ATI Med Surg Review Questions

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men Check Answer Question Feedback Close ExplanationCorrect Answer: A. Children The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, through hand-to-mouth contact, or via another form of close contact.

A nurse is preparing a client for a bone scan. Which of the following statements indicates that the client understands the pre-procedure teaching? (Select all that apply.) A. "I will have to drink a radioactive solution before the test begins." B. "A special camera will scan the bones in my entire body." C. "There will be better absorption of the radiation by healthy bone." D. "I'll have to drink a lot of water to help get the radiation out of my body." E. "I understand the radiation is harmless, and I don't have to worry about it."

Correct Answers: B. "A special camera will scan the bones in my entire body." D. "I'll have to drink a lot of water to help get the radiation out of my body." E. "I understand the radiation is harmless, and I don't have to worry about it." A bone scan is a radionuclide procedure that allows viewing of the entire skeleton. It is less common than other diagnostic tests but is still useful for identifying hairline fractures and some malignancies. The client should drink plenty of fluids to promote urinary excretion of the radioactive material. Also, the nurse should reassure the client that the radioactive material is not dangerous because it deteriorates quickly in the body and exits via urine and stool.

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I should check my heart rate at the same time each day." B. "I don't have to take my antihypertensive medications now that I have a pacemaker." C. "I should keep a pressure dressing over the generator until the incision is healed." D. "I cannot stand in front of our new microwave oven when it is on."

Correct Answer: A. "I should check my heart rate at the same time each day." The nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider.

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

Correct Answer: A. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade

Correct Answer: A. Acidosis Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1°C (1.8°F) per hour.

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure B. Place the client leaning forward over the bedside table for the procedure C. Inform the client he will be sedated during the procedure D. Instruct the client to fast for 6 hr prior to the procedure

Correct Answer: A. Ask the client to empty his bladder before the procedure The nurse should ask the client to empty his bladder before the procedure to prevent injury to the bladder.

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Beef liver B. Oranges C. Turnips D. Whole milk

Correct Answer: A. Beef liver The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, and poultry. A 3 oz serving of beef liver contains 4.17 mg of iron.

A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables

Correct Answer: A. Fortified milk Fortified milk provides 2.45 mcg of vitamin D, which promotes calcium absorption from the gastrointestinal tract. Adults up to age 70 need 600 international units of vitamin D per day and 800 international units thereafter. Therefore, fortified milk is a good source of vitamin D.

A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? A. Increased hematocrit level B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity

Correct Answer: A. Increased hematocrit level The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume.

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

Correct Answer: A. Lentils The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. A 1-cup serving of lentils contains 3.6 mg of iron.

A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider? A. Meperidine B. Amitriptyline C. Gabapentin D. Propranolol

Correct Answer: A. Meperidine Opioids are more effective for residual limb pain rather than phantom limb pain. Additionally, meperidine is not recommended for chronic pain because long-term use can cause accumulation of a toxic metabolite.

A nurse is preparing to care for a client who is in 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. Encouraging 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

Correct Answer: A. Offering the client a diet high in fluid and fiber A client who is immobile is at risk of constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function.

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? A. Prevents excessive pressure on suture lines B. Allows gastric lavage after surgery C. Allows early postoperative feeding D. Facilitates obtaining gastric specimens for testing

Correct Answer: A. Prevents excessive pressure on suture lines The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention.

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit

Correct Answer: A. Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma-rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4°C (101.1°F) D. Oxygen saturation 92%

Correct Answer: A. Right shoulder pain The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can promote client comfort.

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

Correct Answer: A. Ulceration Ulceration, bleeding, and exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet." D. "I will take aspirin to relieve my pain."

Correct Answer: B. "I will avoid bending over." The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create intraocular hemorrhage.

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."

Correct Answer: B. "I will lie on my stomach for 30 min a few times a day." The client should lie prone 3 or 4 times per day for 20 to 30 minutes. This position will help reduce the risk of developing hip flexion contractures.

A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre-procedure teaching? A. "I have to keep my leg straight throughout the whole procedure." B. "The doctor will be able to see if I have signs of rheumatoid arthritis." C. "I should expect to stay overnight until I can walk around." D. "I'll have a scar that will be about an inch long."

Correct Answer: B. "The doctor will be able to see if I have signs of rheumatoid arthritis." An arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis, and internal joint injuries.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab

Correct Answer: B. Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

Correct Answer: B. Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. 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 hr C. Re-apply a bandage to the residual limb every 12 hr D. Apply dressings to the site in a proximal-to-distal direction

Correct Answer: B. Assist the client into a prone position every 4 hr The nurse should assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours following an amputation to reduce the risk of flexion contractures.

A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of which of the following foods when the inflammation subsides? A. Cucumbers and tomatoes B. Cabbage and peaches C. Strawberries and corn D. Figs and nuts

Correct Answer: B. Cabbage and peaches When the acute inflammation has subsided, the client should increase his intake of foods that are high in fiber, such as wheat bran, whole-grain bread, and fresh fruits and vegetables that do not contain seeds.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

Correct Answer: B. Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum

Correct Answer: B. Epidermis Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of skin cancer.

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive salivation B. Finger contractures C. Periorbital edema D. Alopecia

Correct Answer: B. Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are 2 types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma, the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.

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

Correct Answer: B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity.

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1,000 mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4 hr for bleeding D. Administer an enema as needed for constipation

Correct Answer: B. Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk of bleeding due to delayed clotting.

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation. 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 min every 8 hr daily D. Turn the client every 4 hr while in bed

Correct Answer: B. Rewrap the residual limb with a bandage 3 times per day The nurse should rewrap the client's residual limb with a pressure bandage 3 times daily. This keeps the bandage taught, which ensures the residual limb will shrink. Rewrapping the bandage also allows the nurse to check the skin for redness or skin breakdown.

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/d

Correct Answer: B. Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.

A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? A. "Not having any more rectal pain will be a relief." B. "I will need to sit on a rubber donut when I am in the chair." C. "I can have only liquids for 2 days before the surgery." D. "The colostomy will start working about 7 days after the surgery."

Correct Answer: C. "I can have only liquids for 2 days before the surgery." The client should consume a full or clear liquid diet for 24 to 48 hours before the surgery to decrease bulk. The client should consume a low-residue diet for several days prior to surgery to decrease peristalsis.

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? A. "I need to stay active to prevent blood clots in my legs." B. "If I have a bad headache, I can take aspirin to get rid of it." C. "I should eliminate uncooked foods from my diet for now." D. "I should eat more iron-fortified cereal to strengthen my blood."

Correct Answer: C. "I should eliminate uncooked foods from my diet for now." The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking destroys, so the client should avoid raw foods.

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. "I'll expect a little leg swelling since I won't be that active for a while." B. "I'll see the doctor every week to change my vena cava filter." C. "I'll call the doctor if I see any blood in my urine or stool." D. "I'll have to take the blood thinner for a few more days."

Correct Answer: C. "I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately.

A nurse is providing teaching to a client who is scheduled for an electroencephalogram in the morning. Which of the following pieces of information should the nurse share? A. "You'll feel some mild electrical sensations like static electricity during the procedure." B. "Do not eat or drink anything except water after midnight." C. "Shampoo your hair before the procedure and don't use any styling products afterward." D. "It's common to have temporary short-term memory loss after the procedure."

Correct Answer: C. "Shampoo your hair before the procedure and don't use any styling products afterward." An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges released by nerve cells in the brain. For the electrodes to adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products.

A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching? A. "Empty the drainage tubes once per day." B. "Showering is permitted before the drainage tubes are removed." C. "The drainage tubes often are removed at the same time as the stitches." D. "Do not begin exercising your arm until the provider removes the drainage tubes."

Correct Answer: C. "The drainage tubes often are removed at the same time as the stitches." The nurse should instruct the client that the provider will remove the drainage tubes at the same time the stitches are removed, usually within 7 to 10 days.

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? x A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nailbed capillary refill

Correct Answer: C. Absence of hair on the legs A progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position

Correct Answer: C. Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.

A nurse is reviewing the dietary choices of a client who has chronic pancreatitis. Which of the following food items should the nurse suggest removing from the client's menu for the following day? A. White rice B. Broiled cod C. Ice cream D. Canned peaches

Correct Answer: C. Ice cream Clients who have chronic pancreatitis should limit their fat intake to no more than 30% to 40% of total calories. Ice cream is high in fat, with 48 g of fat in a 1-cup serving of vanilla ice cream. The client should choose healthier fat-containing options to support a balanced diet, such as avocados and nuts.

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

Correct Answer: C. Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch.

A nurse is providing teaching to a client who has Addison's disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of the teaching? A. Sliced bananas B. Baked potato C. Turkey and cheese sandwich D. Plain yogurt with peaches

Correct Answer: C. Turkey and cheese sandwich A turkey and cheese sandwich is high in protein, carbohydrates, and sodium. A client who has Addison's disease requires a diet low in potassium and high in sodium, carbohydrates, and protein. Addison's disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex). Addison's disease occurs when the adrenal glands do not produce enough cortisol and, in some cases, aldosterone.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted lesions B. A large, tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. A fluid-filled vesicular rash in the genital region

Correct Answer: C. Unilateral, localized, nodular skin lesions Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces localized, nodular skin lesions.

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

Correct Answer: C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.

A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the following directions should the nurse provide? A. "You should fast for 8 hours after the PSA test." B. "Annual PSA screening should begin at age 40." C. "Expected PSA values will decrease as you get older." D. "You should not ejaculate for 24 hours prior to the PSA test."

Correct Answer: D. "You should not ejaculate for 24 hours prior to the PSA test." PSA is a glycoprotein manufactured in the prostate that is used to screen for prostate cancer. Ejaculation within 24 hours prior to the test can falsely elevate levels of PSA.

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? A. Sudden hemoptysis B. Acute diarrhea C. Frontal headache D. Acute confusion

Correct Answer: D. Acute confusion Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber diet. Which of the following food items should the nurse remove from the client's meal tray? A. Canned fruit B. White bread C. Broiled hamburger D. Coleslaw

Correct Answer: D. Coleslaw Coleslaw contains raw cabbage, which is high in fiber. Clients who are following a low-fiber diet should avoid most raw vegetables.

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia D. Hyperkalemia

Correct Answer: D. Hyperkalemia A client who has chronic kidney disease can have hyperkalemia, which is a potassium level greater than 5.0 mEq/L. The expected reference range for potassium is 3.5 to 5.0 mEq/L. Other manifestations of hyperkalemia can include palpitations, dysrhythmias, nausea, and muscle weakness.

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice with an enlarged liver D. Petechiae and ecchymosis

Correct Answer: D. Petechiae and ecchymosis A client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all 3 major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? A. Use of hydrochlorothiazide B. Chronic use of acetaminophen C. Allergic external otitis D. Sclerosis of the ossicles

Correct Answer: D. Sclerosis of the ossicles Sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention? A. A full pitcher of water is sitting on the client's bedside table within the client's reach. B. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube. D. The head of the bed is elevated to 20°.

Correct Answer: D. The head of the bed is elevated to 20°. The head of the bed should be elevated to at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move through the digestive system and lessens the possibility of regurgitation.

A nurse is providing teaching to the guardian of a child who has celiac disease. Which of the following foods should the nurse instruct the guardian to omit from the child's diet? A. Cornflakes B. Reduced-fat milk C. Canned fruits D. Wheat bread

Correct Answer: D. Wheat bread Clients who have celiac disease should eliminate as much gluten as possible from their diets. Wheat, rye, and barley contain gluten and should be eliminated from the diet of a child who has celiac 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 Check Answer

Correct Answers: A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher E. Avoid digging in the garden The nurse should instruct the client to avoid large crowds or gatherings of people, especially if individuals have been ill or exposed to illness; this can place clients who have HIV at risk of infection. The client should clean the toothbrush by running it through the dishwasher. If the client does not have a dishwasher, rinsing the toothbrush with bleach followed by hot water is also effective at destroying bacteria on the toothbrush. The client should avoid digging in the garden because exposure to the dirt, which contains bacteria and organisms, places the client at risk of infection.

A nurse is determining a client's risk of developing osteoporosis. The nurse should identify which of the following as risk factors for bone loss? (Select all that apply.) A. Small body frame B. Hypertension C. African-American ethnicity D. Low vitamin D intake E. Smoking

Correct Answers: A. Small body frame D. Low vitamin D intake E. Smoking Females have a higher risk of developing osteoporosis than males. Other risk factors include family history, low body mass index, and a small body frame. Consuming inadequate levels of calcium and vitamin D, smoking, and ingesting high amounts of alcohol or caffeine also increase the risk of developing osteoporosis.

A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select all that apply.) A. Hemodialysis B. Biopsy C. Immunosuppression D. Balloon angioplasty E. Surgical repair

Correct Answers: A. Hemodialysis B. Biopsy C. Immunosuppression Clients who develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and creatinine levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to undergo a biopsy to determine the correct diagnosis. Immunosuppressive medication therapy is essential after kidney transplantation to protect the new kidney.

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (Select all that apply.) A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices

Correct Answers: A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine The nurse should inform the client that allopurinol is an antigout medication that reduces uric acid, which helps prevent uric acid stone formation. Immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise. Purine increases the risk of uric acid stone formation; organ meats, poultry, fish, red wine, and gravy are high in purine.

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply.) A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises

Correct Answers: A. NPO status B. Alternative methods of communication D. Changes in body image E. Swallowing exercises The client will receive fluids and nutrition via an enteral tube while healing from the surgery. Radical neck dissection interrupts vocal communication, so the nurse should determine with the client and family how the client will prefer to communicate. Extensive resection can result in some disfigurement and permanent tracheostomy; the nurse should help prepare the client for these changes. Swallowing can be challenging after an extensive resection. The client might require the assistance of a speech-language pathologist to provide swallowing exercises and techniques.

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in respiratory isolation B. Monitor vital signs every 2 hr C. Assess neurological status every 4 hr D. Maintain the client in a modified Trendelenburg position E. Keep the client's room darkened

Correct Answers: B. Monitor vital signs every 2 hr C. Assess neurological status every 4 hr E. Keep the client's room darkened The nurse should monitor the client's vital signs to assess for changes consistent with increased intracranial pressure. In addition, the nurse should monitor the client's neurological status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Lost vision can improve with eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

Correct Answers: D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm.