In the future, I will lift heavy objects by bending at the knees and keeping my back straight." C) "I will need to complete several weeks of physical therapy before my back will feel better" D) "I should rest in bed for the next 5 to 7 days before going back to work."

B) "In the future, I will lift heavy objects by bending at the knees and keeping my back straight." Rationale: Principles of good body mechanics include wide base of support, low center of gravity, bending at the knees, using stronger muscle groups, holding lifted item close to body, facing the direction, push rather than pull, alternating between rest and activity

81. Medications: The home care nurse cares for a client diagnosed with type 1 diabetes. The client receives therapy in a four-dose protocol. The client injects rapid-acting insulin subq at 1145. The nurse knows the peak of action of rapid-acting insulin occurs at which time? A) 1200 B) 1245 to 1345 C) 1445 to 1545 D) 1745 to 1945

B) 1245 to 1345 Rationale: Peak action is 60 minutes after administration; dose is based on anticipated intake of carbohydrates.

6. Musculoskeletal: A client diagnosed with type 1 diabetes is scheduled for a right below-the-knee-amputation (BKA) due to a gangrenous toe. The client asks the nurse why the amputation is so extensive. The nurse's response is based on which understanding? A) A BKA ensures enough skin to form a flap over the residual limb. B) A BKA results in better circulation and healing. C) A BKA amputation facilitates earliest prosthesis training. D) A BKA significantly reduces edema of the residual limb.

B) A BKA results in better circulation and healing. Rationale: Level of an amputation is based on the adequacy of circulation. Leaving tissues that are poorly supplied with blood would cause poor healing and could lead to the development of additional gangrene.

26. Musculoskeletal: The nurse provides care for a client in Buck traction. Which is the most important nursing action to maintain effective traction? A) Encourage the client to limit body movements B) Allow weights to hang freely at all times C) Remove weights immediately when client reports discomfort D) Give pain medication regularly

B) Allow weights to hang freely at all times Rationale: The weights should hang freely, not touching bed or floor as not to compromise traction system

101. Cardiovascular:vThe nurse provides care for a client with acute chest pain. The client's skin is cool and clammy, and blood pressure and heart rate are elevated. The client appears short of breath as well as restless and anxious. Which action does the nurse take first? A) 12-lead ECG B) Assess pain and administer analgesia C) Administers anticoagulant as prescribed D) Gives brief orientation to the unit

B) Assess pain and administer analgesia Rationale: ADPIE, The nurse should assess the pain and implement a strategy to reduce pain, administering analgesic. Analgesic works to reduce pain and anxiety which reduces preload... decreases workload of the heart.

14. Musculoskeletal: Three hours after arriving in the orthopedic unit, a client reports a hot feeling under the cast. Which action does the nurse take first? A) Instructs the client to lie still since the cast is newly applied B) Assess the circulation in the casted extremity and changes the client's position C) Takes the client's temperature for other signs of infection D) Medicates the client for pain and notifies the HCP of the report

B) Assess the circulation in the casted extremity and changes the client's position Rationale: Heat is a sign of pressure... pressure can limit circulation (ABCs)

37. Musculoskeletal: A nurse is caring for a client who is 72 hours postoperative following an AKA. Which of the following actions should the nurse take? A) Elevate the residual limb on a soft pillow B) Assist the client into a prone position every 4 hours C) Re-apply a bandage to the residual limb every 12 hours D) Apply dressings to the site in a proximal-to-distal direction.

B) Assist the client into a prone position every 4 hours Rationale: The nurse should instruct the client to lie in a prone position for 20-30 minutes every 3 to 4 hours. This prevents the client from developing contractures while in bed.

79. Medications: The nurse provides care for a client who is prescribed propranolol. What information found in the client's history causes the nurse to hold the medication and contact the HCP? A) History of myocardial infarction B) Asthma since childhood C) History of infective endocarditis D) Hypertension for five years

B) Asthma since childhood Rationale: An adverse reaction of propranolol is bronchospasm/bronchial construction. Therefore, propranolol is contraindicated to use if a client has a history of asthma.

1. Musculoskeletal: The nurse cares for the school-aged child diagnosed with a fracture of the tibia located in the epiphyseal plate. What is a major complication associated with this type of fracture? A) Muscle atrophy of the affected leg B) Bone growth of the fractured leg may be affected C) Increased risk of osteomyelitis of the affected leg D) Development of degenerative joint disease

B) Bone growth of the fractured leg may be affected Rationale: epiphyseal plate is the site of continuous growth

12. Musculoskeletal: A client diagnosed with an injury to the lower back has been on complete bed rest for the last two days. Which should the nurse do when assisting the client in getting out of bed for the first time? A) Remove the elastic stockings and sequential compression devices the client has been wearing. B) Dangle the client at the side of the bed for a few minutes before the client stands up. C) Allow UAP to ambulate the client down the hall. D) Encourage the client to walk independently as far as possible, holding onto the wall for support.

B) Dangle the client at the side of the bed for a few minutes before the client stands up. Rationale: Orthostatic hypotension

98. Cardiovascular: The nurse provides care for a client diagnosed with angina. The nurse understands nitroglycerin is used in the treatment of angina pectoris for which reason? A) Prevents attacks precipitated by stressful events B) Decreases preload C) Produces coronary artery dilation in sclerotic vessels D) Corrects medication-induced dysrhythmias

B) Decreases preload Rationale: Nitroglycerin dilates the peripheral vessels and BP is decreased... decreasing preload.

85. Cardiovascular: A patient has VF. The nurse understands that the most effective treatment besides CPR is which of the following? A) Antiarrhythmics B) Defibrillation C) Ventilation D)Epinephrine

B) Defibrillation Rationale: Defibrillation is necessary to stop VF and hope for a return to a perfusing rhythm. Antiarrhythmics, epinephrine, and ventilation are all a part of the resuscitation after defibrillation.

43. Musculoskeletal: A nurse is caring for a client for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? A) Inspect the client's skin underneath the boot every 12 hr B) Encourage the client to perform dorsiflexion of the affected extremity every 2 hr C) Remove the weights from the traction while repositioning the client in bed D) Loosen the ropes if the client reports muscle spasms in the affected extremity

B) Encourage the client to perform dorsiflexion of the affected extremity every 2 hr Rationale: Dorsiflexion is performed q2hr to assess for nerve damage.

32. Musculoskeletal: A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A) Hypovolemic shock B) Fat embolism syndrome C) Thrombophlebitis D) Avascular bone necrosis

B) Fat embolism syndrome Rationale: S/S include petechial rash, hypoxemia

80. Medications: The nurse understands which type of insulin has the longest duration of action? A) Regular B) Glargine C) Isophane D) Lispro

B) Glargine Rationale: Glargine is long acting insulin with a duration of 24 hours. The onset is 3-4 hours.

73. Infectious Disease: A nurse is teaching a client who has HIV about how the virus is transmitted. Which of the following statements should the nurse include the teaching? A) HIV can be transmitted as soon as a person develops manifestations B) HIV can be transmitted to anyone who has had contact with infected blood C) HIV is transmitted through the respiratory route via droplets D) HIV is transmitted only during the active phase of the virus

B) HIV can be transmitted to anyone who has had contact with infected blood Rationale: The highest concentration of the virus is in blood but also isolated in other body fluids.

29. Musculoskeletal: A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? A) Remove the weight temporarily to reposition the client to the correct alignment in bed B) Have the client use a trapeze to pull himself up while ensuring the weight hangs freely C) Lift the rope off the pulley while the client rocks back and forth to reposition himself D) Lift the weight manually while another staff member moves the client up in bed

B) Have the client use a trapeze to pull himself up while ensuring the weight hangs freely Rationale: The nurse should ensure that the traction is hanging freely. The client can use the bar to move up in bed.

82. Medications: The nurse instructs a client about the correct way to administer insulin. Which statement, by the client, requires follow-up teaching? A) I will use my abdomen for the morning injection B) I will inject insulin into the back of my left arm prior to weight training C) I will inject insulin to the subq tissue D) I will dispose the used needle into the puncture resistant container

B) I will inject insulin into the back of my left arm prior to weight training Rationale: The client should not inject insulin into a limb that will be exercised because the absorption will be faster and may cause hypoglycemia.

42. Musculoskeletal: A nurse is teaching a client who had an amputation of the left lower leg 3 days ago. Which of the following statements indicates that the client understands how to care for the incision and his left upper leg? A) I should use powder inside my limb sock to keep it cool B) I will lie on my stomach for 30 min a few times a day C) I should expect some drainage with a strong odor because I had gangrene D) I will keep elevating my leg on 2 pillows to keep the swelling down

B) I will lie on my stomach for 30 min a few times a day Rationale: This position will help reduce the risk of developing hip flexion contractures.

103. Cardiovascular: A client is diagnosed with angina, and the nurse instructs the client about care at home. The nurse determines that teaching is effective. If the client makes which statement? A) If I have chest pain, I should stop my activity and take an aspirin B) If I have chest pain, I should stop my activity and take a nitroglycerin tablet C) I can take another aspirin if my chest pain doesn't subside in 30 minutes D) If I have chest pain, I should rest for 30 minutes and then take a nitroglycerin tablet

B) If I have chest pain, I should stop my activity and take a nitroglycerin tablet Rationale: Angina is chest discomfort caused by the heart's inability to provide oxygen to the cardiac muscle; this is a warning sign of ischemia. Anginal pain is relieved by rest and nitroglycerin.

112. Blood transfusions: The nurse provides care for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs during the transfusion? A) Decreased pulse rate, increased BP, decreased respirations B) Increased pulse rate, increased BP, increased respirations C) Increased pulse rate, increased BP, decreased respirations D) Decreased pulse, decreased BP, increased respirations

B) Increased pulse rate, increased BP, increased respirations Rationale: If a blood transfusion occurs too quickly, fluid overload can occur and signs of HF will be seen. S/S dyspnea, tachycardia, irregular HR, increased BP

55. Infectious Disease: The nurse assesses a client reporting fatigue and shortness of breath due to AIDS. Which action does the nurse take first? A) Refer the client to occupational therapy B) Instruct the client to sit while preparing meals C) Instruct the client to perform all activities in the morning D) Suggest to the client that accepting limitations is best

B) Instruct the client to sit while preparing meals Rationale: Energy conservation technique

52. Infectious Disease: The nurse provides care for a client with AIDS. The nurse knows the client is at high risk to develop which disease? A) Glioblastoma multiforme B) Kaposi sarcoma C) Hepatocarcinoma D) Melanoma

B) Kaposi sarcoma Rationale: Kaposi sarcoma is associated with a depressed immune system which could be caused by HSV, a comorbidity of HIV.

33. Musculoskeletal: A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A) Sensation of heat on the surface of the cast B) Paresthesias of the extremity C) Pruritus of the extremity D) Musty odor noted from the cast materials

B) Paresthesias of the extremity Rationale: 6 P's Pain Paresthesia Pallor Paralysis Poikilothermia Pulselessness

36. Musculoskeletal: A nurse caring for a client who is 3 days pos-op following a BKA. Which of the following actions should the nurse take? A) Place the client on a soft mattress B) Rewrap the residual limb with a bandage 3 times per day C) Assist the client into a prone position for 20 minutes every 8 hours daily D) Turn the client every 4 hours while in bed

B) Place the client on a soft mattress Rewrap the residual limb with a bandage 3 times per day Rationale: This ensures that the residual limb will shrink and allows for the nurse to check the skin.

78. Medications: The nurse provides care for a client receiving levothyroxine sodium. Which indicates a nursing consideration for this medication? A) Side effects include weight gain and tachycardia B) Provide medication at the same time daily C) Assess for a decreased pulse rate D) Medication is given over a 10-day period

B) Provide medication at the same time daily Rationale: It is important that the nurse administer levothyroxine sodium at the same time every day to maintain therapeutic blood levels. Medication should be given on an empty stomach.

34. Musculoskeletal: A nurse caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. This client is experiencing which of the following complications? A) Pneumonia B) Pulmonary embolism C) Tension pneumothorax D) Tuberculosis

B) Pulmonary embolism Rationale: Immobility puts patients at risk for pulmonary embolism. The patient may have tachycardia, chest petechiae and decreased SaO2.

54. Infectious Disease: The nurse cares for six clients diagnosed with AIDS. How does the nurse coordinate the necessary transmission-based precautions? A) Ensures that everyone on the unit wears gloves at all times B) Reminds the staff that standard precautions are needed C) Post a sign on the door of all clients with AIDS or other infectious disorders D) Teaches the clients to warn others that they have AIDS

B) Reminds the staff that standard precautions are needed Rationale: Standard precautions are needed for clients with AIDS.

93. Cardiovascular: The nurse provides care for a client diagnosed with angina. The client is scheduled for a cardiac catheterization and tells the nurse, "I get a rash when I eat strawberries or shellfish." Which intervention does the nurse perform first? A) Notifies the dietitian of the client's food allergies B) Stops preparations for the test C) Assesses for the presence of a rash during the procedure D) Determines the presence of other food allergies

B) Stops preparations for the test Rationale: A reaction to shellfish may indicate an allergy to the iodine contrast medium used in the test. HCP should be notified.

11. Musculoskeletal: The nurse provides care for an older adult client right days after an open reduction and internal fixation of the right hip. The nurse intervenes if which observation is made? A) The client are half of the food on the breakfast tray. B) The client is not wearing elastic stockings. C) The client must have assistance to transfer from the bed to the bedside commode. D) The client requires pain medication three times per day.

B) The client is not wearing elastic stockings. Rationale: DVT common after surgery. Elastic stockings or SCD should be worn at all times.

119. Infection control: The nurse identifies a staff member using standard precautions appropriately if which action is observed? A) The staff member wear gloves when taking the blood pressure of client diagnosed with AIDS B) The staff member places contaminated linens in a leak-proof bag C) The staff member irrigates an abdominal wound wearing a gown and gloves D) The staff member removes gloves after bathing a client and puts on a clean pair of gloves to bathe another client

B) The staff member places contaminated linens in a leak-proof bag

72. Infectious Disease: A nurse is conducting dietary teaching for a client who has AIDS. Which of the following instructions should the nurse include in the teaching? A) Discard leftovers after 8 hr B) Use a separate cutting board for poultry C) Thaw frozen foods at room temperature D) Store cold foods at 10C(50F) or less

B) Use a separate cutting board for poultry Rationale: Raw poultry can contain bacteria which may contaminate other foods or work surfaces. Using a separate cutting board prevents cross-contamination of work surfaces when preparing food.

92. Cardiovascular: The nurse educator reviews ECGs with a group of new nurses. The QRS complex reflects which activity? A) Atrial depolarization B) Ventricular depolarization C) Ventricular repolarization D) Central venous pressure

B) Ventricular depolarization Rationale: The QRS complex represents depolarization of the ventricles.

48. Infectious Disease: The nurse follows up with a client who has just been told the HIV test is positive. The client states, "I don't deserve to have AIDS. I'm not gay. The test must be wrong." Which response by the nurse is both accurate and therapeutic? A) The test isn't wrong. You most likely got AIDS from your high-risk behavior. B) Your past drug use puts you at high risk for HIV. I can see this news is distressing. Let's talk about it. C) HIV is not a death sentence anymore. But, you will need time to adjust to this news. I'll talk to you about it later. D) Homosexuals are not the only people who get AIDS. You can get it from doing drugs with dirty needles.

B) Your past drug use puts you at high risk for HIV. I can see this news is distressing. Let's talk about it. Rationale: It is therapeutic to offer to discuss the client's feelings at this time to help the client adjust to the news.

99. Cardiovascular: The nurse provides discharge teaching for a client with a diagnosis of angina. It is most important for the client to report which occurrence? A) Chest pain following sexual activity B) Headache after taking nitroglycerin C) Change in the character of the pain D) Chest pain after eating a large meal

C) Change in the character of the pain Rationale: Changes in pain.. change in health status.. must be reported to HCP.

31. Musculoskeletal: A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The client's left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first? A) Obtain an x-ray of the injured leg B) Apply ice packs to the affected area C) Check neurovascular status distal to the injury D) Elevate the affected leg on 2 pillows

C) Check neurovascular status distal to the injury Rationale: ADPIE and ABC priority

40. Musculoskeletal: A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A) Ecchymosis of the thigh B) Serous drainage at the pin site C) Chest petechiae D) Muscle spasms in the left leg

C) Chest petechiae Rationale: S/S of a fat embolism include petechial rash... could progress to acute respiratory failure

60. Infectious Disease: A client diagnosed with AIDS asks the clinic nurse about the risk of opportunistic infections. Which risk factor increases the client's risk of AIDS? A) Increased age of the client B)History of tobacco use C) Decreased T cell or CD4 cell count D) Increased number of sexual contacts

C) Decreased T cell or CD4 cell count Rationale: As the T cell or CD4 count decreases to less than 200, the risk for opportunistic infections and cancers is high

91. Cardiovascular: The nurse understands the primary purpose of promoting rest for a client following a myocardial infarction includes which rationale? A) Facilities accurate cardiac monitoring B) Promotes sleep and better oxygenation C) Decreased the workload of the heart D) Allows regeneration of the myocardium

C) Decreased the workload of the heart Rationale: The client has altered tissue perfusion due to the MI. Rest will decreased the workload of the heart by reducing myocardial oxygen consumption.

27. Musculoskeletal: The nurse provides care for a client with a newly applied plaster cast to the lower extremity. The nurse takes which action? A) Sets up a fan to blow on the cast and maintains the client in supine position B) Rests the casted leg on the mattress and avoids handling it until it dried C) Elevates the leg on pillows and leaves the cast open to air D) Covers the cast lightly with a sheet until completely dry

C) Elevates the leg on pillows and leaves the cast open to air Rationale: Elevation helps to prevent edema. Leaving the cast open to air helps it to dry.

102. Cardiovascular: When formulating a nursing care plan for a client following a myocardial infarction, the nurse includes which goal? A) Return to the pre-illness activity B) Achieve the optimum level of health C) Free from pain and dysrhythmias D) Eliminate all stress from the lifestyle

C) Free from pain and dysrhythmias Rationale: This goal is realistic, achievable, and measurable.

57. Infectious Disease: The nurse cares for a client diagnosed with confusion due to AIDS dementia complex. It is most important for the nurse to take which action? A) Ask the client to identify the day and date B) Assist the client to answer questions asked by the family C) Give the client simple directions D) Explain the day's schedule during breakfast

C) Give the client simple directions Rationale: The nurse should use short, uncomplicated sentences when communicated with this client.

107. Endocrine: The nurse on the medical unit expects which medication to be administered to the client newly diagnosed with type 2 diabetes mellitus who is experiencing hyperglycemia? A) Glucosamine B) Glucagon C) Glipizide D) Insulin glargine

C) Glipizide Rationale: Glipizide is an oral hypoglycemic agent used to manage type 2 diabetes mellitus. It decreases blood glucose by stimulating insulin release from functioning pancreatic cells and by increasing insulin receptor sensitivity.

51. Infectious Disease: A client with a history of IV drug use and numerous partners request HIV testing. The HIV test returns a negative result. Which should be the priority action for the nurse? A) Encourage the client to have safe sex B) Explain to the client the continued change of developing HIV if high-risk behaviors continue C) Help the client identify high-risk behaviors and provide information to help decrease these risks D) Inform the client to return every year for another HIV test as long as high-risk continue

C) Help the client identify high-risk behaviors and provide information to help decrease these risks Rationale: The client needs to participate in identification of high-risk behaviors and learn techniques to decrease the risks or help client change their lifestyle.

105. Cardiovascular: The nurse provides care for a client diagnosed with CAD. Which client statement indicates to the nurse and understanding of the disease process? A) Notify HCP if I have to take any sublingual nitroglycerin B) I will massage the area around my nitroglycerin patch C) I will go to the hospital if pain persists after I have taken my medication and rested D) I will work out for 2 hours every day

C) I will go to the hospital if pain persists after I have taken my medication and rested Rationale: If pain persists after rest and administration of nitroglycerin, the client should report to the ED for further evaluation.

49. Infectious Disease: The nurse instructs a client diagnosed with HIV about barrier precautions and methods to prevent HIV transmission. Which best indicates to the nurse that the client understands the teaching? A) I will get an HIV test every three months B) I will sign the client education form since I understand all that you have taught me C) I will not have unprotected sexual intercourse D) The client nods yes when asked if the information is understood

C) I will not have unprotected sexual intercourse Rationale: Primary risk factor

59. Infectious Disease: The nurse teaches a client diagnosed with AIDS how to prevent the transmission of AIDS. Which client statement indicates the teaching is effective? A) I will stop swimming B) I will use only disposable dishes C) I will only have sex when using a condom D) I am going to live by myself. I don't want to contaminate my family.

C) I will only have sex when using a condom Rationale: AIDS is spread through direct contact with body fluids

106. Endocrine: A nurse is providing discharge teaching about foot care to a client who has diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? A) I can use a heating pad on my feet to keep them warm B) I can go barefoot as long as I stay inside the house C) I will wash my feet daily and apply lotion, except between my toes D) I will trim my toenails every morning by rounding the corners

C) I will wash my feet daily and apply lotion, except between my toes Rationale: Diabetic neuropathy is a risk factor for amputation of an extremity. The client should inspect feet daily and clean them. Lotion should not be applied in between the toes to avoid promoting an environment that favors bacterial growth.

2. Musculoskeletal: The nurse witnesses a car hit a pedestrian in the parking lot. As the nurse approaches the pedestrian, the pedestrian cried out, "I think my leg is broken!" Which action does the nurse take first? A) Askes the client to move the ankle and foot on the affected side B) Tells the client to lie perfectly still and remain calm C) Inspects the affected leg for evidence of bleeding D) Immobilizes the affected leg

C) Inspects the affected leg for evidence of bleeding Rationale: First expose the extremity for bleeding, swelling or any deformity

68. Infectious Disease: A nurse is caring for a client who has HIV. The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse provide? A) That is your decision alone B) I would if I were you C) It sounds like you are unsure what to say to your partner D) Your provider is required by law to notify your partner

C) It sounds like you are unsure what to say to your partner Rationale: This response uses therapeutic communication tools of clarifying and restatement

5. Musculoskeletal: The nurse provides care for an older adult client. The client is diagnosed with a pathological fracture of the 9th thoracic vertebra. What is most likely cause of the fracture for this client? A) Osteogenesis imperfecta B) Osteogenic sarcoma C) Osteoporosis D) Osteochondroma

C) Osteoporosis Rationale: Pathological fracture is caused by an underlying disease; Osteoporosis is a disease. Osteoporosis is more common in post menopausal women(older adults) due to the loss of estrogen. Compression fractures of the spine are common as a result of vertebral bone mass.

96. Cardiovascular: The nurse prepares a client diagnosed with a myocardial infarction for a cardiac catheterization. The nurse recognizes that a history of allergy to which allergen is most closely associated with an allergic reaction to the dye? A) Eggs B) Penicillin C) Oysters D) Sulfa medications

C) Oysters Rationale: Shellfish

70. Infectious Disease: A nurse is teaching a client who has AIDS about the transmission of PCP. Which of the following pieces of information should the nurse include in the teaching? A) PCP is sexually transmitted from person to person B) You were most likely exposed to a contaminated surface such as a drinking glass C) PCP results from an impaired immune system D) You might have contracted PCP from a family pet

C) PCP results from an impaired immune system Rationale: PCP exists as part of the normal flora of the lungs and develops into a fungus. It becomes a pathogen when the immune system is compromised.

16. Musculoskeletal: The nurse provides care for a client who is ambulating using crutches with partial weight bearing on the left leg. The nurse teaches the client how to bear partial weight while using crutches. With which leg or crutch will the nurse teach the client to lead? A) Right crutch B) Left crutch C) Right leg D) Left leg

C) Right leg Rationale: 3-point gait is for partial weight bearing. Full weight-bearing on the right leg. Partial weight bearing on left leg. Right leg moves first to bear the weight, then crutches and left leg move at the same time for support

108. Endocrine: The nurse provides care for a client admitted with a diagnosis of diabetic ketoacidosis. The nurse anticipates which type of insulin will be prescribed? A) Rapid B) Long C) Short D) Intermediate

C) Short Rationale: Short-acting (regular) insulin IV is administered for diabetic ketoacidosis.

74. Infectious Disease: A nurse is caring for a client who has had HIV. Which of the following types of isolation should the nurse implement to prevent transmission of HIV? A) Protective isolation B) Droplet precautions C) Standard precautions D) Airborne precautions

C) Standard precautions Rationale: Standard precautions protect from infection through direct or indirect contact with infectious blood or bodily fluids.

53. Infectious Disease: The home care nurse visits a client diagnosed with AIDS. The nurse intervenes if which observation of the caregiver is made? A) The caregiver asks guests if they are sick before visiting the client B) The caregiver disinfects the bathroom with 1:10 solution of household bleach C) The caregiver uses bare hands to place the client's soiled linens in a laundry hamper D) The caregiver washes the dishes in the dishwasher

C) The caregiver uses bare hands to place the client's soiled linens in a laundry hamper Rationale: Infection precautions

10. Musculoskeletal: The nurse provides instruction about using crutches to a client diagnosed with a fractured left tibia. The client is to be non weight bearing. Which nursing observation indicated the client is able to use the crutches safely? A) The client advances the crutches, then swings both legs forward to the crutches. B) The client advances the right crutch with the left leg, then the left crutch with the right leg. C) The client advances both crutches and the left leg simultaneously, then advances the right leg to the crutches. D) The client advances both crutches and the right leg simultaneously, then slides the left leg to the crutches.

C) The client advances both crutches and the left leg simultaneously, then advances the right leg to the crutches. Rationale: When non weight bearing, both crutches with the affected extremity then unaffected leg while body weight supported on the hand's

7. Musculoskeletal: An older client is diagnosed with a fractured humerus and is recovering at home. Which nursing observation in the home requires an immediate intervention? A) The bathroom is equipped with grab bars. B) Small area rugs have been removed. C) The client ambulates wearing socks. D) The stairs are well lit.

C) The client ambulates wearing socks. Rationale: The client should wear shoes or slippers with non skid surfaces. Socks may be slippery and cause falls.

13. Musculoskeletal: The client appears angry and demanding following a BKA. Which interpretation by the nurse of this client's behavior is most justifiable? A) The client is seeking attention to compensate for the loss B) The client is placing the blame for difficulties on others C) The client is having difficulty accepting the new body image D) The client feels alienated by the hospital staff

C) The client is having difficulty accepting the new body image

3. Musculoskeletal: The nurse provides care for a client immediately following a right below-the-knee amputation. The nurse is most concerned if which observation is made? A) The client periodically naps. B) The client reports a throbbing headache C) The client reports persistent pain at the operative site. D) The client voices concern about being able to use a prosthesis.

C) The client reports persistent pain at the operative site. Rationale: Persistent pain the operative site could indicate infection which would lead to notification of the health care provider

9. Musculoskeletal: A client has a cast removed after a broken tibia. Which action does the nurse identify is contraindicated for care of the extremity after the cast is removed? A) Provide support for the extremity after cast removal. B) Gently wash the extremity's skin to remove dried, scaling skin. C) Vigorously massage the extremity's skin to restore circulation. D) Apply emollient lotion to extremity's skin to soothe dry skin.

C) Vigorously massage the extremity's skin to restore circulation. Rationale: May cause skin breakdown and release a thrombus.

56. Infectious Disease: A new client comes to the HIV clinic and asks the nurse, "Which test will confirm a diagnosis of HIV?" Which is the correct answer for the nurse to give to the client? A) Coproporhyrin B) Direct Coombs C) Western blot D) Fluorescent treponemal antibody

C) Western blot Rationale: Test used to confirm the client is HIV positive

8. Musculoskeletal: The nurse teaches a client diagnosed with a fractured left femur that is in a cast. The client asks how to keep the muscles of the legs strong during the time the cast is on the left leg. Which response by the nurse is the best? A) "It is important to perform an active range of motion every day with you left leg." B) "I'll teach your patient to perform active assistive range-of-motion exercises." C) "Perform left leg lifts with a 2-lb weight attached to your ankle." D) "I'll teach you how to do isometric exercises with your left leg."

D) "I'll teach you how to do isometric exercises with your left leg." Rationale: Isometric exercises, quadriceps setting or straight leg raises is indicated for muscle strength and venous return.

115. Blood transfusions: A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A) 0.45% NaCl B) D5 0.9 NaCl C) D10W D) 0.9 NaCl

D) 0.9 NaCl

120. Priority: The nurse is caring for four patients in the cardiology clinic. Which patient should be referred to the provider first? A) A new patient presenting with a systolic murmur requiring evaluation before a dental appointment B) A patient complaining of shortness of breath and recent weight gain presenting with tachycardia C) A former IV drug user presenting to the clinic with a fever and red, painless nodes on her hands D) A patient complaining of recent onset chest pain that is not relieved with rest

D) A patient complaining of recent onset chest pain that is not relieved with rest Rationale: This patient needs to be evaluated for an MI due to the presence of unstable angina.

110. Sickle Cell: A nurse is admitting a client who is in a sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? A) Flexion of the extremities B) Therapeutic hypothermia C) Upright positioning D) Ample hydration

D) Ample hydration

94. Cardiovascular: The nurse assesses a client's rhythm strip and interprets the rhythm to be atrial fibrillation. On which criteria does the nurse base this analysis? A) Normal and regular rate, normal P wave, PR interval greater than 0.20 seconds, normal QRS B) Atrial rate 250 to 350 bpm, ventricular rate is irregular and greater than 100, sawtooth P wave, variable PR interval C) Rate is regular and greater than 100 bpm, normal P wave, normal PR interval, normal QRS D) Atrial rate is irregular and 350 to 600 bpm, ventricular rate is variable and irregular, P wave is chaotic, PR interval is not measurable

D) Atrial rate is irregular and 350 to 600 bpm, ventricular rate is variable and irregular, P wave is chaotic, PR interval is not measurable Rationale: These are characteristics of Afib. Afib is a quivering or irregular heartbeat.

116. Cholecystectomy: A nurse is performing a preoperative assessment of a client to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods? A) Cabbage B) Oatmeal C) Milk D) Bananas

D) Bananas Rationale: An allergy to bananas is a risk factor that indicates the client could also be allergic to latex.

25. Musculoskeletal: The nurse makes a home health care visit to a client with a fractured right femur. The nurse assesses the client's ability to safely use crutches. The nurse intervenes if which observation is made? A) When standing the crutch tips are placed 6 inches in front of and 6 inches to the side of each foot B) The client ambulates using 3-point gait C) When going down steps, the client stands on the unaffected leg and places the crutches on the next step D) Before the client sits in a chair, the client stands on the unaffected leg and transfers both crutches to the hand on the affected side of the body

D) Before the client sits in a chair, the client stands on the unaffected leg and transfers both crutches to the hand on the affected side of the body Rationale: This describes and unsafe procedure. The client should transfer both crutches to the hand on the unaffected side of the body, then support weight on the unaffected leg and crutches, and then lower to sit in the chair.

84. Cardiovascular: The nurse understands transcutaneous pacing is necessary for which symptomatic patient? A) Sinus tachycardia B) Sinus rhythm with PACs C) Atrial fibrillation (AF) D) Complete heart block

D) Complete heart block Rationale: A symptomatic patient in complete heart block requires pacing to restore adequate cardiac output.

89. Cardiovascular: The nurse provides care for a client diagnosed with CAD. The client exercises three times per week, but now experiences shortness of breath and fatigue when exercising. The client asks the nurse, "Why can't I go to the gym anymore without feeling tired within 5 minutes?" Which is the nurse's best response? A) The humidity in the air affects your heart's ability to function B) Your lungs are over-expanded, which makes it difficult to catch your breath C) You are exhausted from all the medical procedures you have been going through. Once you are rested, you will be able to exercise again D) Due to an inadequate blood supply to the heart, your heart is unable to meet your body's oxygen needs during exercise

D) Due to an inadequate blood supply to the heart, your heart is unable to meet your body's oxygen needs during exercise Rationale: Stenosis or spasms in the coronary arteries decreased blood supply to the myocardium

62. Infectious Disease: A neighbor tells the nurse about using a home testing kit for AIDS. The test results were positive. Which action does the nurse take first? A) Informs the neighbor's HCP B) Does not eat any food prepared by neighbor C) Notes the test results in neighbor's hospital record D) Encourage neighbor to discuss further testing with HCP

D) Encourage neighbor to discuss further testing with HCP Rationale: HCP needs definitive testing to prescribe ART.

22. Musculoskeletal: An older adult client has an open reduction and internal fixation of the left femoral head after a fracture. Which action by the nurse is best? A) Offer clear liquid diet B) Keep client turned to the non-operative side C) Instruct the client to exercise the arms D) Encourage the client to cough and deep breathe every 2 hours

D) Encourage the client to cough and deep breathe every 2 hours Rationale: Prevention of atelectasis

28. Musculoskeletal: The nurse teaches a client with a BKA to care for the residual limb at home. The nurse advises the client to take which action? A) Apply cream daily to the residual limb B) Cover the residual limb with a nylon sock C) Keep the residual limb elevated D) Expose the residual limb to air

D) Expose the residual limb to air Rationale: Exposure to air helps to facilitate healing. Keeping the limb clean and dry is needed for prosthesis fitting.

63. Infectious Disease: The nurse provides care for a client diagnosed with AIDS. The client is now in the advanced stage of the disease and reports severe diarrhea. The nurse intervenes if the client makes which statement? A) I will eat cooked or canned fruits or vegetables B) I will eat high-potassium foods C) I will drink plenty of fluids between meals D) I will take a liquid nutritional supplement at least twice a day

D) I will take a liquid nutritional supplement at least twice a day Rationale: Nutritional supplements may make diarrhea worse due to high sugar or dairy content.

111. Sickle Cell: A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A) Hypokalemia B) Lead poisoning C) Hypercalcemia D) Iron toxicity `

D) Iron toxicity

15. Musculoskeletal: The nurse provides care for a client in balanced suspension traction. The client reports pain in the affected extremity and the nurse administers the prescribed medication. One hour later the client states, "I don't know why, but the pain isn't getting any better." Which action does the nurse take first? A) Contact HCP B) Offers back rub C) Assess level of pain D) Performs neurovascular assessment

D) Performs neurovascular assessment Rationale: Sudden unrelenting pain is a sign of compartment syndrome.

58. Infectious Disease: The nurse provides care for a client with AIDS who has a CD4+ T cell count of 120. The nurse knows the client is at risk to develop which infection? A) Beta-hemolytic streptococcal infection B) Helicobacter pylori infection C) Hepatitis A infection D) Pneumocystis pneumonia (PCP)

D) Pneumocystis pneumonia (PCP) Rationale: Patients with a CD4+ T cell count of less than 200 are at risk for PCP.

17. Musculoskeletal: The nurse provides care for a client after an amputation with an immediate prosthetic fitting. The nurse includes which activity in the client's plan of care? A) Assess drainage B) Observe dressing for signs of excessive bleeding C) Elevate the residual limb for no less than 48 hours D) Provide cast care on the affect extremity

D) Provide cast care on the affect extremity Rationale: Immediate prosthetic fitting requires a plaster-cast, a cast requires cast care

71. Infectious Disease: A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A) Nonproductive cough, fever, and shortness of breath B) Lesions on the retina that produce blurred vision C) Onset of progressive dementia D) Reddish-purple skin lesions

D) Reddish-purple skin lesions Rationale: Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular

83. Medications: The nurse plans to administer both regular and intermediate-acting insulin to a client diagnosed with type 1 diabetes. Which actions by the nurse reflect correct understanding of the proper administration procedure? A) The nurse draws up either insulin, followed by the other B) The nurse draws up the intermediate-acting insulin first, followed by the regular insulin C) The nurse draws each insulin up in a separate syringe D) The nurse draws up the regular insulin first, then the intermediate-acting insulin (NPH) is cloudy.

D) The nurse draws up the regular insulin first, then the intermediate-acting insulin (NPH) is cloudy. Rationale: Regular insulin (short-acting) insulin is clear... intermediate-acting

121. Priority: The nurse is taking care of four patients admitted for uncontrolled hypertension. Which of the following patients should the nurse see immediately? A) The patient with a BP of 200/95 that denies any symptoms but has a strong family history of stroke B) The patient with a BP of 158/95 with an elevated BUN and creatinine complaining of nocturia C) The patient with a BP of 162/75 complaining of noticeable vision impairment in the left eye over the last 2 months D) The patient with a BP of 155/92 complaining of left-sided weakness, facial drooping, and slurred speech

D) The patient with a BP of 155/92 complaining of left-sided weakness, facial drooping, and slurred speech

104. Cardiovascular: The nurse provides care for a client admitted to the unit with a diagnosis of acute myocardial infarction. The nurse understands a cardiac monitor is attached to this client for which reason? A) To monitor the client's condition and pain status B) To prevent another, more serious heart attack from occurring C) To verify the diagnosis of acute myocardial infarction D) To detect any life-threatening changes in the heart rhythm

D) To detect any life-threatening changes in the heart rhythm Rationale: A cardiac monitor displays the client's heart rate and rhythm

113. Blood transfusions: A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed RBCs. Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A) Warm the unit of blood to room temperature before administering it B) Administer acetaminophen prior to the blood transfusion C) Give an antihistamine prior to the transfusion D) Use a transfusion pump to regulate and maintain the transfusion at a slower rate

D) Use a transfusion pump to regulate and maintain the transfusion at a slower rate

109. Endocrine: A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching? A) Wear nylon socks with shoes B) Wear flip flops instead of going barefoot when outside C) Apply moisturizing cream between your toes D) Wash your feet daily using lukewarm water and soap

D) Wash your feet daily using lukewarm water and soap Rationale: This is normal foot care for a client with diabetes mellitus. The client should keep the feet clean and free from dirt which can cause an infection, and inspect feet daily for cuts or calluses which can develop into a foot ulcer.

75. Infectious Disease: A nurse is providing discharge teaching to the partner of a client who has AIDS. Which of the following statements by the client's partner indicates a need for further teaching? A) I will dispose of soiled tissues in separate plastic bags B) I'll clean up blood spills immediately with hot water C) I know that handwashing is an important preventive measure D) I will wash soiled clothes in hot water

Rationale: The client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products.