Med-Surg Practice Questions

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Which response by the nurse would be most appropriate to the client comment "I know I won't feel as much pain with this knee surgery as I did with the other one when I was 20 years younger"? a. "You are most likely correct." b. "It should not be quite as bad with the newer technology." c. "You need to consider that you are getting older, and might experience more pain." d. "Your pain response might be the same, since one's pain sensitivity does not decrease with age."

Correct answer: d Rationale: There is no evidence that normal aging decreases sensitivity to pain. This is a common misconception. The client did not anticipate feeling as much pain compared with a prior surgery, but the nurse needs to explain this concept.

A client presents to her gynecologist's office as follow-up to a tumor found in her left breast. Today the client will be undergoing a procedure to remove part of the large tumor by cutting through the skin. Which procedure will this client be having done today? Hint: Table 14-9 Surgical Diagnostic Procedures Answer Choices: 1. A fine-needle biopsy 2. A needle core biopsy 3. An incisional biopsy 4. An excisional biopsy

Answer: 3 Rationale: A fine-needle biopsy uses a very thin needle to aspirate a small amount of tissue from the tumors. A needle core biopsy uses a slightly larger needle than that used for a fine-needle biopsy to extract a small amount of tissue from tumors that cannot be aspirated by fine-needle aspiration. An incisional biopsy is the removal of part of a larger tumor by cutting through the skin. An excisional biopsy is the removal of an entire tumor through operation.

A nursing student is learning about the theories of carcinogenesis. Which statement by the nursing student indicates the need for further teaching? 1. "Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics." 2. "Inherited cancers can become inactive by deletion or mutation." 3. "The theory of cellular mutation suggests that carcinogens cause mutations in cellular RNA." 4. "Known carcinogens include viruses, drugs, hormones, and chemical and physical agents."

Answer: 3 Rationale: Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics. Inherited cancers can become inactive by deletion or mutation. The theory of cellular mutation suggests that carcinogens cause mutations in cellular DNA, not RNA. Known carcinogens include viruses, drugs, hormones, and chemical and physical agents.

The nurse would report to the physician which of the following laboratory values for a client newly diagnosed with AIDS? Select all that apply. 1. CD4 cell count 344/mm3 2. T4 cell count 150 3. WBC 6,500 4. CD4 lymphocytes 12% 5. Viral load 11,500 copies/mL

Answers: 1; 2; 4; 5 Rationale: The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 call count is greater than 1,000/mm3 . All of the labs are abnormal except for the WBC, which was within normal range (4,500-10,000).

A new-to-practice nurse is caring for a client who suffered a blast injury to the eye. Which nursing intervention, performed by this new-to-practice nurse, would require follow-up by the preceptor? Hint: Disaster-Related Eye Injuries Answer Choices: 1. The nurse encourages the client to rub the eye to get out specks of dust. 2. The nurse uses eyewash to flush the client's eye. 3. The nurse stabilizes the eye with a rigid shield. 4. The nurse tapes a plastic bag full of crushed ice to the client's forehead.

Answer: 1 Rationale: Clients should be cautioned not to rub the eye that has specks of dust or debris in it. They should instead use eyewash, flushing the eye with copious amounts of water. The eye should be stabilized with a rigid shield without pressure. A plastic bag full of crushed ice can be taped to the forehead to rest gently on the injured eye.

A nurse is working during a routine, scheduled disaster drill. The nurse is reviewing the stages and phases of a disaster with a new-to-practice nurse. Which answer choice, if provided by this new-to-practice nurse, correctly lists the order of the stages of a disaster? Answer Choices: 1. The nondisdaster stage, the predisaster stage, the impact stage, the emergency stage, and the reconstruction stage 2. The predisaster stage, the nondisaster stage, the impact stage, the emergency stage, and the reconstruction stage 3. The emergency stage, the predisaster stage, the nondisaster stage, the emergency stage, and the reconstruction stage 4. The impact stage, the nondisaster stage, the predisaster stage, the emergency stage, and the reconstruction stage

Answer: 1 Rationale: The five stages of disaster preparedness are the nondisaster or interdisaster stage, the predisaster stage, the impact stage, the emergency stage, and the reconstruction or rehabilitation stage.

A client presents to the ED (Emergency Department) after sustaining a penetrating wound to the neck. The client is dyspneic and cyanotic, and has evidence of subcutaneous emphysema. What does the nurse expect the physician to do initially? 1. Intubate the client because of the severe wound. 2. Notify the next of kin regarding the client's condition. 3. Order x-rays of the lumbar area to assess for fractures. 4. Administer a beta blocker to alleviate the sympathetic response.

Answer: 1 Rationale: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, or air bubbling from the wound. The key is early identification of the need for intubation before the client has no airway at all. The physician will do all of the options in the question; however, the most important is to maintain the airway.

The client reports to the Emergency Department with signs of drug use. The client reports having ingested "mellow yellows." Which of the following medications will be indicated to manage a potential overdose? 1. Narcan 2. Diazepam 3. Haldol 4. Vitamin B12

Answer: 2 Rationale: "Mellow yellows" are a type of hallucinogen. Diazepam can be prescribed to manage signs of an overdose. Narcan is used to treat an overdose of opiates. Haldol can be administered to manage an overdose of phenocyclidine piperidine (PCP). Vitamin B12 is used to manage the neurologic symptoms that might accompany a nitrate overdose.

The nurse needs to change a dressing on the client's abdomen. Which of the following techniques should be implemented? 1. Contact precautions 2. Standard precautions 3. Droplet precautions 4. Airborne precautions

Answer: 2 Rationale: Standard precautions are used on all clients, regardless of whether they have a know infectious disease. Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids. Since the client has an abdominal dressing, the nurse will use standard precautions.

A client with HIV states "I don't think I am going to live much longer. I feel so bad." The nurse determines that which of the following would be the best response? 1. "You will be fine; you just need to let the medication have a chance to work." 2. "It must be very difficult for you right now dealing with your diagnosis." 3. "You need to be more positive about your diagnosis because it will improve your chances of surviving this disease." 4. "Try not to be negative. You need to give yourself some time to feel better about your diagnosis."

Answer: 2 Rationale: The nurse should be realistic with the client. The nurse cannot give false reassurance or false hope about a terminal illness. It is important for the nurse to express empathy for the client.

The nurse is caring for a client with thinning of the nails. Which test result would most likely be the reason for this nail disorder? 1. A low pulse ox 2. A low hemoglobin 3. A low serum albumin 4. A low white blood cell count

Answer: 3 Rationale: Thinning of the nails in seen in nutritional deficiencies. Trauma to the nails usually causes thickening. Other causes of thick nails include psoriasis, fungal infections, and decreased peripheral vascular blood supply.

A client presents to a major trauma center for evaluation after being struck by a car while riding a bicycle. Identify the sequence of interventions for a rapid assessment that should be completed on the client. 1. Assessment of level of consciousness (LOC) and pupillary function 2. Assessment of obvious injuries 3. Assessment of the airway, using the jaw thrust or chin lift maneuver 4. Assessment of family support for client 5. Assessment of circulation, including pulses, skin color, and the temperature of the skin

Answer: 3, 5, 1, 2, 4 Rationale: Many different methods help healthcare providers determine the seriousness of the client's injuries and the potential for survival. A rapid but comprehensive trauma assessment, completed on the scene, includes airway and breathing assessment first; circulation assessment to palpate peripheral and central pulses; assessment of capillary refill, skin color, and temperature, and identification of any external sources of bleeding. Level of consciousness and papillary function should be assessed as well. Once the nurse determines that the ABCs have been assessed, then the nurse can continue to assess for any obvious injuries.

A nurse is concerned about potential substance abuse by a coworker. Which of the following behaviors warrants further investigation? 1. The nurse in question frequently requests the largest patient care assignment for the shift. 2. The nurse in question prefers not to be the "medication nurse" on the shift. 3. The nurse in question declines to take scheduled breaks. 4. The nurse in question frequently wastes medications.

Answer: 4 Rationale: Excessive medication wasting could be a sign that a nurse is using or diverting drugs. The nurse might be wasting erroneous amounts of medications. The nurse who is unable or unwilling to manage a patient care assignment could be a substance abuser. Taking frequent or lengthy breaks might signal substance abuse.

A nursing student is studying the functions of the skin. Which statement by the nursing student indicates the need for further teaching? Answer Choices: 1. "The epidermis protects tissues from physical, chemical, and biologic damage." 2. "The dermis regulates body temperature by dilating and constricting capillaries." 3. "The eccrine sweat glands regulate body heat by excretion of perspiration." 4. "The apocrine sweat glands cushion the scalp and provide insulation in cold weather."

Answer: 4 Rationale: The epidermis protects tissues from physical, chemical, and biologic damage. The dermis regulates body temperature by dilating and constricting capillaries. The eccrine sweat glands regulate body heat by excretion of perspiration. The apocrine sweat glands are a remnant of the sexual scent gland. Hair cushions the scalp and provides insulation in cold weather.

The nurse is assisting an 18-year-old female client to plan a healthy diet to support recent weight loss. Which of the following should be included in the dietary plan? Select all that apply. a. 200 mg folic acid are recommend in the daily diet. b. Eat at least six servings of grains. c. To avoid constipation, keep daily iron intake below 21 mg. d. Fat intake should be limited to less than 30% of the daily caloric intake.

Answer: b; d Rationale: Grain intake should include at least six servings daily. To maintain a healthy weight and reduce incidence of cardiovascular disease, fat intake should not exceed 30% of the daily intake. Folic acid intake should be at 400 mg daily. Iron is a vital ingredient in the daily diet. 18 mg daily is reflective of the desired amount. Constipation should be managed by an adequate fluid and fiber intake.

When evaluating the laboratory values of the burn-injured client, which of the following can be anticipated? a. Elevated hemoglobin and elevated hematocrit levels b. Elevated hemoglobin and decreased hematocrit levels c. Decreased hemoglobin and decreased hematocrit levels d. Decreased hemoglobin and elevated hematocrit levels

Answer: d Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration and fluid shifts from the intravascular compartment.

The physician has prescribed isotretinoin (Accutane) to a female client. Which of the following should be included in the instructions to the client? Select all that apply. 1. Take pills on an empty stomach to avoid nausea and vomiting. 2. Avoid prolonged exposure to sunlight. 3. Use a reliable form of contraception one month prior to and during use of the medication.. 4. Avoid the use of vitamin A supplements. 5. Use caution when driving at night.

Answers: 2; 4; 5 Rationale: The medication could cause hypersensitivity to sun. Vitamin A supplements are to be avoided, as they might increase the effects of the medication. The medication could reduce night vision, so caution is recommended. The medication should be taken with meals. The use of two reliable methods of contraception is needed the month prior to, during, and one month after use of the medication.

A client is receiving a narcotic for severe acute pain. Which of the following should the nurse encourage the client to consume on a greater level due to the pain medication? a. Vitamin D b. Fiber c. Protein d. Carbohydrates

Correct answer: b Rationale: Clients who are administered narcotics are a risk for constipation. Increasing fiber in the diet will help to decrease this effect. Increasing vitamin D, protein, and carbohydrates is not needed specifically related to the effect of a narcotic medication.

A nursing student is learning about integumentary changes in the elderly. Which change is expected in an older adult? 1. A decrease in abdominal fat 2. An increase in perfusion 3. A decrease in vitamin D production 4. An increase in vasomotor response

Answer: 3 Rationale: In the elderly, there will be an increase in abdominal fat due to the redistribution of adipose tissue. There will be a decrease in perfusion of the dermis. There will be a decrease in vitamin D production of the epidermis. There will be a decrease in the vasomotor response of the dermis.

A formerly homeless client has been treated for alcoholism. The client's physical examination reveals the client is underweight and malnourished. Which of the following medications prescribed by the physician is intended to manage the client's nutritional status? 1. Folic acid 2. Magnesium sulfate 3. Methadone 4. Sertraline (Zoloft)

Answer: 1 Rationale: Folic acid may be prescribed to manage the alcoholic client's nutritional imbalances and correct the associated vitamin deficiencies. Magnesium sulfate is used to control seizures. Methadone is prescribed to manage heroin cravings. Sertraline (Zoloft) is used to reduce anxiety and stabilize the mood.

When assessing a client who presents with a pituitary disorder, for which of these clinical manifestations should the nurse evaluate the client? 1. Enlargement of the hands and feet 2. Smooth, silky hair 3. Facial hair growth 4. Purple striae over the trunk

Answer: 1 In the client experiencing a pituitary disorder such as acromegaly, there might be enlargement of the hands and feet. Smooth silky hair and hirsutism are associated with hyperthyroidism. Purple striae are associated with an adrenal disease such as Cushing's disease.

The physician has ordered for the nurse to obtain a sputum specimen. The nurse understands that the sputum specimen should be collected: 1. Immediately after the first dose of antibiotic is administered. 2. 30 minutes after the first dose of antibiotics is administered. 3. During the first dose of antibiotics. 4. Before the first dose of antibiotics is administered.

Answer: 4 Rationale: When the physician orders a specimen to be collected, the nurse should collect the specimen before the first dose of antibiotics is administered to ensure adequate organisms for culture.

You are the nurse caring for four clients on a medical-surgical unit. Evaluate the order of assessing these clients. 1. A male who was in an MVC four days ago who is preparing for discharge 2. A female restrained passenger in an MVC three days ago, who is receiving treatment for burns on 20% of her right leg 3. A male client admitted yesterday from an MVC who complains of severe pain in the chest when he takes a deep breath 4. A client admitted 24 hours ago for observation after a neck injury who complains to the nurse about numbness in the left arm

Answer: 4, 3, 2, 1 Rationale: The nurse should always assess the client's based on the ABCs (airway, breathing, and circulation). The nurse should always assess the client with possible airway problems. The client with a neck injury with numbness in the left arm could be a severe problem because this could represent a circulation problem. All of these clients will require the nurse to carry out a rapid assessment. The client being discharged will require extensive education; therefore, the nurse should assess clients in distress prior to seeing a client preparing for discharge.

The client who has suffered a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the client? a. Morphine 10 mg IM q.3-4h. b. Morphine 4 mg IV q.5m. c. Meperidine 75 mg IM q.3-4h. d. Meperidine 50 mg PO q.3-4h.

Answer: b Rationale: Morphine is preferred over meperidine for the burn-injured client. The intravenous route is preferred over oral and intramuscular routes.

Each client's response to pain may be influenced by multiple factors. Select all that apply: a. Age b. Past experience with pain c. Cultural influences d. Knowledge

Correct Answers: a; b; c; d Rationale: All factors listed can influence a client's response to pain.

A client with AIDS is taking an antiretroviral medication. The client complains of nausea, fever, severe diarrhea, and anorexia. Which of the following medications would be the most effective to relieve the anorexia, as well as to stimulate the client's appetite? 1. Megestrol (Megace) 2. Ciprofloxacin (Cipro) 3. Zidovudine (Retrovir, AZT) 4. Abacavir (Ziagen)

Answer: 1 Rationale: Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client's appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.

A 45-year-old client voices concerns about gaining 12 pounds over the past two years. The client reports no change in dietary habits. Which response by the nurse is most appropriate? a. "Age-related changes in metabolism can result in weight gain despite consistent dietary intake." b. "Are you exercising?" c. "You might be eating more than you think." d. "You are getting older."

Answer: a Rationale: A reduction in metabolic rate often accompanies aging. This will cause weight gain despite not eating more calories. Asking the client about exercise fails to provide the needed information to the client. It also assumes the client is sedentary. Implying the client is overeating is judgmental, and will do little to establish a therapeutic rapport. The client is aware of aging. Pointing this out does little to meet the client's obvious interest in more information.

An African-American male is discussing his dietary intake with the nurse. The nurse encourages the client to keep sodium intake below 1,500 mg per day. The client reports he does not have any known risk for the development of hypertension and feels this is too restrictive. How should the nurse respond? a. "African-Americans typically have higher sodium levels than their Caucasian counterparts." b. "This is the amount of sodium intake recommended for everyone." c. "This is what will be best for you." d. "Do you eat a great deal of salt?"

Answer: a Rationale: After generations of conditioning, African-Americans frequently have higher sodium levels. The recommended sodium intake for African-Americans is slightly lower than are the levels for their Caucasian peers. Simply telling the client the recommendation is "best" does not provide an adequate level of information. The amount of salt ingested by the client should be recorded, but this is not the best response.

A patient who had been in a house fire is experiencing a productive cough. What color should the nurse expect the patient's sputum to exhibit? 1. Ye 1. Yellow 2. White 3. Black 4. Red

Answer:3 1. Yellow and yellowish-green sputum are associated with bacterial infections. 2. White sputum most often is associated with viral infections. 3. Black sputum is associated with exposure to a fire because of the inhalation of smoke. 4. Red sputum reflects blood in the sputum (hemoptysis), which is associated with conditions such as pneumococcal pneumonia and pulmonary edema.

A client is admitted with hypokalemia. Which medication that the client has been prescribed might have contributed to this problem? a. Thiazide diuretic b. Narcotic c. Corticosteroid d. Muscle relaxer

Correct answer: C Rationale: Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics.

A client has returned to the unit following surgery. The nurse knows that which intervention will provide the most pain relief for the client? a. Offer pain relief before the client complains of pain. b. Wait until the client can describe the pain specifically. c. Assess the pain level every four hours around the clock. d. Allow the client to "sleep off" the anesthesia, and then offer pain medication.

Correct answer: a Rationale: Anticipating a client's pain will ensure a more manageable pain experience than will waiting until the client complains of pain. Pain management need to be implemented prior to the client describing specific postoperative pain, or "sleeping off" anesthesia. If the client is asleep, she should not be awakened simply to assess the pain every four hours unless there are other significant nonverbal signs during sleep that indicate the client is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

Pain can be managed by classes of medications. Which class is also used to treat migraine headaches? a. Antidepressants b. Local anesthetics c. Anticonvulsants d. Narcotics

Correct answer: c Rationale: Some seizure medications are effective with peripheral pain, such as with migraine headaches. This is a type of neuropathic pain, and can be treated with an anticonvulsant.

The nurse is caring for four clients on a medical-surgical unit. Which client should the nurse see initially? 1. A client admitted with hepatitis A who has had severe diarrhea for the last 24 hours 2. A client admitted with pneumonia who is has small amounts of yellow productive sputum 3. A client admitted with fever of unknown origin (FUO) who has been without fever for the last 48 hours 4. A client admitted with a wound infection whose WBC is 8,500 mm3

Answer: 1 Rationale: The nurse must decide which client should be seen on the initial rounds of the day. The nurse must remember that the first client to be seen should be the client who needs the attention of the nurse initially. A client with hepatitis A does experience diarrhea, but diarrhea for the last 24 hours could cause the client to have a problem with dehydration and experience a state of fluid volume deficit.

When performing an endocrine assessment on a client, the nurse asks the client if she has experienced weight changes. Evaluating weight changes might provide the nurse with data about which endocrine systems? Select all that apply. 1. Adrenal gland 2 Thyroid gland 3. Parathyroid gland 4. Pituitary gland 5. Gonads

Answer: 1; 2; 4 In adrenal, thyroid, and pituitary disease, the client's weight changes might provide information as to the endocrine disorder the client is experiencing. The client might gain weight with an adrenal disorder such as Cushing's disease, or thyroid disease such as hypothyroidism or hyperthyroidism. The pituitary gland controls ADH, which influences the renal tubules to absorb water. The parathyroid gland regulates calcium and phosphorous, whereas the gonads influence estrogen and androgens.

The physician has ordered for the client to receive a trough blood level to evaluate the therapeutic effect of an antibiotic. The nurse understands that the trough should be ordered: 1. A few minutes before the next scheduled dose of medication. 2. 1-2 hours after the oral administration of the medication. 3. 30 minutes after the IV administration. 4. During the infusion of the antibiotic.

Answer: 1 Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range—the minimum and maximum blood levels at which the drug is effective—is known for a given drug. By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough (usually a few minutes before the next scheduled dose), it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.

A nurse is working during a routine, scheduled disaster drill. The nurse is reviewing the stages and phases of a disaster with a new-to-practice nurse. Which answer choice, if provided by this new-to-practice nurse, correctly lists the order of the stages of a disaster? 1. The nondisdaster stage, the predisaster stage, the impact stage, the emergency stage, and the reconstruction stage 2. The predisaster stage, the nondisaster stage, the impact stage, the emergency stage, and the reconstruction stage 3. The emergency stage, the predisaster stage, the nondisaster stage, the emergency stage, and the reconstruction stage 4. The impact stage, the nondisaster stage, the predisaster stage, the emergency stage, and the reconstruction stage

While conducting a home health care visit, the nurse is asked to administer insulin to the client's ailing husband. What action by the nurse is indicated? 1. The nurse should refuse to administer the medication. 2. The nurse may agree to assist with the administration of the insulin this time only but should caution the client and family that this is not the purpose for their visit. 3. The nurse should contact the physician for the husband for an order for the medication. 4. The nurse should contact his supervisor to obtain permission to administer the medication.

Answer: 1 Rationale: The home healthcare nurse is there to care for the client. Providing nursing services for the other members of the household is not appropriate. Legal issues would preclude the nurse from providing care without an order. Making contact with the physician is not appropriate, as the client's husband is not a client of the home health agency.

The nurse is educating a group of parents about the cause of Turner's syndrome. The nurse explains to the parents that Turner's syndrome is due to a variation in chromosomal number called: 1. Monosomy. 2. Trisomy. 3. Euploidy. 4. Polyploidy.

Answer: 1 Rationale: Turner's syndrome results from the loss of a single chromosome from a pair known as monosomy. Trisomy is the gain of a single chromosome, making a total of three copies of a certain chromosome. This can result in trisomy 21, or Down syndrome. Euploidy is the presence of the normal number of 46 chromosomes, and polyploidy is the condition where more than two pairs of all of the chromosomes are present.

A client presents to the physician's office with a superficial lesion. The nurse understands that the client's physician will need to perform a test to differentiate between an infectious and inflammatory lesion. Which test would best determine this? Hint: Diagnostic Tests of the Integumentary System Answer Choices: 1. Shave skin biopsy 2. Incisional skin biopsy 3. Punch skin biopsy 4. Excisional skin biopsy

Answer: 1 Rationale: A shave skin biopsy is done to shave off superficial lesions and to differentiate infectious from inflammatory lesions. An incisional skin biopsy is done to differentiate benign lesions from skin cancers. A punch skin biopsy is done to differentiate benign lesions from skin cancer. An excisional skin biopsy also is done to differentiate benign lesions form skin cancers.

A student nurse is studying risk factors in developing cancer. Which client should this student nurse determine to have the highest risk of developing cancer? Hint: Incidence and Mortality Answer Choices: 1. An African-American man 2. A Native American woman 3. A Hispanic man 4. A Hispanic woman

Answer: 1 Rationale: African-Americans are more likely to develop cancer than is any other ethnic or racial group in the United States. Cancer incidence and mortality are lower in Native American men and women than in any other ethnic or racial group. The incidence and mortality rates for all types of cancer are 35-39 percent lower in Hispanics.

Answer: 1 Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range—that is, the minimum and maximum blood levels at which the drug is effective—is known for a given drug. By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects.

A client newly diagnosed with cancer is speaking to the nurse in the physician's office. The nurse knows that because of this new diagnosis, the client might experience different physiologic and psychologic symptoms. Which effects would the nurse consider possible physiologic or psychologic effects of cancer? Hint: Physiologic and Psychologic Effects of Cancer Answer Choices: 1. Hyperglycemia, nephrotic syndrome, and body image concerns 2. Altered taste and smell, deep vein thrombosis, and increased leukocytes 3. Hypoglycemia, grief, and anorexia-cachexia syndrome 4. Decreased intracranial pressure, isolation, and acute pain

Answer: 1 Rationale: Box 14-5 lists the physiologic and psychosocial effects of cancer. Some effects include hyperglycemia, nephrotic syndrome, body image concerns, altered taste and smell, deep vein thrombosis, decreased leukocytes, grief, anorexia-cachexia syndrome, increased intracranial pressure, isolation, and acute or chronic pain.

A client involved in a minor accident reports having used "crank" an hour ago. The client denies having used the drug before. Based upon your knowledge, what manifestations can be anticipated? 1. The client might report feelings of increased strength and intelligence. 2. The client will display increased strength and cognition. 3. The client will be drowsy. 4. The client will exhibit hallucinations and paranoia.

Answer: 1 Rationale: Crank is a form of methamphetamine. It will promote the client to feel as if she has increased strength and intelligence. These are simply the client's impressions, and are not present in reality. Drowsiness is not anticipated for this client. Hallucinations and paranoia might be seen in an individual who has been using crank for a long period of time.

A client with a history of latex allergies develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following would the nurse perform initially? 1. Administer epinephrine 1:100,000 IV per MD orders. 2. Collect a detailed history from the client regarding the history of latex allergies. 3. Teach the client regarding using a kit that contains treatment for allergic reactions. 4. Administer diphenhydramine (Benadryl) by mouth every four hours per physician's orders.

Answer: 1 Rationale: For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Intravenous epinephrine using a 1:100,000 concentrations may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.

While preparing for the discharge of an elderly, terminally ill client, the family asks for information concerning the most appropriate time to become involved with a hospice agency. What action by the nurse is most correct? 1. Assist the family with making contact with hospice at this time. 2. Determine the client's expected life expectancy to gauge when the contact should be made. 3. Encourage the family to "hold off" making the contact until death is very close. 4. Determine what expectations the family has of the hospice agency.

Answer: 1 Rationale: Hospice agencies provide vital services to clients who are facing death and to their families. Information concerning available services should be met with facts. This is an indication of willingness to embrace the supportive service. Referrals for elderly clients should be prompt. It is inappropriate to determine life expectancy. This is an inaccurate measurement of the degree of services needed. Waiting until the time of death nears does not leave much time for the hospice agency to assist the family.

The nurse is caring for a client in the ICU who sustained a traumatic injury several days ago. During the assessment, the nurse notes that the client is hypotensive, oliguric, and has cool pale skin and acidosis. The nurse understands that these manifestations are indicative of: 1. Hypovolemic shock. 2. Cardiogenic shock. 3. Septic shock. 4. Anaphylactic shock.

Answer: 1 Rationale: Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock affects all body systems. Clients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present with a client who presents with a traumatic injury. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.

The mother of a severely handicapped child states she is exhausted and voices the need to "take a break" to the nurse. What type of referral would best benefit the client? 1. A respite care provider 2. Hospice care agency 3. Home care 4. Ambulatory clinic

Answer: 1 Rationale: Individuals who are faced with caring for ill or handicapped family members might need to have a "break." The best option would be for a respite care provider. Respite care offers short in-home services in which the care provider would be freed from her duties for a short time. Hospice care is designed to assist the dying client and family members. Home health care is best for clients who are unable to leave their home for care services. Ambulatory clinics are used for clients who are in need of limited point-of-care medical services.

A client with renal cancer is preparing for discharge. The nurse is teaching both the client and the family about when to call for help after discharge. Which statement by the client indicates that teaching has been successful? 1. "I should call my physician if I experience new bleeding from any site." 2. "I should call my physician if I have an oral temperature higher than 100.5°F." 3. "I should call my physician if I have an episode of diarrhea." 4. "I should call my physician if I experience an occasional headache."

Answer: 1 Rationale: Instruct the client or family member to call the nurse or physician if any of the following signs or symptoms occur: oral temperature higher than 101.5°F; severe headache; significant increase in pain at usual site, especially if the pain is not relieved by the medication regimen, or severe pain at a new site; difficulty breathing; new bleeding from any site; confusion, irritability, or restlessness; verbalizations of deep sadness or a desire to end life; changes in eating patterns; changes in body functioning, such as severe diarrhea or constipation; withdrawal; frequent crying; greatly decreased activity level; and the appearance of edema in the extremities or significant increase in edema already present.

A client has an area of rough, thickened, hardened epidermis. Which disorder could be the reason for this skin lesion? Answer Choices: 1. Chronic dermatitis 2. Athlete's foot 3. Earring piercing 4. Psoriasis

Answer: 1 Rationale: Lichenification is a rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing. An example of lichenification is chronic dermatitis. A fissure is a linear crack with sharp edges, extending into the dermis. Examples of a fissure include cracks at the corners of the mouth or in the hands, or those seen with athlete's foot. A keloid is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. An example of a keloid is scar tissue from ear piercing. Scales are shedding flakes of greasy, keratinized skin tissue. Examples of scales include dry skin, dandruff, psoriasis, and eczema.

The nurse is caring for a client with oculocutaneous albinism. Which statement by the nurse demonstrates a good understanding of this disorder? Answer Choices: 1. "Oculocutaneous albinism causes hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin." 2. "Oculocutaneous albinism is characterized by elevated scars, has a familial tendency, and is most commonly found in African-Americans." 3. "Oculocutaneous albinism is the sudden appearance of white patches on the skin, and has a familial tendency." 4. "Oculocutaneous albinism is an autosomal-dominant inheritance disorder that causes hyperpigmentation of the skin, hair, and eyes."

Answer: 1 Rationale: Oculocutaneous albinism is an autosomal-recessive, not -dominant, inheritance disorder. Oculocutaneous albinism causes hypopigmentation, not hyperpigmentation, of the skin, hair, and eyes as a result of an inability to synthesize melanin. Vitiligo, not oculocutaneous albinism, is the sudden appearance of white patches on the skin, and has a familial tendency. Keloids, not oculocutaneous albinism, are elevated scars, have a familial tendency and are more commonly found in African- Americans.

A client has a diagnosis of AIDS. The nurse is teaching the client regarding a diet with increased kilocalories. Which of the following diets would indicate that the client has an understanding of the appropriate diet? 1. Spaghetti and meat sauce, raisin salad, whole grain roll with butter, vanilla milkshake (with Ensure), and a piece of pecan pie 2. Baked chicken (thigh), cabbage, small green salad, slice of white bread, dried prunes, and a soda 3. Red beans and rice, slaw, tomato, crackers, chocolate pudding, and iced tea 4. Vegetable soup, small piece of cornbread, banana pudding, and water

Answer: 1 Rationale: Provide a diet high in protein and kilocalories. A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. The diet with the most kilocalories is the spaghetti and meat sauce with the vanilla milkshake made with Ensure and pecan pie.

The client is diagnosed with Huntington's disease. While at a follow-up visit with the physician, the client breaks down and questions her ability to cope with the situation. What response by the nurse will be most beneficial to the client? 1. "You are certainly facing a difficult road ahead." 2. "Unfortunately, your prognosis is bleak." 3. "How have other members of your family coped with this diagnosis?" 4. "You should contact a support group."

Answer: 1 Rationale: The client is facing a terminal illness. The illness is characterized by a continual and increasing loss of function and control. The client needs to have validation of her feelings. The client realizes the prognosis is bleak, and will not benefit from the nurse's restating the obvious. Certainly, Huntington's disease is inherited, and the client might have family members who have faced the disease, but this line of questioning will not provide comfort for the client. A support group might be helpful, but suggestions about joining should follow supportive statements by the nurse.

The home health nurse observes several small, round bruises on the back side of an elderly client's arms. What action by the nurse is indicated first? 1. Question the client about the cause of the bruises. 2. Discuss the bruises with the client's spouse. 3. Document the bruises, with plans to review them for changes on the next visit. 4. Contact the home health supervisor to report the findings.

Answer: 1 Rationale: The client should be asked about the cause of the bruises. Nurses suspecting abuse are legally required to report it. Pending the client's response, the supervisor will likely require notification. The client's spouse should not be the first contact concerning the bruises, as he might be the source of the injury. Documentation about the findings is indicated. Delaying action until the next visit does not meet the legal responsibilities of the nurse.

During a home care visit, the nurse notices the client's dressing supplies are not being kept in a readily assessable environment. The nurse has discussed this with the client and family in previous visits. What action by the nurse is indicated? 1. Document the activities relating to the situation. 2. Continue to discuss the issues each visit. 3. Notify the physician. 4. Take the supplies and arrange to bring them back with each visit.

Answer: 1 Rationale: The nurse has attempted to address the concerns with the client and family. The client's failures to make changes in routine indicate a lack of intent to change. Continued discussion likely will prove futile. There is no need to notify the physician at this time. Taking custody of the supplies, carrying them around and bringing them back each time, is not feasible for the nurse. Goals of the nurse are not necessarily shared by the client.

After suffering a massive cerebral hemorrhage, a client of American Indian descent is not expected to survive. The family arrives at the hospital. In conversation with the family, they report they observe most of their religious and cultural traditions. Which of the following interventions by the nursing staff would be most appropriate? 1. Offer the family a private room to sit together. 2. Discourage the family from sitting with their loved one prior to death. 3. Discuss the possibility of transferring the client home for the death. 4. Encourage the family to assist in the care of the dying client.

Answer: 1 Rationale: Traditional American Indians prefer to mourn in private. They often will mourn away from the dying client. While the American Indian culture might not encourage the family to be with the dying individual, it is not appropriate for the nurse to discourage the family from having time with the client at this critical point. The severity of the client's condition does not allow for transfer at this time. Traditional American Indian rituals associated with death do not encompass assistance with the care.

A client presents to the trauma center after sustaining multiple injuries. The client experienced severe blood loss prior to arriving at the trauma center. The physician has ordered for the client to receive blood immediately. The nurse understands that since there is not sufficient time for type and crossmatch, the client will therefore receive: 1. O group blood. 2. A group blood. 3. B group blood. 4. AB group blood.

Answer: 1 Rationale: Type O blood is the universal donor. ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen; these antibodies are called anti-A and anti-B. The person with blood type B has A antibodies, the person with type A has B antibodies, the person with type O has both types of antibodies, and the person with AB has no antibodies; therefore, this client is known as the universal recipient.

The nurse is caring for four clients on a medical-surgical unit. The secretary gives the nurse the morning labs. Which of the following labs would require that the nurse call the physician and inform the healthcare provider about the client's abnormalities? 1. WBC 14,600 mm3 2. Serum protein 6.9 g/dL 3. I & D (incision and drainage) showing no growth for the last 24 hours 4. Albumin 4.2 g/dL

Answer: 1 Rationale: When the nurse is caring for several clients, all of the labs should be checked frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is abnormal. (Normal WBC 4,000-10,000 mm3 .) All of the other lab results are within acceptable range; therefore, the results should not be called in to the physician.

The nurse is caring for four clients on a medical-surgical unit. The secretary gives the nurse the morning labs. Which of the following labs would require that the nurse call the physician and inform the healthcare provider regarding the client's abnormalities? 1. WBC 14,600 mm3 2. Serum protein 6.9 g/dL 3. I & D (incision and drainage) showing no growth for the last 24 hours 4. Albumin 4.2 g/dL

The nurse is assessing the client for an endocrine problem. During the health assessment interview, it is essential that the nurse obtain which data about the skin when the client is experiencing hypothyroidism? 1. Is the skin rough and dry? 2. Is the skin smooth? 3. Is the skin clammy? 4. Does the client have brown shiny patches on the lower extremities?

Answer: 1 The client experiencing hypothyroidism has rough, dry skin. Smooth skin is associated with hyperthyroidism. Cool, clammy skin is found in clients with low blood sugar. Brown shiny patches on the lower extremities are associated with poor circulation.

Which of these laboratory results would be most important for the nurse to assess in the client who has Graves' disease? 1. Thyroxine 2. Urine-specific gravity 3. Cortisol level 4. Calcium level

Answer: 1 Thyroxine (T4) is the hormone secreted by the thyroid gland. Thyroxine (T4) is converted to triiiodothyronine (T3), and both are secreted in response to thyroid- stimulating hormone (TSH). Urine-specific gravity would be measured to provide information about the posterior pituitary. The adrenal gland produces cortisol. The parathyroid gland regulates calcium and phosphorous.

A 25-year-old male presents to the trauma center after a motor vehicle collision. The nurse is assessing the client and notes the abdomen to be distended with bruising around the umbilicus. Which of the following diagnostics would the nurse anticipate the physician ordering for the client? Select all that apply. 1. CBC (complete blood count) 2. Blood type and crossmatch 3. Urine drug screen 4. Thyroid profile 5. RA factor

Answer: 1; 2; 3 Rationale: The diagnostic tests ordered once the client reaches the hospital depend on the type of injury the client has sustained. Tests that might be ordered will include blood type and crossmatching for the client's serum and donor red blood cells. Blood alcohol level and urine drug screen might be ordered to assess alcohol or drugs. Thyroid studies should always be considered, but based on the client's presenting symptoms, it is not a critical diagnostic at this time.

A nurse is performing an assessment of the client's nails. Which assessment should be included in this examination? Select all that apply. 1. Inspect nail thickness. 2. Inspect nail color. 3. Inspect nail curvature. 4. Inspect for pitting. 5. Inspect for grooves.

Answer: 1; 2; 3; 4; 5 Rationale: Nails should be inspected for color and thickness. Also, the surface of the nail should be inspected for nail folds, grooves, pitting, curvature, and inflammation.

In order to perform a physical assessment of the client experiencing an endocrine disorder, the nurse should include: (Select all that apply.) 1. Measurement of height and weight. 2. Assessment of skin, hair, and nails. 3. Evaluation of deep tendon reflexes. 4. Evaluation of the respiratory system. 5. Assessment of the musculoskeletal system.

Answer: 1; 2; 3; 5 The nurse performing an assessment of the endocrine system should inspect the skin, nails, hair, affect, reflexes, musculoskeletal system, height, and weight. The respiratory system does not influence the endocrine system.

A group of students is attending an in-service about do-not-resuscitate orders. Which of the following statements by one of the students indicate the need for further teaching? Select all that apply. 1. "Do-not-resuscitate orders are a form of euthanasia." 2. "My nursing license will not be in jeopardy if I follow do-not resuscitate orders." 3. "If a client does not have completed do-not-resuscitate orders, I can just participate in a 'slow code'." 4. "Do-not-resuscitate orders may be rescinded if the client wishes."

Answer: 1; 3 Rationale: Do-not-resuscitate orders outline the plans for a patient who stops breathing. Euthanasia refers to the process of initiating actions to cause or promote a death. The concepts are not the same. Participation in a "slow code" is malpractice. The nurse is legally bound to make every effort to revive any client who does not have valid do-not- resuscitate orders. Nurses who follow the policies of their facilities regarding the use of do-not-resuscitate orders will not face legal action. The client retains the right to change her perspective concerning their code status.

The nurse is assessing a geriatric client. Which age-related changes should the nurse expect to see in this client? Select all that apply. 1. Dry skin 2. Perspiration 3. Double chin 4. Skin tears 5. Purpura

Answer: 1; 3; 4; 5 Rationale: Dry skin is common due to a decrease in eccrine and apocrine activity. This also causes perspiration to be absent. A double chin forms from the redistribution of adipose tissue in the subcutaneous skin layer. Skin tears can be caused by a decrease in thickness of the elderly client's epidermis. Skin tears and purpura can occur due to the flattening of the dermal-epidermal junction.

The nurse is assessing a client's wound for signs and symptoms of inflammation. Which of the following would alert the nurse that the client is exhibiting signs of inflammation? Select all that apply. 1. Leg edema 2. Leg cool to touch 3. Severe pain from swelling 4. Decreased peripheral pulses 5. Severe erythema of leg

Answer: 1; 3; 5 Rationale: Regardless of the cause, location, or extent of the injury, the acute inflammatory response follows the sequence of vascular response, cellular and phagocytic response, and healing. Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged. The cardinal signs of inflammation include erythema, local heat caused by the increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of function caused by the swelling and pain.

Answer: 1; 3; 5 Rationale: Regardless of the cause, location, or extent of the injury, the acute inflammatory response follows the sequence of vascular response; cellular and phagocytic response; and healing. Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged. The cardinal signs of inflammation include erythema, local heat caused by the increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid at site, pain from tissue swelling and chemical irritation of nerve endings, loss of function caused by the swelling, and pain.

An Emergency Department nurse is working when two school buses carrying 75 children each collide in route to an out-of-state field trip. The Emergency Department nurse knows that reverse triage will need to be instituted. Which principles come under reverse triage? Select all that apply. Answer Choices: 1. When there is a mass casualty event with greater than 100 victims, reverse triage may be instituted. 2. A very basic reverse triage system is to categorize or label victims needing the most support and emergency care as red, so they can be treated first. 3. Victims most likely to survive are color-coded black, and are treated first. 4. Reverse triage works on the principle of the greatest good for the greatest number. 5. Reverse triage works on the principle of the greatest good for the most critically ill.

Answer: 1; 4 Rationale: During a disaster, nurses may be expected to perform triage. Triage means sorting. A mass casualty is an event with more than 100 victims, thus necessitating reverse triage. Victims least likely to survive or who are already dead are color-coded black. Reverse triage works on the principle of the greatest good for the greatest number.

When assessing a client with a traumatic brain injury, the nurse assesses the client for which of the following signs and symptoms that would be consistent with brain death? Select all that apply. 1. Absence of gag or corneal reflex 2. Toxic metabolic disorders 3. Response to deep stimuli 4. Absence of oculovestibular reflex 5. Apnea with PaCO2 of 66 mm Hg

Answer: 1; 4; 5 The clinical signs of brain death criteria include apnea with a PaCO2 greater than 60 mmHg, no response to deep stimuli, no spontaneous movement, no gag or corneal reflex, no oculocephalic or oculovestibular reflex, and absence of toxic or metabolic disorders. The diagnostic tests used to confirm brain death include electroencephalogram and cerebral blood flow studies.

A client who is a bone marrow transplant recipient develops a maculopapular rash on the palms of both hands and the soles of the feet. The client complains of severe abdominal pain with bloody diarrhea. The nurse would suspect that the client is experiencing: 1. Chronic tissue rejection. 2. Graft-versus-host disease. 3. Acute tissue rejection. 4. Hyperacute tissue rejection.

Answer: 2 If a transplant client develops a maculopapular pruritic rash beginning on the palms of the hands and soles of the feet, it indicates GVH (Graft-versus-host disease). The rash can spread to involve the entire body and lead to desquamation. Gastrointestinal manifestations include abdominal pain, nausea, and bloody diarrhea. GVH that lasts longer than 100 days is said to be chronic. Chronic tissue rejection occurs from 4 months to years after transplant of new tissue. Acute tissue rejection is the most common type of rejection, and occurs between 4 days and 3 months after the transplant. Acute rejection is mediated primarily by the cellular immune response, resulting in transplant cell destruction. The client experiencing rejection demonstrates manifestations of the inflammatory process, with fever, redness, swelling, elevated BUN, creatinine, lower enzymes, and elevated bilirubin and cardiac enzymes.

A teen client is brought to the Emergency Department by parents. The client's mother reports the client reported taking goofballs and hootch before refusing to communicate further. Based upon your knowledge, which of the following will be the greatest concern for this client? 1. The client will require close observation for seizure activity. 2. The client will require close observation for respiratory depression. 3. The client will require close observation for signs of withdrawal. 4. The client will require close observation for signs of hallucinations.

Answer: 2 Rationale: "Goofballs" are barbiturates. These are central nervous system depressants. "Hootch" is a street term for alcohol. Barbiturates and hootch are a lethal combination. The client who has ingested both items is at risk for varying degrees of sedation, up to coma and death. Seizure activity, signs of withdrawal, and hallucinations are not the greatest risks for this client.

A nursing coordinator is being briefed on a situation that needs special attention. A school bus transporting a local university's basketball team has just crashed in the rain on the side of the road. The bus was transporting approximately 60 people. Which classification would most closely describe the situation? Hint: Types of Disasters Answer Choices: 1. A natural disaster 2. A multiple-casualty incident 3. A manmade disaster 4. A mass-casualty incident

Answer: 2 Rationale: Disasters are typically called multiple-casualty incidents if more than 2 but fewer than 100 people are injured. Mass casualties refer to incidents where more than 100 people are injured. Natural disasters are caused by acts of nature or emerging diseases. Manmade disasters are either accidental or intentional.

An Emergency Department nurse is working when a dirty bomb detonates at a nearby shopping mall. Which types of injuries should the nurse expect to see in the victims? Hint: Types of Disasters and Common Injuries Answer Choices: 1. Fractured limbs and spinal injury 2. Radiation sickness 3. Thermal burns 4. Overexertion and exhaustion

Answer: 2 Rationale: Radiation sickness commonly occurs with a radiological dispersion bomb (dirty bomb) blast. Fractured limbs and spinal injury can occur with blunt trauma. Thermal burns occur with nuclear detonation. Overexertion and exhaustion occur in snowstorm-related injuries.

A nurse is teaching a seminar on disaster preparedness to a group of senior citizens at an assisted living facility. Which statement, if made by a client, demonstrates the need for further teaching? 1. "I need to keep a list of names and phone numbers of significant persons or relatives to be notified in a secure place in case of an emergency." 2. "I need to keep a 24-hour supply of medications and the style and serial numbers of medical devices in a secure place in case of an emergency." 3. "I need to keep a list of allergies, blood type, checkbook, credit cards, and dietary needs in a secure place in case of an emergency." 4. "I need to keep a blanket, sturdy shoes, warm clothes, hearing aids, and hearing aid batteries in a secure place in case of an emergency."

Answer: 2 Rationale: Teaching about disaster preparedness is important in all communities. A current list of medications, doses, and times of administration should be kept in an easily accessible, secure place. The names and phone numbers of significant persons, relatives, those with power of attorney, healthcare providers, or any others to be notified in case of an emergency should also be kept in an easily accessible place. Additionally, the following materials should be considered essential in keeping with the person should evacuation to a shelter be necessary: eyeglasses and eyeglass prescriptions; style and serial numbers of medical devices, such as pacemakers; healthcare policies and numbers; identification; list of allergies; blood type; checkbook; credit cards; insurance agent's name and number; driver's license; 72-hour supply of medications; dentures; list of special dietary needs; sturdy shoes; warm clothing; blankets; incontinence briefs; prostheses; hearing aids; hearing aid batteries; extra wheelchair batteries; oxygen; and other assistive devices.

An Emergency Department nurse is informed of a nearby bombing at the World Trade Center. This nurse needs to be aware of the principles of triage and decontamination. In which zone does decontamination usually occur? 1. In the hot zone 2. In the warm zone 3. In the cold zone 4. In the artic zone

Answer: 2 Rationale: The site of the disaster where a weapon was released or where the contamination occurred is called the hot zone. It is considered contaminated, and only those persons in the appropriate personal protective equipment may enter this zone. The warm zone is adjacent to the hot zone. Another name for this area is the control zone. This area is where the decontamination of victims or triage and emergency treatment takes place. The cold zone is considered to be the safe zone.

Which of these factors in the client's history is most likely related to the development of a pituitary disorder? 1. Carpal spasms 2. Dwarfism 3. An enlarged thyroid nodule 4. Hyperpigmentation of the skin

Answer: 2 Dwarfism results from insufficient growth hormone produced by the pituitary gland. Carpal spasms can indicate a parathyroid gland disorder. An enlarged thyroid nodule could be associated with a thyroid malignancy. Hyperpigmentation of the skin might be associated with an adrenal disorder such as Addison's disease or Cushing's syndrome.

The admitting department alerts the nurse on a medical-surgical unit that a client with active tuberculosis (TB) is being admitted to the unit. Which type of isolation is appropriate based on the client's diagnosis? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

Answer: 2 In addition to handwashing and standard precautions, the nature and spread of some infectious diseases require that special techniques be used to protect uninfected clients and workers. The client with pulmonary tuberculosis will be placed in airborne precautions. The client should be placed in a private room with special ventilation that does not allow air to circulate to general hospital ventilation; a mask or special filter respirators will be used for everyone entering the room.

The admitting department alerts the nurse on a medical-surgical unit that a client with active tuberculosis (TB) is being admitted to the unit. Which type of isolation should be informed based on the client's diagnosis? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

Answer: 2 In addition to handwashing and standard precautions, the nature and spread of some infectious diseases require that special techniques be used to protect uninfected clients and workers. The client with pulmonary tuberculosis will be placed in airborne precautions. The client should be placed in a private room with special ventilation that does not allow air to circulate to general hospital ventilation; mask or special filter respirators will be used for everyone entering the room.

At the time of admission, the client is asked if he has a healthcare directive. The client reports that his daughter will be allowed to make health-related decisions if he becomes incapacitated. Based upon your knowledge, the client has a/n: 1. Living will. 2. Healthcare surrogate. 3. Durable power of attorney. 4. Advanced directive.

Answer: 2 Rational: The healthcare surrogate is an individual who will make medical decisions in the event the client becomes unable to do so. The living will provides written directions about life-prolonging decisions. The power of attorney delegates the decision maker concerning business matters.

A client is admitted to the medical intensive unit after being involved in a motor vehicle collision. During the nurse's initial assessment, the client develops hypotension, and severe jugular distension with a tracheal deviation. What does the nurse suspect has occurred? 1. Hemorrhage 2. Tension pneumothorax 3. Compensatory shock 4. Hypovolemic shock

Answer: 2 Rationale: A tension pneumothorax is a special type of pneumothorax that is life- threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.

The client, age 20, dies after an unsuccessful resuscitation attempt. What nursing action is indicated first? 1. Notify the funeral home. 2. Document the time of death. 3. Contact the physician. 4. Contact the orderly for transport to the morgue.

Answer: 2 Rationale: After death, the time must be recorded in the client's record. After documentation is completed, the attending physician will require notification. Notification of the funeral home must wait pending a decision about the need for an autopsy as well as a review of the family's wishes. Transportation of the body to the morgue can take place after the family members have been notified and allowed to see their loved one.

The hospice nurse is working with the family of a 30-year-old client who is dying. The client voices concerns about how her death will be perceived by her 7-year-old child. What advice from the nurse would be most beneficial? 1. Advise the client that children that age emotionally distance themselves from the death. 2. Explain to the client that children of this age recognize death is permanent. 3. Encourage the client to begin to prepare the child by explaining that death is permanent, as the child fears separation, and might lack comprehension of permanent separation. 4. Advise the client that children at this age fear death.

Answer: 2 Rationale: Age is a great determinant of beliefs about death. Children at this age understand the finality of death. At the age of 7, children do not have the emotional maturity to distance themselves from death. The ability to understand separation has been mastered by the age of 7. The fear of death is typically seen in children this young.

A client is being treated for an elevated, darkened area of excess scar tissue. A nurse is explaining the reason for this skin lesion to a nursing student. Which statement by the nursing student indicates that teaching has been effective? Answer Choices: 1. "This scar was caused by the wearing away of the superficial epidermis, causing a moist, shallow depression." 2. "This scar was caused by excessive collagen formation during healing." 3. "This scar was caused by skin loss extending into the dermis or subcutaneous tissue." 4. "This scar was caused by wasting of the skin due to loss of collagen."

Answer: 2 Rationale: Erosion is the wearing away of the superficial epidermis, causing a moist, shallow depression. Because erosions do not extend into the dermis, they heal without scarring. A keloid is an elevated, irregular area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. Atrophy is a translucent, dry paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin.

The nurse is evaluating a group of clients for referral to a home health agency. Each of the clients is on the Medicare program. Which client is most likely to qualify for home health services? 1. The postoperative client needing reevaluated by the physician six weeks postoperatively 2. The client having a moderate-sized stage III pressure ulcer requiring daily dressing changes 3. The bedridden client who's physician has prescribed oral antibiotic therapy for two weeks 4. The client having large stage I pressure ulcer

Answer: 2 Rationale: Home care is indicated for clients for whom travel to the healthcare provider would be impossible or quite difficult. A large stage III pressure ulcer would be painful for the client during travel. Daily dressing changes would not be a typical function of the physician's office, and would ideally be completed in the home. The client requiring a postoperative assessment in six weeks does not appear to have any limitations presented. Oral antibiotic therapy does not present challenges to the client that signal the need for home care. The stage I pressure ulcer does not have skin breakdown or require professional healthcare services.

The nurse is caring for an African-American client who has a serum bilirubin of 6 mg/100 mL. What is the best way of assessing for changes in skin color in this client? Hint: Table 15-2 Skin Color Assessment Variations in People with Light and Dark Skin Answer Choices: 1. Assess the sclera. 2. Assess the palms of the hands. 3. Assess the fingernails. 4. Assess the mucous membranes.

Answer: 2 Rationale: Jaundice is the yellowish discoloration of the skin, mucous membranes, and sclera of the eyes, caused by increased amounts of bilirubin or other pigments in the blood. An increased serum bilirubin is when the value is greater than 2-3 mg/100 mL. In clients with dark skin, yellowing is best assessed at the junction of the hard palate and the soft palate, or on the palms of the hands.

The nurse is colleting data from a client regarding past alcohol use history. What question will provide the greatest amount of information? 1. Are you a heavy drinker? 2. How often do you use alcohol? 3. Drinking doesn't cause any problems for you, does it? 4. Is alcohol use a concern for you?

Answer: 2 Rationale: Open-ended questions will elicit the greatest amount of information. Asking closed questions will limit the information obtained.

A client who was a victim of rape six months ago presents to an outpatient clinic for the treatment of post-traumatic stress disorder (PTSD). Which data collected during the client's assessment would indicate a manifestation associated with PTSD? 1. The client denied anger or shock. 2. The client discussed severe nightmares related to the traumatic event. 3. The client denied the need for drug or alcohol counseling. 4. The client stated that her family is very supportive.

Answer: 2 Rationale: Post-trauma syndrome is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the client can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the client often experiences flashbacks and nightmares of the traumatic event. The client also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships.

A client diagnosed with scabies asks the nurse how he "caught" the disorder. What information should be provided to the client? 1. The disorder is transmitted by the feces of infected animals. 2. The disorder is transmitted by contact with infected persons or their possessions. 3. Scabies is a bacterial infection transmitted by direct contact with infected persons. 4. Scabies is a fungal infection transmitted by contact with infected respiratory secretions.

Answer: 2 Rationale: Scabies is the result of infestation of the itch mite. It is transmitted via contact with infected people or their contaminated articles. Scabies is a parasitic disorder. It is not bacterial, viral, or fungal.

Answer: 2 Rationale: Standard precautions are used on all clients, regardless of whether they have a known infectious disease. Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids. Since the client has an abdominal dressing, the nurse will use standard precautions.

A postoperative client is preparing for discharge. A home health nurse has been scheduled to call on the client in two days. The client tires easily and voices an inability to concentrate on all of the information the nurse is attempting to review. Which of the subjects concerning the client's condition and home care may be deferred for the home health nurse? 1. The recommended diet after discharge 2. The activities that will take place during the four-week checkup with the physician 3. Potential adverse reactions of the prescribed medications 4. The actions of the prescribed medications

Answer: 2 Rationale: The client must be discharged with the needed information to safely manage until the home healthcare nurse has the first visit in two days. Information concerning prescribed medications and the recommended diet are of the greatest priority, as they will require action by the client prior to the health nurse's visit. A discussion involving activities planned four weeks in the future can wait until the client is better able to tolerate the information.

The charge nurse is preparing assignments for the shift. Two of the clients have been diagnosed with herpes zoster. When planning cares assignments, which of the following nurses should be assigned to care for these clients? 1. The nurse who is pregnant at 24 weeks' gestation 2. The nurse who had chickenpox just one year ago 3. The nurse who has never had chickenpox 4. The nurse who is in her first trimester of pregnancy

Answer: 2 Rationale: The client who has had chickenpox is the safest choice to provide care. The lesions should be avoided by all pregnant women regardless of gestation. The client who has never had chickenpox could be infected by the disorder.

Which of the following interventions would be essential for the nurse to assess first for a client admitted with severe facial injuries? 1. Assess the client's level of consciousness. 2. Assess for signs of stridor, cough, or respiratory distress. 3. Assess the need for suctioning. 4. Assess the mouth for loose teeth or obvious problems with the mouth.

Answer: 2 Rationale: The client with multiple injuries is at great risk for developing airway obstruction and apnea. All of the choices are very important; however, the most important intervention for the nurse to assess is always to make sure the airway is patent and maintainable. The nurse should assess for manifestations of airway obstruction including stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness.

A client is being seen for a problem with the eccrine sweat glands. Because of this structural problem, the nurse knows that which function will be impacted in this client? 1. Body temperature regulation 2. Regulation of body heat by excretion of perspiration 3. Sebum secretion 4. Sexual scent gland

Answer: 2 Rationale: The dermis regulates body temperature by dilating and constricting capillaries. The eccrine sweat glands regulate body heat by excretion of perspiration. Sebaceous (oil) glands secrete sebum, which lubricates skin and hair, and plays a role in killing bacteria. The apocrine sweat glands function as a remnant of the sexual scent gland.

The nurse is orienting a new graduate. The nurse is reinforcing the importance of standard precautions. Which of the following observations by the nurse would require further education regarding standard precautions? 1. The graduate nurse understands to wash hands when entering and exiting the client's room. 2. The graduate nurse wears gloves when serving breakfast trays to various clients. 3. The graduate nurse wears a gown, gloves, and goggles when suctioning a client. 4. The graduate nurse leaves all supplies in the room of a client who is in contact isolation.

Answer: 2 Rationale: The nurse must have an understanding of standard precautions. Prevention is the most important measure to prevent nosocomial infections. Standard precautions were published in 1996 that provide guidelines for the handling of blood and other body fluids. These guidelines are used with all clients, regardless of whether they have a known infectious disease. Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids. It is not necessary for the nurse to wear gloves while delivering food trays to the client, because there is not contact with the client.

The nurse is orienting a new graduate. The nurse is reinforcing the importance of standard precautions. Which of the following observations made by the nurse would require further education regarding standard precautions? 1. The graduate nurse understands to wash hands when entering and exiting the client's room. 2. The graduate nurse wears gloves when serving breakfast trays to various clients. 3. The graduate nurse wears a gown, gloves, and goggles when suctioning a client. 4. The graduate nurse leaves all supplies in the room of a client who is in contact isolation.

Answer: 2 Rationale: The nurse must have an understanding of standard precautions. Prevention is the most important measure to prevent nosocomial infections. Standard precautions were published in 1996, providing guidelines for the handling of blood and other body fluids. These guidelines are used with all clients, regardless of whether they have a known infectious disease. Standard precautions are used by all healthcare workers who have direct contact with clients or their body fluids. It is not necessary for the nurse to wear gloves while delivering food trays to the client because there is no contact with the client.

A client is admitted to the hospital with a history of squamous-cell lung cancer. Upon admission, the client exhibits signs of arm and periorbital edema. Within the hour, the client exhibits dyspnea, cyanosis, tachypnea, and an altered level of consciousness. Which action should the nurse take FIRST? 1. Call the physician. 2. Administer oxygen. 3. Monitor vital signs. 4. Initiate seizure precautions.

Answer: 2 Rationale: The superior vena cava can be compressed by mediastinal tumors or adjacent thoracic tumors. The most common cause is small-cell or squamous-cell lung cancers. Signs and symptoms can develop slowly, and include facial, periorbital, and arm edema as early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits can occur. Emergency measures include the following: Provide respiratory support with oxygen, and prepare for a tracheostomy; monitor vital signs; administer corticosteroids to reduce edema; if the disorder is due to a clot, administer antifibrinolytic or anticoagulant drugs; provide a safe environment, including seizure precautions.

A client with a history of tinea pedis reports concerns about developing the disorder again. Which of the following interventions suggested by the nurse will reduce the likelihood of a reoccurrence? 1. Begin to wear cotton undergarments 2. Wear sandal style footwear 3. Soak affected extremities in salted water nightly 4. Apply lotions to moisturize potential areas of outbreak daily

Answer: 2 Rationale: Tinea pedis is a fungal infection of the soles of the feet, toes, and toenails. The condition is chronic, and can be seen more when the feet are hot and perspire. Wearing of open-style shoes such as sandals would allow the feet to be open to air. Cotton undergarments would not impact tinea pedis. They could assist in the management of tinea corporis. Salt water is not associated with the management of tinea pedis. Lotions would increase moisture to the areas and potentially cause additional problems.

The nurse is performing an assessment on client experiencing hypoparathyroidism. While taking a blood pressure on this client, the nurse notes spasms of the hands. The nurse should document this clinical manifestation as: 1. Chvostek's sign. 2. Trousseau's sign. 3. Turner's sign. 4. Cullen's sign.

Answer: 2 Trousseau's sign is elicited when placing a blood pressure cuff on the arm; when the cuff is inflated, the client experiences carpal spasms. Chvostek's sign is elicited by tapping on the face in front of the ear and observing for contractions of the muscle. Turner's sign indicates retroperitoneal bleeding. Cullen's sign is associated with retroperitoneal bleeding.

A nurse is monitoring a client who is receiving a unit of packed red blood cells. The client suddenly develops chest pains, hives, chills, and hypotension. Number the action that the nurse would take in order of priority. _____ 1. Start normal saline at KVO (keep vein open). _____ 2. Stop the transfusion. __ ___ 3. Notify the physician and blood bank. _____ 4. Remove the blood bag and the tubing with the blood in it. _____ 5. Obtain a urine specimen and send to the lab.

Answer: 2, 4, 1, 3, 5 Rationale: The client is experiencing an adverse reaction to the blood transfusion. The blood should be stopped immediately if a reaction occurs, no matter how mild. The nurse should remove the blood bag and the tubing with blood in it. Flush new intravenous tubing with normal saline, keeping the IV line open. Notify the physician and the blood bank. If a reaction is suspected, send the blood and administration set to the laboratory with a freshly drawn blood sample and urine specimen from the client. These will be used to identify the reaction as well as its effect on the client.

A client develops hyperthermia related to a diagnosis of Pneumonia. Which of the following nursing interventions would be effective in the treatment of hyperthermia? Select all that apply. 1. Increase the temperature of the room environment to prevent shivering. 2. Use ice packs and a tepid bath as needed. 3. Administer antipyretic medications per physician's orders. 4. Promote frequent rest periods to increase energy reserve. 5. Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance.

Answer: 2; 3; 4 Rationale: Hyperthemia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects or, when prolonged, can cause life- threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures. The nurse should use ice packs, cool/tepid baths, or hypothermia blanket with caution. The nurse should enforce frequent rest periods because rest increases energy reserve, which is depleted by an increased metabolic, heart, and respiratory rate. The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance.

A client develops hyperthermia related to a diagnosis of pneumonia. Which of the following nursing interventions would be effective in the treatment of hyperthermia? Select all that apply. 1. Increase the temperature of the room environment to prevent shivering. 2. Use ice packs and a tepid bath as needed. 3. Administer antipyretic medications per physician's orders. 4. Promote frequent rest periods to increase energy reserve. 5. Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance.

Answer: 2; 3; 4 Rationale: Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects, and when prolonged can cause life- threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution. The nurse should enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance.

Which of the following manifestations would the nurse expect to see with a client who has had previous knee surgery who suffered a surgical infection with signs of systemic manifestations? Select all that apply. 1. Erythema 2. WBC 14,200 mm3 3. Pain at the surgical site 4. 10% Bands 5. Respiratory rate of 16 6. Pulse 114

Answer: 2; 3; 6 Rationale: The client is post-surgical repair of the knee. The nurse should be able to distinguish between local reactions and system reactions. An elevated WBC and 10% bands are indicative of an infection. Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia. Local manifestations include erythema, warmth, pain, edema, and functional impairment, whereas systemic manifestations include elevated temperature above 100.4°F, pulse greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm3 or > 10% bands.

The nurse has admitted a client who has a diagnosis of Crytosporidium. Which care activity would be appropriate to delegate to the UAP (unlicensed assistive personnel)? Select all that apply. 1. Obtain a detailed history regarding the client's history. 2. Obtain the client's admitting height and weight. 3. Review the client's home medications, and complete the medication reconciliation sheet. 4. Obtain the client's admitting vital signs. 5. Educate the client regarding the diet that the physician has ordered.

Answer: 2; 4 Rationale: The nurse can never delegate assessment or education. The nurse can appropriately delegate to the UAP the task of obtaining weight, height, and vital signs. The nurse practice act assists the nurse with the tasks that can be delegated. Anytime the nurse delegates activities to other professionals, that nurse is accountable for the overall nursing care of the client.

Which of the following manifestations would the nurse expect to see with a client who has had knee surgery and who suffered a surgical infection with signs of systemic manifestations? Select all that apply. 1. Erythema 2. WBC 14,200 mm3 3. Pain at the surgical site 4. 10% bands 5. Respiratory rate of 16 6. Pulse 114

Answer: 2; 4; 6 Rationale: The client is post-surgical repair of the knee. The nurse should be able to distinguish between local reactions and system reactions. An elevated WBC and 10% bands are indicative of an infection. Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia. Local manifestations include erythema, warmth, pain, edema, and functional impairment, whereas systemic manifestations include elevated temperature above 100.4°F, pulse greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm3 or > 10% bands.

A home health nurse is preparing to begin a series of visits with a client. Based upon the client's condition, the client is expected to require home care visits weekly for the next two months. Which of the following tasks should take place first? 1. Set priorities. 2. Assess the home environment. 3. Establish trust and rapport. 4. Promote learning.

Answer: 3 Rationale: The basis for a successful long-term relationship between the nurse and the client is founded in trust. Once a rapport is established, it will be possible to begin to identify priorities that are of mutual interest. A review of the home environment will be needed to determine needs for all aspects of care and to promote and maintain safety. Learning is an ongoing process. The client will be more receptive to interventions by the nurse once a rapport is established.

A client hospitalized for diagnostic testing reports an intense fear of being found to have a terminal condition. What response by the nurse will be most therapeutic? 1. "There is no indication you are going to die." 2. "I am not sure why you feel that way." 3. "What has your doctor told you about your condition?" 4. "What types of symptoms lead you to feel this way?"

Answer: 3 Rationale: The client is demonstrating signs of death anxiety. This involves a fear of dying. The nurse's responsibility will be to determine what has caused this belief. Telling the client that the feelings are unfounded will do little to ease the client's anxiety. Further, this might not be entirely true. Expressing to the client a lack of understanding about his feelings will not gain much data or promote a rapport between the client and the nurse.

The client with herpes zoster reports difficulty resting at night. The nurse assists the client to manage this concern. Which of the following interventions will best aid the client? 1. Massage the irritated skin areas with lotion. 2. Apply powder to the lesions. 3. Encourage the client to take prescribed antipruritic agents approximately one hour before bedtime. 4. Use heavy bed linens to avoid chilling at night.

Answer: 3 Rationale: The client with herpes zoster might express difficulty sleeping. The inability to rest is often related to pruritus. The use of antipruritic agents prior to bedtime will facilitate rest. Lotions and powders can irritate the skin lesions. Heat will increase the occurrence of itching.

The nurse is educating a group of nursing students regarding parents who are carriers of certain genetic conditions. The nurse understands that carriers are: 1. Results of an altered gene on the X chromosome. 2. A problem on the Y chromosome. 3. Parents who have a single gene alteration on one chromosome or a pair of chromosomes. 4. Diseases that occur in spite of the fact that there exists one unaltered gene.

Answer: 3 Rationale: The definition of a carrier is "an individual with a recessive condition who has inherited one altered gene from his mother and one from his father." In most cases, neither parent is affected; therefore, each of the parents must have a single gene alteration on one chromosome of a pair.

During a home health visit, the client indicates he feels he might need physical therapy to facilitate his recovery. What action by the nurse is indicated? 1. The nurse should contact the client's insurance carrier to determine benefit eligibility. 2. The nurse should provide the client with the contact information for a local agency that offers physical therapy services. 3. The nurse should contact the physician to discuss the client's concerns. 4. The nurse should advise the client to contact the physician to discuss his concerns.

Answer: 3 Rationale: The home health nurse is responsible for making contact with needed agencies. Contact with the physician will be needed to initiate physical therapy.

A nurse assesses a client with hypoparathyroidism who has a positive Trousseau's sign. The nurse should develop a plan of care based on which of these nursing diagnoses? 1. Fluid Volume, Excess 2. Breathing Pattern, Ineffective 3. Comfort, Readiness for Enhanced 4. Tissue Perfusion, Ineffective

Answer: 3 A positive Trousseau's sign causes painful carpal spasms due to decreased calcium. A diagnosis for which a plan of care should be developed is Alteration in comfort. Fluid volume excess is not associated with hypoparathyroidism, and might be the result of pituitary problems. The parathyroid gland does not influence respirations. The parathyroid gland is responsible for phosphorous and calcium regulation.

A client is suspected of having a reaction. Which lab test would alert the nurse regarding the possibility of a hypersensitivity reaction? 1. Eosinophils of 2% of the total WBC 2. Indirect Coombs' showing no agglutination 3. Patch test with a one-inch area of erythema 4. Rh antigen with negative results

Answer: 3 Rationale: A patch test assesses a one-inch area impregnated with the allergen, which is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations). Direct Coombs' test detects antibodies in the client's RBC that damage and destroy the cells. This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs. This is also part of the crossmatch of a blood type and crossmatch. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1-4%, which is within normal range.

A client is attending a health fair at work today. The client shows the nurse a new sore on the forearm that has been increasing in size and will not heal. The nurse caring for this client knows that which of the following signs could also point to a diagnosis of a malignant neoplasm? 1. Rapid growth, well-defined borders, and cohesiveness 2. Invasive, local, and does not stop at tissue border 3. Noncohesive, invasive, and invades and destroys surrounding tissues 4. Slow growth, well-defined borders, and encapsulated

Answer: 3 Rationale: Benign neoplasms are local, cohesive, with well-defined borders. They push other tissues out of the way, are characterized by slow growth, are encapsulated, are easily removed, and do not recur. Malignant neoplasms are invasive, are noncohesive, do not stop at the tissue border, invade and destroy surrounding tissues, are characterized by rapid growth, metastasize to distant sites, are not always easy to remove, and can recur.

After surgery, the nurse notes a client is unable to achieve pain relief from the analgesics prescribed. A review of the client's medical records reveals a history of alcohol abuse. What inferences can the nurse make? 1. The client has an unreported addiction to the pain medication being prescribed. 2. The client has a history of using this medication at home. 3. The client is likely cross-tolerant to the prescribed analgesic. 4. The client has a dual diagnosis relating to alcohol and drug addiction.

Answer: 3 Rationale: Cross-tolerance results when tolerance to one substance also results in a tolerance to another drug. The client's heavy use of alcohol likely has resulted in a tolerance to alcohol and, by association, to the prescribed analgesic. There are no data to support a suspicion that the client takes the medication at home or is addicted to the medication.

A nurse is performing an admission assessment on a client with AIDS. Which of the following questions would be inappropriate for the nurse to ask the client in the interview process? 1. "Have you ever experimented with recreational drugs?" 2. "How long have you had AIDS?" 3. "Does your partner have AIDS?" 4. "Have you had any fever, diarrhea, or chills over the last 48 hours?"

Answer: 3 Rationale: During the interview process, the nurse should ask questions specific to the client's history, including current medications, diet, and signs and symptoms that the client has experienced. The nurse cannot ask about the client's partner.

The nurse is assessing a client admitted with heart failure exacerbation. The client has 3+ lower extremity edema. Which description most accurately describes this client's edema? 1. Slight pitting, no obvious distortion 2. Deeper pit, no obvious distortion 3. Pit is obvious, extremities are swollen. 4. Pit remains with obvious distortion.

Answer: 3 Rationale: Edema is the accumulation of fluid in the body's tissues. Edema can be assessed by depressing the client's skin. 1+ edema is slight pitting with no obvious distortion. 2+ edema is a deeper pit, but there is no obvious distortion. In 3+ edema, the pit is obvious, and the extremities are swollen. In 4+ edema, the pit remains, with obvious distortion.

A nursing student is studying for a pharmacology examination on chemotherapeutic agents. Which statement by the nursing student indicates the need for further teaching? Answer Choices: 1. "The main hormones used in cancer therapy are the corticosteroids, which are phase-specific." 2. "Mitotic inhibitors are drugs that act to prevent cell division during the M phase." 3. "Antitumor antibiotics disrupt RNA replication and DNA transcription." 4. "Alkylating agents basically act on preformed nucleic acids by creating defects in tumor DNA."

Answer: 3 Rationale: Hormones and hormone antagonists are one class of chemotherapeutic agents. The main hormones used in cancer therapy are the corticosteroids, which are phase- specific. Mitotic inhibitors are drugs that act to prevent cell division during the M phase. Antitumor antibiotics disrupt DNA replication and RNA transcription, not the other way around. Alkylating agents basically act on preformed nucleic acids by creating defects in tumor DNA.

Which of the following manifestations indicate a systemic reaction associated with an inflammatory response? 1. Erythema 2. Pain 3. Tachypnea (RR 26) 4. Edema

Answer: 3 Rationale: If the nurse observes a systemic reaction, the client will exhibit manifestations including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction.

Which of the following manifestations indicates a systemic reaction associated with an inflammatory response? 1. Erythema 2. Pain 3. Tachypnea (RR 26) 4. Edema

Which statement made by the client taking an immunosuppressive agent would require further teaching? 1. "I know to call the physician if I start experiencing a lot of bruising." 2. "I should drink plenty of water to keep me from getting dehydrated." 3. "I should drink a lot of fruit juices, such as grapefruit juice." 4. "If I experience any joint pain, I should take ibuprofen for the pain as needed every four hours."

Answer: 3 Rationale: Immunosuppressive agents inhibit T cell development and activation. They are given concurrently with a glucocorticoids and in combination with other immunosuppressants, and inhibit immune system activity and organ rejection. Nursing responsibilities include monitoring BUN and creatinine for evidence of nephrotoxicity. The client should avoid grapefruit juice, which can raise cyclosporine levels by 50-200% and increase the risk of toxicity. Fluids should be increased to maintain good hydration and urinary output. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents.

The nurse is preparing to administer influenza vaccines to a mass drive-through clinic. Which statement by a client would indicate further questioning prior to giving the client the influenza vaccine? 1. "I am allergic to horse hair." 2. "I try to get my vaccine every year." 3. "I am not allergic to anything except eggs." 4. "My husband had a severe allergic reaction after he received his influenza vaccine."

Answer: 3 Rationale: Influenza vaccines are recommended for person at high risk for serious sequelae of influenza. The nurse should be aware that client with a sensitivity to eggs should not receive the vaccine. Vaccines prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs.

Answer: 3 Rationale: Influenza vaccines are recommended for person at high risk for serious sequelae of influenza. The nurse should be aware that clients with a sensitivity to eggs should not receive the vaccine. Vaccines prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs.

A nursing student is performing integumentary assessments on older adult clients. Which skin lesion would best name the client's brown benign macule with a defined border? 1. Keratoses 2. Angiomas 3. Lentigines 4. Telangiectases

Answer: 3 Rationale: Keratoses are the horny growth of keratinocytes. Angiomas are benign vascular tumors with dilated blood vessels, found in the middle to upper dermis. Lentigines, or liver spots, are brown or black benign macules with a defined border. Telangiectases are single dilated blood vessels, capillaries, or terminal arteries.

The nurse is assessing the client's perception of safety issues in the home. Which of the following questions and statements will best assist the nurse in obtaining the needed data? 1. "Do you feel safe at home?" 2. "Can you see room for improving safety at home?" 3. "Please tell me some safety concerns you have." 4. "Have you ever fallen at home?"

Answer: 3 Rationale: Open-ended questions or statements will yield the most information. Encouraging the client to share safety concerns will allow the greatest exchange of information directly related to the identified topic. Asking the client about feeling safe at home is broad, and might not yield the desired information.

During a routine physical, the nurse asks the client about alcohol use. The client denies alcohol use. The client reports having alcoholic parents, and wonders about the likelihood of becoming an alcoholic as well. What response by the nurse is most correct? 1. "You are right to avoid alcohol use." 2. "You will likely become an alcoholic." 3. "There are studies that support a genetic link for developing alcoholism." 4. "You should be fine to drink."

Answer: 3 Rationale: Studies have identified a link between biologic factors and the development of an addiction. Although the client does have an increased risk, advising the client he is right to avoid drinking, or that he will become an alcoholic, is inappropriate. Giving the client permission to drink does not address the question being posed by the client.

A competent elderly client has a living will. The living will expressed the desire to avoid resuscitation and heroic life support measures. The family members are not supportive of this directive. Which of the following actions by the nursing staff is most appropriate? 1. Contact the Social Services department. 2. Notify the hospital attorney. 3. Place the document on the chart. 4. Explain to the client that the conflict could invalidate the document.

Answer: 3 Rationale: The client is competent. The wishes of the client must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. A lack of support by the family does not invalidate the document.

The home health nurse is planning the day. Which of the following clients should the nurse see first? 1. A client with wasting syndrome who has end-stage AIDS who needs modifications and education regarding dietary changes 2. A client with a long history of AIDS who is receiving IV antibiotics daily for toxoplasmosis 3. A client with PCP (Pneumocystis carinii pneumonia) who called the office to report a new onset of fever, cough, and SOB this AM 4. A client with AIDS who is receiving Epivir (lamivudine) because of a diagnosis of a low CD4 cell count

Answer: 3 Rationale: The home health nurse should see the client with Pneumocystis carinii pneumonia because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first and obtain vital signs and perform a respiratory assessment initially.

The home health nurse has identified a series of concerns while providing services to a client. During one of the visits, the nurse becomes concerned about criminal activity in the home. What initial action by the nurse is most appropriate? 1. Dial 911 to obtain assistance in removing the client from the home. 2. Contact the physician to discuss the situation. 3. Leave the home. 4. Advise the client to leave the home as soon as possible.

Answer: 3 Rationale: The nurse working in the client's home must always be aware of personal safety. Leaving the home in the presence of criminal activity would be the safest alternative. Removing the client from the home is beyond the scope of the nurse's responsibility. Contact with the physician might be indicated, but it does not have a higher priority than leaving the scene to ensure personal safety.

A client with breast cancer is receiving 5-Fluorouracil (5-FU). Based on knowledge of this medication, and anticipated adverse effects or side effects, which nursing action should the nurse perform? Hint: Table 14-10 Classifications of Chemotherapeutic Drugs Answer Choices: 1. Monitor ECG. 2. Assess lung sounds. 3. Test stool for occult blood. 4. Encourage daily fluid intake of 2-3 liters.

Answer: 3 Rationale: The possible adverse effects or side effects associated with 5-FU are stomatitis, alopecia, nausea and vomiting, gastritis, enteritis, diarrhea, anemia, leucopenia, and thrombocytopenia. Assessing for bleeding by checking stool for occult blood is recommended in this client. Monitoring the ECG is recommended in clients receiving antitumor antibiotics. Assessing lung sounds is recommended in clients receiving alkylating agents, due to the potential for developing pulmonary fibrosis. Encouraging a daily fluid intake of 2-3 liters is recommended also for clients receiving alkylating agents because they could potentially develop renal failure.

A client has reported to the physician's office with complaints of an inability to sleep at night. During the data collection, the client reports her estranged husband died a little over a year ago. She states "I am not sure why this is so difficult, I really couldn't stand him near the end." Which response by the nurse is most appropriate? 1. "You seem angry." 2. "You should contact a therapist." 3. "Sometimes a rocky relationship with someone at the time of their death can impact your ability to grieve." 4. "You are just entering the grief process, things will get better."

Answer: 3 Rationale: Unresolved conflict at the time of death can impact the ability of survivors to successfully grieve the deceased. The client's demeanor does not seem angry. It is inappropriate for the nurse to refer the client to a therapist. Referrals must be initiated by the physician. The death occurred more than a year ago. The client's continued inability to sleep indicates impaired grieving.

A client is receiving IV vancomycin for the treatment of Clostridium difficile. The nurse understands that the client who develops flushing, tachycardia, and hypotension during the infusion of vancomycin indicates: 1. Ototoxicity effect. 2. Superinfection. 3. Red man syndrome. 4. Hives.

Answer: 3 Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It is only effective against gram-positive bacteria, especially Staphylococcus aureus and Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 minutes or more to avoid "red man" syndrome. The syndrome is characterized by erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy and agitated.

The nurse is teaching the client about ways to increase personal safety in the home. During the interaction, the client advises the nurse that he has no plans to make the recommended changes. What response by the nurse is most appropriate? 1. "You might not get well if you do not follow my recommendations." 2. "I will need to tell your physician the home is not safe enough." 3. "If you need more information about what we have discussed, please let me know." 4. "I might not be able to continue my visits if you do not conform."

Answer: 3 Rationale: When providing patient teaching, the nurse must be aware that not all recommendations considered important by the nurse will be held at the same priority by the client. A failure to have the same goals does not mean the interaction is without merit. Telling the client he might not recover might not be true. At no time should the client feel threatened by the nurse's responses. Implying that the visits will stop or that the physician will be called could be considered threatening.

Which of these approaches would be most appropriate for the nurse to take when assessing the thyroid gland of an adult client? 1. Stand in front of the client and palpate the thyroid. 2. Place the client supine and palpate one side of the neck at a time. 3. Stand behind the client and palpate the thyroid. 4. Have the client flex the neck forward and palpate the thyroid.

Answer: 3 The thyroid is palpated by standing behind the client and placing the fingers on each side of the trachea below the thyroid, and asking the client to swallow to palpate the right lobe. Repeat the procedure, tilting the neck to the left. The nurse has better access to the thyroid from a posterior approach than from the anterior aspect. Placing the client supine would not permit the nurse to have full access to the neck. Flexing the neck forward if there were a mass could occlude the airway.

A nursing student is performing a functional health pattern interview of a client. If the student needs to assess the health perception and health management of the client, which question by the nursing student is best? Answer Choices: 1. "Do you bruise easily?" 2. "How well do your cuts and scratches heal?" 3. "Do you have any allergies to foods, plants, or pets?" 4. "Have you noticed swelling around your eyes or ankles?"

Answer: 3 Rationale: "Do you bruise easily?" is a question used to assess activity and exercise. "How well do your cuts and scratches heal?" is a question used to assess nutritional/metabolic. "Do you have any allergies to foods, plants, or pets?" is a question used to assess health perception and health management. "Have you noticed swelling around your eyes or ankles?" is a question used to assess elimination.

A nurse is assessing a client whose lab values this morning include a sodium of 144 mEq/L, a potassium of 3.8 mEq/L, a hemoglobin of 8.4 g/dL, and a glucose of 105 mg/dL. Which assessment might correlate with these findings? 1. The nail plate is separate from the nailbed. 2. The nail folds are inflamed and swollen. 3. The nail is spoon-shaped. 4. The nail has a transverse groove.

Answer: 3 Rationale: A normal hemoglobin in men is 13.5-16.5 g/dL. A normal hemoglobin in women is 12.0-15.0 g/dl. A normal sodium is 135-147 mEq/L. A normal potassium is 3.5-5.2 mEq/L. A normal glucose is 60-110 mg/dl. In this question stem, the client has a normal sodium, potassium, and glucose. The hemoglobin is low. Thin, spoon-shaped nails might be seen in anemia.

A client is admitted to the Emergency Department after taking PCP (phencyclidine piperidine). The physician has determined that the client overdosed on the drug. You are anticipating the care that will be provided to this client. What actions can be anticipated? Select all that apply. 1. Induce vomiting. 2. Obtain materials to assist with lavage. 3. Initiate seizure precautions. 4. Initiate an IV. 5. Administer Narcan as prescribed.

Answer: 3; 4 Rationale: The client has taken an overdose of phencyclidine piperidine (PCP), which can produce an adrenaline-like response, or "speed" reaction. PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The client will require an IV line. The client will need to have seizure precautions such as padded side rails initiated. Vomiting is induced for overdoses of alcohol, barbiturates, and benzodiazepines. Narcan is a narcotic antagonist administered for opiate overdose.

A client who has a clinical manifestation of exophthalmus is in the clinic. Based on this finding, the nurse would also assess the client for: 1. Dry, thick nails. 2. Dry skin. 3. Decreased reflexes. 4. An enlarged thyroid gland.

Answer: 4 Exophthalmus is a clinical manifestation associated with hyperthyroidism. Dry, thick nails; dry skin; and decreased reflexes are associated with hypothyroidism.

The nurse is developing a teaching plan for a group of parents who need genetic counseling. Which statement by a parent would indicates the need for further education? 1. "We understand that half of the sets of chromosomes come from the mother and the other half come from the father." 2. "We understand that the 23rd pair of chromosomes will determine if our child will be male or female." 3. "We understand that a chromosome called a karyotype is a chromosomal profile." 4. "We understand that are all the chromosomes are the same size in males and females alike."

Answer: 4 Rational: A basic understanding of the cell, DNA, cell division, and chromosomes is important for young families receiving genetic counseling. The cell nucleus contains about 6 feet of DNA that are tightly wound and packaged into 23 pairs of chromosomes, making a complete set of 46 chromosomes. The structure and number of chromosomes can be shown by karyotype, or picture of an individual's chromosomes. There are two copies of each chromosome. One copy, or half of the complete set of these 46 chromosomes, is inherited from the mother, and the other copy is inherited from the father. For example, an individual will have two #1 chromosomes, one inherited from her mother and one inherited from her father. These two copies or pairs of inherited chromosomes are called homologous pairs. Chromosomes are numbered according to size, with chromosome #1 being the largest and chromosome 22 being the smallest. The first 22 pairs of chromosomes, known as autosomes, are alike in males and females. The 23rd pair, the sex chromosomes, determines an individual's gender. A female has two copies of the X chromosomes (one copy inherited from each parent) and a male has one X chromosome (inherited from his mother) and a Y chromosome (inherited from his father). These X and Y chromosomes are known as sex chromosomes. The remaining 22 pairs of non-sex chromosomes are alike in both males and females, and are called autosomes.

A student nurse extern is working for the summer on an oncology unit. The extern's preceptor has been explaining the characteristics of malignant cells. Which statement by the student nurse extern demonstrates a good understanding of the information? Hint: Characteristics of Malignant Cells Answer Choices: 1. "Malignant cells continue to perform cellular functions." 2. "The transformation into a malignant cell is reversible if treated promptly." 3. "Malignant cells rarely break away from the primary tissue site and travel to other locations." 4. "The work of malignant cells is simpler than that of normal cells."

Answer: 4 Rationale: A characteristic of malignant cells is loss of specialization and differentiation. Malignant cells do not perform typical cellular functions. Another characteristic of malignant cells is irreversibility. The transformation into a malignant cell is irreversible. Rarely does a malignant neoplasm revert to a benign state. Transplantability is another characteristic of malignant cells. Malignant cells often break away from the primary tissue site and travel to other locations in the body. Simplified metabolic activities are another characteristic of malignant cells. The work of malignant cells is simpler than that of normal cells.

When planning care for the client newly diagnosed with herpes zoster, which of the following nursing diagnoses has the highest priority? 1. Health Maintenance, Ineffective 2. Anxiety 3. Deficient Knowledge 4. Pain, Acute

Answer: 4 Rationale: All of the nursing diagnoses presented are applicable to the client diagnosed with herpes zoster. In the initial period of the disorder, pain is a primary concern. Until the pain is successfully managed, teaching, anxiety, and health maintenance behaviors cannot be altered.

A 34-year-old client, who is at her annual gynecologic examination, is being taught about early screening for breast cancer. The client has a sister and mother with a history of breast cancer. Which action by the client demonstrates good screening techniques for someone with her family history? Answer Choices: 1. Routine breast exams to begin after age 35 2. Reporting of any changes in breast tissue to the health provider at the next routine visit 3. Annual screening mammography staring at age 40 4. Clinical breast examination every three years

Answer: 4 Rationale: American Cancer Society guidelines for cancer screening include routine breast self-examination starting at age 20; prompt reporting of any change in breast tissue to healthcare provider; clinical breast examination every three years from ages 20 to 39, and yearly thereafter; annual screening mammography starting at age 40, except in women at increased risk, who may have more frequent mammography or other tests such as breast ultrasound exams.

A client is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision. What should be the initial action by the nurse when the client arrives in the Emergency Department (ED)? 1. Assess the client's abdomen for any abnormalities. 2. Assess the client's cervical spine for tenderness. 3. Assess the client for signs of neurological deficits. 4. Assess the client's airway for patency.

Answer: 4 Rationale: Assessment of the airway is the highest priority in the trauma client. Assessment includes determining airway patency. If the client is unresponsive, manual opening of the airway using a jaw thrust or chin lift maneuver is necessary. Once the airway is opened, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the client is responsive and can vocalize, that is a good indication that the airway is clear. All of the other responses are important, but certainly the nurse should address airway initially. The nurse should assess the cervical spine area after initial ABC assessment. The nurse is always concerned about the neurological assessment of a client, but this client has a blunt trauma injury from a motor vehicle, therefore this would not be the initial assessment for the client.

The client has been diagnosed with chronic sorrow related to her husband's recent diagnosis of terminal cancer. Which action by the nurse would be most helpful to the client? 1. Question the client about her knowledge of cancer treatment options. 2. Question the client about her husband's prognosis. 3. Determine the means used by the client to cope with loss in the past. 4. Encourage the client to identify potential sources of emotional support.

Answer: 4 Rationale: Chronic sorrow is a recurring sense of overwhelming sadness in response to a loss. The best means to assist the client is to assist the client to discuss her feelings. The use of emotional supports will enable the client to manage these seemingly all- encompassing emotions. The client is attempting to discuss her own feelings. Turning the conversation's focus to the client's knowledge about her husband's illness would not meet the needs presented. Past coping does not influence the needs accompanying chronic sorrow.

A client is admitted to the ICU (intensive care unit) after sustaining multiple injuries. The physician has ordered for the client to receive a colloid solution. Which one of the following solutions would be appropriate for the nurse to infuse, based on the physician's orders? 1. 9% saline 2. D5 ½ NS 3. 5% dextrose in water (D5W) 4. 25% albumin

Answer: 4 Rationale: Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran. Crystalloid solutions contain dextrose or electrolytes dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the interstitial space.

The client with a history of alcohol abuse is being discharged. The physician has prescribed disulfiram (Antabuse). The client asks about the action of the medication. Which of the following statements by the nurse is most correct? 1. "The medication will help curb your craving for alcohol." 2. "The medication will reduce the anxiety you might experience during this difficult time." 3. "The medication will prevent seizures and other symptoms of withdrawal." 4. "The medication will prevent your body from breaking down alcohol."

Answer: 4 Rationale: Disulfiram (Antabuse) is used in the management of clients with alcohol dependence. The medication will prevent the body from breaking down alcohol, and will cause illness if taken and alcohol is then ingested. The medication does not reduce the craving for alcohol, reduce onset of seizures, or lessen anxiety.

A client is admitted with a traumatic injury to the spinal cord. He develops marked bradycardia, with a bounding pulse. The client becomes extremely restless, and the nurse notes that the client has developed oliguria as well. The nurse would suspect: 1. Anaphylactic shock. 2. Septic shock. 3. Hypovolemic shock. 4. Neurogenic shock.

Answer: 4 Rationale: Neurogenic shock is the result of an imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle. If parasympathetic overstimulation or sympathetic understimulation persists, sustained vasodilation occurs, and blood pools in the venous and capillary beds. The manifestations of hypovolemic shock result directly from the decrease in circulating blood volume and the initiation of compensatory mechanisms. Clients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present with a client who presents with a traumatic injury. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.

A nursing student is reading about the concept of parish nursing. Which of the following statements indicates understanding of the key concepts of parish nursing? 1. "You must practice a certain faith to be involved in parish nursing." 2. "Parish nurses are independent practitioners providing care to members of a selected church." 3. "Parish nursing is reserved for nurse practitioners." 4. "Parish nurses may be employed by a hospital."

Answer: 4 Rationale: Parish nursing seeks to provide health care to traditionally underserved populations. Involvement in parish nursing is not limited to select faiths. The parish nurse may work directly for the church involved or be contracted by the church to provide nursing services and perform referrals. Parish nursing is not limited to nurse practitioners.

The mother of a teenaged female experiencing a severe case of acne voices concern about her daughter's hygiene habits. Which of the following responses by the nurse is best? 1. "Your daughter needs to improve her facial hygiene to help in reducing the severity of the acne outbreaks." 2. "The greatest culprit for the acne is dietary habits, not inadequate hygiene." 3. "Are you embarrassed by her appearance?" 4. "What are your concerns about her hygiene practices?"

Answer: 4 Rationale: Soliciting the concerns about her daughter's hygiene practices is primary. Once the concerns are identified, it will allow the nurse to begin to address the disorder and any related concerns. Dietary intake and hygiene are not the primary causes of acne. Acne is caused by excess sebum production. It is premature of the nurse to address the potential for the mother to be embarrassed about her daughter's condition.

A client at risk for the development of skin cancer is discussing sun exposure prevention with the nurse. What information should be included in the discussion? 1. Sunscreen is not needed on cloudy days. 2. The higher the sunscreen rating, the less the protection provided. 3. When swimming, sunscreen should be reapplied every four hours. 4. A higher-rated sunscreen is needed between 10 a.m. and 3 p.m.

Answer: 4 Rationale: Sun exposure is greatest between 10 a.m. and 3 p.m. Sun exposure is possible on both cloudy and sunny days. The higher the level of the sunscreen's rating, the greater the protection. When swimming, sunscreen should be reapplied hourly.

A client who has experienced a burn injury has been brought to the Emergency Department by family members. Which of the following interventions by the nurse is of the highest priority at this time? a. Determination of the type of burn injury b. Determination of the types of home remedies attempted prior to the client's coming to the hospital c. Assessment of past medical history d. Determination of body weight

Answer: a Rationale: Determination of the type of burn is the first step. The type of injury will dictate the interventions performed. Determining the use of home remedies, past medical history, and body weight must be completed, but are not of the highest priority.

A client is being treated for alcohol dependency. During the treatment, the client reports having been treated and undergone detoxification three times in the past. The client states that this time has been more difficult than the previous detoxification experiences. What information can be provided to the client? 1. Aging can impact the ability of the body to handle detoxification from alcohol and drugs. 2. Increased difficulty with alcohol detoxification is likely the result of an addiction to another substance at the same time. 3. The dependency might have been greater this time. 4. With each subsequent episode, detoxification becomes more difficult.

Answer: 4 Rationale: The body responds more harshly with each episode of detoxification. Aging does not play a role in the process. There is no evidence to support addiction to additional substances or an increased degree of dependence.

The client who lives alone indicates concerns about their ability to perform the necessary dressing changes after discharge. Which action by the nurse is indicated at this time? 1. Explain to the client that she will need to seek the assistance of a friend or neighbor to help as needed. 2. Make a referral to the home healthcare agency preferred by the client. 3. Contact the hospital social worker. 4. Discuss the client's anticipated needs with the physician.

Answer: 4 Rationale: The client will likely need home health care. Home care requires a physician's order. The nurse will need to initiate the referral process. In some facilities, a discharge planner might be involved. The services of the hospital social worker are not indicated by the information provided. The client has already indicated the absence of assistance. If the client lacks the social resources for it, it will be up to the healthcare team to locate community-based resources.

Which of the following statements by the client who has HIV would require further teaching by the healthcare professional? 1. "I know I have to practice safe sex with my partner." 2. "I will not share my toothbrush or razor with my partner." 3. "I know I can't donate blood anymore since I have HIV." 4. "I know to use an oil-based lubricant to prevent spread of the disease to my partner."

Answer: 4 Rationale: The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse; avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants—not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited.

A client reports intense itching of the scalp and face. Pediculosis is identified in the hair and eyebrows. Which of the following should be included in the information provided to the client? 1. "You should start washing your hair more often to avoid this condition." 2. "A single treatment will manage the infestation." 3. "Infestations in the eyebrows will be treated by applying a thin layer of permethrin 1% cream (NIX) to the brows." 4. "Apply the medication for at least 30 minutes before washing it off."

Answer: 4 Rationale: The treatment should be applied for at least 30 minutes and up to a period of 8 hours. The cleanliness of the hair has little to do with the presence of pediculosis. At least two treatments will be needed to treat the condition successfully. Permethrin 1% (NIX) should never be used around the eyes. Lice in the lashes or brows should be treated with petroleum jelly.

When planning care for a client at risk for the development of pressure ulcers, which of the following should be included in the care? 1. Turn the client q.4h. 2. Massage pressure areas with lotion q.4h. 3. Use inflatable donut rings to reduce pressure on the sacrum. 4. Initiate a frequent toileting schedule.

Answer: 4 Rationale: Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. The client should be turned at least every two hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable donut rings are contraindicated, as they increase pressure and reduce perfusion to affected areas.

Answer: 4 Rationale: When the physician orders a specimen to be collected, the nurse should collect the specimen before the first dose of antibiotics is administered, to ensure adequate organisms for culture.

A client scheduled for an assessment of the endocrine system asks the nurse "Is this going to hurt?" The nurse's best response is: 1. "The assessment will consist of a health assessment interview." 2. "A complete head-to-toe assessment will not be necessary." 3. "The assessment will involve anesthesia and multiple laboratory studies." 4. "The assessment will not be painful. What concerns or questions do you have? I will explain the procedure as I go along."

Answer: 4 The client should be provided with an opportunity to ask questions or voice concerns, and should be informed that the nurse will explain the procedure as it is performed. The assessment is not painful; it consists of interview, a physical assessment, and laboratory studies. The client should have a head-to-toe physical examination. No anesthesia is needed for an endocrine assessment.

A nurse is caring for a client undergoing brachytherapy. Which precaution should the nurse take when caring for this client? Answer Choices: 1. Care for this client regardless of pregnancy status. 2. Maintain the least possible distance form the client. 3. Avoid indirect exposure with radioisotopes containers. 4. Wear a monitoring device to measure whole-body exposure.

Answer: 4 Rationale: Many safety principles apply when caring for a client receiving radiation. Refer to box 14-6 for a complete list. In brachytherapy, the radioactive material is placed directly into or adjacent to the tumor. If pregnant, avoid contact with radiation sources. Maintain the greatest possible distance from the source of radiation. Avoid direct, not indirect, exposure with radioisotopes containers; for example, do not touch the container. Wear a monitoring device to measure whole-body exposure.

The burn-injured client has been prescribed silver nitrate. Which of the following nursing interventions should be included for the client? a. Monitor daily weight. b. Prepare to change the dressings every two hours. c. Report black skin discolorations. d. Push fluid intake.

Answer: a Rationale: Taking silver nitrate can result in hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by the determination of daily weights. Changing the dressing q.2h. is too frequent for the client. Black discolorations in the skin are anticipated for clients using silver nitrate, and do not highlight a complication of therapy. Silver sulfadiazine, not silver nitrate, administration can result in the development of sulfa crystals in the urine.

The nurse is preparing to teach a class for a group of new parents. The nurse is attempting to determine what topic would be of the greatest interest to the audience. What selection would be most appropriate? a. Safety b. Chronic illness prevention c. Problem-solving skills d. Interventions to manage depression

Answer: a Rationale: The parents of small children are interested in information geared toward keeping them safe. Household safety is a priority for children of all ages. The families attending the session likely will have limited interest in preventing illness, as they typically represent a healthy segment of the population. Depression is a greater concern for older adults.

During a class for teens, a participant states she frequently "overindulges" in numerous activities, including eating. She questions her likelihood for becoming addicted to alcohol as a result of her "addictive personality." What information should be provided to the client? a. There are no data to support the existence of an addictive personality, although individuals who become addicted to substances frequently display an affinity for engaging in risky behaviors. b. It is true the addictive personality does have a greater incidence of becoming addicted to a variety of substances. c. There is no relationship between addiction and personalities who are prone to "overindulgence." d. The client is not at an advanced enough age to make this determination.

Answer: a Rationale: Certain personality traits are associated with risk-taking behaviors and addiction. There is a relationship between personality type and addiction. Age does not play a factor in this scenario.

After the skin graft procedure to the leg, the client is returned to the burn care unit. When positioning the client, which of the following positions will be most therapeutic for the client? a. Elevate the HOB 30 degrees. b. Elevate the affected extremity. c. Maintain the HOB flat. d. Place the client flat with the affected extremity abducted.

Answer: b Rationale: Elevating the affected extremity will reduce edema and promote perfusion. Elevating the HOB, leaving the HOB flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which of the following laboratory values is the best indicator of nutritional status? a. Creatine phosphokinase (CPK) b. BUN levels c. Glycosuria d. Hemoglobin

Answer: c Rationale: Glucose in the urine is seen after a major burn injury. It signals the need to re- evaluate the client's nutritional plan. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury dependent upon the fluid status.

A 75-year-old client seeks care at an ambulatory clinic. The client reports having experienced extreme drowsiness after recently taking dosages of an over-the-counter cold medication. When collecting data, the nurse notes the client reports taking only the prescribed amount of the preparation. What inferences can be made by the nurse concerning the events? a. The client likely has taken more of the preparation than stated. b. The client likely has experienced a reaction between the cold medication and other routine medications. c. The client's age has influenced his response to the medication. d. The client is allergic to the cold medication.

Answer: c Rationale: Older clients often experience altered responses to medications. These changes are in response to age-related developments in the kidneys and liver. There is no evidence the client has taken too much medication. There is no information provided to indicate the client is taking other medications. Allergic reactions typically manifest with integumentary- or respiratory-related symptoms.

When monitoring the vital signs of the client who has experienced a major burn injury, the nurse notes a heart rate of 112 and a temperature of 99.9°F. Which of the following best describes the findings? a. The client is demonstrating manifestations consistent with the onset of an infection. b. The client is demonstrating manifestations consistent with an electrolyte imbalance. c. These values are normal for the client's post-burn injury condition. d. The client is demonstrating manifestations consistent with renal failure.

Answer: c Rationale: The burn-injured client is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response.

The client having severe burns over more than half of his body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration? a. The amount of urine output will be greatest in the first 24 hours after the burn injury. b. The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as the diuresis begins. c. The amount of urine will be reduced in the first 24-48 hours, and will then increase. d. The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.

Answer: c Rationale: The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. The diuresis begins between 24 and 36 hours after the burn injury.

The nurse is reviewing the laboratory results of the renal system for a client who experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would the nurse expect to see? Select all that apply. a. Creatinine clearance reduced b. BUN reduced c. Uric acid decreased d. GFR reduced e. Specific gravity elevated

Answer: d; e Rationale: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in reduction in filtration rate and an increase in specific gravity. During this period, BUN levels and uric acid are increased.

During a routine physical examination for a 52-year-old Caucasian male, the client declines to have his prostate gland examined. He states he does not have a family history and does not feel he is at risk. What initial response by the nurse is most appropriate? a. "You may refuse any screening test you wish." b. "I will need to tell the physician about your refusal." c. "Your risk factors increase with aging." d. "You are right, Caucasian men have less incidence of prostate cancer."

Answer: c Rationale: The need for prostate screening begins at age 50. Individuals with risk factors should begin screening at age 45. The client's age places him at an increased risk, so he should begin the screening process. While the client may refuse any testing, this does not allow the client to engage in secondary levels of prevention. The client's refusal should be recorded in the medical record but not used as a means to coerce the client.

A client has presented with a burn injury. The injury site is pale and waxy with large flat blisters. The client asks questions about the severity of the injury and how long it will take for this injury to heal. Based upon your knowledge, what information should be provided to the client? a. The wound is a partial-thickness burn, and could take up to two weeks to heal. b. The wound is a superficial burn, and will take up to three weeks to heal. c. The wound is a deep partial-thickness burn, and will take more than three weeks to heal. d. Wound healing is individualized.

Answer: c Rationale: The wound describes is a deep partial-thickness burn. Deep partial thickness wounds will take more than three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days.

The physician has ordered the cleansing of a burn injury to a client's ear. After cleaning the wound, which of the following steps should be completed next? a. Cover the ear with a sterile dressing. b. Provide a soft pillow to cushion the area. c. Use a foam doughnut to reduce pressure to the area. d. Place cotton gauze between the head and the ear to reduce the incidence of adhesions.

Answer: c Rationale: To reduce pressure to the area, doughnut rings are recommended. Burns to the ears are not covered with dressings. A soft pillow will increase pressure to the area. Placement of cotton gauze will provide a source of irritation to the area, and should be avoided.

A client is being evaluated in the Emergency Department after suffering severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this manifestation? a. Reduced vascular permeability at the site of the burned area b. Decreased osmotic pressure in the burned tissue c. Increased fluids in the extracellular compartment d. Inability of the damaged capillaries to maintain fluids in the cell walls

Answer: d Rationale: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.

When collecting data at the immunization clinic, which of the following disclosures by the client would cause the nurse to hold administration of the varicella vaccine? a. History of an allergic reaction to yeast bread b. Itching and swelling on the face and hands after ingesting eggs c. A low grade temperature within the past two days d. A blood transfusion after undergoing surgery three months ago

Answer: d Rationale: Contradictions for the varicella vaccine include pregnancy, suppressed immunity, and a recent history of a blood transfusion. Recent hyperthermia and allergies to yeast or eggs do not indicate a potential difficulty with the administration of the varicella vaccine.

The nurse is planning an in-service to discuss primary levels of disease prevention. Which of the following topics should be included in this presentation? a. A discussion concerning the use of available community rehabilitation facilities b. Available locations for diabetes screening c. The need for annual colonoscopy examinations d. The elimination of smoking and alcohol use

Answer: d Rationale: Primary prevention involves activities geared toward the prevention of illness and disease. Screening activities such as glucose testing and colonoscopy examinations are a form of secondary prevention. Rehabilitation activities are considered a tertiary level of prevention.

A client is scheduled to undergo grafting to a burn injury to the arm. Which of the following statements by the nurse should be included in the teaching prior to the procedure? a. "You will need to report any itching, as it might signal infection." b. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure." c. "The procedure will be performed in your room." d. "You will begin to perform exercises to promote flexibility and reduce contractures after five days."

Answer: d Rationale: The client will begin to perform range-of-motion exercises after five days. Itching is not a symptom of infection but an anticipated occurrence that signals cellular growth. The ideal time to perform the procedure is early in the treatment of the burn injury. The procedure is performed in a surgical suite.

While working in the Emergency Department, the nurse is planning care for the client who has been admitted with a burn injury. Which of the following areas will be included in the plan of care? a. Fluid management b. Nutrition c. Psychosocial support d. Fluid resuscitation

Answer: d Rationale: The nurse caring for the client during the emergent stage of burn injuries will be expected to administer intravenous fluids to meet the body's needs. Fluid management will take place in the burn unit or intensive care unit. Nutrition management will begin in the burn unit and continue throughout the client's care. Psychosocial support will be needed once the client has stabilized.

A 45-year-old woman presents to the ambulatory clinic for a gynecological examination. The health history reveals no significant personal or family medical history. What information concerning health-promotion behaviors should be presented to the client? a. It is time to begin having mammograms every other year. b. If the client is in a monogamous relationship, Pap smears will not be needed. c. Bone density examinations are indicated every year. d. Recommended calcium intake is at least 1,200 mg per day.

Answer: d Rationale: The recommended calcium intake is at least 1,200 mg per day. This will be beneficial in the prevention of osteoporosis. Women should begin having annual mammograms by age 40. Pap smears are continued for women in monogamous relationships. For women with no significant risk for the development of osteoporosis, bone density examinations should be done every other year.

A college student is studying for final examinations. The student falls ill and presents to the student health center. The student is diagnosed with Epstein-Barr virus. The student has a history of smoking and recreational cocaine use, and works for a floor refinishing company part-time. Which risk factors are present in this student for developing cancer? Select all that apply. Hint: Known Carcinogens Answer Choices: 1. Drug use 2. Occupation 3. Age 4. Smoking 5. Viral infection

Answers: 1; 2; 4; 5 Rationale: Several viruses have been associated with the development of cancer. Some of these viruses include herpes simplex viruses I and II, the human cytomegalovirus, Epstein-Barr virus, the human herpesvirus-6, the hepatitis B virus, the papillomavirus, and the human T-lymphotropic viruses. Viruses play a significant role in weakening immunologic defenses against neoplasms. Some recreational drugs are also implicated as carcinogens. Immunosuppressant promoters include heroin and cocaine. Examples of industrial and environmental carcinogens include polycyclic hydrocarbons, found in soot; benzopyrene, found in cigarette smoke; and arsenic, found in pesticides. Other industrial and environmental chemicals are considered promotional agents. These include wood and leather dust, polymer esters used in plastics and paints, carbon tetrachloride, asbestos, and phenol.

A client reports a pain level of 6 on a 0-10 pain scale. The nurse offers to review the orders for additional pain medication. The client states "I really don't want to take any more pain medication, because I am afraid I will become addicted." The nurse's response should focus on which concept? a. Physical dependence on pain medication is uncommon during the short-term postoperative use. b. This client already might have an addiction problem. c. This client might benefit from a placebo dose. d. The physician should be notified to discuss pain management.

Correct answer: a Rationale: Clients might fear "addiction" or physical dependence on pain medications, especially opioids, postoperatively. The duration of use is typically short-term, and this concern should be discussed, but is not anticipated to occur. The client who already has an addiction problem most likely would be requesting more medication, not refusing it. The client is verbalizing pain, so administration of a placebo is unethical, against client rights for pain management, and should not be administered. It is within the scope of the nurse to review and make decisions with the client regarding safe use of pain medications that have been ordered by the physician. The physician does not need to be called at this time unless the nurse's interventions with the client are unsuccessful.

During the discharge teaching process, the nurse explains the physician's order for the client to take Motrin (ibuprofen) at home for any further discomfort. Since this is an NSAID (nonsteroidal anti-inflammatory drug), what other teaching will be done with this client who also has diabetes? a. NSAIDs can increase the effect of hypoglycemic medications. b. NSAIDs can decrease the effect of anticoagulant medications. c. NSAIDs cause minimal gastrointestinal side effects. d. NSAIDs have no effect on fever.

Correct answer: a Rationale: The diabetic client needs to be taught that NSAIDs can cause an increased response to hypoglycemic medications. The client's hypoglycemic medications might need to be altered to adjust for this. NSAIDs can increase the effect of anticoagulant medications, not decrease them. NSAIDs could cause gastrointestinal bleeding, and should be taken with meals, milk, or a full glass of water to decrease gastric irritation. NSAIDs have anti-inflammatory, analgesic, and antipyretic (fever-lowering) effects.

A client is experiencing a multisystem fluid volume deficit. Symptoms present include tachycardia; pale, cool skin; and decreased urine output. These signs are most likely a direct result of: a. The body's natural compensatory mechanisms. b. Pharmacological effects of a diuretic. c. Effects of rapidly infused intravenous fluids. d. Cardiac failure.

Correct answer: a Rationale: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this client.

A nursing student is teaching her peers about pain. Which teaching point supports the idea that each person's pain response should be assessed individually in each situation? a. "Everyone has the same pain threshold." b. "Everyone has a unique tolerance to pain." c. "Everyone perceives painful stimuli at the same intensity." d. "Most people have the same the pain response to surgery."

Correct answer: b Rationale: Each person's pain tolerance is different, and will need to be assessed on an individual basis. Everyone has the same pain threshold and perceives pain at the same intensity. Even though the same surgery is performed on different people, each individual might have a different pain response.

Clients with severe hyponatremia will need which specific intervention once the diagnosis is made? a. Infection precautions b. Seizure precautions c. High-risk fall precautions d. Neutropenic precautions

Correct answer: b Rationale: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, and having an oral airway at the bedside would be included. Infection or neutropenic precautions and high-risk fall precautions are not specifically indicated.

A client is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? a. Fluid volume deficit b. Fluid volume excess c. Liver failure d. Seizure activity

Correct answer: b Rationale: Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. Liver failure is not anticipated related to postoperative intravenous fluid administration. Seizure activity would more commonly be associated with electrolyte imbalances.

An elderly woman is complaining of lower leg pain. Which information found in her medical history would be the most likely indicator of this pain? a. History of cardiovascular disease b. History of shingles c. History of smoking for 20 years d. History of alcoholism

Correct answer: b Rationale: Post-herpetic neuralgia (following shingles) is an example of a chronic neuralgia type of pain. There has been damage to a peripheral nerve, which has resulted in the current pain. Cardiovascular disease, a history of smoking, and alcoholism are not the likely direct causes of this pain.

The nurse is providing preoperative teaching to a client with diabetes. The client states "I know I won't need as much insulin after surgery, since I haven't had anything to eat or drink since midnight." Which response by the nurse would be most appropriate? a. "You are right, the insulin need will be less postoperatively." b. "Your insulin need will be adjusted and most likely will increase due to the stress of surgery on your body." c. "We will give you your usual dose of insulin just prior to surgery." d. "You will be given insulin during surgery to avoid complications postoperatively."

Correct answer: b Rationale: The stress of surgery, not of being n.p.o. preoperatively, often increases rather than decreases blood sugar, and thus insulin needs. Insulin is not typically given just prior to or during surgery.

Following a coughing episode, a client who is 12 hours postoperative from abdominal surgery notifies the nurse of "a feeling of pressure in the surgical wound." The nurse observes that the surgical wound is open. The initial response by the nurse should be: a. Check the client's vital signs, then notify the physician. b. Cover the wound with a sterile dressing moistened with normal saline, then notify the physician. c. Notify the physician. d. Place the client in the Trendelenburg position.

Correct answer: b Rationale: When the wound dehiscence occurs, the site must be covered immediately and be kept sterile. The physician should then be notified. The client will be returning to surgery. Vital signs can be taken after the wound is covered and the physician notified. Client positioning is not the priority.

Which of the following tests would be indicated when a client who has a history of cardiovascular disease is receiving intravenous fluids? a. Cardiac catheterization b. Echocardiogram c. Fluid challenge d. Central venous pressure monitoring

Correct answer: c Rationale: A fluid challenge may be performed to evaluate the cardiovascular and renal function related to fluid volume capabilities. This can prevent fluid volume overload. Cardiac catheterization and echocardiogram are directly related to evaluating cardiovascular disease. Central venous pressure monitoring is a method of evaluating fluid volume status.

A client is receiving intraspinal analgesia. Nursing care will focus on: a. Decrease in heart rate. b. Increase in heart rate. c. Increase in urine output. d. Decrease in urine output.

Correct answer: c Rationale: Intraspinal narcotics can block the micturition reflex, causing urinary retention. A Foley catheter might need to be inserted. The respiratory rate, not the heart rate, would be another focus directly related to intraspinal anesthesia.

An extensive spinal surgery was performed on a client five days ago. The client continues to have pain despite around-the-clock dosing of a narcotic. When assessing the client's pain, the nurse discovers that the client's pain level is not decreasing significantly between doses. This is an example of which of the following? a. Pseudoaddiction b. Psychologic drug dependence c. Drug tolerance d. Addiction

Correct answer: c Rationale: Over a period of time, a person's body might require a progressively greater amount of a drug to achieve the same results. Pseudoaddiction involves drug-seeking behavior as a result of inadequate pain relief. Psychologic drug dependency is seen with psychologic drug withdrawal symptoms. Addiction is a compulsive use of a drug despite negative consequences.

The nurse is planning to administer a pain medication to a client who is two hours postoperative following bowel resection surgery. The client has four standing orders for pain medication. The nurse should administer which medication based on this situation? a. Select the one that will be given intramuscularly (IM) to work quickly. b. Select the one that is ordered on a "p.r.n." basis. c. Select the one to be administered intravenously by patient demand and under patient control. d. Select the one to be administered orally.

Correct answer: c Rationale: Patient-controlled analgesia allows self-management of pain, and is a common postoperative method of administering pain medication. The advantages to this method are dose precision, timeliness, and convenience. Selecting an oral medication or a "p.r.n." medication two hours after a major surgery would not be the most effective. The medication that is administered IM is not typically recommended for moderate-to-severe pain that will require more than one dose.

When preparing a client for surgery, the nurse observes that the client has been crying. When the nurse asks the client to sign the surgery consent form, the client states "I guess I should just go ahead and sign it, even though I'm not really sure about doing this." The best response by the nurse would be: a. "Most people are usually nervous before surgery." b. "The surgeon is waiting, so you should decide." c. "What concerns are you having?" d. "Should we just cancel your surgery?"

Correct answer: c Rationale: The nurse has a responsibility to assess further what the client is upset/concerned about prior to surgery. If the nurse was present when the physician gave informed consent, he can reinforce any information. If he was not present, or there are still questions, the surgeon should be notified to make any other clarifications. The surgery should not just be cancelled. Telling the client that others are usually nervous does not address this client's individual needs. The client has a right to have all questions answered prior to signing a consent for surgery, and should not be pressured for any reason.

A postoperative client has an indwelling urinary catheter in place. Which 24-hour urine output total volume would necessitate a primary healthcare provider to be notified? a. 1,000 milliliters b. 750 milliliters c. 1,200 milliliters d. 600 milliliters

Correct answer: d Rationale: A urine output of less than 30 milliliters per hour must be reported to the primary healthcare provider. This indicates inadequate renal perfusion, placing the client at increased risk for acute renal failure and inadequate tissue perfusion. A minimum of 720 milliliters over a 24-hour period is desired. (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours).

What is a primary concern regarding fluid and electrolytes when caring for the older adult who is intermittently confused? a. Risk of kidney damage b. Risk of stroke c. Risk of bleeding d. Risk of dehydration

Correct answer: d Rationale: As an adult ages, the thirst mechanism declines. This, in a client with an altered level of consciousness, can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues.

Upon review of the medical history prior to surgery, the nurse notes that a client has a history of alcoholism. The nurse makes a point to bring this to the surgeon's attention when informed consent is being provided. The rationale for this action would be: a. The client could be at risk for depression postoperatively. b. The client will be at greater risk for respiratory complications postoperatively. c. The client could be dehydrated. d. The client might require more general anesthesia.

Correct answer: d Rationale: Clients need to be assessed for surgical risk factors preoperatively for planning. There is no reason to anticipate depression, respiratory complications, or dehydration simply due to a history of alcoholism. Damage to the client's liver might have occurred, and this could affect how the client metabolizes medications.

Discharge teaching is being done by the nurse for a client who had a myocardial infarction. The client asks why the pain he experienced prior to the event was felt primarily in his left arm. The nurse's best response would be: a. "Cardiac pain is generally unexplainable." b. "Were you doing some physical activity with your arm just prior to the event?" c. "What you are describing relates to psychogenic pain." d. "Pain in the arm related to cardiac tissue damage is a type of referred pain."

Correct answer: d Rationale: Pain in a spinal nerve can be felt over the skin in any body area where neurons share the same spinal nerve route. This is known as a dermatome. Cardiac pain is explainable as referred pain. Pain in the arm did not trigger the cardiac event. Psychogenic pain occurs in the absence of a diagnosed physiological cause or event.

A client has a history of malignant hyperthermia. A bowel resection with colostomy placement surgery is scheduled. The nurse anticipates which type of anesthesia will be used with this client? a. Regional anesthesia b. Inhaled anesthesia c. Conscious sedation d. Total intravenous anesthesia

Correct answer: d Rationale: The client is having a major surgery. General anesthesia would be indicated. Inhaled and total intravenous anesthesia are general anesthesia options. The use of inhaled anesthesia in a client with a history of malignant hyperthermia would be avoided, as it can trigger malignant hyperthermia. Total intravenous anesthesia would be used in this situation.

The nurse has many teaching responsibilities preoperatively. From the following list, select all topics that would be within the nurse's scope to provide instructions about preoperatively: a. Diaphragmatic breathing b. Positioning/turning in bed c. Coughing exercises d. Potential risks of the surgery

Correct answers: a; b; c Rationale: Measures to ensure respiratory, circulatory, and gastrointestinal functioning are important for the nurse to teach the client preoperatively. The physician would discuss the potential risks and benefits of the surgery during the informed consent process.

Pain in the elderly is subject to many misconceptions. Which of the following are common misconceptions related to aging? Select all that apply. a. Opioids will cause excessive respiratory depression. b. Aging decreases a person's sensitivity to pain. c. Older adults are likely to become addicted to narcotics if used. d. Pain is an expected part of the aging process.

Correct answers: a; b; c; d Rationale: All are common misconceptions that the nurse must be aware of when caring for older adults. There are basic truths to each misconception that must be explored and discussed.

Assessment findings that would alert the nurse that a client might be at greater risk for deep vein thrombosis include: (Select all that apply.) a. Client is 35 years old. b. Client has varicose veins. c. Client is obese. d. Client is on an anticoagulant medication.

Correct answers: b; c Rationale: The development of a blood clot is an increased risk in the client with an impaired circulatory system; as evidenced by varicose veins, a client who is obese, and over the age of 40 years, has an infection or malignancy. Anticoagulant medications are given to dissolve clots, and do not increase the risk of development.

Clients experiencing a fluid volume deficit would most likely exhibit which of the following lab results? Select all that apply. a. Increased serum potassium b. Decreased serum sodium c. Increased hemoglobin d. Increased hematocrit

Correct answers: c; d Rationale: Increased hemoglobin and hematocrit are common due to loss of intravascular volume and hemoconcentration. A decreased, not increased, potassium level is common in fluid volume deficits. Serum sodium levels can be within normal limits with an isotonic fluid deficit, or increased when the loss is water only.

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