Int. MS Exam Questions
5.9 A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurses best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia". B. "To detect and treat bradycardia, which is an excessively slow heart rate". C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and ineffectively". D. "To shock your heart if you have a heart attack at home".
A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia".
3.9 The nurse working on a cardiac care unit is caring for a client whose stroke volume has increased. The nurse is aware that afterload influences a clients stroke volume. The nurse recognizes that afterload is increased when there is what? A. Arterial vasoconstriction B. Venous vasoconstriction A. Arterial vasodilation B. Venous vasodilation
A. Arterial vasoconstriction
5.1 The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration
A. Pneumothorax
3.3 A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action? A. Rapidly assess the clients cardiopulmonary status B. Arrange for an ECG C. Increase the height of the clients bed D. Manage the clients anxiety
A. Rapidly assess the clients cardiopulmonary status
4.3 A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64mmHg, HCO3 = 24 mmHg. What does the ABG reflect? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis
A. Respiratory acidosis
5.6 An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the clients plan of care? A. Suction the clients airway secretions B. Immobilize the ribs with an abdominal binder C. Prepare the client for surgery D. Immediately sedate and intubate the client.
A. Suction the clients airway secretions
6.1 A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurses nutritional teaching plan has been effective? A. "I will have a ham and cheese sandwich for lunch" B. "I will have a baked potato with broiled chicken for dinner" C. "I will have a tossed salad with cheese and croutons for lunch". D. "I will have chicken noodle soup with crackers and an apple for lunch"
B. "I will have a baked potato with broiled chicken for dinner"
2.1 A nurse educator is reviewing a clients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C. The kidneys react rapidly to compensate for imbalances in the body D. The kidneys regulate the bicarbonate level in the intracellular fluid
B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
3.4 Two units PRBC's have been prescribed for a client who has experienced a GI bleed. The client is highly reluctant to receive a transfusion, stating "I'm terrified of getting AIDs from a blood transfusion". How can the nurse best address the clients concerns? A. "All donated blood is treated with antiretroviral medications before is it used". B. "That did happen in some high profile cases in the 20th century, but it is no longer a possibility". C. HIV was eradicated from the blood supply in the early 2000's". D. "The chances of contracting AIDS from a blood transfusion are exceedingly low".
D. "The chances of contracting AIDS from a blood transfusion are exceedingly low".
4.7 A client with a history of rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedure. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which medication? A. Enoxaparin B. Metoprolol C. Azathioprine D. Amoxicillin
D. Amoxicillin
3.7 A clients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the clients dietary intake of potassium. What should the nurse recommend? A. Apples B. Fish C. Rice D. Bananas
D. Bananas
4.6 The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem dysfunction? A. Hyperthermia B. Tachycardia C. Hyertension D. Bradypnea
D. Bradypnea
6.3 A client has been admitted to the neurological ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection and removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A. Gag reflex B. Deep tendon reflexes C. Abdominal girth D. Hearing acuity
A. Gag reflex
2.3 The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? (Select all that apply) A. Intracranial Hemorrhage B. Infection of cerebrospinal fluid C. Increased ICP D. Focal neurologic signs E. Altered pituitary function
A. Intracranial Hemorrhage C. Increased ICP D. Focal neurologic signs E. Altered pituitary function
3.2 A client with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus on? (Select all that apply) A. Pain control B. Management of treatment complications C. Interpretation of diagnostic tests D. Assistance with self care E. Administration of treatments
A. Pain control B. Management of treatment complications D. Assistance with self care E. Administration of treatments
2.9 A 25-year old female client with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the client is not receiving treatment for her brain metastases, what is the nurses most appropriate action? A. Promoting the clients functional status and ADL's B. Ensuring that the client receives adequate palliative care C. Ensuring that the family does not tell the client that her condition is terminal D. Promoting adherence to the prescribed medication regimen
B. Ensuring that the client receives adequate palliative care
3.8 An adult client has requested a "do not resuscitate" (DNR) order in light of his recent diagnosis with late-stage pancreatic cancer. The clients son and daughter-in-law are strongly opposed to the clients request. What is the primary responsibility of the nurse? A. Perform a "slow code" until a decision is made. B. Honor the request of the client. C. Contact a social worker or mediator to intervene. D. Temporarily without nursing care until the physician talks to the family.
B. Honor the request of the client.
5.2 A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the clients nutritional needs as quickly as possible. B. Initiating the infusion slowly and monitoring the clients fluid and glucose tolerance. C. Changing the rate of administration every 2 hours based on serum electrolyte values. D. Increasing the rate of administration at mealtimes to mimic the circadian rhythm of the body
B. Initiating the infusion slowly and monitoring the clients fluid and glucose tolerance.
5.8 A nurse is reviewing the trend of a clients scores on the Glasgow Come Scale (GCS). This allows the nurse to gauge what aspect of the clients status? A. Reflex activity B. Level of consciousness C. Cognitive ability D. Sensory involvement
B. Level of consciousness
4.2 The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD? A. Development of an atrial-septal defect B. Myocardial Ischemia C. Formation of a pulmonary embolism D. Release of potassium ions from cardiac cells
B. Myocardial Ischemia
1.4 The nurse is providing discharge teaching for a client who developed a pulmonary embolism after total knee replacement. The client has been converted from heparin to sodium warfarin anticoagulant therapy. What should the nurse teach the client? A. Warfarin will continue to break up the clot over a period of weeks. B. Warfarin must be taken concurrent with ASA to achieve anticoagulation C. Anticoagulant therapy usually lasts between 3 and 6 months D. He should take a vitamin supplement containing vitamin K
C. Anticoagulant therapy usually lasts between 3 and 6 months
2.6 The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A. Epistaxis B. Periorbital edema C. Bruising over the mastoid D. Unilateral facial numbness
C. Bruising over the mastoid
4.9 The nurse in the medical ICU is caring for a client who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the client have that could cause inadequate ventilation? A. Endocarditis B. Multiple myeloma C. Guillain -Barré syndrome D. Overdose of amphetamines
C. Guillain -Barré syndrome
4.10 The nurse is creating a plan of care for a client with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this client? A. Absence of complications B. Adherence to the self-care program C. Improved cardiac output D. Increased activity tolerance
C. Improved cardiac output
1.3 A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client is kidney disease partially loses the ability to regulate changes in pH. "What is the cause of this partial inability? A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B. The kidneys buffer acids through electrolyte changes C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH
C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH
4.8 The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding? A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury C. This is an accurate indicator of myocardial injury D. This results indicates muscle injury, but does not specify the source
C. This is an accurate indicator of myocardial injury
4.4 A nurse is admitting a client diagnosed with late-stage gastric cancer. The clients family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the clients late diagnosis? A. Gastric cancer does not cause signs and symptoms until metastasis has occurred. B. Adherence to screening recommendations for gastric cancer is exceptionally low. C. Early symptoms of gastric cancer are usually attributed to constipation. D. The early symptoms of gastric cancer are usually not alarming or highly unusual.
D. The early symptoms of gastric cancer are usually not alarming or highly unusual.
3.1 The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10 point scale C. Measuring the clients heart rhythm at least every 6 hours D. Monitoring the clients level of consciousness each shift
A. Checking the client's capillary blood glucose levels regularly
5.4 The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? (Select all that apply) A. Confusion B. Shortness of breath C. Numbness and tingling in the extremities D. Chest pain E. Bradycardia F. Diuresis
A. Confusion E. Bradycardia
1.5 A gerontological nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? A. The effects of brain tumors are often attributed to the cognitive effects of aging. B. Brain tumors in older adults do not normally produce focal effects. C. Older adults typically have numerous benign brain tumors by the eighth decade of life D. Brain tumors cannot normally be treated in clients over age 75
A. The effects of brain tumors are often attributed to the cognitive effects of aging.
1.9 The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he does not have any pain. What would be the nurses best response? A. "Taking an aspirin every day is an easy way to help restore the normal function of your heart" B. "An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attack" C. "Taking an aspirin every day is a simple way to make your blood penetrate your heart more freely" D. "An aspirin a day eventually helps your blood carry more oxygen that it would, otherwise"
B. "An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attack"
4.5 A 69-year old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? (Select all that apply) A. Obtain a blood type and cross-match B. Administer antipyretics as prescribed C. Perform frequent neurological assessments D. Monitor pain levels and administer analgesics E. Place the client in positive pressure isolation
B. Administer antipyretics as prescribed C. Perform frequent neurological assessments D. Monitor pain levels and administer analgesics
6.5 A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT from occurring? A. Placing the client on a fluid restriction as prescribed B. Applying thigh-high elastic stockings C. Administering an antifibrinolytic agent D. Assisting the client with passive range-of-motion (PROM) exercises
B. Applying thigh-high elastic stockings
1.1 A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planning in light of the possibility of what potential complications? (Select all that apply) A. Malignant Hyperthermia B. Atelectasis C. Pneumonia D. Hemorrhage E. Chronic Gastritis
B. Atelectasis C. Pneumonia D. Hemorrhage (Debate about A. Malignant Hyperthermia)
1.7 A client with gastric cancer has been scheduled for a total gastrectomy. During the pre-operative assessment, the client confides in the nurse that she feels like she will be "mutilated by the surgery". The nurse should plan interventions that address what nursing diagnosis? A. Disturbed Body Image related to surgery B. Deficient Knowledge related to risks and expectations of surgery C. Anxiety related to surgery D. Chronic Low Self-Esteem related to surgery
B. Deficient Knowledge related to risks and expectations of surgery
1.8 A client is receiving the first of two prescribed units of PRBC's. Shortly after the initiations of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurses priority action? A. Position the client in high fowlers B. Discontinue the transfusion C. Auscultate the clients lungs D. Obtain a blood specimen from the client
B. Discontinue the transfusion
1.6 Fresh frozen plasma (FFP) has been prescribed for a hospital client. Prior to the administration of this blood product, the nurse should prioritize what client education? A. Infection risks associated with FFP administration B. Physiologic functions of plasma C. Signs and symptoms of a transfusion reaction D. Strategies for managing transfusion-associated anxiety
C. Signs and symptoms of a transfusion reaction
6.2 A patient with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the clients admission (TPN) has been started. Why should the nurse start the infusion of TPN slowly? A. Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C. Malnourished clients who receive fluids too rapidly are at risk for hypernatremia. D. Clients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate.
B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
2.5 A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities
B. Neck flexion produces flexion of knees and hips
2.7 The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBC's) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate intervention? A. Notify the clients health care provider B. Stop the transfusion immediately C. Remove the clients IV access D. Assess the clients chest sounds and vital signs
B. Stop the transfusion immediately
1.10 A client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the clients level of anxiety. Which of the following actions is most likely to accomplish this? A. The nurse gauges the clients response to hypothetical outcomes. B. The client is encouraged to express fears openly. C. The nurse provides detailed and accurate information about the disease. D. The nurse closely observes the clients body language.
B. The client is encouraged to express fears openly.
5.5 A client has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the clients asks the nurse how treatment is decided upon. What would be the nurses best response? A. "The type of treatment depends on the clients age and health status". B. "The type of treatment depends on what the client wants when given the options". C. "The type of treatment depends on the cell type of cancer, the stages of the cancer, and the clients health status". D. "The type of treatment depends on the discussion between the client and the physician of which treatment is best"
C. "The type of treatment depends on the cell type of cancer, the stages of the cancer, and the clients health status".
3.6 The nurse planning the care of a client with head injuries is addressing the clients nursing diagnosis of "sleep deprivation". What action should the nurse implement? A. Administer a benzodiazepine at bedtime each night? B. Do not disturb the client between 2220 and 0600 C. Cluster overnight nursing activities to minimize disturbances. D. Ensure that the client does not sleep during the day.
C. Cluster overnight nursing activities to minimize disturbances.
6.4 A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the clients complaints of headache? A. Initiating a patient-controlled analgesia (PCA) of morphine sulfate B. Administering hydromorphone IV as needed C. Dimming the lights and reducing stimulation D. Distracting the client with activity
C. Dimming the lights and reducing stimulation
5.10 A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer? A. Promotion of nutrient-dense, low-fat diet B. Annual screening of endoscopy for clients over 50 with a family history of esophageal cancer C. Early diagnosis and treatment of gastroesophageal reflux disease D. Adequate fluid intake and avoidance of spicy foods
C. Early diagnosis and treatment of gastroesophageal reflux disease
2.2 A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects the client is experiencing dumping syndrome. What interventions is the most appropriate? A. Stop the tube feed and aspirate stomach contents. B. Increased the hourly feed rate so it finishes earlier C. Keep the client in semi-fowler position for 1 hour after feedings. D. Administer fluid replacement by IV.
C. Keep the client in semi-fowler position for 1 hour after feedings.
5.3 A nurse is preparing to administer a patient's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurse's best action? A. Recognize this as an expected finding. B. Place the bag in a warm environment for 30 minutes. C. Shake the bag vigorously for 10 to 20 seconds. D. Contact the pharmacy to obtain a new bag of PN.
D. Contact the pharmacy to obtain a new bag of PN. Feedback: Before PN infusion is administered, the solution must be inspected for separation, oily appearance (also known as a "cracked solution"), or any precipitate (which appears as white crystals). If any of these are present, it is not used. Warming or shaking the bag is inappropriate and unsafe.
4.1 A patient is being treated with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has fluid volume deficit. What electrolyte imbalance is occurring? A. Hyponatremia B. Hypomagnesemia C. Hypophosphatemia D. Hypercalemia
D. Hypercalemia
1.2 Which of the following is the most plausible nursing diagnosis for a client whose treatment for colon cancer has necessitated a colostomy? A. Risk for Unstable Blood Glucose due to changes in digestion and absorption B. Unilateral Neglect related to decreased physical mobility C. Risk for Excessive Fluid Volume related to dietary changes and changes in absorption D. Ineffective Sexuality Patterns related to changes in self-concept
D. Ineffective Sexuality Patterns related to changes in self concept
2.4 A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolytes
D. Maintaining fluid and electrolytes
2.8 A client diagnosed with cancer of the lung has just been told he has metastases to the brain. What change in health status would the nurse attribute to the clients metastatic brain disease? A. Chronic pain B. Respiratory distress C. Fixed pupils D. Personality changes
D. Personality changes
2.10 A clients large bowel obstruction has failed to resolve spontaneously and the clients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this client? A. Administering bowel stimulants as prescribed B. Administering bulk forming laxatives as prescribed C. Performing deep palpation as prescribed to promote peristalsis D. Preparing the client for surgical bowel resection
D. Preparing the client for surgical bowel resection
5.7 A client in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter should the nurse monitor most closely on a client who is postoperative following an embolectomy? A. Lung function testing B. Pressure in the vena cava C. White blood cell differential D. Pulmonary arterial pressure
D. Pulmonary arterial pressure
3.10 An older adult client with heart failure in being discharged home on an ACE inhibitor and a loop diuretic. The clients most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient's subsequent care, what nursing diagnosis should be identified? A. Risk for ineffective tissue perfusion related to dysrhythmia B. Risk for fluid volume excess related to medication regimen C. Risk for ineffective breathing pattern related to hypoxia D. Risk for falls related to hypotension
D. Risk for falls related to hypotension
3.5 The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurses most appropriate response? A. Administer sublingual nitroglycerin to allow the client to finish the test. B. Initiate cardiopulmonary resuscitation. C. Administer analgesia and slow the test. D. Stop the test and monitor the client closes.
D. Stop the test and monitor the client closes.