Medsurg exam 2

Multiple Choice 14. The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? A. Early ambulation B. Increased dietary intake of protein C. Maintaining the client in a supine position D. Administering aspirin with warfarin

A Rationale: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding. PTS: 1 REF: p. 535 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A clinic nurse is caring for a client admitted with acquired immunodeficiency syndrome (AIDS). The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of which complication? A. Human immunodeficiency virus (HIV) encephalopathy B. B-cell lymphoma C. Kaposi sarcoma D. Wasting syndrome

A Rationale: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. B-cell lymphoma is a type of non-Hodgkin lymphoma, and fatigue and weight loss are some typical signs and symptoms. Kaposi sarcoma is a malignancy that impacts clients with HIV/AIDS and involves epithelial layers of blood and lymphatic vessels. Lesions on the skin and lymphedema can cause pain and infections. Wasting syndrome is related to HIV/AIDS and involves involuntary loss of 10% of total weight with diarrhea and fevers. None of the other listed complications normally have cognitive and behavioral manifestations. PTS: 1 REF: p. 1023 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice Chapter 18: Management of Patients with Upper Respiratory Tract Disorders 1. The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season? A. Wash hands frequently. B. Gargle with warm salt water regularly. C. Dress self and infant warmly. D. Take preventative antibiotics as prescribed.

A Rationale: Handwashing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly do not suppress transmission. In addition, antibiotics are not prescribed for a cold. PTS: 1 REF: p. 498 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values? A. Increased eosinophils B. Increased neutrophils C. Increased serum albumin D. Decreased blood glucose

A Rationale: Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in clients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts. PTS: 1 REF: p. 1041 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing. Which symptom is most closely associated with the early stages of laryngeal cancer? A. Hoarseness B. Dyspnea C. Dysphagia D. Frequent nosebleeds

A Rationale: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Nosebleeds are not associated with a diagnosis of laryngeal cancer. PTS: 1 REF: p. 515 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 23. A school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention should be the initial action of the school nurse? A. Assess for signs and symptoms of anaphylaxis. B. Assess for erythema and urticaria. C. Administer an over-the-counter (OTC) antihistamine. D. Administer epinephrine.

A Rationale: If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction. PTS: 1 REF: p. 1047 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration

A Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, and aspiration. PTS: 1 REF: p. 594 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. After the completion of testing, a 7-year-old client's allergies have been attributed to the family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote which action? A. Removing the cat from the family's home B. Administering over-the-counter antihistamines to the client regularly C. Keeping the cat restricted from the client's bedroom D. Maximizing airflow in the house

A Rationale: In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the client's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines. PTS: 1 REF: p. 1049 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. At present, members of which group are most affected by new cases of HIV? A. Male-to-male sexual contact B. Heterosexual contact C. Male-to-male sexual contact with injection drug use D. People 25 to 29 years of age

A Rationale: In the United States from 2012 to 2016, male-to-male sexual contact accounted for approximately 67% of new cases, male-to-male contact with injection use 3%, heterosexual contact 24%, and people 25 to 29 years of age 32.9%. PTS: 1 REF: p. 1008 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 5. The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax? A. Diminished or absent breath sounds on the affected side B. Paradoxical chest wall movement with respirations C. Sudden loss of consciousness D. Muffled heart sounds

A Rationale: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade. PTS: 1 REF: p. 581 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? A. Maintaining a patent airway B. Preventing the need for suctioning C. Maintaining the sterility of the client's airway D. Increasing the client's lung compliance

A Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning, to maintain sterility or to increase compliance because none of these are important if the client's airway is not patent. PTS: 1 REF: p. 566 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A nurse is caring for a 6-year-old client with cystic fibrosis. To enhance the child's nutritional status, which priority intervention should be included in the plan of care? A. Pancreatic enzyme supplementation with meals B. Provision of five to six small meals per day rather than three larger meals C. Total parenteral nutrition (TPN) D. Magnesium, thiamine, and iron supplementation

A Rationale: Nearly 90% of clients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical. PTS: 1 REF: p. 645 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. The nurse is performing a respiratory assessment of an adult client and is distinguishing between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. How should the nurse distinguish between these normal breath sounds? A. Their location over a specific area of the lung B. The volume of the sounds C. Whether they are heard on inspiration or expiration D. Whether or not they are continuous breath sounds

A Rationale: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Breath sounds are not distinguished solely on the basis of volume. Normal breath sounds are heard on both inspiration and expiration, and are continuous. PTS: 1 REF: p. 482 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Response 26. A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize? A. The client will successfully mobilize pulmonary secretions. B. The client will maintain an oxygen saturation level of ³98%. C. The client's pulmonary blood pressure will decrease to within reference ranges. D. The client will resume prediagnosis level of function within 72 hours.

A Rationale: Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of the client with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals. PTS: 1 REF: p. 632 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? A. "A PFT measures how much air moves in and out of your lungs when you breathe." B. "A PFT measures how much energy you get from the oxygen you breathe." C. "A PFT measures how elastic your lungs are." D. "A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood."

A Rationale: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly. PTS: 1 REF: p. 486 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 26. The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? A. The client may chronically produce excess red blood cells. B. The client may frequently experience a low relative plasma volume. C. The client may have impaired stem cell function. D. The client may previously have undergone bone marrow biopsy.

A Rationale: Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy. PTS: 1 REF: p. 896 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 3. The nurse is providing care for a client who has recently been diagnosed with chronic obstructive pulmonary disease. When educating the client about exacerbations, the nurse should prioritize which topic? A. Identifying specific causes of exacerbations B. Prompt administration of corticosteroids during exacerbations C. The importance of prone positioning during exacerbations D. The relationship between activity level and exacerbations

A Rationale: Prevention is key in the management of exacerbations, and it is important for the client to identify which factors cause exacerbations. Corticosteroids are not normally used as a "rescue" medication, and prone positioning does not enhance oxygenation. Activity in the morning may need to be delayed for an hour or two for bronchial secretions that have collected overnight in the lungs to clear. Therefore, the right amount of activity, at the right time, can impact exacerbations, but prevention is the priority. PTS: 1 REF: p. 616 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client's absolute neutrophil count (ANC) is 440/mm3 but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this client? A. Meticulous hand hygiene B. Timely administration of antibiotics C. Provision of a nutrient-dense diet D. Maintaining a sterile care environment

A Rationale: Providing care for a client with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care. PTS: 1 REF: p. 930 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? A. "The younger you are when you start smoking, the higher your risk of lung cancer." B. "The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays." C. "The risk for lung cancer is determined mostly by what type of cigarettes you smoke." D. "The risk for lung cancer depends primarily on the other risk factors for cancer that you have."

A Rationale: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor. PTS: 1 REF: p. 578 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. A nurse has been asked to give a workshop on chronic obstructive pulmonary disease for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has which pathophysiologic effect? A. Increases the amount of mucus produced B. Destabilizes hemoglobin C. Shrinks the alveoli in the lungs D. Collapses the alveoli in the lungs

A Rationale: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung. Smoking is not known to destabilize hemoglobin, shrink the alveoli in the lungs, or collapse the alveoli in the lungs. PTS: 1 REF: p. 605 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 12. The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? A. Incentive spirometry B. Intermittent positive-pressure breathing (IPPB) C. Positive end-expiratory pressure (PEEP) D. Bronchoscopy

A Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used. PTS: 1 REF: p. 530 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize? A. The importance of adhering closely to the prescribed medication regimen B. The disease being a lifelong, chronic condition that will affect activities of daily living (ADLs) C. TB being self-limiting but taking up to 2 years to resolve D. The need to work closely with the occupational and physical therapists

A Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable. PTS: 1 REF: p. 550 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 40. The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cm H2O B. 15 cm H2O C. 10 cm H2O D. 5 cm H2O

A Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction. PTS: 1 REF: p. 596 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 36. A nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the client achieve the goal of maintaining effective oxygenation? A. Teach the client strategies for promoting diaphragmatic breathing. B. Administer supplementary oxygen by simple face mask. C. Teach the client to perform airway suctioning. D. Assist the client in developing an appropriate exercise program.

A Rationale: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in clients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate. PTS: 1 REF: p. 627 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A. Slow the infusion rate and monitor the client closely. B. Discontinue the transfusion and begin resuscitation. C. Pause the transfusion and administer a 250 mL bolus of normal saline. D. Discontinue the transfusion and administer a beta-blocker, as prescribed.

A Rationale: The client is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the client closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the client's fluid overload. PTS: 1 REF: p. 904 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? A. Risk for disturbed body image related to skin lesions B. Risk for disuse syndrome related to dermatitis C. Risk for ineffective role performance related to dermatitis D. Risk for self-care deficit related to skin lesions

A Rationale: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit. PTS: 1 REF: p. 1057 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care? A. Administer an analgesic before coughing and deep breathing. B. Ambulate the client at least three times daily. C. Arrange for a soft-textured diet and increased fluid intake. D. Encourage the client to speak as little as possible.

A Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Because deep breathing and coughing prevent atelectasis, the client should be given an analgesic prior to performing these respiratory exercises. A soft diet is not necessarily indicated, and there is no need for the client to avoid speaking. Ambulation has multiple benefits, but pain management is not among them. PTS: 1 REF: p. 554 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, which statement by the client should prompt the nurse to refer the client for further assessment? A. "Lately, I have this cough that just never seems to go away." B. "I find that I don't have nearly the stamina that I used to." C. "I seem to get nearly every cold and flu that goes around my workplace." D. "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."

A Rationale: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections, and fatigue are not characteristic early signs of lung cancer. PTS: 1 REF: p. 579 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. An office worker eats a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger, and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed-type (type IV)

A Rationale: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 39. A 5-year-old client has been diagnosed with a severe food allergy. Which instruction should the nurse include when educating the parents about this client's allergy and care? A. Wear a medical identification bracelet. B. Know how to use the antihistamine pen. C. Know how to give injections of lidocaine. D. Avoid live attenuated vaccinations.

A Rationale: The nurse also advises the parents to have the client wear a medical identification bracelet and to be able to identify symptoms of food allergy. Clients and their families do not carry antihistamine pens, they carry epinephrine pens. Lidocaine is not self-administered to treat allergies. The client may safely be vaccinated. PTS: 1 REF: p. 1047 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? A. Increase oral fluids unless contraindicated. B. Call the nurse for oral suctioning, as needed. C. Lie in a low Fowler or supine position. D. Increase activity.

A Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms. PTS: 1 REF: p. 539 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? A. Administer the platelets as rapidly as the client can tolerate. B. Establish IV access as soon as the platelets arrive from the blood bank. C. Ensure that the client has a patent central venous catheter. D. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.

A Rationale: The nurse should infuse each unit of platelets as fast as client can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion. PTS: 1 REF: p. 902 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 33. A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A. Perianal region and oral mucosa B. Sacral region and lower abdomen C. Scalp and skin over the scapulae D. Axillae and upper thorax

A Rationale: The nurse should inspect all the client's skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection. PTS: 1 REF: p. 1027 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngectomy. The nurse should encourage the client to use which appliance during recovery at home? A. A room humidifier B. An air conditioner C. A water purifier D. A radiant heater

A Rationale: The nurse stresses the importance of humidification at home and instructs the family to obtain a humidifier before the client returns home. Air conditioning may be too cool and drying for the client. A water purifier or radiant heater is not necessary. PTS: 1 REF: p. 519 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 30. A client with multiple food and environmental allergies expresses frustration and anger over having to be so watchful all the time and wonders if it is really worth it. Which response by the nurse would be best? A. "I can only imagine how you feel. Would you like to talk about it?" B. "Let's find a quiet spot, and I'll teach you a few coping strategies." C. "That's the same way that most clients who have a chronic illness feel." D. "Do you think that maybe you could be managing things more efficiently?"

A Rationale: To assist the client in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the client. The client is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the client has been mismanaging this health problem, and the nurse should not make comparisons with other clients. Further assessment should precede educational interventions. PTS: 1 REF: p. 1054 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 12. A client has been diagnosed with a lymphoid stem cell defect. This client has the potential for a problem involving which of the following? A. Plasma cells B. Neutrophils C. Red blood cells D. Platelets

A Rationale: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells. PTS: 1 REF: p. 885 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate? A. Help the client to sit, with head lowered below knees. B. Administer supplementary oxygen by nasal prongs. C. Obtain a full set of vital signs. D. Inform a health care provider or other primary care provider.

A Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. The client should be observed for another 30 minutes. There is no immediate need for a health care provider's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs. PTS: 1 REF: p. 898 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed? A. Iron deficiency anemia B. Pernicious anemia C. Sickle cell disease D. Hemolytic anemia

A Rationale: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica. PTS: 1 REF: p. 914 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. A client with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? A. Administer antidiarrheal medications on a scheduled basis, as prescribed. B. Encourage the client to eat three balanced meals and a snack at bedtime. C. Increase the client's oral fluid intake. D. Encourage the client to increase his or her activity level.

A Rationale: Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the client's diarrhea is not caused by an infectious microorganism. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the client has frequent diarrhea. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? A. Presence of a cough and gag reflex B. Absence of nausea C. Ability to demonstrate deep inspiration D. Oxygen saturation of greater than or equal to92%

A Rationale: After the procedure, it is important that the client takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration. PTS: 1 REF: p. 491 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A. Risk for imbalanced fluid volume related to low albumin B. Risk for infection related to low albumin C. Ineffective tissue perfusion related to low albumin D. Impaired skin integrity related to low albumin

A Rationale: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection. PTS: 1 REF: p. 890 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A nurse is planning the care of a client with acquired immunodeficiency syndrome (AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client? A. Ineffective airway clearance B. Impaired oral mucous membranes C. Imbalanced nutrition: Less than body requirements D. Activity intolerance

A Rationale: Although all these nursing diagnoses are appropriate for a client with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the client with PCP. Airway and breathing take top priority over the other listed concerns because of the immediacy of the health consequences. PTS: 1 REF: p. 1028 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 39. The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A. Stable vital signs and arterial blood gases (ABGs) B. Pulse oximetry above 80% and stable vital signs C. Stable nutritional status and ABGs D. Normal level of consciousness

A Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Clients who are weaned may or may not have a normal level of consciousness. PTS: 1 REF: p. 569 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction? A. A client with an anaphylactic reaction after a bee sting B. A client with a skin reaction resulting from adhesive tape C. A client with a diagnosis of myasthenia gravis D. A client with rheumatoid arthritis

A Rationale: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by immunoglobulin E antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV, and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction. PTS: 1 REF: p. 1041 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 8. An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? A. Initiate chest physiotherapy. B. Immobilize the ribs with an abdominal binder. C. Prepare the client for surgery. D. Immediately sedate and intubate the client.

A Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes chest physiotherapy and controlling pain. Intubation is required only for severe flail chest injuries, not small flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment. Immobilization of the ribs with an abdominal binder is not necessary for a small flail chest injury. PTS: 1 REF: p. 591 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 40. The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment? A. Asthma B. Obstructive sleep apnea C. Community-acquired pneumonia D. Pulmonary edema

A Rationale: Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors. PTS: 1 REF: p. 475 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which client is at greatest risk for developing chronic pharyngitis? A. A client who is a habitual user of alcohol and tobacco B. A client who is a habitual user of caffeine and other stimulants C. A client who eats a diet high in spicy foods D. A client who has gastrointestinal reflux disease (GERD)

A Rationale: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, experience chronic cough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor. PTS: 1 REF: p. 504 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The emergency department (ED) nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. Which condition should the ED nurse suspect? A. Fracture of the cribriform plate B. Rupture of an ethmoid sinus C. Abrasion of the soft tissue D. Fracture of the nasal septum

A Rationale: Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum. PTS: 1 REF: p. 513 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse is providing education to a client diagnosed with acute rhinosinusitis. For which possible complication should the nurse teach the client to seek follow-up care? A. Periorbital edema B. Headache unrelieved by over-the-counter medications C. Clear drainage from nose D. Blood-tinged mucus when blowing the nose

A Rationale: Client teaching is an important aspect of nursing care for the client with acute rhinosinusitis. The nurse instructs the client about symptoms of complications that require follow-up. Referral to a health care provider is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the client has acute rhinosinusitis. A persistent headache does not necessarily warrant follow-up. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client? A. Packed red blood cells (PRBCs) B. Vitamin K C. Oral anticoagulants D. Heparin infusion

A Rationale: Clients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh-frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be prescribed once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the client's bleeding. PTS: 1 REF: p. 939 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A client has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to which complication? A. Sinus infections B. Esophageal strictures C. Pharyngitis D. Laryngitis

A Rationale: Clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of clients with these tubes is critical. Use of a nasogastric tube is not associated with the development of esophageal strictures, pharyngitis, or laryngitis. PTS: 1 REF: p. 501 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is caring for a client who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the client for which clinical manifestation? A. Hemoptysis B. Pain on inspiration C. Pigeon chest D. Dry cough

A Rationale: Clinical manifestations of bronchiectasis include hemoptysis, chronic cough, copious purulent sputum, and clubbing of the fingers. Because of the copious production of sputum, the cough is rarely dry. A pigeon chest or pectus carinatum is a deformity of the chest wall, with children and adolescents being typically affected. Pigeon chest is not associated with this disease. Pain on inspiration is usually associated with respiratory conditions such as pleurisy, pneumonia, or pneumothorax. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A pediatric nurse practitioner is caring for a 2-year-old client who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. Which potential causative agent that may trigger an attack should the nurse describe? A. Household pets B. Inadequate sleep C. Psychosocial stress D. Bacteria

A Rationale: Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Although some research links inadequate sleep to making asthma worse, it is not a common trigger for attacks. Psychosocial stress is anything that translates to a perceived threat to social status. Stress is listed as a trigger for asthma, but this type of stress is unlikely in a 2-year-old client. A viral, not bacterial, component is linked to asthma triggers. PTS: 1 REF: p. 634 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for a client who needs education on medication therapy for allergic rhinitis. The client is to take cromolyn daily. In providing education for this client, how should the nurse describe the action of the medication? A. It inhibits the release of histamine and other chemicals. B. It inhibits the action of proton pumps. C. It inhibits the action of the sodium-potassium pump in the nasal epithelium. D. It causes bronchodilation and relaxes smooth muscle in the bronchi.

A Rationale: Cromolyn inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 28. A client with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond? A. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body." B. "A platelet transfusion often further blunts your body's own production of platelets." C. "Finding a matching donor for a platelet transfusion is exceedingly difficult." D. "A very small percentage of the platelets in a transfusion are actually functional."

A Rationale: Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not because the platelets are nonfunctional but because the client's antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed. Matching the client's blood type is not usually necessary for a platelet transfusion. Platelet transfusions do not exacerbate low platelet production. PTS: 1 REF: p. 933 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 9. A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? A. Encourage the client and family to be active partners in the management of the immunodeficiency. B. Encourage the client and family to manage the client's activity level and activities of daily living effectively. C. Make sure that the client and family understand the importance of monitoring fluid balance. D. Make sure that the client and family know how to adjust dosages of the medications used in treatment.

A Rationale: Encouraging the client and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis. This transcends the client's activity and functional status. Medications should not be adjusted without consultation from the primary provider. Fluid balance is not normally a central concern. PTS: 1 REF: p. 1007 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often? A. Every 2 hours when the client is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the client from coughing D. When the nurse needs to stimulate the cough reflex

B Rationale: It is usually necessary to suction the client's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa. PTS: 1 REF: p. 559 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS? A. Risk for disuse syndrome related to Kaposi sarcoma B. Impaired skin integrity related to Kaposi sarcoma C. Diarrhea related to Kaposi sarcoma D. Impaired swallowing related to Kaposi sarcoma

B Rationale: Kaposi sarcoma is a type of cancer caused by human herpesvirus-8 that involves the epithelial layer of blood and lymphatic vessels. It exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs, which may be the first manifestation of HIV, can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymosis (hemorrhagic patches) and edema. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome. PTS: 1 REF: p. 1022 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client is learning about a new diagnosis of asthma with the asthma nurse. What medication will best prevent the onset of acute asthma exacerbations? A. Diphenhydramine B. Montelukast C. Albuterol sulfate D. Epinephrine

B Rationale: Many manifestations of inflammation can be attributed in part to leukotrienes. Medications categorized as leukotriene antagonists or modifiers such as montelukast block the synthesis or action of leukotrienes and prevent signs and symptoms associated with asthma. Diphenhydramine prevents histamine's effect on smooth muscle. Albuterol sulfate relaxes smooth muscle during an asthma attack. Epinephrine relaxes bronchial smooth muscle but is not used on a preventative basis. PTS: 1 REF: p. 1052 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. The nurse is describing normal erythrocyte physiology to a client who has a diagnosis of anemia. The nurse should explain that the erythrocytes consist primarily of which substance? A. Plasminogen B. Hemoglobin C. Hematocrit D. Fibrin

B Rationale: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. Erythrocytes are not made of fibrin or plasminogen. Hematocrit is a measure of erythrocyte volume in whole blood. PTS: 1 REF: p. 887 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 33. A client was prescribed an oral antibiotic for the treatment of sinusitis. The client has now stopped, reporting the development of a rash shortly after taking the first dose of the drug. Which response by the nurse would be most appropriate? A. Encourage the client to continue with the medication while monitoring the skin condition closely. B. Refer the client to a primary care provider to have the medication changed. C. Arrange for the client to go to the nearest emergency department. D. Encourage the client to take an over-the-counter antihistamine with each dose of the antibiotic.

B Rationale: On discovery of a medication allergy, clients are warned that they have a hypersensitivity to a particular medication and are advised not to take it again. As a result, the client would need to liaise with the primary provider. There is no need for emergency care unless symptoms worsen to involve respiratory function. An antihistamine would not be an adequate or appropriate recommendation from the nurse. PTS: 1 REF: p. 1058 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. An asthma educator is teaching a client newly diagnosed with asthma and the family about the use of a peak flow meter. The educator should teach the client that a peak flow meter measures highest airflow during which type of breath? A. Forced inspiration B. Forced expiration C. Normal inspiration D. Normal expiration

B Rationale: Peak flow meters measure the highest airflow during a forced expiration. PTS: 1 REF: p. 639 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 24. A client has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function? A. Acid-base balance B. Perfusion C. Diffusion D. Ventilation

B Rationale: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acid-base balance. PTS: 1 REF: p. 467 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A. Folic acid B. Vitamin B12 C. Lactulose D. Magnesium sulfate

B Rationale: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia. PTS: 1 REF: p. 918 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A. Myocardial muscle tissue B. All body fluids C. Cerebral tissue D. Venous and arterial vessel walls

B Rationale: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue. PTS: 1 REF: p. 891 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A. Administration of prophylactic antibiotics B. Administration of pneumococcal vaccine to vulnerable individuals C. Obtaining culture and sensitivity swabs from all newly admitted clients D. Administration of antiretroviral medications to clients over age 65

B Rationale: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A one-time vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum. PTS: 1 REF: p. 532 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized? A. Risk for infection related to skin sloughing B. Risk for acute pain related to loss of skin integrity C. Risk for impaired skin integrity related to cutaneous lesions D. Risk for impaired gas exchange related to airway obstruction

D Rationale: Edema of the respiratory tract can compromise the airway in clients with hereditary angioedema. As such, this is a priority nursing diagnosis over pain and possible infection. Skin integrity is not threatened by angioedema. PTS: 1 REF: p. 1060 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time would it be best for the nurse to collect the sample? A. Immediately after a meal B. First thing in the morning C. At bedtime D. After a period of exercise

B Rationale: Sputum samples ideally are obtained early in the morning before the client has had anything to eat or drink. PTS: 1 REF: p. 488 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client's room. The nurse asks when the client produced the sputum specimen, and the client states that the specimen is about 4 hours old. What action should the nurse take? A. Immediately take the sputum specimen to the laboratory. B. Discard the specimen and assist the client in obtaining another specimen. C. Refrigerate the sputum specimen and submit it once it is chilled. D. Add a small amount of normal saline to moisten the specimen.

B Rationale: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions. PTS: 1 REF: p. 488 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? A. Position the client in high Fowler position B. Discontinue the transfusion. C. Auscultate the client's lungs. D. Obtain a blood specimen from the client.

B Rationale: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens. PTS: 1 REF: p. 903 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? A. The client must not have received an immunization within 7 days. B. The nurse should administer albuterol 30 to 45 minutes prior to the test. C. Prophylactic epinephrine should be given before the test. D. Emergency equipment should be readily available.

D Rationale: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing. PTS: 1 REF: p. 1044 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A gerontologic nurse is analyzing the data from a client's focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiologic change? A. Increased diffusion of gases B. Decreased diffusion capacity for oxygen C. Decreased shunting of blood D. Increased ventilation

B Rationale: The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age. PTS: 1 REF: p. 470 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 11. A nurse is caring for a client who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse explains that the client should self-administer epinephrine at which site? A. Forearm B. Thigh C. Deltoid muscle D. Abdomen

B Rationale: The client is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will automatically inject a premeasured dose of epinephrine into the subcutaneous tissue. The muscle of the lateral thigh is the best site to administer epinephrine because it is one of the largest muscles in the body and has significant blood flow, which allows more rapid absorption of the medication than in the smaller muscles in the forearm or shoulder (deltoid) or subcutaneously in the abdomen. PTS: 1 REF: p. 1048 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders 1. A client with sickle cell disease is taking narcotic analgesics for pain control. Which intervention by the nurse would decrease the risk for narcotic substance abuse? A. Encourage the client to rely on complementary and alternative therapies. B. Encourage the client to seek care from a single provider for pain relief. C. Teach the client to accept chronic pain as an inevitable aspect of the disease. D. Limit the reporting of emergency department visits to the primary health care provider.

B Rationale: The client should be encouraged to use a single primary provider to address health care concerns. Emergency department visits should be reported to the primary provider to achieve optimal management of the disease. It would be inappropriate to teach the client to simply accept the pain. Complementary therapies are usually insufficient to fully address pain in sickle cell disease. PTS: 1 REF: p. 925 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. Which assessment should the nurse prioritize? A. The client's swallowing ability B. The client's airway patency C. The client's pain level D. Signs and symptoms of infection

B Rationale: The client with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters, including swallowing ability, pain level, and signs and symptoms of infection, all of which can be assessed after assessing the client's airway patency. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client's current antiretroviral regimen includes enfuvirtide (T-20). What dietary counseling will the nurse provide based on the client's medication regimen? A. Avoid high-fat meals while taking this medication. B. Limit fluid intake to 2 L/day. C. Limit sodium intake to 2 g/day. D. Take this medication without regard to meals.

D Rationale: Enfuvirtide (T-20) is injected subcutaneously, so meals are not an important variable. Protein, sodium, and fluid levels are not significant. PTS: 1 REF: p. 1020 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? A. An increased hemoglobin and decreased hematocrit B. A decreased hemoglobin and hematocrit C. A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW) D. An increased mean corpuscular volume (MCV) and red cell distribution width (RDW)

B Rationale: The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The client will have normal MCV and RDW because the erythrocytes are normal in appearance. PTS: 1 REF: p. 915 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 18. A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF? A. Alveolar mucus plugging, infection, and eventual bronchiectasis B. Bronchial mucus plugging, inflammation, and eventual bronchiectasis C. Atelectasis, infection, and eventual COPD D. Bronchial mucus plugging, infection, and eventual COPD

B Rationale: The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and progresses to involve all lobes. Infection, atelectasis, and COPD are not hallmark pathologies of CF. PTS: 1 REF: p. 643 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 15. A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which individual is most likely to have anemia? A. A 50-year-old black woman who is going through menopause B. An 81-year-old woman who has chronic heart failure C. A 48-year-old man who travels extensively and has a high-stress job D. A 13-year-old girl who has just experienced menarche

B Rationale: The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia. PTS: 1 REF: p. 911 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A client has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the client asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response? A. "In many cases, this type of cancer spreads to other parts of the body." B. "This cancer usually does not spread to distant sites in the body." C. "You will have to speak to your oncologist about that." D. "When it spreads to other parts of the body, the care team will treat it aggressively."

B Rationale: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The client's prognosis is determined by the oncologist, but the client has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the client's concerns. PTS: 1 REF: p. 515 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 32: Management of Patients with Immune Deficiency Disorders 1. A client has just been diagnosed with a primary immune deficiency disease (PIDD). The client has done some research online and believes this is an unlikely diagnosis due to the client's age. At which stage of life are people most commonly diagnosed with PIDD? A. Early childhood B. Infancy C. Adolescence D. Early adulthood

B Rationale: The majority of PIDDs, which are a grouping of rare genetic disorders that impair the immune system, are commonly diagnosed in infancy, with a male to female ratio of 5 to 1. However, some PIDDs are not diagnosed until adolescence or early adulthood. There are more than 200 forms of PIDDs with 270 different genes associated with this condition. PTS: 1 REF: p. 1005 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 22. A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? A. Obtain serial ABG samples. B. Monitor pulse oximetry readings. C. Perform chest auscultation. D. Monitor incentive spirometry volumes.

B Rationale: The nurse assesses the client with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status. PTS: 1 REF: p. 540 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. The nurse is doing discharge teaching in the ED with a client who had a nosebleed. What should the nurse include in the discharge teaching of this client? A. Avoid blowing the nose for the next 45 minutes. B. In case of recurrence, apply direct pressure for 15 minutes. C. Do not take aspirin for the next 2 weeks. D. Seek immediate medical attention if the nosebleed recurs.

B Rationale: The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the client is instructed to seek additional medical attention. ASA is not contraindicated in most cases and the client should avoid blowing the nose for an extended period of time, not just 45 minutes. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A nurse at an allergy clinic is providing education for a client starting immunotherapy for the treatment of allergies. Which education should the nurse prioritize? A. Scheduling appointments for the same time each month B. Keeping appointments for desensitization procedures C. Avoiding antihistamines for the duration of treatment D. Keeping a diary of reactions to the immunotherapy

B Rationale: The nurse informs and reminds the client of the importance of keeping appointments for desensitization procedures, because dosages are usually adjusted on a weekly basis, and missed appointments may interfere with the dosage adjustment. Appointments are more frequent than monthly, and antihistamines are not contraindicated. There is no need to keep a diary of reactions. PTS: 1 REF: p. 1054 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 26. A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care? A. Facilitation of long-term intubation B. Restoration of adequate gas exchange C. Attainment of effective coping D. Self-management of oxygen therapy

B Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated. PTS: 1 REF: p. 556 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client is in the primary infection stage of human immunodeficiency virus (HIV). Which statement regarding this client's current health status is most accurate? A. The client's HIV antibodies are successfully, but temporarily, killing the virus. B. The client is infected with HIV but lacks HIV-specific antibodies. C. The client's risk for opportunistic infections is at its peak. D. The client may or may not develop long-standing HIV infection.

B Rationale: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease. PTS: 1 REF: p. 1013 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 11. A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A. Safe transfusion for clients with a history of transfusion reactions B. Prevention of viral infections from another person's blood C. Avoidance of complications in clients with alloantibodies D. Prevention of alloimmunization

B Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other secondary advantages include safe transfusion for clients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in clients with alloantibodies. PTS: 1 REF: p. 898 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

1. A client is having the tonsils removed. The client asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response? A. "The tonsils separate your windpipe from your throat when you swallow." B. "The tonsils help to guard the body from invasion of organisms." C. "The tonsils make enzymes that you swallow and which aid with digestion." D. "The tonsils help with regulating the airflow down into your lungs."

B Rationale: The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The tonsils do not aid digestion, separate the trachea from the esophagus, or regulate airflow to the bronchi. PTS: 1 REF: p. 464 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember

Multiple Choice 30. A client with human immunodeficiency virus (HIV) is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this client should expect the health care provider to prescribe which medication for the management of the client's diarrhea? A. Fluoxetine B. Octreotide acetate C. Levofloxacin D. Valganciclovir

B Rationale: Therapy with octreotide acetate, a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Fluoxetine is an antidepressant and would not be prescribed for the treatment of chronic diarrhea. Levofloxacin is an antibiotic and would not likely be prescribed for chronic severe diarrhea. Valganciclovir is an antiviral medication that is used to treat cytomegalovirus infection and would not be prescribed to treat chronic diarrhea. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 20: Management of Patients with Chronic Pulmonary Disease 1. A nurse is caring for a 21-year-old client whose medical history includes an alpha1-antitrypsin deficiency. This client has an increased risk of which health problem? A. Pulmonary edema B. Panacinar emphysema C. Cystic fibrosis (CF) D. Empyema

B Rationale: This deficiency predisposes young adult clients to rapid development of panacinar lobular emphysema, even in the absence of smoking. Alpha-antitrypsin deficiency is a genetic disorder that may affect the lungs or liver. It is a risk factor for chronic obstructive pulmonary disease. Alpha1-antitrypsin is an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency does not influence the client's risk of pulmonary edema, CF, or empyema. PTS: 1 REF: p. 607 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. While assessing a client who has pneumonia, the nurse has the client repeat the letter E while the nurse auscultates. The nurse notes that the client's voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented? A. Bronchophony B. Egophony C. Whispered pectoriloquy D. Sonorous wheezes

B Rationale: This finding would be documented as egophony, which can be best assessed by instructing the client to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound. PTS: 1 REF: p. 482 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 29. The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A. Sputum production B. Shortness of breath C. Throat discomfort D. Epistaxis

B Rationale: Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis. Follow-up care in the health care facility and at home involves monitoring the client for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication. PTS: 1 REF: p. 492 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status? A. Risk for deficient fluid volume related to impaired erythropoiesis B. Risk for infection related to tissue hypoxia C. Acute pain related to uncontrolled hemolysis D. Fatigue related to decreased oxygen-carrying capacity

D Rationale: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The client may have an increased risk of infection due to impaired immune function, but fatigue is more likely. PTS: 1 REF: p. 912 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A medical client rings the call bell and expresses alarm to the nurse, stating, "I've just coughed up this blood. That can't be good, can it?" How can the nurse best determine whether the source of the blood was the client's lungs? A. Obtain a sample and test the pH of the blood, if possible. B. Try to see if the blood is frothy or mixed with mucus. C. Perform oral suctioning to see if blood is obtained. D. Swab the back of the client's throat to see if blood is present.

B Rationale: Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the client's mouth would not reveal the source. PTS: 1 REF: p. 474 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor? A. An attack on the platelets by antibodies B. Decreased production of platelets C. Impaired communication between platelets D. An autoimmune process causing platelet malfunction

B Rationale: Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Impaired platelet communication, antibodies, and autoimmune processes are not typical pathologies. PTS: 1 REF: p. 932 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Notify the client's health care provider. B. Stop the transfusion immediately. C. Remove the client's IV access. D. Assess the client's chest sounds and vital signs.

B Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed. PTS: 1 REF: p. 906 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? A. 75 cells/mm3 of blood B. 200 cells/mm3 of blood C. 325 cells/mm3 of blood D. 450 cells/mm3 of blood

B Rationale: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS. PTS: 1 REF: p. 1014 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? A. Dermatitis B. Petechiae C. Urticaria D. Alopecia

B Rationale: When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair loss). PTS: 1 REF: p. 931 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend? A. "Position a fan blowing toxic substances away from you to prevent you from being exposed." B. "Wear protective attire and devices when working with a toxic substance." C. "Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins." D. "Always wear a disposable paper face mask when you are working with inhalable toxins."

B Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area. PTS: 1 REF: p. 577 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 13. A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath after a prolonged episode of coughing. On assessment, the nurse notes an oxygen saturation of 84%, asymmetrical chest movement, and decreased breath sounds on the right side. Which condition should the nurse suspect and which interventions should the nurse implement based on these signs and symptoms? A. Expected response to coughing; give supplemental oxygen and encourage deep breathing exercises B. Pneumothorax; give supplemental oxygen and continue to monitor the client C. Oxygen toxicity; lower any supplemental oxygen and continue to monitor the client D. Chronic atelectasis; give supplemental oxygen and encourage deep breathing exercises

B Rationale: Development of a pneumothorax, a potentially life-threatening complication of COPD, may be spontaneous or related to severe coughing or large intrathoracic pressure changes. The combination of asymmetry of chest movement, differences in breath sounds, and a decreased pulse oximetry are indications of pneumothorax. In response, the nurse should administer supplemental oxygen and continue close bedside monitoring of this client. The signs and symptoms described are not normal findings after coughing or due to chronic atelectasis (alveolar collapse). While a decrease in saturation is expected after coughing, due to irritation of airways and decreased ability to fully oxygenate, the saturation was lower than expected. Oxygen toxicity occurs when too high of a concentration of oxygen is given over a period of time, which triggers a severe inflammatory response. Because no specific duration or amount of oxygen was listed and a hallmark of this condition is substernal discomfort and progressive respiratory difficulties, this was an unlikely choice. PTS: 1 REF: p. 623 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 10. A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize? A. Smoking up to three cigarettes weekly is generally allowable. B. Chronic inhalation of indoor toxins can cause lung damage. C. Minor respiratory infections are considered to be self-limited and are not treated with medication. D. Activities of daily living (ADLs) should be clustered in the early morning hours.

B Rationale: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all clients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit clients to perform these without excessive distress. PTS: 1 REF: p. 605 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 28. A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a correct understanding of this medication? A. "This drug may make my heart beat slower." B. "This drug is particularly good at preventing asthma attacks during exercise." C. "I'll make sure to use this each time I feel an asthma attack coming on." D. "I understand that this drug is less effective at controlling night-time symptoms."

B Rationale: LABAs are effective in the prevention of exercise-induced asthma. They are also used with anti-inflammatory medications to control asthma symptoms, particularly those that occur during the night. LABAs are not indicated for immediate relief of symptoms. are not used for management of acute asthma symptoms. Tachycardia, not bradycardia, is a potential adverse effect of this medication. PTS: 1 REF: p. 639 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. The nurse is caring for a client with a history of a renal transplant who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the client asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in this client? A. The client will have exaggerated symptoms of rhinosinusitis due to immunosuppression. B. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. C. Chronic rhinosinusitis can damage the transplanted organ. D. Immunosuppressive drugs can cause organ rejection.

B Rationale: URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection. PTS: 1 REF: p. 503 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 25. A nurse is assessing a client who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply. A. Pulmonary hypertension B. Airway obstruction C. Pulmonary infections D. Genetic disorders E. Atelectasis

B, C, D Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis. PTS: 1 REF: p. 631 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 29. A client has been transported to the emergency department after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. A. Facilitate lung function testing. B. Assess breath sounds. C. Measure the client's oxygen saturation by oximeter. D. Monitor the client's respiratory pattern. E. Assess the client's respiratory rate.

B, C, D, E Rationale: The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context. PTS: 1 REF: p. 1054 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply. A. White blood cell count B. Protein level C. Albumin level D. Platelet count E. Glucose level

B, C, E Rationale: The nurse assesses the client's general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the client's nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the client's nutritional status. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. An interdisciplinary team is planning the care of a client with bronchiectasis. What aspects of care should the nurse anticipate? Select all that apply. A. Occupational therapy B. Antimicrobial therapy C. Positive pressure isolation D. Chest physiotherapy E. Smoking cessation

B, D, E Rationale: Chest physiotherapy, antibiotics, and smoking cessation are cornerstones of the care of clients with bronchiectasis. Occupational therapy and isolation are not normally indicated. PTS: 1 REF: p. 631 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A client is brought to the emergency department by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which assessment parameters should the nurse monitor most closely? Select all that apply. A. Coping B. Level of consciousness C. Oral intake D. Arterial blood gases E. Vital signs

B, D, E Rationale: Trauma clients are usually treated in the ICU. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment but would become more important later during recovery. PTS: 1 REF: p. 590 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 22. A nurse's assessment reveals that a client with chronic obstructive pulmonary disease may be experiencing bronchospasm. Which assessment findings would suggest that the client is experiencing bronchospasm? Select all that apply. A. Fine or coarse crackles on auscultation B. Wheezes or diminished breath sounds on auscultation C. Reduced respiratory rate or lethargy D. Slow, deliberate respirations and diaphoresis E. Labored and rapid breathing

B, E Rationale: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, labored breathing and agitation, not slow, deliberate respirations, reduced respiratory rate, or lethargy. PTS: 1 REF: p. 642 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment? A. A 1.5 L/day fluid restriction B. A high-potassium, low-sodium diet C. A liquid or soft diet D. A high-protein diet

C Rationale: A liquid or soft diet is provided during the acute stage of the disease, depending on the client's appetite and the degree of discomfort that occurs with swallowing. The client is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake. PTS: 1 REF: p. 504 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client asks the nurse why an infection in the upper respiratory system is affecting the clarity of the client's speech. The nurse should describe the role of what structure? A. Trachea B. Pharynx C. Paranasal sinuses D. Larynx

C Rationale: A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tube-like structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound. PTS: 1 REF: p. 463 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 5. The nurse is assessing a new client with reports of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? A. Sickle cell disease B. Hemophilia C. Megaloblastic anemia D. Thrombocytopenia

C Rationale: A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease, hemophilia, and thrombocytopenia do not have symptoms involving the tongue. PTS: 1 REF: p. 912 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 21. A nurse is caring for a client hospitalized with AIDS. A friend comes to visit the client and privately asks the nurse about the risk of contracting HIV when visiting the client. What is the nurse's best response? A. "Do you think that you might already have HIV?" B. "Your immune system is likely very healthy." C. "AIDS isn't transmitted by casual contact." D. "You can't normally contract AIDS in a hospital setting."

C Rationale: AIDS is commonly transmitted by contact with blood and body fluids. Clients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection. PTS: 1 REF: p. 1032 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is caring for a client who has been scheduled for a bronchoscopy. How should the nurse prepare the client for this procedure? A. Administer a bolus of IV fluids. B. Arrange for the insertion of a peripherally inserted central catheter. C. Administer nebulized bronchodilators every 2 hours until the test. D. Withhold food and fluids for several hours before the test.

D Rationale: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary. PTS: 1 REF: p. 491 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the client's previous medication regimen may have contributed to the development of this disorder? A. Calcium carbonate B. Vitamin B12 C. Aspirin D. Vitamin D

C Rationale: Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the potential to induce a platelet defect. PTS: 1 REF: p. 935 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 11. A client is undergoing testing to assess for a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? A. Increased tactile fremitus, egophony, and the chest wall dull on percussion B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on percussion C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on percussion

C Rationale: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion. PTS: 1 REF: p. 484 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A school nurse is caring for a 10-year-old client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? A. Administer corticosteroids by metered dose inhaler. B. Administer inhaled anticholinergics. C. Administer an inhaled beta-adrenergic agonist. D. Use a peak flow monitoring device.

C Rationale: Asthma exacerbations are best managed by early treatment and education of the client. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in clients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath. PTS: 1 REF: p. 635 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 39. Which of the following circumstances would most clearly warrant autologous blood donation? A. The client has type-O blood. B. The client has sickle cell disease or a thalassemia. C. The client has elective surgery pending. D. The client has hepatitis C.

C Rationale: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation. PTS: 1 REF: p. 898 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice Chapter 28: Assessment of Hematologic Function and Treatment Modalities 1. A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse understands that this process takes place primarily in which location? A. Spleen B. Kidneys C. Bone marrow D. Liver

C Rationale: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of red blood cells. However, blood cells are not primarily formed in the spleen, kidneys, or liver. PTS: 1 REF: p. 885 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 6. A nurse is preparing to care for a client with bronchiectasis. The nurse should recognize that this client is likely to experience respiratory difficulties related to what pathophysiologic process? A. Intermittent episodes of acute bronchospasm B. Alveolar distention and impaired diffusion C. Dilation of bronchi and bronchioles D. Excessive gas exchange in the bronchioles

C Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles that results from destruction of muscles and elastic connective tissue. It is not characterized by acute bronchospasm, alveolar distention, or excessive gas exchange. PTS: 1 REF: p. 631 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which action? A. Apply a cold pack to the affected area. B. Apply heat to the forehead. C. Perform postural drainage. D. Increase fluid intake.

D Rationale: For a client diagnosed with acute sinusitis, the nurse should instruct the client that increasing fluid intake and elevating the head of the bed can promote drainage. Applying a cold pack to the affected area and applying heat to the forehead will not promote sinus drainage. Postural drainage is used to remove bronchial secretions. PTS: 1 REF: p. 502 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 23. The nurse is teaching a client with allergic rhinitis about the safe and effective use of medications. Which information would be the most essential to give this client about preventing possible drug interactions? A. Prescription medications can be safely supplemented with over-the-counter (OTC) medications. B. Use only one pharmacy so the pharmacist can check drug interactions. C. Read drug labels carefully before taking OTC medications. D. Consult the Internet before selecting an OTC medication.

C Rationale: Client education is essential when assisting the client in the use of all medications. To prevent possible drug interactions, the client is cautioned to read drug labels before taking any OTC medications. Some websites are reliable and valid information sources, but this is not always the case. Clients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 37. Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education? A. Infection risks associated with FFP administration B. Physiologic functions of plasma C. Signs and symptoms of a transfusion reaction D. Strategies for managing transfusion-associated anxiety

C Rationale: Clients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some clients, but transfusion reactions are life-threatening and should be addressed first. Teaching about the functions of plasma is not likely a high priority. PTS: 1 REF: p. 903 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. A client has been scheduled for a bone marrow aspiration and admits to the nurse being worried about the pain involved with the procedure. Which statement by the nurse when providing client education would be most accurate? A. "You'll be given painkillers before the test, so there won't likely be any pain." B. "You'll feel some pain when the needle enters your skin, but none during the aspiration." C. "Most people feel some brief, sharp pain when the marrow is aspirated." D. "I'll be there with you, and I'll try to help you keep your mind off the pain."

C Rationale: Clients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the client should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the client's fears of pain, because this does not help the client know what to expect. Although a local anesthetic agent is administered to the skin, subcutaneous tissue, and periosteum of the bone, it is not possible to anesthetize the bone itself, and the client will most likely experience sharp, brief pain during the actual aspiration. Painkillers are not necessarily given before the test and would not likely block all pain from the aspiration. PTS: 1 REF: p. 894 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 7. A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring? A. So that the client's functional needs can be met immediately B. So that medications can be given as prescribed and signs of adverse reactions noted C. So that early signs of impending infection can be detected and treated D. So that the nurse's documentation can be thorough and accurate

C Rationale: Continual monitoring of the client's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the client's status. Continual monitoring is not primarily motivated by the client's functional needs or medication schedule. The nurse's documentation is important, but less so than infection control. PTS: 1 REF: p. 1007 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 29. It is cold season, and the school nurse has been asked to provide an educational event for the parent teacher organization of the local elementary school. Which information should the nurse include in education about the treatment of pharyngitis? A. Pharyngitis is more common in children whose immunizations are not up to date. B. There are no effective, evidence-based treatments for pharyngitis. C. Use of warm saline gargles or throat irrigations can relieve symptoms. D. Heat may increase the spasms in pharyngeal muscles.

C Rationale: Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. Applying heat to the throat would reduce, not increase, spasms in the pharyngeal muscles. There is no evidence that pharyngitis is more common in children whose immunizations are not up to date. Warm saline gargles and throat irrigations are evidence-based treatments for pharyngitis. PTS: 1 REF: p. 504 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 19. The nurse is caring for a client with epistaxis in the emergency department. Which information should the nurse include in client discharge teaching as a way to prevent epistaxis? A. Keep nasal passages clear. B. Use decongestants regularly. C. Humidify the indoor environment. D. Use a tissue when blowing the nose.

C Rationale: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose blowing, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated. PTS: 1 REF: p. 512 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 6. A client with a diagnosis of primary immunodeficiency disease informs the nurse that the client has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client's vital signs are within reference ranges, what action should the nurse take? A. Administer a nebulized bronchodilator. B. Perform oral suctioning. C. Assess the client for signs and symptoms of infection. D. Teach the client deep breathing and coughing exercises.

C Rationale: Dyspnea and cough are among the varied signs and symptoms that may suggest infection in an immunocompromised client. There is no indication for suctioning or the use of nebulizers. Deep breathing and coughing exercises do not address the client's complaints or the likely etiology. PTS: 1 REF: p. 1006 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A. Anxiety related to diagnosis of cancer B. Altered nutrition related to swallowing difficulties C. Ineffective airway clearance related to airway alterations D. Impaired verbal communication related to removal of the larynx

C Rationale: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions. PTS: 1 REF: p. 516 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem? A. Pneumoconiosis B. Pleural effusion C. Acute respiratory failure D. Pneumonia

C Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms. PTS: 1 REF: p. 556 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 39. A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process and has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client? A. The client will be started on fluoxetine in 1 month. B. Antiretroviral therapy will begin within 3 months. C. Follow-up testing will be promptly performed to confirm the result. D. The client will be monitored for signs and symptoms of HIV to determine the need for treatment.

C Rationale: Follow-up testing is performed if the initial test result is positive to ensure a correct diagnosis. These tests include antibody differentiation tests, which distinguish HIV-1 from antibodies, and HIV-1 nucleic acid tests, which look for the virus RNA directly. Antiretroviral therapy may be needed, but the next step would be to confirm the diagnosis. Fluoxetine, an antidepressant, would be prescribed if the client developed severe depression, which is not evident in this scenario. The client would not simply be monitored for signs and symptoms of HIV to determine treatment; the client would undergo follow-up testing to determine the need for treatment. PTS: 1 REF: p. 1015 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? A. Salmon accompanied by whole milk B. Mixed vegetables and brown rice C. Beef liver accompanied by orange juice D. Yogurt, almonds, and whole grain oats

C Rationale: Food sources high in iron include organ meats, other meats, beans (e.g., black and pinto), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. All of the listed foods are nutritious, but liver and orange juice are most likely to be of benefit to iron stores. PTS: 1 REF: p. 914 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A pediatric nurse is working with an interdisciplinary team and parents to care for a 6-month-old client who has recently been diagnosed with severe combined immune deficiency (SCID). Which treatment is likely of most benefit to this client's type of primary immune deficiency disease (PIDD)? A. Combined radiotherapy and chemotherapy B. Antibiotic therapy C. Hematopoietic stem cell transplantation (HSCT) D. Treatment with colony-stimulating factors (CSFs)

C Rationale: HSCT is a curative modality for some PIDDs, such as SCID. The stem cells may be from embryos or adults. SCID's onset is typically manifested by 6 months of age or earlier. SCID causes a child to be born with little or no immune system and historically resulted in frequent deaths due to multiple infections. Newborn screening in recent years has resulted in early inventions with HSCT and gene therapy. Radiation and chemotherapy, antibiotics, and CSF do not provide a cure. PTS: 1 REF: p. 1005 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client reports having hereditary angioedema. The nurse should identify which implication of this health condition? A. It will result in increased loss of work days. B. It may cause episodes of weakness due to reduced cardiac output. C. It can cause life-threatening airway obstruction. D. It is a risk factor for ischemic heart disease.

C Rationale: Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work, reduced cardiac function, or ischemic heart disease. PTS: 1 REF: p. 514 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 32. A client has presented with signs and symptoms that are consistent with contact dermatitis. Which aspect of care should the nurse prioritize when working with this client? A. Promoting adequate perfusion in affected regions B. Promoting safe use of topical antihistamines C. Identifying the offending agent, if possible D. Teaching the client to safely use an EpiPen

C Rationale: Identifying the offending agent is a priority in the care of a client with dermatitis. This provides a cure via removal of the offending agent, rather than being limited to treating the symptoms. Topical antihistamines can provide some relief from itching, especially with allergic dermatitis, but identifying and removing the offending agent takes is a higher priority, as it would allow the client to not need to use a topical antihistamine. An epinephrine auto injector (EpiPen) is typically used to treat anaphylaxis, not contact dermatitis. Inadequate perfusion occurs with peripheral artery disease or vasoconstriction but is not associated with contact dermatitis. PTS: 1 REF: p. 1057 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect? A. Cytotoxic reaction due to contact with the powder in the gloves B. Immune complex reaction due to contact with anesthetic gases C. Anaphylaxis due to a latex allergy D. Delayed reaction due to exposure to cleaning products

C Rationale: Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction. PTS: 1 REF: p. 1062 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 17. A client presents to the walk-in clinic reporting a dry, irritating cough and production of a small amount of mucus-like sputum. The client also reports soreness in the chest in the sternal area. The nurse should suspect that the primary care provider will assess the client for which health problem? A. Pleural effusion B. Pulmonary embolism C. Tracheobronchitis D. Tuberculosis

C Rationale: Initially, the client with tracheobronchitis has a dry, irritating cough and expectorates a scant amount of mucoid sputum. The client may report sternal soreness from coughing and have fever or chills, night sweats, headache, and general malaise. Pleural effusion and pulmonary embolism do not normally cause sputum production and would likely cause acute shortness of breath. Hemoptysis is characteristic of tuberculosis. PTS: 1 REF: p. 531 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action? A. Position the client in a prone position to minimize bleeding. B. Establish IV access for the administration of vitamin K. C. Prepare for the administration of factor VIII. D. Administer a normal saline bolus to increase circulatory volume.

C Rationale: Injuries to clients with hemophilia necessitate prompt administration of clotting factors. Vitamin K is not a treatment modality and a prone position will not be appropriate for all types and locations of wounds. A normal saline bolus is not indicated. PTS: 1 REF: p. 936 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises? A. Lie supine to facilitate air entry. B. Avoid pursed-lip breathing unless absolutely necessary. C. Use diaphragmatic breathing. D. Use chest breathing.

C Rationale: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing. PTS: 1 REF: p. 620 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 19. The nurse is caring for an older client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of topical lidocaine. For what complication related to the administration of large doses of topical lidocaine in older adults should the nurse assess? A. Decreased urine output and hypertension B. Headache and vision changes C. Confusion and lethargy D. Jaundice and elevated liver enzymes

C Rationale: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in an older adult, which may be due to the large doses of lidocaine given during the procedure. The other listed signs and symptoms are not specific to this problem. PTS: 1 REF: p. 483 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is creating a plan of care for a client diagnosed with acute laryngitis. Which intervention should be included in the client's plan of care? A. Place warm washcloths on the client's throat, as needed. B. Have the client inhale warm steam three times daily. C. Encourage the client to limit speech whenever possible. D. Limit the client's fluid intake to 1.5 L/day.

C Rationale: Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool, not warm, steam or an aerosol. Fluid intake should be increased, not limited. Warm washcloths on the throat will not help relieve the symptoms of acute laryngitis. PTS: 1 REF: p. 507 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A client with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in clients with AIDS by increasing body fat stores? A. Psyllium B. Momordica charantia C. Megestrol D. Ranitidine

C Rationale: Megestrol acetate, a synthetic oral progesterone preparation, promotes significant weight gain. In clients with HIV infection, it increases body weight primarily by increasing body fat stores. Psyllium is a fiber source. Momordica charantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine was previously used to prevent ulcers but was removed from the market in April 2020. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. The nurse on the pediatric unit is caring for a 10-year-old child with a diagnosis of hemophilia. The nurse should assess carefully for indication of what nursing diagnosis? A. Hypothermia B. Diarrhea C. Ineffective coping D. Imbalanced nutrition: Less than body requirements

C Rationale: Most clients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition. PTS: 1 REF: p. 937 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? A. Teaching focuses on safe and effective use of antibiotics. B. The client should be preliminarily screened for surgery. C. Symptom management is the main focus of medical and nursing care. D. The focus of care is resting the voice to prevent chronic hoarseness.

C Rationale: Nursing care for clients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance. PTS: 1 REF: p. 504 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 18. A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of which health problem? A. Adenoiditis B. Chronic tonsillitis C. Obstructive sleep apnea D. Laryngeal cancer

C Rationale: Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This client's symptoms are not suggestive of laryngeal cancer. PTS: 1 REF: p. 510 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse's review of a client's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following? A. Respiratory function B. Evidence of decreased tissue perfusion C. Signs and symptoms of infection D. Recent changes in activity tolerance

C Rationale: Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance. PTS: 1 REF: p. 889 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following? A. Organic acids B. Solvents C. Asbestos D. Gypsum

C Rationale: Pneumoconiosis is a general term given to any lung disease caused by dusts that are breathed in and then deposited deep in the lungs causing damage. Pneumoconiosis is usually considered an occupational lung disease, and includes asbestosis, silicosis, and coal workers' pneumoconiosis, also known as "Black Lung Disease." Asbestos is among the more common causes of pneumoconiosis. Organic acids, solvents, and gypsum do not have this effect. PTS: 1 REF: p. 576 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for a client with bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this client's care? A. Oral administration of diuretics B. Intravenous fluids to reduce the viscosity of secretions C. Postural chest drainage D. Pulmonary function testing

C Rationale: Postural drainage is part of all treatment plans for bronchiectasis, because draining of the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Diuretics and IV fluids will not aid in the mobilization of secretions. Lung function testing may be indicated, but this assessment will not relieve the client's symptoms. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform? A. Have the client identify the blood type in writing. B. Ensure that the client has granted verbal consent for transfusion. C. Assess the client's vital signs to establish baselines. D. Facilitate insertion of a central venous catheter.

C Rationale: Prior to a transfusion, the nurse must take the client's temperature, pulse, respiration, and blood pressure to establish a baseline. Written consent is required, and the client's blood type is determined by type and cross match, not by the client's self-declaration. Peripheral venous access is sufficient for blood transfusion. PTS: 1 REF: p. 900 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement? A. Note the corticosteroid use in the electronic health record and continue with the test. B. Modify the skin test to check for grass, mold, or dust allergies only. C. Administer sodium valproate to reverse the effects of corticosteroid usage. D. Cancel and reschedule the skin test when the client stops taking the corticosteroid.

D Rationale: Corticosteroids and antihistamines, including over-the-counter allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. If the client takes one of these medications within this time frame, the nurse should cancel the skin test and reschedule for a time when the client is not taking it. The nurse should not continue with the test. The nurse should not modify the test. Administration of sodium valproate is used to reverse corticosteroid-induced mania, not to reverse it effects, in general. PTS: 1 REF: p. 1045 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 41. The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client? A. Safe technique for self-suctioning of secretions B. Technique for performing postural drainage C. Correct and safe use of oxygen therapy equipment D. How to provide safe and effective tracheostomy care

C Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or intravenous medications) may be continued at home. Therefore, the nurse needs to instruct the client and family in their correct and safe use. The scenario does not indicate the client needs suctioning, postural drainage, or tracheostomy care. PTS: 1 REF: p. 582 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 16. A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? A. Expiratory wheezes B. Inspiratory wheezes C. Rhonchi D. Crackles

D Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure. PTS: 1 REF: p. 483 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is completing a client's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? A. "Have you ever been employed in a factory, smelter, or mill?" B. "Does anyone in your family have any form of lung disease?" C. "Do you currently smoke, or have you ever smoked?" D. "Have you ever lived in an area that has high levels of air pollution?"

C Rationale: Smoking is the single most important contributor to lung disease, exceeding the significance of environmental, occupational, and genetic factors. PTS: 1 REF: p. 474 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is caring for an adult client recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating clients with non-small cell tumors is what method? A. Chemotherapy B. Radiation C. Surgical resection D. Bronchoscopic opening of the airway

C Rationale: Surgical resection is the preferred method of treating clients with localized non-small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred. PTS: 1 REF: p. 580 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 39. A client with a severe exacerbation of chronic obstructive pulmonary disease requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? A. Nonrebreathing mask B. Tracheostomy collar C. Venturi mask D. Face tent

C Rationale: The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. It is used primarily for clients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The Venturi mask uses the Bernoulli principle of air entrainment (trapping the air like a vacuum), which provides a high airflow with controlled oxygen enrichment. For each liter of oxygen that passes through a jet orifice, a fixed proportion of room air is entrained. Varying the size of the jet orifice and adjusting the flow of oxygen can deliver a precise volume of oxygen. The other methods of oxygen delivery listed, the nonrebreathing mask, tracheostomy collar, and face tent, do not use the Bernoulli principle and thus lack the precision of a Venturi mask. PTS: 1 REF: p. 613 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood? A. A capillary blood sample B. Pulse oximetry C. An arterial blood gas (ABG) study D. A complete blood count (CBC)

C Rationale: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool, but does not replace ABG measurement because it is not as accurate. A CBC does not indicate the concentration of oxygen. PTS: 1 REF: p. 487 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. The nurse is assessing the respiratory status of a client who is experiencing an exacerbation of emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A. Rhonchi during expiration B. Wheezing with discontinuous breath sounds C. Faint breath sounds with prolonged expiration D. Faint breath sounds with fine crackles

C Rationale: The breath sounds of the client with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged. Fine crackles are soft, high-pitched, discontinuous popping sounds heard in mid to late inspiration that are associated with interstitial pneumonia, restrictive pulmonary disease, or bronchitis. Wheezing is a continuous, musical, high-pitched, shrill sound associated with chronic bronchitis or bronchiectasis. Rhonchi are deep, lower-pitched rumbling sounds, with a snoring quality, that are associated with secretions or a tumor. PTS: 1 REF: p. 482 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse in the intensive care unit is caring for a client with pulmonary hypertension. Which finding should the nurse expect to assess? A. Pulmonary artery pressure greater than 20 mm Hg B. Flat neck veins C. Dyspnea at rest D. Enlarged spleen

C Rationale: The main symptom in pulmonary hypertension is dyspnea. At first dyspnea occurs with exertion, then eventually at rest. A client with pulmonary hypertension will have a pulmonary artery pressure greater than 25 mm Hg at rest and distended neck veins secondary to right-sided heart failure. The nurse would expect the liver, not the spleen, to be enlarged secondary to engorgement in pulmonary hypertension. PTS: 1 REF: p. 575 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 14. A client is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. Which food items would the nurse inform the client are common allergens? A. Citrus fruits and rice B. Root vegetables and tomatoes C. Eggs and wheat D. Hard cheeses and vegetable oils

C Rationale: The most common food allergens are seafood (lobster, shrimp, crab, clams, fin fish), peanuts, tree nuts, eggs, wheat, milk, and soy. Citrus fruits, rice, root vegetables, tomatoes, hard cheeses, and vegetable oils are not common allergens. PTS: 1 REF: p. 1061 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 16. A nurse should prioritize and closely monitor a client for a potentially severe anaphylactic reaction after the client has received which medical intervention? A. Measles-mumps-rubella vaccine B. Rapid administration of intravenous fluids C. Computed tomography with contrast solution D. Nebulized bronchodilator

C Rationale: The most severe anaphylaxis, sometimes referred to as anaphylactic shock, is caused by antibiotics and radiocontrast agents. The computed tomography scan with contrast dye uses these agents. Vaccines can produce an anaphylactic reaction but are usually localized and not severe. Intravenous fluid and bronchodilators may be used to manage anaphylaxis in clients with symptoms of bronchospasm or hypotension, but they are not typically associated with triggering anaphylactic shock themselves. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's health care provider because these symptoms are suggestive of what issue? A. Pneumothorax B. Lung tumors C. Infection D. Pulmonary edema

C Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum. PTS: 1 REF: p. 473 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse's best action? A. Remove the client's drain and apply pressure with a sterile gauze. B. Assess the client, reposition the client supine, and apply wall suction to the drain. C. Rapidly assess the client and notify the surgeon about the client's bleeding. D. Administer a STAT dose of vitamin K to aid coagulation.

C Rationale: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be given without an order. PTS: 1 REF: p. 520 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A. "Complementary therapies generally have not been approved, so clients are usually discouraged from using them." B. "Researchers have not looked at the benefits of alternative therapy for clients with HIV, so we suggest that you stay away from these therapies until there is solid research data available." C. "Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks." D. "You'll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach."

C Rationale: The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment. PTS: 1 REF: p. 1026 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 18. While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? A. Eupnea B. Apnea C. Biot respiration D. Cheyne-Stokes

C Rationale: The nurse will document that the client is demonstrating a Biot respiration pattern. Biot respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. PTS: 1 REF: p. 477 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 4. A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A. Take the iron with dairy products to enhance absorption. B. Increase the intake of vitamin E to enhance absorption. C. Iron will cause the stools to darken in color. D. Limit foods high in fiber due to the risk for diarrhea.

C Rationale: The nurse will inform the client that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy. PTS: 1 REF: p. 915 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 26. A client's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client's immune response. This is known as what physiologic state? A. Static stage B. Latent stage C. Viral set point D. Window period

C Rationale: The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though they are infected. PTS: 1 REF: p. 1013 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A. Shallow respirations B. Increased anterior-posterior (AP) diameter C. Bilateral wheezes D. Bradypnea

C Rationale: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's AP diameter does not normally change. PTS: 1 REF: p. 633 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 38. The home care nurse is assessing a client who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the client in the home environment? A. The client desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. B. The client requires a high-flow system for use with a tracheostomy collar. C. The client desires a portable oxygen delivery system that can deliver 2 L/min. D. The client's respiratory status requires a system that provides an FiO2 of 65%.

C Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The client desiring a portable oxygen delivery system of 2 L/min will benefit from the use of an oxygen concentrator. PTS: 1 REF: p. 630 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 35. While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C Rationale: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. PTS: 1 REF: p. 596 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing diagnosis should the nurse prioritize in the client's plan of care? A. Risk for disuse syndrome related to ineffective peripheral circulation B. Functional urinary incontinence related to urethral occlusion C. Ineffective tissue perfusion related to thrombosis D. Ineffective thermoregulation related to hypothalamic dysfunction

C Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis. PTS: 1 REF: p. 920 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 32. A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching? A. Increased respiratory secretions B. Bradycardia C. Oral candidiasis D. Decreased level of consciousness

C Rationale: Thrush or oral candidiasis is a fungal infection that presents with white lesions on the tongue and/or inner cheeks of the mouth. Clients should rinse their mouth after administration or use a spacer to prevent thrush, a common complication associated with use of inhaled corticosteroids. Increased respiratory secretions normally do not occur, although a cough may develop. Tachycardia, or a fast heart rate, rather than bradycardia, or a slow heart rate, is listed as an adverse effect. A decreased level of consciousness is not associated with this medication because it does not cause sedation nor is it an opiate. PTS: 1 REF: p. 635 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 7. A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

C Rationale: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 26. A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action? A. Housing the resident in a private room B. Implementing a passive ROM program C. Implementing of a plan for fall prevention D. Providing the client with a high-fiber diet

C Rationale: To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake. PTS: 1 REF: p. 931 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance? A. Vitamin E B. Vitamin D C. Iron D. Magnesium

C Rationale: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is creating a care plan for a client who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. Which form of alaryngeal communication is generally most preferred? A. Esophageal speech B. Electric larynx C. Tracheoesophageal puncture D. American sign language (ASL)

C Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, electric larynx, and ASL. PTS: 1 REF: p. 517 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand

Multiple Response 28. A client has just been diagnosed with lung cancer. After the health care provider discusses treatment options and leaves the room, the client asks the nurse how the treatment is decided upon. What would be the nurse's best response? A. "The type of treatment depends on the client's age and health status." B. "The type of treatment depends on what the client wants when given the options." C. "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the client's health status." D. "The type of treatment depends on the discussion between the client and the health care provider of which treatment is best."

C Rationale: Treatment of lung cancer depends on the cell type, the stage of the disease, and the client's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the client's age or the client's preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the client and the health care provider of which treatment is best, though this discussion will take place. PTS: 1 REF: p. 580 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 28. A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young, I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? A. "Newer antihistamines are combined with a stimulant that offsets drowsiness." B. "Most people find that they develop a tolerance to sedation after a few months." C. "The newer antihistamines are different than in years past, and cause less sedation." D. "Have you considered taking them at bedtime instead of in the morning?"

C Rationale: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if any at all. Tolerance to sedation did not usually occur with first-generation drugs, and newer antihistamines are not combined with a stimulant. Although taking an antihistamine at bedtime may be a suitable option for the client, it is not the nurse's best response because it does not inform the client of the newer antihistamines, which cause little or no sedation and thus could be taken any time of day. PTS: 1 REF: p. 1050 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 34. A client with a history of atrial fibrillation has contacted the clinic reporting an accidental overdose on prescribed warfarin. The nurse should recognize the possible need for which antidote? A. Intravenous immunoglobulins (IVIG) B. Factor IX C. Vitamin K D. Factor VIII

C Rationale: Vitamin K is given as an antidote for warfarin toxicity. IVIG is a form of immunosuppressive therapy given to treat immune thrombocytopenic purpura and to counteract hemolytic transfusion reaction and neutralizing antibodies (inhibitors) that develop in response to factor replacement therapy in clients with hemophilia. IVIG is not used as an antidote for warfarin toxicity. Factors VIII and IX are clotting factors that are deficient in clients with hemophilia due to a genetic defect; these clients may receive recombinant forms of these factors to treat their condition. PTS: 1 REF: p. 945 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 34. The ED nurse is assessing the respiratory function of a client who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what condition? A. Pleurisy B. Emphysema C. Asthma D. Pneumonia

C Rationale: Wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing? A. Gradually increase levels of physical exertion. B. Change filters on heaters and air conditioners frequently. C. Take prescribed medications as scheduled. D. Avoid goose-down pillows.

C Rationale: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks. PTS: 1 REF: p. 640 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 12. A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of which chronic health problem would most likely prompt this diagnosis? A. Herpes simplex B. Human immunodeficiency virus (HIV) C. Spina bifida D. Hypogammaglobulinemia

C Rationale: Clients with spina bifida are at a particularly high risk for developing a latex allergy. Clients with spina bifida are at high risk because they have had multiple surgeries, multiple urinary catheterization procedures, and other treatments involving use of latex products, and latex allergy develops as a result of repeated exposure to the proteins and polypeptides in natural rubber latex. Clients with herpes simplex, HIV, or hypogammaglobulinemia (decreased level of gamma immunoglobulins) are less likely than clients with spina bifida to have as many surgeries or other treatments that would expose them to latex. PTS: 1 REF: p. 1062 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client? A. Signs of oxygen toxicity B. A moon face C. A barrel chest D. Long, thin fingers

C Rationale: In chronic obstructive pulmonary disease (COPD) clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The client with COPD is more likely to have finger clubbing, which is an abnormal rounded appearance of the fingertips, rather than long, thin fingers. Clubbed fingers are the result of chronically low blood levels of oxygen. A moon face is swelling of the face due to increased fat deposits. This may be a sign of Cushing syndrome or a side effect of steroid use. Signs of oxygen toxicity, such as facial pallor or behavioral changes, may be possible but are not the most likely physical findings for this client. PTS: 1 REF: p. 606 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A. Antihypertensives B. Penicillins C. Sulfa-containing medications D. Aspirin-based drugs E. NSAIDs

C, D, E Rationale: The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function. PTS: 1 REF: p. 934 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 31. A nurse is developing a care plan for a client with chronic obstructive pulmonary disease (COPD) admitted to the hospital for the second time this year with pneumonia. Which nursing diagnoses would be appropriate for this client? Select all that apply. A. Ineffective airway clearance related to inhalation of toxins B. Activity intolerance related to oxygen supply and demand C. Impaired gas exchange related to ventilation-perfusion inequality D. Ineffective health management related to fatigue E. Deficient knowledge regarding self-care related to preventable complications

C, E Rationale: Impaired gas exchange and deficient knowledge are the appropriate diagnoses for this client based on the information provided. Pneumonia is an acute infection of the parenchyma whose pathophysiology typically triggers an inflammatory response in the lung. In a client with COPD who already has chronic inflammation, gas exchange becomes further compromised. Areas of the lung receive either oxygen but no blood flow or blood flow but no oxygen (ventilation/perfusion inequality). Because this was the second admission for the same diagnosis, deficient knowledge of prevention strategies should be included for this client. Although ineffective airway clearance is a possibility, not enough information is provided to conclude that it was a result of toxins such as cigarette smoke. Activity intolerance and health management should be addressed as a risk because pneumonia and COPD impact activity and cause fatigue, but not enough information was provided to make these a problem. PTS: 1 REF: p. 620 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Drag and Drop 35. A nurse is providing ongoing care for a client who is positive for human immunodeficiency virus (HIV), and assessment reveals a client with a newly delayed and shortened speech pattern. The client, who previously had no neurological or motor deficits, has forgotten that they are in the hospital and has trouble getting out of bed. Which problem is the client most likely experiencing related to these signs and symptoms? A. Cryptococcal meningitis B. Cytomegalovirus retinitis C. Peripheral neuropathy D. Subcortical neurodegenerative disease

D Rationale Subcortical neurodegenerative disease is known as HIV-associated neurocognitive disorder (HAND). Signs can be subtle and include changes in language, memory, and problem solving, as well as slowing psychomotor skills. Early identification is important as HAND can be treated by changing antiretroviral medications. Cryptococcal meningitis is a form of subacute meningitis. Signs include fever, malaise, and headache. Retinitis caused by cytomegalovirus retinitis is the leading cause of blindness in clients with acquired immunodeficiency syndrome. Peripheral neuropathy is a common neurological symptom at any stage of HIV infection. Signs and symptoms are pain in the feet and functional impairment. PTS: 1 REF: p. 1023 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? A. Assessment of body image B. Assessment of jugular venous pressure C. Assessment of carotid pulse D. Assessment of swallowing ability

D Rationale: A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The client's body image should be assessed, but dysphagia has the potential to affect the client's airway, and is a consequent priority. PTS: 1 REF: p. 520 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. The nurse is caring for a client who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the client to tilt the head forward, and the nurse applies pressure to the nose, but the client's nose continues to bleed. Which intervention should the nurse next implement? A. Apply ice to the bridge of the nose. B. Lay the client down. C. Arrange for transfer to the local emergency department. D. Insert a cotton tampon in the affected nare.

D Rationale: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down could block the client's airway. Transfer to the emergency department is necessary only if the bleeding becomes serious. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A nurse is providing health education to the family of a client with bronchiectasis. Which technique should the nurse prioritize teaching the client's family members? A. The correct technique for chest palpation and auscultation B. Techniques for assessing the client's fluid balance C. The technique for providing deep nasotracheal suctioning D. The correct technique for providing postural drainage

D Rationale: A focus of the care of bronchiectasis is helping clients clear pulmonary secretions; consequently, clients and families are taught to perform postural drainage. Chest palpation and auscultation and assessment of fluid balance are not prioritized over postural drainage. Nasotracheal suctioning is not normally necessary. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 33. A client with von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? A. The client should not undergo the normal bowel cleansing protocol prior to the procedure. B. The client should receive a unit of fresh-frozen plasma 48 hours before the procedure. C. The client should be admitted to the surgical unit on the day before the procedure. D. The client should be given necessary clotting factors before the procedure.

D Rationale: A goal of treating vWD is to replace the deficient protein (e.g., vWF or factor VIII) prior to an invasive procedure to prevent subsequent bleeding. Bowel cleansing is not contraindicated and FFP does not reduce the client's risk of bleeding. There may or may not be a need for preprocedure hospital admission. PTS: 1 REF: p. 939 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? A. Taking prophylactic antibiotics as prescribed B. Adhering to the treatment regimen in order to cure the disease C. Avoiding airplanes, buses, and other crowded public places D. Setting realistic short- and long-term goals

D Rationale: A major area of teaching involves setting and accepting realistic short-term and long-term goals. Emphysema is not considered curable and antibiotics are not used on a preventative basis. The client does not normally need to avoid public places. PTS: 1 REF: p. 608 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin levels despite active treatment. Which assessment finding would signal complications of anemia? A. Venous ulcers and visual disturbances B. Fever and signs of hyperkalemia C. Epistaxis and gastroesophageal reflux D. Shortness of breath and peripheral edema

D Rationale: A significant complication of anemia is heart failure from chronic diminished blood volume and the heart's compensatory effort to increase cardiac output. Clients with anemia should be assessed for signs and symptoms of heart failure, including dyspnea and peripheral edema. None of the other listed signs and symptoms is characteristic of heart failure. PTS: 1 REF: p. 912 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 3. A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention? A. Hepatectomy B. Vitamin K administration C. Platelet transfusion D. Splenectomy

D Rationale: A splenectomy may be the course of treatment if autoimmune hemolytic anemia does not respond to conservative treatment. Vitamin K administration is treatment for vitamin K deficiency and does not resolve anemia. Platelet transfusion may be the course of treatment for some bleeding disorders. Hepatectomy would not help the client. PTS: 1 REF: p. 927 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate? A. Position the client in the high Fowler position whenever possible. B. Temporarily eliminate animal protein from the client's diet. C. Make sure the client eats at least two servings of raw fruit each day. D. Obtain a stool culture to identify possible pathogens.

D Rationale: A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Clients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the bed. PTS: 1 REF: p. 1027 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)? A. IgA B. IgM C. IgG D. IgE

D Rationale: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions. IgE (0.004% of total Ig) appears in serum; takes part in allergic and some hypersensitivity reactions; and combats parasitic infections. IgA (15% of total Ig) appears in body fluids (blood, saliva, tears, and breast milk, as well as pulmonary, gastrointestinal, prostatic, and vaginal secretions); protects against respiratory, gastrointestinal, and genitourinary infections; prevents absorption of antigens from food; and passes to neonate in breast milk for protection. IgM (10% of total Ig) appears mostly in intravascular serum; appears as the first Ig produced in response to bacterial and viral infections; and activates the complement system. IgG (75% of total Ig) appears in serum and tissues (interstitial fluid); assumes a major role in bloodborne and tissue infections; activates the complement system; enhances phagocytosis; and crosses the placenta. PTS: 1 REF: p. 1039 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. A nurse is educating a client about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? A. Stem cell differentiation B. Cytokine production C. Phagocytosis D. Antibody production

D Rationale: B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies. Cytokines are produced by NK cells. Stem cell differentiation greatly precedes B lymphocyte production. PTS: 1 REF: p. 889 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 33. A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid

D Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure. PTS: 1 REF: p. 596 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 34. A client has sought care, stating that the client developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the client developed? A. Type I B. Type II C. Type III D. Type IV

A Rationale: Type I hypersensitivity reactions are unanticipated severe allergic reactions that are rapid in onset, characterized by edema in many tissues, including the larynx, and often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Urticaria (hives) is a type I hypersensitive allergic reaction of the skin that is characterized by the sudden appearance of intensely pruritic pink or red discrete papules that progress to wheals of variable size. Type II, or cytotoxic, hypersensitivity reactions occur when antibodies are directed against antigens on cells or basement membranes of tissues. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia. Type III, or immune complex, hypersensitivity reactions are damaging inflammatory reactions caused by the insoluble immune complexes formed by antigens that bind to antibodies. Examples of type III reactions include systemic lupus erythematosus, serum sickness, nephritis, and rheumatoid arthritis. Type IV, or delayed, hypersensitivity reactions are T cell-mediated immune reactions that typically occur 24 to 48 hours after exposure to an antigen. Examples of type IV reactions include contact dermatitis, graft-versus-host disease, Hashimoto's thyroiditis, and sarcoidosis. PTS: 1 REF: p. 1057 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 35. A client lives with a diagnosis of sickle cell disease and receives frequent blood transfusions. The nurse should recognize the client's consequent risk of what complication of treatment? A. Hypovolemia B. Vitamin B12 deficiency C. Thrombocytopenia D. Iron overload

D Rationale: Clients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels. PTS: 1 REF: p. 905 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. On admission to a medical unit, a client with human immunodeficiency virus (HIV) tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result? A. Efavirenz B. Doravirine C. Nevirapine D. Etravirine

A Rationale: Use of efavirenz, even as part of a combination drug, may lead to false-positive results with cannabinoid and benzodiazepine screening assays. Efavirenz, doravirine, nevirapine and etravirvine are all non-nucleoside reverse transcriptase inhibitors that bind and block the HIV enzyme and prevent replication in the body. Doravirine, nevirapine, and etravirvine do not have the adverse side effect of false-positives for cannabinoid and benzodiazepine. PTS: 1 REF: p. 1019 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember

Multiple Choice 4. The ED nurse is assessing a client who is reporting dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? A. Bronchoconstriction B. Pneumonia C. Hemoptysis D. Hemothorax

A Rationale: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia (an infection of the lungs), hemoptysis (the expectoration of blood from the respiratory tract), or hemothorax (a collection of blood in the space between the chest wall and the lung). PTS: 1 REF: p. 473 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiologic state? A. The client's tissue demands may be met, but the client will be unable to respond to physiological stressors. B. The client's short-term oxygen needs will be met, but the client will be unable to expel sufficient CO2. C. The client will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D. The client will experience respiratory alkalosis with no ability to compensate.

A Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiologic stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results. PTS: 1 REF: p. 470 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client with Wiskott-Aldrich syndrome (WAS) is admitted to the medical unit. The nurse caring for the client should prioritize which intervention? A. Protective isolation B. Fresh-frozen plasma (FFP) administration C. Chest physiotherapy D. Nutritional supplementation

A Rationale: Clients with WAS are at a grave risk for infection; infection prevention is a priority aspect of nursing care. Nutritional supplementation may be necessary, but infection prevention is paramount. Chest physiotherapy and FFP administration are not indicated. PTS: 1 REF: p. 1006 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. A client on the medical unit reports experiencing significant dyspnea, despite not having recently performed any physical activity. What assessment question should the nurse ask the client while preparing to perform a physical assessment? A. "On a scale from 0 to 10, how bad would you rate your shortness of breath?" B. "When was the last time you ate or drank anything?" C. "Are you feeling any nausea along with your shortness of breath?" D. "Do you think that some medication might help you catch your breath?"

A Rationale: Gauging the severity of the client's dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication. PTS: 1 REF: p. 471 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 14. The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? A. Emphysema B. Pulmonary fibrosis C. Pleural effusion D. Acute respiratory distress syndrome (ARDS)

A Rationale: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, such as in emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS. PTS: 1 REF: p. 466 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 15. An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A. Stool for occult blood B. Bone marrow biopsy C. Lumbar puncture D. Urinalysis

A Rationale: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? A. Severed blood vessels constrict. B. Thromboplastin is released. C. Prothrombin is converted to thrombin. D. Fibrin is lysed.

A Rationale: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed. PTS: 1 REF: p. 890 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 40. A client is scheduled to undergo a bone marrow aspiration. When preparing the client for the procedure, which action would the nurse do first? A. Ensure informed consent has been obtained. B. Cleanse the skin with an antiseptic. C. Administer a local anesthetic. D. Cover the area with a sterile drape.

A Rationale: The first step in the procedure is ensuring that informed consent has been obtained by the health care provider, nurse practitioner, or health care provider assistant performing the procedure and includes the reason the procedure is being performed, alternatives, and risks of the procedure. Risks include infection, bleeding, and pain. After informed consent is obtained, the client is assisted to either a prone or lateral decubitus position. The skin is cleansed using aseptic technique and either a chlorhexidine-based solution or povidone-iodine. A sterile drape is applied, and the skin is numbed using local anesthesia. PTS: 1 REF: p. 894 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes which type of impairment? A. Impaired gas exchange B. Collapsed bronchial structures C. Necrosis of the alveoli D. Closed bronchial tree

A Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues. PTS: 1 REF: p. 464 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A nurse has asked the nurse educator if there is any way to predict the severity of a client's anaphylactic reaction. Which response by the nurse educator would be best? A. "The faster the onset of symptoms, the more severe the reaction." B. "The reaction will be about one-third more severe than the client's last reaction to the same antigen." C. "There is no way to gauge the severity of a client's anaphylaxis, even if it has occurred repeatedly in the past." D. "The reaction will generally be slightly less severe than the last reaction to the same antigen."

A Rationale: The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. None of the other statements is an accurate description of the course of anaphylactic reactions. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 20. A client is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals a fever and a new onset of fine crackles on lung auscultation. Which action by the nurse would be the most appropriate? A. Apply supplementary oxygen by nasal cannula. B. Administer bronchodilators by nebulizer. C. Liaise with the respiratory therapist and consider high-flow oxygen. D. Inform the health care provider that the client may have an infection.

D Rationale: Clients with sickle cell disease are highly susceptible to infection, thus any early signs of infection should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated. PTS: 1 REF: p. 924 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client has been brought to the emergency department after being found unresponsive, and anaphylaxis is suspected. The care team should attempt to assess for which potential causes of anaphylaxis? Select all that apply. A. Foods B. Medications C. Insect stings D. Autoimmunity E. Environmental pollutants

A, B, C Rationale: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities. PTS: 1 REF: p. 1047 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 38. A nurse is performing the admission assessment of a client who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A. Current medication regimen B. Identification of client's support system C. Immune system function D. Genetic risk factors for HIV E. History of sexual practices

A, B, C, E Rationale: Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function, and sexual history. HIV does not have a genetic component. PTS: 1 REF: p. 1014 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. The occupational health nurse is assessing an employee who has just had respiratory exposure to a toxin. What should the nurse assess? Select all that apply. A. Time frame of exposure B. Type of respiratory protection used C. Immunization status D. Breath sounds E. Intensity of exposure

A, B, D, E Rationale: Key aspects of any assessment of clients with a potential occupational respiratory history include job and job activities, exposure levels, general hygiene, time frame of exposure, effectiveness of respiratory protection used, and direct versus indirect exposures. The client's current respiratory status would also be a priority. Occupational lung hazards are not normally influenced by immunizations. PTS: 1 REF: p. 577 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A nurse is completing the nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A. Serum albumin level B. Weight history C. White blood cell count D. Body mass index E. Blood urea nitrogen (BUN) level

A, B, D, E Rationale: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the client's ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment. PTS: 1 REF: p. 1032 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A female client who is HIV negative arrives for a gynecologist appointment and reports that her husband, who is HIV positive, no longer wants to wear a latex condom. Which alternative treatments would the nurse recommend to reduce the likelihood of HIV transmission? Select all that apply. A. Dental dam B. Polyurethane female condom C. Microbicidal vaginal suppository D. Non-latex male condoms E. Pre-exposure prophylaxis

A, B, E Rationale: A dental dam, which is a flat piece of latex, can be used for oral contact with the vagina or penis. A polyurethane female condom is an effective contraceptive and also effective in preventing the transmission of HIV. Pre-exposure prophylaxis involves one pill containing 2 HIV medications daily to prevent HIV conversion. A microbicidal vaginal suppository is currently not a reality, although clinical trials are occurring. Non-latex/lambskin male condoms will not protect the client from HIV due to permeability. Breakage is usually related to polyurethane condoms, which are more effective than lambskin. PTS: 1 REF: p. 1011 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply. A. Hepatitis B. Acute kidney injury C. HIV D. Malignant melanoma E. Cholecystitis

A, C Rationale: Viral illnesses have the potential to cause ITP. Acute kidney injury, malignancies, and gallbladder inflammation are not typical causes of ITP. PTS: 1 REF: p. 933 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. A client has been diagnosed with Stevens-Johnson syndrome. Which factors are common triggers of this condition? Select all that apply. A. Tamoxifen and vemurafenib B. Exposure to cold objects, cold fluids, or cold air C. Allopurinol and nevirapine D. Wearing clothing washed in a detergent E. Radiation in combination with phenytoin

A, C, E Rationale: Stevens-Johnson syndrome is a severe reaction commonly triggered by medication. The syndrome can evolve into extensive epidermal necrosis and become life-threatening. Among the many medications that trigger this condition are tamoxifen, vemurafenib, allopurinol and nevirapine. The combination of radiation and antiepileptic drugs such as phenytoin can also trigger this condition. Exposure to cold objects, cold fluids, or cold air can trigger cold urticaria, resulting in wheals (hives) or angioedema, but would not trigger Steven-Johnson syndrome. Wearing clothing washed in a detergent can trigger contact dermatitis but would not trigger Steven-Johnson syndrome. PTS: 1 REF: p. 1058 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply. A. Potential drug toxicities B. Needed dietary changes C. Potential drug interactions D. Sleep pattern disturbances E. Adherence requirements

A, C, E Rationale: The health care provider will need to understand potential drug toxicities, such as rashes and hypersensitivity reactions, which could imitate acute HIV seroconversion and require monitoring. The health care provider will also need to understand potential drug interactions, such as with supplements and vitamins, which could change the effectiveness of PEP. The health care provider will also need to understand adherence requirements, as adherence to the daily use of the PEP is paramount to its effectiveness. Typically, for most of PEP, there are no specific dietary changes needed. Sleep pattern disturbances generally do not happen with administration of these medications. PTS: 1 REF: p. 1012 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 4. A nurse is implementing the care plan of diarrhea related to enteric pathogens of human immunodeficiency virus infections. Which interventions are needed to reach the goal of resuming usual bowel habits? Select all that apply. A. Administer antimicrobials. B. Restrict fluid to 1500 mL/50.7 fl oz daily. C. Implement a BRAT diet. D. Administer antitussives. E. Establish normal bowel pattern.

A, D, E Rationale: After establishing the client's normal pattern of bowel habits (i.e., frequency, time, consistency, color) and current problems (i.e., diarrhea, constipation, abdominal cramps/pain), a stool sample is then collected to identify any pathogenic organisms and any antimicrobial therapy needed. The BRAT (bananas, rice, applesauce, tea, and toast) diet is a type of bland diet that reduces stimulation/hyperactivity of the bowels. It is a temporary step. Unless contraindicated, clients are encouraged to maintain a fluid intake of 3L/0.793GL (3000 mL/1014 fl oz) daily to prevent hypovolemia. Antitussives are medications used to suppress cough and are not used to restore normal bowel patterns. PTS: 1 REF: p. 1027 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply. A. Chest tightness B. Crackles C. Bradypnea D. Wheezing E. Cough

A, D, E Rationale: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 9. Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A. Leukocytes B. Natural killer cells C. Cytokines D. Platelets E. Erythrocytes

A, D, E Rationale: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells. PTS: 1 REF: p. 885 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 5. The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. A. Using appropriate personal protective equipment B. Placing clients in negative pressure isolation rooms C. Placing clients in positive pressure isolation rooms D. Using safe injection practices E. Performing hand hygiene

A, D, E Rationale: Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions. PTS: 1 REF: p. 1011 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 19. A 67-year-old client with severe bilateral arthritis of the hands has been diagnosed with chronic obstructive pulmonary disease. Which inhalation delivery method is best for the bronchodilator ordered for this client? A. A conventional pressurized metered-dose inhaler (pMDI) B. A small-volume nebulizer (SVN) C. A breath-actuated pressurized metered-dose inhaler (pMDI) D. A dry-powder inhaler (DPI)

B Rationale: A SVN is the best choice for the client with severe arthritis in both hands. The SVN is a machine that mixes the medication and turns it into a mist. The client then uses a handheld apparatus or mask and just breathes in the treatment. Any pMDI requires dexterity between inspiration and the mechanics of the inhaler to be effective. Although DPIs rely solely on inspiration for medication delivery, they still require the user to press a button or lever to dispense the medication. Poor inhaler technique has been linked to a lack of symptom control. PTS: 1 REF: p. 616 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 25. The nurse is caring for a client with a severe nosebleed. The health care provider inserts a nasal sponge. What should the nurse teach the client about this intervention? A. The sponge creates a risk for viral sinusitis B. The sponge can stay in place for 3 to 4 days if needed C. The client should remain supine while the sponge is in place D. NSAIDs are contraindicated while the sponge is in place

B Rationale: A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 3 or 4 days if necessary to control bleeding. This does not require the client to be supine or to avoid all NSAIDs. Packing does not increase the risk for sinusitis. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is assessing a newly admitted medical client and notes there is a depression in the lower portion of the client's sternum. This client's health record should note the presence of what chest deformity? A. A barrel chest B. A funnel chest C. A pigeon chest D. Kyphoscoliosis

B Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax. PTS: 1 REF: p. 477 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. A nurse is developing a teaching plan for a client with chronic obstructive pulmonary disease. What should the nurse include as the most important area of teaching? A. Avoiding extremes of heat and cold B. Setting and accepting realistic short- and long-term goals C. Adopting a lifestyle of moderate activity D. Avoiding emotional disturbances and stressful situations

B Rationale: A major area of teaching involves setting and accepting realistic short- and long-term goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals. PTS: 1 REF: p. 629 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 40. The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. Which method of oxygen delivery is most appropriate for the client's needs? A. Nonrebreathing mask B. Nasal cannula C. Venturi mask D. Partial-rebreathing mask

B Rationale: A nasal cannula is used when the client requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for clients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The client's respiratory status does not require a partial- or non-rebreathing mask. PTS: 1 REF: p. 613 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders 1. A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? A. Acute respiratory distress syndrome (ARDS) B. Atelectasis C. Aspiration D. Pulmonary embolism

B Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing. PTS: 1 REF: p. 527 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the client begins to exhibit signs and symptoms of a transfusion reaction. The client is suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed type (type IV)

B Rationale: A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions. This type of reaction does not result from types I, III, or IV reactions. PTS: 1 REF: p. 1041 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 27. The nurse is performing a respiratory assessment of a client who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A. An appropriate perfusion-diffusion ratio B. An adequate ventilation-perfusion ratio C. Adequate diffusion of gas in shunted blood D. Appropriate blood nitrogen concentration

B Rationale: Adequate gas exchange depends on an adequate ventilation-perfusion ratio. There is no perfusion-diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen. PTS: 1 REF: p. 468 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 29. A firefighter was trapped in a fire and is admitted to the intensive care unit for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of acute respiratory distress syndrome (ARDS) and is intubated. Which other supportive measure should be initiated in this client? A. Psychological counseling B. Nutritional support C. High-protein oral diet D. Occupational therapy

B Rationale: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS. PTS: 1 REF: p. 572 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family? A. Beginning immunotherapy B. Carrying an epinephrine pen C. Maintaining the child's immunization status D. Avoiding all foods that have a high potential for allergies

B Rationale: All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies. PTS: 1 REF: p. 1063 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment? A. The client will be given a low dose of epinephrine before the treatment. B. The client will remain in the clinic to be monitored for 30 minutes following the injection. C. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. D. The allergen will be given by the peripheral intravenous (IV) route.

B Rationale: Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. Because of this risk, the client must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. Therapeutic failure is evident when a client does not experience a decrease in symptoms within 12 to 24 months. Epinephrine is not given prior to treatment and the IV route is not used. PTS: 1 REF: p. 1053 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? A. Antibodies to donor leukocytes remained in the blood. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. The blood was infused too quickly and overwhelmed the client's circulatory system.

B Rationale: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction. PTS: 1 REF: p. 901 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 27. A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client? A. A client who has previously been treated for tuberculosis B. A client who is at 30 weeks' gestation C. A client who is on estrogen-replacement therapy D. A client with a severe allergy to eggs

B Rationale: Antihistamines are contraindicated during the third trimester of pregnancy. Previous tuberculosis, hormone therapy, and food allergies do not contraindicate the use of antihistamines. PTS: 1 REF: p. 1051 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 32. A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old child, who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother? A. "I will relay your request promptly to the doctor, but I suspect that the doctor won't get back to you if it's a cold." B. "I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus." C. "I'll phone in the prescription for you since it can be prescribed by the pharmacist." D. "Amoxicillin is not likely the best antibiotic, but I'll call in the right prescription for you."

B Rationale: Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the client that the health care provider will not respond to the request. PTS: 1 REF: p. 504 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 23. A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor? A. Recent blood donation B. Evidence of lung disease C. A history of venous thromboembolism D. Impaired renal function

B Rationale: Any reduction in oxygenation, such as lung disease, can cause secondary polycythemia. Blood donation does not precipitate this problem and impaired renal function typically causes anemia, not polycythemia. A history of venous thromboembolism is not a likely contributor. PTS: 1 REF: p. 929 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position? A. Review images from the client's portable chest x-ray. B. Turn the client to enable assessment of all lung fields. C. Assess the breath sounds accessible from the anterior chest wall. D. Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.

B Rationale: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the client is recumbent, it is essential to turn the client to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. A chest x-ray does not allow assessment of breath sounds. Assessment of only breath sounds accessible from the anterior chest wall neglects breath sounds that can only be assessed in other lung fields. All lung fields need to be assessed whether oxygen saturation is low or not. PTS: 1 REF: p. 483 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients? A. Encouraging clients to carry a corticosteroid rescue inhaler at all times B. Educating clients about recognizing and avoiding asthma triggers C. Teaching clients to utilize alternative therapies in asthma management D. Ensuring that clients keep their immunizations up to date

B Rationale: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate clients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations. PTS: 1 REF: p. 641 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 30. A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate? A. Apply an icepack to the blood that remains to be infused. B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider. C. Disconnect the bag of PRBCs, cool for 30 minutes, and then administer. D. Administer the remaining PRBCs by the IV direct (IV push) route.

B Rationale: Because of the risk of increased bacterial proliferation in the PRBCs and subsequent infection in the client, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route. PTS: 1 REF: p. 901 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A client is being treated for the effects of a longstanding vitamin B12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency? A. The client has irregular menstrual periods. B. The client is a vegan. C. The client donated blood 60 days ago. D. The client frequently smokes marijuana.

B Rationale: Because vitamin B12 is found only in foods of animal origin, vegans may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is performing the health interview of a client with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the client about the current medication regimen. Which medication would put the client at a higher risk for recurrent epistaxis? A. Oxymetazoline nasal B. Beclomethasone C. Levothyroxine D. Albuterol

B Rationale: Beclomethasone should be avoided in clients with recurrent epistaxis because it is a risk factor. The other listed medications do not increase the risk for epistaxis. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess? A. Fluid intake for the last 24 hours B. Arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B Rationale: Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins. PTS: 1 REF: p. 569 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. The nurse is caring for a client with lung metastases who just underwent a mediastinotomy. What is the nurse's priority postprocedure care? A. Assisting with pulmonary function testing (PFT) B. Maintaining the client's chest tube C. Administering oral suction as needed D. Performing chest physiotherapy

B Rationale: Chest tube drainage is required after mediastinotomy. PFT may be needed, but it would be a lower priority than maintaining the chest tube. The client would need chest tube drainage after a mediastinotomy, not oral suctioning. Given that the client is healing from the incision made during the procedure, chest physiotherapy would be inappropriate at this time. PTS: 1 REF: p. 492 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client is scheduled for a splenectomy. During discharge education, which teaching point should the nurse prioritize? A. Adhering to prescribed immunosuppressant therapy B. Reporting any signs or symptoms of infection promptly C. Ensuring adequate folate, iron, and vitamin B12 intake D. Limiting activity postoperatively to prevent hemorrhage

B Rationale: Clients face an increased risk for infection following splenectomy; therefore, long-term use of antibiotic therapy is indicated. After splenectomy, the client is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, clients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary, and immunosuppressants would be strongly contraindicated. PTS: 1 REF: p. 895 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. A nurse is providing discharge education to a client who has recently been diagnosed with a bleeding disorder. Which topic should the nurse prioritize when teaching this client? A. Avoiding buses, subways, and other crowded, public sites B. Avoiding activities that carry a risk for injury C. Keeping immunizations current D. Avoiding foods high in vitamin K

B Rationale: Clients with bleeding disorders need to understand the importance of avoiding activities that increase the risk of bleeding, such as contact sports. Immunizations involve injections and may be contraindicated for some clients. Clients with bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may be beneficial, not detrimental. PTS: 1 REF: p. 931 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 28. A client states that the client's family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to which factor? A. Cold viruses are increasingly resistant to common antibiotics. B. The virus is shed for 2 days prior to the emergence of symptoms. C. A genetic predisposition to viral rhinitis has recently been identified. D. Overuse of over-the-counter (OTC) cold remedies creates a "rebound" susceptibility to future colds.

B Rationale: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses, and OTC medications do not have a "rebound" effect. Genetic factors do not exist for viral rhinitis. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 11. The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? A. Carboxyhemoglobin level B. Brain natriuretic peptide (BNP) level C. C-reactive protein (CRP) level D. Complete blood count

B Rationale: Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem. PTS: 1 REF: p. 572 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 3. The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding? A. Obtain a sputum sample. B. Perform a swallowing assessment. C. Inspect the client's tongue and mouth. D. Assess the client's nutritional status.

B Rationale: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the client's tongue, mouth, and nutrition is not directly relevant to the problem of aspiration. PTS: 1 REF: p. 472 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A nurse is performing an admission assessment on a client with stage 3 human immunodeficiency virus (HIV). After assessing the client's gastrointestinal system and analyzing the data, which nursing diagnosis is most likely to be the priority? A. Acute abdominal pain B. Diarrhea C. Bowel incontinence D. Constipation

B Rationale: Diarrhea is a problem in many clients with HIV and acquired immunodeficiency syndrome. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 21. The nurse is providing care for a 73-year-old client who has a hematologic disorder. Which change in hematologic function is age-related? A. Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. B. Older adults are less able to increase blood cell production when demand suddenly increases. C. Stem cells in older adults eventually lose their ability to differentiate. D. The ratio of plasma to erythrocytes and lymphocytes increases with age.

B Rationale: Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat decreased rate. The proportion of functional cells does not greatly decrease, and the relative volume of plasma does not change significantly. PTS: 1 REF: p. 891 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 29. A client has come into contact with HIV. As a result, HIV glycoproteins have fused with the client's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? A. Integration B. Attachment C. Cleavage D. Budding

B Rationale: During the process of attachment, glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle. PTS: 1 REF: p. 1014 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A client with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this client's hematologic disorder? A. "When did you last have a blood transfusion?" B. "What medications have you taken recently?" C. "Have you been under significant stress lately?" D. "Have you suffered any recent injuries?"

B Rationale: Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly always precipitated by medications. Blood transfusions, stress, and injury are less common triggers. PTS: 1 REF: p. 926 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client has sustained a cut to the hand, immediately initiating the process of hemostasis. Following vasoconstriction, which event in the process of hemostasis will take place? A. Fibrin will be activated at the bleeding site. B. Platelets will aggregate at the injury site. C. Thromboplastin will form a clot. D. Prothrombin will be converted to thrombin.

B Rationale: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action. PTS: 1 REF: p. 890 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 27. A nurse has participated in organizing a blood donation drive at a local community center. Which client would most likely be disallowed from donating blood? A. A client who is 81 years of age B. A client whose blood pressure is 78/49 mm Hg C. A client who donated blood 4 months ago D. A client who has type 1 diabetes

B Rationale: For potential blood donors, systolic arterial blood pressure should be 80 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation (donors are only required to wait at least 8 weeks between donations), and diabetes is not a contraindication. PTS: 1 REF: p. 897 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 13. The nurse is conducting a presurgical interview for a client with laryngeal cancer. The client reports drinking approximately 20 oz (600 mL) of vodka per day. It is imperative that the nurse inform the surgical team so the client can be assessed for risk of which condition? A. Increased risk for infection B. Delirium tremens C. Depression D. Nonadherence to postoperative care

B Rationale: Given the client's reported alcohol intake and considering that alcoholism is a known risk factor for cancer of the larynx, it is essential to assess the client for risk of delirium tremens, which occurs among clients with alcohol use disorder during withdrawal from alcohol, such as would occur in the hospital following surgery. Infection is a risk in the postoperative period, but not an appropriate answer based on the client's history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client's health history reveals daily consumption of two to three bottles of wine. The nurse would consider increased risk for which hematologic disorder when planning assessments and interventions for this client? A. Leukemia B. Anemia C. Thrombocytopenia D. Lymphoma

B Rationale: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; Red blood cell levels are typically affected more than platelet levels (i.e., thrombocytopenia). PTS: 1 REF: p. 893 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. The perioperative nurse has admitted a client who has just undergone a tonsillectomy. The nurse's postoperative assessment should prioritize which potential complication of this surgery? A. Difficulty ambulating B. Hemorrhage C. Infrequent swallowing D. Bradycardia

B Rationale: Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a client after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does. PTS: 1 REF: p. 506 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release? A. Constriction of small venules B. Contraction of bronchial smooth muscle C. Dilation of large blood vessels D. Decreased secretions from gastric and mucosal cells

B Rationale: Histamine's effects during the immune response include contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm, dilation of small venules, constriction of large blood vessels, and an increase in secretion of gastric and mucosal cells. PTS: 1 REF: p. 1040 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? A. Oral temperature of 37.2°C (99°F) B. Tachypnea and restlessness C. Frequent loose stools D. Weight loss of 0.45 kg (1 lb) since yesterday

B Rationale: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue addressed. PTS: 1 REF: p. 1028 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 23. A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A. A chest tube B. A tracheostomy C. An endotracheal tube D. A feeding tube

B Rationale: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction. PTS: 1 REF: p. 598 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A client with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A. Appropriate use of prophylactic antibiotics B. Importance of personal hygiene C. Signs and symptoms of wasting syndrome D. Strategies for adjusting antiretroviral dosages

B Rationale: Infection control is of high importance in clients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the client's CD4+ count is below 50. PTS: 1 REF: p. 1033 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. A night nurse is reviewing the next day's medication administration record (MAR) of a hospital client who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? A. Ensure that the day nurse knows not to give the antiemetic. B. Contact the prescriber to have the subcutaneous option discontinued. C. Reassess the client's need for antiemetics. D. Remove the subcutaneous route from the client's MAR.

B Rationale: Injections must be avoided in clients with hemophilia. Consequently, the nurse should ensure that the prescriber makes the necessary change. The nurse cannot independently make a change to a client's MAR in most cases. Facilitating the necessary change is preferable to deferring to the day nurse. PTS: 1 REF: p. 936 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client is being treated in the emergency department for epistaxis. Pressure has been applied to the client's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using which treatment to control the bleeding? A. Irrigation with a hypertonic solution B. Nasopharyngeal suction C. Normal saline application D. Silver nitrate application

D Rationale: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis. Normal saline application would not alleviate epistaxis. PTS: 1 REF: p. 512 NAT: Client Needs: Safe, Effective Care Environment: Management of Care |Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse educating a client with anemia is describing the process of red blood cell production. When the client's kidneys sense a low level of oxygen in circulating blood, which physiologic response is initiated? A. Increased stem cell synthesis B. Decreased respiratory rate C. Arterial vasoconstriction D. Increased levels of erythropoietin

D Rationale: If the kidney detects low levels of oxygen, as occurs when fewer red blood cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity. PTS: 1 REF: p. 887 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A 42-year-old client is admitted to the ED after an assault. The client received blunt trauma to the face and has a suspected nasal fracture. What intervention should the nurse perform? A. Administer nasal spray and apply an occlusive dressing to the client's face. B. Position the client's head in a dependent position. C. Irrigate the client's nose with warm tap water. D. Apply ice and keep the client's head elevated.

D Rationale: Immediately after the fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used. PTS: 1 REF: p. 513 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action? A. Smoking decreases the amount of mucus production. B. Smoke particles compete for binding sites on hemoglobin. C. Smoking causes atrophy of the alveoli. D. Smoking damages the ciliary cleansing mechanism.

D Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites. PTS: 1 REF: p. 544 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 20. A nurse is preparing to perform an admission assessment on a client with chronic obstructive pulmonary disease (COPD). It is most important for the nurse to review which of the following? A. Social work assessment B. Finances C. Chloride levels D. Available diagnostic tests

D Rationale: In addition to the client's history, the nurse reviews the results of available diagnostic tests. Social work assessment is not a priority for the majority of clients. Chloride levels are relevant to cystic fibrosis, not COPD. Immediate physiological status would be more important than finances. PTS: 1 REF: p. 619 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for a client who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A. Spleen and kidneys B. Kidneys and pancreas C. Pancreas and liver D. Liver and spleen

D Rationale: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce blood cells for the body. PTS: 1 REF: p. 885 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. A client comes into the clinic reporting fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. Which condition should the nurse most suspect the client has? A. A hypoproliferative anemia B. A leukemia C. Thrombocytopenia D. A hemolytic anemia

D Rationale: In hemolytic anemias, premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes into the plasma; the released hemoglobin is converted in large part to bilirubin, and therefore the bilirubin concentration rises. The increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates erythropoietin production. This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes. Hypoproliferative anemias, leukemia, and thrombocytopenia lack this pathology and presentation. PTS: 1 REF: p. 911 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A client's plan of care specifies postural drainage. Which action should the nurse perform when providing this noninvasive therapy? A. Administer the treatment with the client in a high Fowler or semi-Fowler position. B. Perform the procedure immediately following the client's meals. C. The client is instructed to avoid coughing during the therapy. D. Assist the client into a position that will allow gravity to move secretions.

D Rationale: In postural drainage, the client assumes a position that allows gravity to facilitate the draining of secretions from all areas of the lungs. Postural drainage is usually performed two to four times per day, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Because the client usually sits in an upright position (i.e., high- or semi-Fowler position), secretions are likely to accumulate in the lower parts of the lungs. Several other positions are used in postural drainage so that the force of gravity helps move secretions from the smaller bronchial airways to the main bronchi and trachea. The client is encouraged to cough and remove secretions during postural drainage. PTS: 1 REF: p. 625 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? A. Using prophylactic antibiotics and performing meticulous hygiene B. Maximizing physical activity and taking OTC iron supplements C. Limiting psychosocial stress and eating a high-protein diet D. Avoiding cold temperatures and ensuring sufficient hydration

D Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic. PTS: 1 REF: p. 924 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 23. The hospital case manager for a group of recently discharged clients with asthma is providing health education. Which aspect of client teaching would have the greatest impact on preventing readmissions? A. Alternative treatment modalities B. Family participation in care C. Pathophysiology of the disease process D. Self-care and the therapeutic regimen

D Rationale: Knowledge about self-care and the therapeutic regimen would have the greatest impact on preventing admissions. For clients, the ability to understand the complex therapies of inhalers, anti-allergy and anti-reflux medications, and avoidance measures are essential for long-term control. Knowledge of alternative treatment modalities, such herbs, vitamins, or yoga, may help but is usually most effective as a complementary measure to an existing plan. Involving the family in care is important and can help the client with compliance, support, and encouragement, but ultimately the client is responsible for their own health. Understanding the pathophysiology of the disease process is important to include in education as it provides a better understanding in regards to causation and how it affects the body. However, how to physically manage asthma takes precedence over understanding in terms of readmission strategies. PTS: 1 REF: p. 629 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. The client has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The health care provider suspects bronchogenic carcinoma. An MRI would most likely assess for which condition in this client? A. Alveolar dysfunction B. Forced vital capacity C. Tidal volume D. Chest wall invasion

D Rationale: MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli (as would be the case in alveolar dysfunction) because the problem is in the bronchi. A static image such as MRI cannot inform pulmonary function tests. PTS: 1 REF: p. 489 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. The nurse is providing health education to the parents of a 3-year-old who has been diagnosed with food allergies. Which statement should the nurse make when teaching this family about the child's health problem? A. "Food allergies are a lifelong condition, but most families adjust well to the necessary lifestyle changes." B. "Consistent use of over-the-counter antihistamines can often help a child overcome food allergies." C. "Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants." D. "Many children outgrow their food allergies in a few years if they avoid the offending foods."

D Rationale: Many food allergies disappear with time, particularly in children. About one third of proven allergies disappear in 1 to 2 years if the client carefully avoids the offending food. Antihistamines do not cure allergies, and an EpiPen is carried for clients with food allergies, not a steroid inhaler. PTS: 1 REF: p. 1061 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 33: Assessment and Management of Patients with Allergic Disorders 1. A client received a bee sting on the lip approximately 2 hours ago and has arrived at an urgent/walk-in clinic for treatment because the swelling is now accompanied by nasal congestion. On assessment, the client reports pruritus and a sensation of warmth at the site. Which degree of anaphylaxis is the client experiencing? A. No systemic reaction B. Moderate systemic reaction C. Severe systemic reaction D. Mild systemic reaction

D Rationale: Mild systemic reactions begin within the first 2 hours after the exposure, and consist of cluster tingling and a sensation of warmth. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes is expected. While onset timing is the same, moderate systemic reactions include bronchospasm, edema of the airways or larynx with dyspnea, cough, and wheezing. Severe systemic reactions have an abrupt onset with symptoms progressing rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Severe systemic reaction should be considered as an emergent situation. A systemic reaction occurred as a vector (the bee sting) and a reaction (signs/symptoms) resulted. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 23. An 18-year-old client who is pregnant has tested positive for human immunodeficiency virus (HIV) and asks the nurse if her baby is going to be born with HIV. Which response by the nurse is the best? A. "Your baby has a one in four chance of being born with HIV." B. "Your health care provider is likely the best one to answer that question." C. "If the baby is HIV-positive, we can't do anything until after the birth, so try not to worry." D. "Your baby could contract HIV before, during, or after delivery."

D Rationale: Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breastfeeding. There is no evidence that the infant's risk is 25%. Deferral to the health care provider is not a substitute for responding appropriately to the client's concern. Downplaying the client's concerns is inappropriate. PTS: 1 REF: p. 1009 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A nurse is planning the care of a client who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? A. Gabapentin (Neurontin) is effective because of the neuropathic nature of the client's pain. B. Opioids partially inhibit the client's synthesis of clotting factors. C. Opioids may cause vasodilation and exacerbate bleeding. D. NSAIDs are contraindicated due to the risk for bleeding.

D Rationale: NSAIDs may be contraindicated in clients with hemophilia due to the associated risk of bleeding. Opioids do not have a similar effect and they do not inhibit platelet synthesis. The pain associated with hemophilia is not neuropathic. PTS: 1 REF: p. 935 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. A client's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this client consequently faces an increased risk of which health problem? A. Bronchitis B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Asthma

D Rationale: Nurses should be aware that atopic dermatitis is often the first step in a process, known as atopic march, that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, or RA. PTS: 1 REF: p. 1057 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV) infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following? A. Immunity to HIV B. An intact immune system C. An AIDS-related complication D. An HIV infection

D Rationale: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications. PTS: 1 REF: p. 1013 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on the client's hands. What should the nurse teach the client to do? A. Wear powdered latex gloves when in public. B. Wash her hands with antibacterial soap every few hours. C. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible. D. Keep the hands well moisturized at all times.

D Rationale: Powdered latex gloves can cause contact dermatitis. Skin should be kept well hydrated and should be washed with mild soap. Maintaining room temperature at 75 to 80°F (24° to 27°C) is excessively warm. PTS: 1 REF: p. 1064 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 33. A nurse is explaining to a client with asthma with a new prescription for prednisone what it is used for. What would be the most accurate explanation that the nurse could give? A. To ensure long-term prevention of asthma exacerbations B. To cure any systemic infection underlying asthma attacks C. To prevent recurrent pulmonary infections D. To gain prompt control of inadequately controlled, persistent asthma

D Rationale: Prednisone is used for a short-term (3-10 days) "burst" to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term. PTS: 1 REF: p. 635 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Select 12. A 25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms? A. Lymphoma B. Leukemia C. Hemophilia D. Hepatic dysfunction

D Rationale: Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic dysfunction. Liver dysfunction can lead to decreased amount of factors needed for coagulation and hemostasis. The majority of hemophiliacs are diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or leukemia. PTS: 1 REF: p. 939 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. A client is being treated for a pulmonary embolism, and the medical nurse is aware that the client experienced an acute disturbance in pulmonary perfusion. This involved an alteration in which aspect of normal physiology? A. Maintenance of constant osmotic pressure in the alveoli B. Maintenance of muscle tone in the diaphragm C. pH balance in the pulmonary veins and arteries D. Adequate flow of blood through the pulmonary circulation.

D Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure. PTS: 1 REF: p. 466 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? A. Incentive spirometry B. Arterial blood gas (ABG) measurement C. Peak flow measurement D. Pulse oximetry

D Rationale: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air. PTS: 1 REF: p. 487 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 35. An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accident D. A client who is being treated for septic shock

D Rationale: Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically identified as a cause. PTS: 1 REF: p. 940 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. The nurse is caring for a client who has just returned to the unit after a colon resection. The client is showing signs of hypoxia. The nurse knows that this is probably caused by: A. nitrogen narcosis. B. infection. C. impaired diffusion. D. shunting.

D Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery, and nitrogen narcosis only occurs from breathing compressed air. PTS: 1 REF: p. 467 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care? A. Nasogastric intubation B. Administration of probiotic supplements C. Bed rest D. Cautious hydration

D Rationale: Supportive treatment of pneumonia in the older adults includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the older adults); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the client. PTS: 1 REF: p. 540 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 25. A client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for the cancer. Which fact about lung cancer treatment should inform the nurse's response? A. The cells in small cell cancer of the lung are not large enough to visualize in surgery. B. Small cell lung cancer is self-limiting in many clients, and surgery should be delayed. C. Clients with small cell lung cancer are not normally stable enough to survive surgery. D. Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

D Rationale: Surgery is primarily used for non-small cell lung cancer, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a client's medical instability are not the limiting factors. Lung cancer is not a self-limiting disease. PTS: 1 REF: p. 578 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin. When assessing the therapeutic response to this medication, which action by the nurse is the most appropriate? A. Assess for signs of myelosuppression. B. Review the client's platelet level. C. Assess the client's capillary refill time. D. Review the client's international normalized ratio (INR).

D Rationale: The INR and activated partial thromboplastin time serve as useful tools for evaluating a client's clotting ability and monitoring the therapeutic effectiveness of anticoagulant medications. The client's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the client for signs of myelosuppression and assessing capillary refill time do not address the effectiveness of anticoagulants. PTS: 1 REF: p. 894 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. Which of the following individuals would be the most appropriate candidate for immunotherapy? A. A client who had an anaphylactic reaction to an insect sting B. A child with allergies to eggs and dairy C. A client who has had a positive tuberculin skin test D. A client with severe allergies to grass and tree pollen

D Rationale: The benefit of immunotherapy has been fairly well established in instances of allergic rhinitis and bronchial asthma that are clearly due to sensitivity to one of the common pollens, molds, or household dust. Immunotherapy is not used to treat type I hypersensitivities. A positive tuberculin skin test is not an indication for immunotherapy. PTS: 1 REF: p. 1053 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 31. Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns? A. "All donated blood is treated with antiretroviral medications before it is used." B. "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C. "HIV was eradicated from the blood supply in the early 2000s." D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

D Rationale: The client can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood. PTS: 1 REF: p. 905 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? A. Teach the client to take deep breaths and cough frequently. B. Use antihistamines daily throughout the year. C. Teach the client to seek medical attention at the first sign of an allergic reaction. D. Modify the environment to reduce the severity of allergic symptoms.

D Rationale: The client is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions is anaphylaxis. Overuse of antihistamines reduces their effectiveness. PTS: 1 REF: p. 1054 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, which instruction should the nurse give the attendees? A. Apply the condom prior to erection. B. A condom may be reused with the same partner if ejaculation has not occurred. C. Use skin lotion as a lubricant if alternatives are unavailable. D. Hold the condom during withdrawal so it doesn't come off.

D Rationale: The condom should be held during withdrawal so it does not come off the penis. The condom should be unrolled over the hard penis, not prior to erection, before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, and cold cream should not be used with condoms because they cause latex deterioration/condom breakage. Condoms should never be reused. PTS: 1 REF: p. 1010 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. The medical nurse is creating the care plan of a client with a tracheostomy requiring mechanical ventilation. Which nursing action is most appropriate? A. Keep the client in a low Fowler position. B. Perform tracheostomy care at least once per day. C. Maintain continuous bed rest. D. Monitor cuff pressure every 8 hours.

D Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours, not once per day, because of the risk of infection. The client should be encouraged to ambulate, if possible, not maintain continuous bed rest, and a low Fowler position is not indicated. PTS: 1 REF: p. 557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? A. Appropriate use of prophylactic antibiotics B. Safe injection of corticosteroids C. Improved skin integrity D. Improved coping with lifestyle modifications

D Rationale: The goals for the client with allergies may include restoration of normal breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications. Antibiotics are not used to treat allergies and corticosteroids, if needed, are not given parenterally. Allergies do not normally threaten skin integrity. PTS: 1 REF: p. 1054 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is caring for a client who has been in a motor vehicle accident and is suspected of having developed pleurisy. Which assessment finding would best corroborate this diagnosis? A. The client is experiencing painless hemoptysis. B. The client's arterial blood gases (ABGs) are normal, but the client demonstrates increased work of breathing. C. The client's oxygen saturation level is below 88%, but the client denies shortness of breath. D. The client's pain intensifies when the client coughs or takes a deep breath.

D Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The client's ABGs would most likely be abnormal, and shortness of breath would be expected. Painless hemoptysis is not characteristic of pleurisy. PTS: 1 REF: p. 553 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A. Ensure that blood components are never infused at a rate greater than 125 mL/h. B. Administer prophylactic antihistamines prior to all blood transfusions. C. Establish baseline vital signs for all clients receiving transfusions. D. Be vigilant in identifying the client and the blood component.

D Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and client identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally given, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction. PTS: 1 REF: p. 901 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common? A. Sudden change in level of consciousness (LOC) B. Recurrent infections C. Anaphylaxis D. Severe fatigue

D Rationale: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis. PTS: 1 REF: p. 892 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 37. The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge? A. Walk 1 mile (1.6 km) 3 to 4 times a week. B. Use weights daily to increase arm strength. C. Walk on a treadmill 30 minutes daily. D. Perform shoulder exercises five times daily.

D Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the client on the importance of performing shoulder exercises five times daily. The client should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks. PTS: 1 REF: p. 585 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. One day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client? A. Keep the remaining tablets for an infection at a later time. B. Discontinue the medications if the fever is gone. C. Dispose of the remaining medication in a biohazard receptacle. D. Finish all the antibiotics to eliminate the organism completely.

D Rationale: The nurse informs the client about the need to take the full course of any prescribed antibiotic. Antibiotics should be taken for the entire prescribed course to eliminate the microorganisms. A client should never be instructed to keep leftover antibiotics for use at a later time. Even if the fever or other symptoms are gone, the medications should be continued. Antibiotics do not need to be disposed of in a biohazard receptacle, though they should be discarded appropriately. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. A client is scheduled to have excess pleural fluid aspirated with a needle to relieve dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe? A. It allows for full expansion of the lungs within the thoracic cavity. B. It prevents the lungs from collapsing within the thoracic cavity. C. It limits lung expansion within the thoracic cavity. D. It lubricates the movement of the thorax and lungs.

D Rationale: The pleural fluid, located between two membranes known as the visceral pleura (which cover the lungs) and the parietal pleura (which line the thorax), serves to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleural fluid does not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity. PTS: 1 REF: p. 465 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Select 10. A client's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? A. Plasminogen B. Thrombin C. Prothrombin D. Plasmin

D Rationale: The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (e.g., after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form. PTS: 1 REF: p. 891 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching? A. Finish the bottle of nasal spray to clear the infection effectively. B. Nasal spray can only be shared between immediate family members. C. Nasal spray should be given in a prone position. D. Overuse of nasal spray may cause rebound congestion.

D Rationale: The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximal distribution of the spray. Only the client should use the bottle. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A. Cognition is decreased. B. Daily arterial blood gases (ABGs) are necessary. C. Slight tracheal bleeding is anticipated. D. The cough reflex is depressed.

D Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the client's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required. PTS: 1 REF: p. 557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 17. A client has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? A. The volume of air inhaled and exhaled with each breath B. The volume of air in the lungs after a maximal inspiration C. The maximal volume of air inhaled after normal expiration D. The maximal volume of air exhaled from the point of maximal inspiration

D Rationale: Vital capacity is measured by having the client take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 4. The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)? A. Production of inadequate quantities of RBCs B. Premature release of immature RBCs C. Injury to the RBCs in circulation D. Abnormalities in the structure and function of RBCs

D Rationale: Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client? A. Administration of IVIG B. Antibiotic administration C. Appropriate use of gloves and goggles D. Thorough and consistent hand hygiene

D Rationale: Hand hygiene is usually considered the most important aspect of infection control. IVIG and antibiotics are not considered infection control measures, though they enhance resistance to infection and treat infection. Gloves and goggles are sometimes indicated but are less effective than hand hygiene. PTS: 1 REF: p. 1007 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A client's total laryngectomy has created a need for alaryngeal speech, which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the client when teaching about this process? A. Training how to perform controlled belching B. Use of an electronically enhanced artificial pharynx C. Insertion of a specialized nasogastric tube D. Fitting for a voice prosthesis

D Rationale: In clients receiving tracheoesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used. PTS: 1 REF: p. 517 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 12. A nurse is performing a focused assessment on a client with bronchiectasis. Which are the most prevalent signs and symptoms of this condition? Select all that apply. A. Radiating chest pain B. Wheezes on auscultation C. Increased anterior-posterior (AP) diameter D. Copious, purulent sputum E. Chronic cough

D, E Rationale: Characteristic symptoms of bronchiectasis include clubbing of the fingers, chronic cough, and production of purulent sputum in copious amounts. Radiating chest pain, along with additional clinical indicators, are more indicative of a cardiovascular condition. Wheezes on auscultation are common in clients with asthma. An increased AP diameter is noted in clients with chronic obstructive pulmonary disease. PTS: 1 REF: p. 631 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. A client with chronic obstructive pulmonary disease has recently begun a new bronchodilator. Which therapeutic effect(s) should the nurse expect from this medication? Select all that apply. A. Negative sputum culture B. Increased viscosity of lung secretions C. Increased respiratory rate D. Increased expiratory flow rate E. Relief of dyspnea

D, E Rationale: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process. PTS: 1 REF: p. 642 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. During a code blue, a nurse sustained a needlestick injury from a client whose human immunodeficiency virus (HIV) status was unknown. The nursing supervisor is notified, an incident report is generated, and a post-HIV exposure prophylaxis checklist is started for this nurse. In which order would the checklist be implemented? A. Administer post-exposure prophylaxis (PEP) medication. B. Advise exposed health care providers to use precautions. C. Get counseling at the time of exposure. D. Undergo early reevaluation after exposure. E. Determine the HIV status of the client.

E, C, B, A, D Rationale : It is important to determine the client's HIV status through rapid testing (if possible) to help guide the appropriate use of PEP medications (as needed). The nurse should receive counseling at the time of exposure. Part of that counseling is to advise the nurse (health care provider) to use precautions (barrier conception, avoid blood donation, pregnancy and breast-feeding) to prevent secondary transmission. PEP medication (if needed) then is given. And the nurse (in this case) is recommended to undergo early reevaluation within 72 hours after exposure. PTS: 1 REF: p. 1012 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply