CFCC 211 Final (iggy)

Question 7 of 11 A client is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the client before the test? "Do not eat or drink for 8 hours before the test." "It will be important to lie still in a reclined position for 20 minutes." "You can have the MRI if you have an internal pacemaker." "All jewelry and clothing with zippers or metal fasteners must be removed."

"All jewelry and clothing with zippers or metal fasteners must be removed." The nurse tells the client that all clothing with zippers or metal fasteners and all jewelry must be removed before undergoing MRI.The client having a closed MRI will lie still in a supine position for 45 to 60 minutes, not 20 minutes, and may require sedation. It is not necessary for the client to be NPO before an MRI. The client cannot undergo MRI when an internal pacemaker or any other metal object is present in the body.

Question 4 of 14 The client who wants to use Truvada for preexposure prophylaxis (PreP) asks the nurse why testing is needed for HIV status before starting this drug. How does the nurse respond? "Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." "The side effects of this drug are worse if you have a detectable HIV viral load." "If you take this drug and are HIV positive, your risk for co-infection with the hepatitis B virus is increased." Some people have a genetic mutation that increases the risk for life-threatening reactions "while taking this drug if they are also HIV positive."

"Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." The drug can help prevent HIV infection, but alone does not adequately suppress viral replication. In addition, taking it when HIV positive often leads to drug resistance. None of the other statements are true.

Question 4 of 16 The nurse is assessing an older client who has bony nodules on finger joints (Heberden and Bouchard nodes). What priority question would the nurse want to ask as part of the client interview? "When did your bony nodules develop?" "How do you feel about having these bony nodules?" "Are you able to independently perform ADLs?" "Are your bony nodules painful or tender?"

"Are you able to independently perform ADLs?" As a result of the client having bony nodules in his or her hands, the most important question for the nurse to ask is to determine if the client is ADL independent. The nurse would also ask the other questions, but they are not the first questions to be asked.

Question 12 of 18 Which statement by a client who has systemic lupus erythematosus (SLE) indicates to the nurse that more education about the disorder and its management is needed? "My friend and I are going to start walking 2 miles daily." "Taking my temperature every day can help me recognize when a flair is starting." "If I still have a lot of pain after taking an NSAID, I can also take acetaminophen." "At the first sign of a flare, I will begin taking my medication again."

"At the first sign of a flare, I will begin taking my medication again." The client's statement suggests that he or she believes that daily medication is not needed and would be required only during a flare. However, daily drug therapy is essential to slow the progression of the disease and organ damage.Low-impact exercise such as walking is highly recommended to maintain mobility and promote cardiovascular health. Fevers are often associated with a flare. There is no contraindication to taking both NSAIDs and acetaminophen.

Question 13 of 28 What is the nurse's best response when a client with emphysema asks how removing part of the lungs through lung volume reduction surgery will improve breathing? "By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." "This surgery is preventive, because the parts of the lungs being removed are those that having the highest probability for developing cancer." "Breathing will be improved because diseased lung parts are removed and replaced with healthy parts." "This surgery makes room for the new lungs when a lung transplant is available."

"By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." Lung volume reduction surgery removes hyperinflated lung areas that contain only stale air and do not contribute to gas exchange. This ensures that respiratory effort results in better gas exchange in the remaining alveoli. Removing some volume also allows respiratory muscle contraction to be more effective.This surgery does not replace any lung tissue and is not performed as a precursor to lung transplantation. The hyperinflated areas are not more susceptible to cancer development than any other lung tissue.

Question 4 of 21 Buck's (skin) traction for a fractured hip is applied to a client while a urinary tract infection is treated before surgery. What instruction will the nurse give assistive personnel (AP) for providing client care related to the traction? "Inspect the pins in the traction for signs of infection." "Remove the boot every shift to inspect the skin." "Do not allow the traction weights to rest on the ground." "Remove traction weights when turning the client."

"Do not allow the traction weights to rest on the ground." Although Buck's traction is not used commonly today because clients have surgical hip repairs to reduce pain, for some clients such as this client, it is used short term until surgery can be performed. The AP should allow the weights to hang freely and not remove them. There are no pins and the boot can be removed by the nurse for skin inspection.

Question 8 of 11 The client asks what tool the physical therapist (PT) used to measure joint range of motion (ROM)? How would the nurse respond? "Goniometer" "Reflex hammer" "Tonometer" "Doppler device"

"Goniometer" A goniometer provides an exact measurement of flexion and extension or joint ROM.A Doppler device is used to check and find pulses. A reflex hammer is used to test and elicit reflexes and is used in neurologic examinations. A tonometer is used to measure tension or pressure in the eye.

uestion 13 of 16 The nurse is planning health teaching for a client starting hydroxychloroquine for rheumatoid arthritis. What instruction would the nurse include in the teaching? "Be aware that the drug may cause secondary types of cancer." "Expect nausea and vomiting for the first week after starting the drug." "Have eye examinations every 6 months while on the drug." "Keep this medication in the refrigerator at all times."

"Have eye examinations every 6 months while on the drug." Hydroxychloroquine is an antimalarial drug with immune modulating and anti-inflammatory properties. Although side effects are usually mild, long-term use of the drug can cause vision problems. The client is taught to have an eye examination prior to starting the drug and every 6 months while on the drug to detect any visual changes.

Question 10 of 14 Which statement made by the nurse during an admission assessment for a client who is HIV positive demonstrates a nonjudgmental approach in discussing sexual practices and behaviors? "You must tell me all of your partners' names, so I can let them know about possibly being infected." "I hope you use condoms to protect your partners." "Have you had sex with men or women or both?" "You don't participate in anal intercourse, do you?"

"Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. By stating the question about anal intercourse as a negative is very judgmental.

Question 6 of 11 Which assessment question is most relevant for the nurse to ask a client on warfarin therapy whose international normalized ratio (INR) is 0.6? "What types of dairy products do you consume on a regular basis? "Have you noticed any bleeding from you gums after brushing or flossing? "How many salads and raw vegetables do you eat per week? "Do you or any member of your family have frequent nose bleeds or bruising?

"How many salads and raw vegetables do you eat per week? The normal INR ranges between 0.8 and 1.1 times the normal control. Lower INRs are associated with an increased risk for clotting. Clients on warfarin therapy, which is a vitamin K antagonist, are expected to have INRs between 2.0 and 3.0 depending on why anticoagulation is needed. Increased vitamin K intake, which is found in raw, leafy green vegetables, reduces the effectiveness of this drug.

Question 3 of 11 Which question will the nurse ask to assess a client's endurance in performing ADLs? "Do you usually eat supper at home or at a restaurant?" "How would you rate your energy level compared with last year?" "What medications do you take daily, weekly, and monthly?" "Have you lost any weight this past year?"

"How would you rate your energy level compared with last year?" The question the nurse needs to ask the client about endurance in performing ADLs is "How is your energy level compared with last year"? Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. None of the other questions are specific to assessment of a client's endurance.

Question 13 of 18 What response by the nurse would be most therapeutic when a client who has systemic lupus erythematosus (SLE) says, "My face has changed so much. I feel really ugly"? "I know what you mean, I feel that way sometimes too." "I bet that was hard to say. Thank you for trusting me with your feelings." "Don't worry, treatment will make everything better." "You look great. It's what is inside that counts."

"I bet that was hard to say. Thank you for trusting me with your feelings." "I bet that was hard to say. Thank you for trusting me with your feelings" is an empathetic response in a hard conversation. It acknowledges the client's bravery for sharing and encourages further therapeutic communication."You look great. It's what is inside that counts" is dismissive of the client's feelings. "Don't worry we will make everything better" is considered false reassurance, this can discount the client's feelings. "I know what you mean, I feel that way sometimes too" is focused on the nurse at a time when the focus should be on the client. All three responses hinder a continued conversation and therapeutic communication.

Question 12 of 16 The nurse has provided health teaching for a female client starting on methotrexate (MTX) for early rheumatoid arthritis. What statement by the client indicates a need for further teaching? "I will try to avoid crowds because I could easily get an infection." "I will start folic acid supplements whichh can help decrease side effects." "I can drink alcohol in small amounts at night to help me relax." "I will use strict birth control while I am taking this drug."

"I can drink alcohol in small amounts at night to help me relax." All of these statements are correct about MTX except that the client needs to avoid all alcoholic beverages to prevent liver toxicity.

Question 6 of 18 A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I'll need to wear special stockings after the procedure." "I can go home 48 hours after the procedure." "I can go home the day of the procedure." "I'll have a drain in place after the procedure."

"I can go home the day of the procedure." The statement that indicates the client correctly understands preoperative teaching of a microdiskectomy is "I can go home the day of the procedure." A microdiskectomy is considered minimally invasive surgery (MIS) and does not typically require an inclient hospital stay.The client who undergoes a minimally invasive surgery does not have to wait 48 hours after the procedure to return home, will not have a drain in place after the procedure, and will not need to wear special stockings after the procedure. These steps are used in the case of traditional open laminectomy, not MIS.

Question 16 of 21 A client who uses a computer for hours each day asks the nurse how to help prevent carpal tunnel syndrome (CTS). Which statement by the client indicates a need for further teaching? "I need to make sure I have an ergonomically sound computer station." "I need to exercise repetitively to strengthen my wrists." "I should stretch my fingers and wrists frequently during the day." "I may need to wear a wrist splint when my wrist gets inflamed."

"I need to exercise repetitively to strengthen my wrists." All of these statements are correct except that CTS is caused by repetitive motion such as that caused by working every day on computers. Repetitive exercises would therefore not be appropriate.

Question 5 of 18 The nurse is teaching a client about starting glatiramer acetate. Which statement by the client indicates a need for further teaching? "I need to take this drug before breakfast at least once a week while I have weakness." "If I get flulike symptoms, which is not very likely, I'll take ibuprofen or acetaminophen." "I will avoid crowds and people who have infections because I'll be immunosuppressed." "I will rotate the site of the injections to prevent skin reactions from the drug."

"I need to take this drug before breakfast at least once a week while I have weakness." Because this drug is given parenterally, there is no need to take it with or without food. All of the other client statements are accurate and demonstrates client understanding.

Question 6 of 22 The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? "I need to use fake sugar in my coffee." "I can still eat Chinese food." "I should not miss any meals." "It is okay to drink a few wine coolers."

"I should not miss any meals." The client understands the teaching plan about trigger control for migraines when the client states that he/she must not miss meals. Until triggers are identified, a headache diary would be considered. Missing meals is a trigger for many people suffering from migraines. The client must not skip any meals until the triggers are identified.Chinese food frequently contains monosodium glutamate. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and need to be eliminated until the triggers are identified.

Question 4 of 28 Which statement made by a client prescribed a reliever drug inhaler for asthma indicates to the nurse correct understanding of this therapy? "If I forget a dose, I will use the inhaler as soon as I remember it." "At night, I will be sure to store the inhaler in a cool, dry place." "I will keep this inhaler with me at all times." "Reliever drugs are needed to prevent asthma attacks."

"I will keep this inhaler with me at all times." The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times because asthma attacks cannot always be predicted.The inhaler is not to be stored at night; it needs to remain with the client for emergency use.Reliever drugs stop an attack and are used when needed, not on a schedule.

Question 11 of 22 A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan. Which statement by the client indicates an understanding of the nurse's discharge instructions? "Birth control is not needed while taking sumatriptan." "Sumatriptan can be taken as a last resort." "I will report any chest pain right away." "St. John's wort can also be taken to help my symptoms."

"I will report any chest pain right away." The client comment that shows that she understands the discharge instructions is that any chest pain must be reported right away. Chest pain must be reported immediately with the use of sumatriptan because triptans cause vasoconstriction.Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans would not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression. Sumatriptan must be taken as soon as migraine symptoms appear.

Question 1 of 11 A client is scheduled for magnetic resonance arthrography of the right knee to determine ligament damage. Which statement by the client indicates a need for further teaching? "I can take ibuprofen to help with any discomfort after the procedure." "I will need to use ice for a day or two after the procedure to prevent swelling." "My knee will be numbed before the needle is inserted into my joint." "I'll only be in the hospital overnight to get the procedure done."

"I'll only be in the hospital overnight to get the procedure done." This test does not require hospitalization. The client will receive local anesthesia where a needle will be inserted to inject a contract medium. After the test is performed, the client would want to use ice and NSAIDs or acetaminophen for discomfort and swelling.

Question 6 of 18 Which client statement about the use and care of an epinephrine autoinjector for a peanut allergy indicates to the nurse that more teaching is needed? "If I inject myself, I will still go immediately to the emergency department." "When needed, I can inject the drug right through my clothing." "My wife and I will both practice putting the device together." "If I keep the injector in the refrigerator, the drug will not expire as quickly."

"If I keep the injector in the refrigerator, the drug will not expire as quickly." Although it is true that the drug may not deteriorate as quickly if refrigerated, the client needs to have the drug with him or her at all times to use as soon as symptoms of anaphylaxis occur in order to prevent death. All other statements for the use and care of an epinephrine autoinjector are correct.

Question 8 of 11 The nurse is teaching an older adult client about visual changes that occur with age. Which statement does the nurse include? "You will have to move reading materials closer to your eyes to focus." "When the sclera turns yellow, you have developed liver problems." "It may take your eyes longer to adjust in a darkened room." "Most visual changes occur before age 40."

"It may take your eyes longer to adjust in a darkened room." The nurse teaches the client that, "It may take your eyes longer to adjust in a dark room." With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments.Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia also commonly begins in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

Question 2 of 11 A client is scheduled to have a bone scan for a suspected bone tumor. What statement by the nurse is correct about the procedure for this test? "It sees sound waves to produce an image of the skeleton." "It requires an injected radioactive material to view entire skeleton." 'It requires an injected iodine-based contrast medium to view the bone." "It relies on magnetic waves to help produce the image of the bone."

"It requires an injected radioactive material to view entire skeleton." A bone scan produces images of the entire skeleton through the use of a radioactive material that is used prior to imaging.

Question 7 of 21 A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "My spouse will be the only person to change my dressing." "It will take me some time to get used to this."

"It will take me some time to get used to this." Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping.Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

uestion 3 of 18 A client has been diagnosed with primary progressive multiple sclerosis (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for further teaching? "It's important I work out in the afternoon so my muscles are warmed up." "I can alternate wearing my eye patch between eyes for double vision." "I should keep my home clutter free so I don't fall." "I always keep my medications in the same place."

"It's important I work out in the afternoon so my muscles are warmed up." More teaching is needed for the client with PPMS when the client says, "It's important I work out in the afternoon so my muscles are warmed up." Working out in the afternoon will increase body temperature and lead to fatigue. Fatigue is a key feature of MS. Working with a physical therapist to develop an appropriate exercise program tailored to the client's condition will be beneficial.If a client has diplopia, wearing an eye patch and alternating it between eyes every few hours may relieve the symptoms. Keeping the home organized and clutter free will decrease the risk of falls. Keeping medications and other important belongings in the same place and maintaining a routine may help with memory deficits that may occur with MS.

Question 11 of 18 The nurse is providing instructions to a client with a cervical spinal cord injury about caring for the halo fixator device. The nurse plans to include which instructions? "Avoid using a pillow under the head while sleeping." "Begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active."

"Keep straws available for drinking fluids." The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.

Question 2 of 16 An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in health teaching related to the client's home safety? "Keep walkways free of clutter." "Keep light low to prevent glare." "Walk slowly on wet floor areas after mopping." "Use area rugs on tile floors."

"Keep walkways free of clutter." The nurse teaches the client that walkways in the home must be clear of clutter and obstacles to help prevent falls.Clients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling. Clients with metabolic bone problems must not walk on wet floors because the potential for falling is too great. Keeping the lights low would not allow the client to see adequately to walk safely or avoid an object on the floor.

Question 8 of 22 The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? "Establishing goals and a daily plan can help." "Can't you take care of your spouse?" "Make sure you take some time off and take care of yourself." "That's not a very nice thing to say."

"Make sure you take some time off and take care of yourself." The nurse's best response to the spouse of the client with dementia is to encourage the wife to take some time off to take care of herself. This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted.Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan may be helpful to the situation but is not responding to the spouse's need. Reprimanding the spouse does not validate his or her feelings and does not allow the nurse to further explore the statement.

Question 10 of 18 What is the nurse's best response to a client newly diagnosed with systemic lupus erythematosus (SLE) who asks why nicotine use, especially cigarette smoking or vaping, should be avoided? "Nicotine reduces blood flow to your organs and increases the risk for permanent damage." "Using nicotine in any form reduces the effectiveness of drug therapy for lupus." "Nicotine promotes muscle cell loss, increases joint inflammation, and reduces functional mobility." "Smoking or vaping increases your risk for lung cancer development."

"Nicotine reduces blood flow to your organs and increases the risk for permanent damage." Nicotine in any form constricts blood vessels and reduces perfusion. Perfusion is already reduced by the vasculitis that is part of the disease. Thus, use of nicotine greatly increases the risk for necrosis of many tissues and organs. Although smoking or vaping do increase the risk for lung cancer, their effects on blood vessels are a greater issue for the client with SLE. Nicotine neither reduces the effectiveness of drug therapy nor promotes muscle cell loss.

Question 9 of 16 A young female client whose mother and grandmother have osteoporosis asks whether she needs to take steps to prevent this disease in herself. What will the nurse tell this client? "Now is the time to begin building strong bones." "Your risk isn't present until age 50; we can talk about it then." "You do not have to worry about symptoms at your age." "You should begin to take steps to prevent disease at age 30."

"Now is the time to begin building strong bones." The nurse will tell this client that peak bone mass is achieved by about 30 years of age in most women, so building strong bone as a young person may be the best defense against osteoporosis in later adulthood. She needs to begin getting adequate calcium and vitamin D now as well as exercising to help build strong bones.The nurse will not tell the client not to worry about symptoms at her age. Beginning at age 30 may be too late. By the time symptoms appear in older adulthood, it is too late to build strong bones.

Question 8 of 18 A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What would be the appropriate response for the nurse? "Only time will tell, but hopefully the client will be able to care for yourself." "Every injury is different, and it is too soon to have any real answers right now." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the primary health care provider. I can help set that up."

"Please request a meeting with the primary health care provider. I can help set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting, however.The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

Question 8 of 12 The nurse is discussing treatment options with a client newly diagnosed with breast cancer. Which client statement indicates a need for further teaching? "If I get radiation, I am not radioactive to others." "I might have chemotherapy before surgery." "Hormonal therapy is used to prevent cancer growth." "Radiation will remove the cancer, so I might not need surgery."

"Radiation will remove the cancer, so I might not need surgery." Further teaching is needed when the client says that, "Radiation will remove the cancer, so I might not need surgery." The purpose of radiation therapy is to kill breast cancer cells that may remain near the site of the original tumor. Typically, radiation therapy follows surgery. Radiation therapy plays a critical role in the therapeutic regimen and is an effective treatment for almost all sites where breast cancer can metastasize.The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth. Chemotherapy drugs destroy breast cancer cells that may be present anywhere in the body. The client receiving radiation therapy is radioactive only if the radiation source is dwelling inside the breast tissue.

Question 3 of 16 A client who has osteopenia is prescribed to begin risedonate. What health teaching would the nurse include about this drug? "Take the drug with dinner or other meal or snack every day." "Remain in an upright position for 30 minutes after taking the drug." "Be sure to follow up with lab work to monitor your liver function." "Be sure to report any new bone pain or infection."

"Remain in an upright position for 30 minutes after taking the drug." Risedonate is an oral bisphosphonate that can cause esophagitis. Therefore, the nurse would teach the client to take the drug before breakfast on an empty stomach with a glass of water, and stay in an upright position (sitting or standing) for at least 30 minutes after taking the drug.

Question 7 of 16 The nurse is caring for a client who has been treated for osteoporosis for 15 years and is starting on denosumab. What health teaching is appropriate for the nurse to include about this drug? "You will receive an IV infusion once a year by your provider." "Take the drug every morning with a glass of water." "Have a dental examination prior to beginning the drug." "See your primary health care provider for twice yearly injections."

"See your primary health care provider for twice yearly injections." Denosumab is a RANKL inhibitor drug administered subcutaneously by a health care professional twice a year. Dental examinations are recommended for clients who are preparing to take bisphosphates.

Question 3 of 11 When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? "My vision has been getting worse gradually." "One of my eyes is green and the other is blue." "My eyes are red and itchy due to allergies." "Something hit my eye while I was cutting grass."

"Something hit my eye while I was cutting grass." The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist.All other reports will be communicated to the ophthalmologist, but do not require immediate intervention. Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color. This is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes, or other eye changes, but this does not require immediate care by an ophthalmologist.

Question 2 of 19 A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? 1-"I will discuss cancelling your medication order with your health care provider." 2-"That sounds like a wonderful idea; and I think it will definitely work!" 3-"That sounds like a great plan; can you tell me more about it?" 4-"Your plan will not work; people with your type of pain need opioids."

"That sounds like a great plan; can you tell me more about it?" Complementary and integrative therapies are most often used to supplement, not replace, medication management. The nurse needs to obtain more data, and will ask for more information about the client's plan.Contacting the health care provider to cancel the medication order is not appropriate. Telling the client that his idea is wonderful and will definitely work is not appropriate, as alternative strategies alone, may not work to relieve the client's pain. Telling the client that his or her plan will not work is dismissive of the client. In addition, the client may not need to be prescribed opioids for the pain.

Question 7 of 16 The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house." "The bus is coming to pick me up from the senior center three times a week so I can play cards."

"The bus is coming to pick me up from the senior center three times a week so I can play cards." Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively.

Question 1 of 18 What is the nurse's best response to a client who had a severe allergic reaction to shrimp states, "I have had shrimp once before and did not have a reaction. Why is this happening now?" "Allergies are tricky, and many reasons for responses are not known." "It is most likely that you didn't eat enough shrimp the first time to cause a reaction." "The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." "This means you may be allergic to something else and not to shrimp."

"The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." Type I reactions have two parts. During the first exposure, the client makes antigen-specific IgE, and becomes sensitized to the allergen. When the sensitized client is re-exposed to the allergen, a more severe reaction occurs.To point out the amount of shrimp eaten is not helpful and could make the client believe that eating only a small amount of shrimp would not cause a reaction. The same is true for option C. Stating that allergies "are tricky" does not help to inform or educate the client about what he or she should do to prevent harm. This response may make the client afraid of everything in his or her environment.

Question 9 of 11 A client is to undergo gonioscopy. When the client asks what this test is for, what is the appropriate nursing response? "This test creates a three-dimensional view of the back of the eye." "Retinal circulation is evaluated by this test." "The ophthalmologist uses the test to determine if you have open-angle or closed-angle glaucoma." "This method of testing will determine if you have blood vessel changes due to disease or drugs."

"The ophthalmologist uses the test to determine if you have open-angle or closed-angle glaucoma." Gonioscopy is performed for clients with high IOP to determine whether open-angle or closed-angle glaucoma is present.A three-dimensional view of the back of the eye is created by ultrasonic imaging of the retina and optic nerve (called ocular coherence tomography). Electroretinography helps the eye care provider to determine if a client has blood vessel changes resulting from disease or drugs. Retinal circulation is evaluated by fluorescein angiography.

Question 9 of 14 Which statement made to the nurse by an assistive personnel (AP) assigned to care for an HIV-positive client indicates a breach of confidentiality and requires further education by the nurse? "The client's spouse told me she got HIV from a blood transfusion." "The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." "I told family members they need to wash their hands when they enter and leave the room." "Yes, I understand the reasons why I have don't need to wear gloves when I feed the client."

"The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or other visitors is not a breach of confidentiality. Understanding the reasons for when and when not to wear gloves when performing direct client care is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

Question 4 of 18 A client with possible multiple sclerosis asks the nurse to explain why she has to have a visual evoked response (VER) test. What statement by the nurse is correct about this diagnostic test? "A group of electrodes will be placed on your scalp so to see how your eyes react." "You will have to lie very still in a tube for the magnetic imaging of your head and neck." "This test will help determine how well the nerves in your eyes transmit a signal." "A contrast medium will be used to visualize any changes in your brain."

"This test will help determine how well the nerves in your eyes transmit a signal." The VER is a noninvasive test that determines how well nerve transmission occurs along the optic nerve pathways.

Question 20 of 29 Which instruction is most appropriate for the nurse to teach a client with persistent thrombocytopenia who is being discharged? "Use a soft-bristled toothbrush." "Avoid large crowds." "Drink at least 2 L of fluid per day." "Elevate your lower legs when sitting."

"Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating the lower legs reduces the risk for dependent edema and clot formation but is not specific to the client with thrombocytopenia.

Question 7 of 20 The nurse is teaching assistive personnel (AP) about how to communicate with an older client who has receptive aphasia. Which instruction would the nurse include? "Use simple short sentences and one-step commands." "Work with the speech-language pathologist for suggestions." "Write sentences or words on a white board for the client." "Speak loudly to ensure that the client can hear."

"Use simple short sentences and one-step commands." Receptive aphasia is an inability to understand words or sentences, whether it is verbal or written. Therefore, using short simple, one-step sentences and commands is the best instruction to provide AP. Unless the client has a heading deficit, there is no need to talk loudly.

Question 5 of 14 Which point is most important for the nurse to include when teaching assistive personnel (AP) about protecting themselves from HIV exposure when caring for HIV-positive clients? "Always wear a mask when entering an HIV-positive client's room." "Talk to the employee health nurse about starting preexposure prophylaxis." "Wear gloves when in contact with clients' mucous membranes or nonintact skin." "Wear full protective gear when providing any care to HIV-positive clients."

"Wear gloves when in contact with clients' mucous membranes or nonintact skin." Standard Precautions are all that is needed when caring for any client, including those who have HIV. Masks and full protective gear are not needed. Preexposure prophylaxis is not used for potential occupational exposure.

Question 5 of 21 The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? "Avoid rigorous exercise." "Avoid contact sports." "Wear helmets when riding a motorcycle." "Avoid driving in inclement weather."

"Wear helmets when riding a motorcycle." Those who ride motorcycles or bicycles should wear helmets to prevent head injury.Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, but it is also opposed to what many health care professionals recommend to maintain health.

Question 3 of 19 The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? 1-"Is the pain really that bad?" 2-"Does it feel like sharp pain?" 3-"When does the pain occur?" 4-"Did someone do this to you?"

"When does the pain occur?" Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and allows the nurse to obtain the most data.Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. Further, this is not an open-ended question. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it feel like sharp pain?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.

Question 4 of 11 A client who is using eyedrops in both eyes develops a viral infection in one eye. What teaching will the nurse provide? "Wash your hands between eyes and put drops in the uninfected eye first." "Don't touch the eyes with the dropper, and you can still use the drops in both eyes." "The other eye has already likely been infected with the virus." "You will need to use a separate bottle of drops for each eye."

"You will need to use a separate bottle of drops for each eye." The appropriate nursing response is that the client will need a separate bottle of eyedrops for each eye. Because of the risk of transmitting the infection to the uninfected eye, clients would receive two bottles of drops labeled "right" and "left" to use in the correct eyes.There is still a risk of transmitting the infection when the dropper is kept from contacting the eye or when hands are washed. With proper technique, transmission of infection to the other eye can be prevented.

Question 5 of 11 What is the nurse's best response when a client with anemia asks "Why am I feeling tired all the time?" "Your brain is not getting enough oxygen." "How many hours are you sleeping at night?" "You are probably dehydrated." "When you are sick, you need to rest more."

"Your brain is not getting enough oxygen." The nurse's best response to the client complaining about feeling tired all the time is "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.

Question 14 of 16 The nurse is caring for a postoperative client with total hip arthroplasty. What actions would the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) Select all that apply. 1-Apply pneumatic or sequential compression devices. 2-Administer anticoagulant therapy. 3-Ambulate the client on the day of surgery. 4-Elevate the client's legs. 5-Keep the legs slightly abducted.

1, 2, 3 Preventive postoperative actions that help prevent VTE include pharmacology (anticoagulants), ambulation, and compression.

Question 20 of 21 A client is admitted to the emergency department following a left severe ankle sprain caused by playing football with friends. What nursing actions will the nurse implement at this time? (Select all that apply.) Select all that apply. 1-Elevate the left leg above the level of the heart. 2-Tell the client to keep his left leg still. 3-Apply an elastic wrap or ankle or compression brace. 4-Administer morphine via IV push. 5-Apply heat to promote blood flow and healing.

1, 2, 3 The nurse follows the RICE approach to emergency care of clients who experience a sports-related injury, which includes rest, ice, compression, and elevation of the affected part. Heat may be used after 24 hours, but ice is needed now to reduce swelling. The client does not need a strong opioid for this injury.

Question 17 of 18 After a client is hospitalized for an anaphylactic reaction to a bee sting, a nurse is teaching the client about the use of an epinephrine autoinjector. Which instruction/ instructions should be included in client education? (Select all that apply.) Select all that apply. 1-Keep the device with you at all times. 2-After administering the device, hospital monitoring is necessary. 3-Use the device before calling 911. 4-If the drug becomes discolored, order a replacement device. 5-The device CANNOT be given through clothing. 6-Inject the device into your arm or your leg.

1, 2, 3, 4 Instruct the client to utilize the device at the first symptom of anaphylactic reaction before calling 911. Hospital monitoring is always necessary after utilizing epinephrine for anaphylaxis. The device should be available at all times, as allergens can be encountered in all life situations. For client safety if the drug becomes discolored, it needs to be replaced.The device CAN be given through a thin layer of clothing. The ideal injection site for an epinephrine automatic injector is in the upper thigh.

Question 15 of 16 The nurse recognizes that a client who has persistent pain may have difficulty with pain management after a total joint arthroplasty. What collaborative interventions are needed to help the client manage postoperative pain? (Select all that apply.) Select all that apply. 1-Establish trust and explain the postoperative pain management plan. 2-Consult the pain management team if needed and available. 3-Plan continuing pain management after discharge. 4-Use multimodal and alternative pain management modalities. 5-Identify at-risk clients preoperatively using a comprehensive assessment.

1, 2, 3, 4, 5

Question 10 of 11 The nurse providing education on eye protection suggests protective eyewear for which client? (Select all that apply.) Select all that apply. 1-Racquetball player 2-Lifeguard 3-Cab driver 4-Registered nurse 5-College student

1, 2, 3, 4, 5 All clients are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play sports need to wear protective eyewear to prevent possible eye injury. Nurses may need protective eyewear to avoid getting or transmitting infection.

Question 18 of 18 The nurse is caring for a client who sustained a complete cervical spinal cord injury and is at risk for autonomic dysreflexia. Which assessment findings would the nurse anticipate if this complication occurs? (Select all that apply.) Select all that apply. 1-Goose bumps above and/or below the injury level 2-Sudden and severe hypertension 3-Severe throbbing headache 4-Profuse sweating above the injury level 5-Nasal congestion and blurred vision 6-Facial and skin flushing

1, 2, 3, 4, 5, 6

Question 18 of 20 The nurse is planning health teaching for a client who had a transient ischemic attack (TIA) to help prevent a major stroke. What teaching would the nurse include? (Select all that apply.) Select all that apply. 1-"Seek a smoking cessation program, if needed." 2-"Increase physical activity by exercising regularly." 3-"Monitor blood pressure frequently to assess control." 4-"Take your prescribed antiplatelet agent as prescribed." 5-"If diabetic, work to achieve glucose control as needed." 6-"Eat a heart-healthy diet every day if possible."

1, 2, 3, 4, 5, 6

Question 16 of 16 The nurse is caring for a client who is at risk for osteoporosis. What lifestyle changes might the client be able to implement to decrease this risk? (Select all that apply.) Select all that apply. 1-Avoiding excessive alcohol consumption 2-Increasing foods high in phosphorus 3-Decreasing consumption of carbonated beverages 4-Preventing a sedentary daily lifestyle 5-Seeking a smoking cessation program, if needed 6-Including more calcium-rich foods into the diet

1, 2, 3, 4, 5, 6 All of these lifestyle changes are needed to avoid modifiable risk factors that contribute to the development of osteoporosis except that foods high in phosphorus should be avoided. If the serum phosphorous/phosphate level increases, the serum calcium level decreases due to their inverse relationship. Low calcium levels can result in bone loss.

Question 18 of 19 The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) Select all that apply. 1-Body language 2-Facial expression 3-Breathing pattern 4-Ability to calm the client 5-Ability to distract the client 6-Picking at skin or clothing 7-Vocalizations

1, 2, 3, 4, 7 Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10:· Breathing (independent of vocalization)· Negative vocalization· Facial expression· Body language· Consolability (ability to calm the patient)Picking at the skin or clothing as well as ability to distract the client are not portions of the PAINAD scale.

Question 27 of 28 Which features will the nurse expect to be present in a client who has long-term chronic obstructive pulmonary disease? (Select all that apply.) Select all that apply. 1-Increased anteroposterior chest diameter from air-trapping 2-Respiratory acidosis with a low pH 3-Poor gas exchange from decreased alveolar surface area 4-Increased eosinophil count 5-Hypercapnia from retained PaCO2 6-Arterial blood gas value with increased PaO2 level

1, 2, 3, 5 Gas exchange is decreased by the increased work of breathing and the loss of alveolar tissue. Although some alveoli enlarge, the overall functional area available for gas exchange is decreased. The client also has a low arterial oxygen (PaO2) level because it is difficult for oxygen to move from diseased alveoli into the blood. Chronic retention of carbon dioxide increases the PaCO2 (hypercapnia) and results in respiratory acidosis. The anteroposterior chest diameter increases from air trapping.The PaO2 level is lower than normal and the eosinophil count does not change unless the client also has eosinophilic asthma.

Question 19 of 20 The nurse is planning discharge teaching for a client after having a carotid angioplasty with stenting. As part of health teaching, what symptoms will the nurse teach the client and family to report to the primary health care provider? (Select all that apply.) Select all that apply. 1-Dysphagia 2-Severe neck pain 3-Neck swelling 4-Mild headache 5-Hoarseness

1, 2, 3, 5 The client or family should notify the primary health care provider about complications of the carotid artery surgery, which include all of these choices except they would want to report a severe headache, not a mild one.

Question 16 of 17 Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) Select all that apply. 1-Continuous nasogastric (NG) tube feedings 2-Bronchoscopy procedure 3-Decreased level of consciousness 4-Magnetic resonance imaging (MRI) procedure 5-Stroke 6-Chest tube

1, 2, 3, 5 The risk for aspiration pneumonia is increased whenever the client has a reduced or absent gas reflex (e.g., decreased level of consciousness, stroke, following local anesthesia for a bronchoscopy procedure), and when a client's lower esophageal sphincter does not close complete. This situation occurs when an NG tube is in place, preventing complete or tight constriction of the sphincter.

Question 16 of 16 The nurse is teaching a client preparing to have a total knee replacement about interventions to help prevent surgical infection. What interventions would the nurse include in this teaching? (Select all that apply.) Select all that apply. 1-Using nasal mupirocin for at least a week before surgery 2-Avoiding sleeping with pets in the client's bed 3-Showering the night before and the morning of surgery with chlorhexidine 4-Giving antibiotics before and after surgery for at least 3 days 5-Sleeping on clean linen wearing clean nightwear

1, 2, 3, 5 these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection.

Question 17 of 17 Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) Select all that apply. 1-Those who were treated previously for active tuberculosis 2-Kidney transplant recipients 3-Homeless adults 4-Those who have received bacille Calmette-Guérin (BCG) vaccine 5-Those in the local prison 6-Recent immigrants to the United States

1, 2, 3, 5, 6 Adults who are at highest risk for TB include those who live in crowded areas such as prisons and homeless shelters, those who are recent immigrants to the United States, those who are taking long-term immunosuppressive agents, and those who have already had active TB.Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

Question 16 of 18 The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) Select all that apply. 1-"When lifting something, the back should be straight and the knees bent." 2-"Do not wear high-heeled shoes." 3-"Standing for long periods of time will help to prevent low back pain." 4-"Begin a regular exercise program to strengthen your back." 5-"Keep weight within 50% of ideal body weight."

1, 2, 4 The nurse includes the following instructions into the low back pain client's teaching plan: don't wear high-heeled shoes, begin a regular exercise program, and keep the back straight and knees bent when lifting something. Wearing high-heeled shoes can increase back strain. Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects and will help to prevent back injury.The client needs to avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight needs to be kept within 10% of ideal body weight and not 50%.

Question 11 of 11 The nurse is reviewing the laboratory test results for a client who was diagnosed with muscular dystrophy (MD) as a child. Which lab results will the nurse expect to be elevated? (Select all that apply.) Select all that apply. 1-Alkaline phosphatase 2-Aldolase 3-Calcium 4-Lactic dehydrogenase (LDH) 5-Creatine kinase (CK-MM)

1, 2, 4, 5 Muscular dystrophy is a group of genetically linked diseases that cause chronic skeletal muscle weakness and organ dysfunction due to smooth muscle involvement. Therefore, this disease affects muscles which cause elevations of muscle enzymes.

Question 17 of 19 The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) Select all that apply. 1-"Medical cannabis is a controlled substance in the United States". 2-"Federal and state law often vary in the legality of medical cannabis use." 3-"The psychoactive component of medical cannabis is removed." 4-"Your health care provider can prescribe cannabis for you." 5-"Side effects of cannabis can include dizziness and increased appetite."

1, 2, 5 Cannabis is a schedule I controlled substance and has been since 1970. Federal and state law often vary in the legality of cannabis use. A health care provider cannot prescribe cannabis in any state; however, they may assess and determine whether a client has a qualifying condition in accordance with state law. Side effects of cannabis include: increased heart rate, increased appetite, dizziness, decreased blood pressure, dry mouth, hallucinations, paranoia, altered psychomotor function, and impaired attention. The psychoactive component, THC, is not removed from medical cannabis.

Question 11 of 11 Which systemic disorder may affect vision and require yearly eye examination by an ophthalmologist? (Select all that apply.) Select all that apply. 1-Hypertension 2-Diabetes mellitus 3-Hepatitis 4-Anemia 5-Multiple sclerosis (MS)

1, 2, 5 Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity.Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

Question 16 of 18 Which statement(s) regarding type IV hypersensitivity reactions is/are true? (Select all that apply.) Select all that apply. 1-The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. 2-Type IV responses are usually directed against non-self but the response is excessive. 3-The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema. 4-The secondary phase, when prolonged, is primarily responsible for autoimmune disorders. 5-Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. 6-Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine.

1, 2, 5, 6 Type IV delayed hypersensitivity reactions have T-lymphocytes (T-cells) as the activated immune system component triggering the excessive responses. A classic example is allergy to poison ivy.Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen; however, histamine is not one of the mediators, making antihistamines of minimal benefit.A type IV response with edema, induration, ischemia, and tissue damage at the site of the exposure typically occurs hours to days after exposure.Angioedema is a type I response, not a type IV response.

Question 21 of 22 The nurse is caring for a client who is diagnosed with middle stage (moderate) Alzheimer disease. What assessment findings would the nurse expect? (Select all that apply.) Select all that apply. 1-Agnosia 2-Mild impaired cognition 3-Sleeping problems 4-Seizures 5-Wandering 6-Psychoses

1, 3, 4, 5, 6 All of these choices except for mild impairment of cognition would be expected. The client with moderate AD has a more marked cognitive impairment.

Question 20 of 22 A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.) Select all that apply. 1-Suction equipment at the bedside 2-Continuous sedation 3-Intravenous (IV) access 4-Bite block at the bedside 5-Side rails raised

1, 3, 5 Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside, and raised side rails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded side rails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

28 A cousin arrives to visit a client recently diagnosed with leukemia. Which responses will the nurse suggest when the cousin asks, "What should I say to her?" (Select all that apply.) Select all that apply. 1-"Just talk about the things you usually talk about with her." 2-"Remind her to be brave and to not cry." 3-"Ask how she is feeling." 4-"Explain what you know about leukemia." 5-"Ask if you can get or do anything for her." 6-"Express how sorry you are that this has happened to her."

1, 3, 5 The nurse suggests some comments a family member of a recently diagnosed client with leukemia might say to the client. The first statement may be, "ask her how she is feeling." This is a broad general opening and would be nonthreatening to the client. Asking if she needs or wants anything a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member would talk to her as she normally would when she hasn't seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option.Telling her to be brave and not to cry is callous and unfeeling. If the client is feeling vulnerable and depressed, telling her to "be brave" shuts off any opportunity for her to express her feelings. There is no need to inform the client about her disease, unless she asks about it. Opening the conversation with discussion about leukemia would be the client's prerogative. Expressing sorrow may convey a sense of hopelessness rather than support.

Question 17 of 18 The nurse is teaching a client starting on fingolimod to treat multiple sclerosis about the drug's possible side and adverse effects. Which effects will the nurse include in the teaching? (Select all that apply.) Select all that apply. 1-Infection 2-Hypertension 3-Diarrhea 4-Tachycardia 5-Facial flushing 6-Nausea/vomiting

1, 3, 5, 6 The nurse teaches the client and family to monitor the client's pulse because fingolimod causes bradycardia rather than tachycardia. Most oral immunomodulating drugs cause facial flushing, GI disturbances, and decreased white blood cell count that can cause the client to be at risk for infection.

Question 15 of 16 Which risk factors are shared by male clients who have osteoporosis or osteomalcia? (Select all that apply.) Select all that apply. 1-High alcohol intake 2-Homelessness 3-Low BMI 4-A history of smoking 5-Inadequate exposure to sunlight

1, 4 High alcohol intake is a risk factor for both osteoporosis and osteomalacia. A history of smoking is a risk factor for osteoporosis only.Inadequate exposure to sunlight and homelessness are risk factors for osteomalacia. A high BMI is a risk factor for both.

Question 11 of 12 The community health nurse is providing education to a group of women about risks for breast cancer. Which factor will the nurse include in the education session? (Select all that apply.) Select all that apply. 1-High breast density 2-First child at age 25 3-Male with gynecomastia 4-Nulliparity 5-Middle-age woman

1, 4 Individuals at high increased risk for breast cancer include women with high breast density as well as nulliparous women.Men are not at high increased risk for breast cancer, although they can develop this condition. Being middle-age and bearing the first child before age 30 does not indicate a high increased risk for breast cancer

Question 26 of 28 Which client statements about using an aerosol inhaler for asthma management indicate to the nurse that he has correct understanding of this drug delivery system? (Select all that apply.) Select all that apply. 1-"I will hold my breath for at least 10 seconds after inhaling the drug." 2-"When I suspect the canister is close to empty, I will shake it to check how much is left." 3-"If I use a spacer, I don't have to wait a minute between the two puffs." 4-"If the spacer makes a whistling sound, I am breathing in too rapidly." 5-"Rinsing my mouth after using the inhaler and then swallowing the rinse ensures I will get all of the drug."

1, 4 Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client is instructed to hold the breath for at least 10 seconds, however attempting to hold the breath for a minute is unnecessary and could pose a threat to oxygenation.The client must wait 1 minute between puffs regardless of the method of delivery of the medication. The client is taught to rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled drug is a corticosteroid; rinsing will help prevent the development of an oral fungal infection. Shaking an inhaler helps ensure that the medication is dispersed and the same dose is delivered in each puff, it does not indicate how much drug remains in the inhaler. The client is taught to read the counter on the inhaler to know how many drug doses remain.

Question 19 of 19 The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.) Select all that apply. 1-Localized pain 2-Sharp pain 3-Negative vocalization 4-Radiating pain 5-Referred pain 6-Pain rated as a 4 on a scale of 0-10.

1, 4, 5 Pain can be described as belonging to one of four categories related to its location: localized, projected, referred, and radiating. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Referred pain is felt in an area distant from the site of painful stimuli. Radiating pain is felt along a specific nerve or nerves.Pain rated as a 4 on a scale of 0-10 describes the intensity of the pain, not the location. Sharp pain describes the quality of the pain, not the location. Negative vocalization is an indicator of the presence of and quality of pain in adults with dementia.

Question 14 of 14 Which conditions or factors will the nurse teach at a community seminar as probable transmission routes for HIV? (Select all that apply.) Select all that apply. 1-Using injection drugs 2-Sitting on public toilets 3-Changing a diaper on an HIV positive child 4-Having unprotected intercourse with multiple partners 5-Breast-feeding 6-Being bitten by mosquitos

1, 4.5 HIV can be transmitted via breast milk from an infected mother to the child. Unprotected intercourse with an HIV positive adult is a major transmission route. HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities with an HIV-positive adult does not cause transmission of HIV. Use of injection drugs is a common transmission route. Casual contact such as changing a diaper, even with feces and urine (unless there is significant blood in these excretions), is not a probable transmission route.

Question 11 of 14 Which statements about the transmission of HIV are true? (Select all that apply.) Select all that apply. 1-Clients with HIV-III and no drug therapy are very infectious. 2-Even with appropriate drug therapy, most clients infected with HIV live only about 5 years after diagnosis. 3-HIV may be transmitted only during the end stages of the disease. 4-The most common transmission route is casual contact. 5-Newly infected clients with a high viral load are very infectious. 6-HIV-positive clients who have an undetectable viral load appear to not transmit the disease.

1, 5, 6 In the first 4 to 6 weeks after infection, the viral numbers in the bloodstream and genital tract are high and sexual transmission is possible. Clients at the end stage of HIV disease (HIV-III [AIDS]) without drug therapy have a high viral load and are particularly infectious. An undetectable viral load now means noninfectious and therefore, not transmittable. Casual contact does not transmit the infection. With appropriate drug therapy, clients with HIV disease live for decades

Question 16 of 19 A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) Select all that apply. 1-Music therapy 2-Assistance by the client with the dressing change 3-Epidural analgesic 4-Transcutaneous electrical nerve stimulation (TENS) 5-Distraction 6-Premedication

1, 5, 6 Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment.Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible.

Question 13 of 14 Which laboratory results does the nurse expect to decrease in a client who has untreated HIV-III (AIDS)? (Select all that apply.) Select all that apply. 1-Total white blood cell count 2-Viral load 3-CD8+ T-cell 4-HIV antibodies 5-CD4+ T-cell 6-Lymphocytes

1, 5, 6 The immune target of HIV is the CD4+ T-cell. With infection of this cell, its circulating levels decline and immune function is reduced over time. As a result, total white blood cell counts decrease and circulating lymphocytes decrease. CD8+ T-cell counts are unaffected. HIV antibodies and viral load increase.

Question 9 of 19 A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? 1-"Please allow the client to push the button when needed." 2-"Please don't touch any equipment in the client's room." 3-"Thank you. I am sure the client appreciated that." 4-"The client is asleep and is not in pain."

1-"Please allow the client to push the button when needed." The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues.Telling the family member not to touch any equipment in the client's room is not only nonspecific, but it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.

Question 5 of 19 A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? 1-Administer the pain medication as requested. 2-Withhold the pain medication. 3-Decrease the client's standard pain medication dose. 4-Give the client a placebo and monitors the outcome.

1-Administer the pain medication as requested. The nurse will administer the pain medication as requested. Both types of persistent (chronic) pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's objective symptoms when managing chronic cancer pain.The nurse would not decrease pain medication under the assumption that, because the client does not exhibit signs of pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication unless the client is medically unstable and the nurse would contact the health care provider.

Question 15 of 19 Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? 1-Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care 2-Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief 3-Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable 4-Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain

1-Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care would be assigned to the LPN/LVN. LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes.Assessments and client education are not within the LPN/LVN scope of practice.

Question 9 of 11 The nurse is using a common scale to grade a client's muscle strength. The client is able to complete range of motion (ROM) only with gravity eliminated. Which grade does the nurse document in this client's record? 0 3 1 2

2 The nurse documents a grade of two (2) for this client because it indicates poor muscle strength. The client can complete ROM only with gravity eliminated.Grade zero (0) indicates no evidence of muscle contractility. Grade one (1) indicates trace muscle strength and shows that the client has no joint motion and slight evidence of muscle contractility. Grade three (3) indicates fair muscle strength, where the client can complete ROM against gravity.

Question 20 of 20 The nurse is caring for a mechanically ventilated client who has an organ donation card and a severe traumatic brain injury. Which assessment findings indicate that the client will be declared as brain dead? (Select all that apply.) Select all that apply. 1-Hypothermia 2-Absence of brainstem reflexes 3-Apnea not due to drugs or diseases 4-Irreversible loss of consciousness 5-Hypotension

2, 3, 4 These three assessment findings meet the American Academy of Neurology guidelines for brain death. However, ancillary imaging tests may be used to validate these findings.

Question 17 of 20 The nurse is teaching a group of older adults about stroke prevention. Which risk factors for stroke would the nurse include? (Select all that apply.) Select all that apply. 1-Female gender 2-High blood pressure 3-Previous stroke or transient ischemic attack (TIA) 4-Smoking 5-Use of oral contraceptives

2, 3, 4, 5 Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

Question 10 of 11 The nurse is performing a focused musculoskeletal assessment on an older female client. What assessment findings associated with aging would the nurse expect? (Select all that apply.) Select all that apply. 1-Scoliosis 2-Kyphosis 3-Decreased range of motion 4-Muscle atrophy 5-Osteoarthritis 6-Widened gait

2, 3, 4, 5, 6 All of these assessment findings are associated with aging, especially in women, except for scoliosis. Scoliosis is a lateral curvature of the spine that is usually diagnosed in children and adolescents.

Question 29 of 29 Which changes in ADLS are most appropriate for the nurse to suggest to a client newly diagnosed anemia about conserving energy? Which instructions would the nurse give to the client? (Select all that apply.) Select all that apply. 1-"Cluster your care together to get through them more quickly." 2-"Accept help from others when you feel especially tired." 3-Take a complete bath or shower daily to promote relaxation." 4-"Stop activity when you feel short of breath or palpitations are present." 5-"Try eating four to six small, easy-to-eat meals daily instead of three larger ones." 6-Sit instead of standing for some tasks such as cutting vegetables."

2, 4, 5, 6

Question 21 of 21 A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 m) fall 2 days ago. The nurse plans to assess the client for which potential complications? (Select all that apply.) Select all that apply. 1-Urinary tract infection (UTI) 2-Acute compartment syndrome (ACS) 3-Fat embolism syndrome (FES) 4-Osteomyelitis 5-Heart failure

2,3,4 ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures.Heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

Question 14 of 19 The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? 1-"Yes, this is a valuable way for all of you to make needed adjustments." 2-"Let's ask your father about your request." 3-"No, his pain relief is more important than your concerns." 4-"I will ask his oncologist about your question."

2- "Let's ask your father about your request." The nurse will respond by indicating that the client's desires about analgesia are the most important consideration in this scenario, and so he would be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker.Although the health care provider might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal.

Question 12 of 19 The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? 1-3:30 p.m. 2-4:30 p.m. 3-4:00 p.m. 4-7:00 p.m.

2- 4:30 p.m. The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client.It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.

Question 24 of 28 Which assessment finding in a client who has had a lobectomy and placement of a chest tube 8 hours ago requires immediate follow-up by the nurse? Report of pain at the chest tube insertion site 3-cm area of red drainage on the incisional dressing 200 mL red drainage from chest tube over 2 hours Client sleepy but able to be aroused

200 mL red drainage from chest tube over 2 hours The nurse must immediately report 200 mL of red drainage over a 2-hour span of time. Chest drainage should slow down after surgery. More than 70 mL of drainage/hour must be reported to the surgeon.A client who had a surgical procedure, anesthesia, and analgesia may spend most of the day sleeping, but should be able to be aroused. A small amount of drainage after surgery is expected, such as a 3-cm area. The nurse should circle the area and report increasing amounts to the surgeon. Pain at the surgical and chest tube insertion site is expected and will be man-aged by the nurse in collaboration with the provider after airway, breathing, and circulation are ensured.

Question 12 of 12 The nurse is teaching a client how to perform breast self-examination (BSE). Which of these techniques does the nurse include in the teaching session? (Select all that apply.) Select all that apply. 1-Perform the self-examination 1 week before a menstrual period. 2-Teach to keep her arm by her side while performing the examination. 3-Remind that a clinical breast examination and mammography are still recommended. 4-Use light, medium, and then firm pressure to feel the tissue. 5-A bra can be left in place during the self-examination.

3, 4 The nurse will teach the client that clinical breast examination and mammography are still recommended for detection of breast cancer, versus reliance on self-breast examination. The client will use light, medium, and then firm pressure to feel the breast tissue.For better visualization, the arm must be placed over the head. The client needs to remove the bra for the examination. The self-examination should be done 1 week after—not before—a menstrual period.

Question 12 of 14 Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) Select all that apply. 1-Oral contraceptives taken consistently 2-Natural-membrane condoms for genital and anal intercourse 3-Latex gloves for finger or hand contact with the vagina or rectum 4-Latex dental dam genital and anal intercourse 5-Water-based lubricant with a latex condom 6-Latex or polyurethane condoms for genital and anal intercourse

3, 4, 5, 6 Latex or polyurethane condoms, dental dams, and gloves for genital and anal intercourse can prevent HIV from contacting susceptible tissues. Water-based lubricants must be used instead of oil-based or greasy lubricants because these can easily rub holes in the condoms. Oral contraceptives provide no protection against transmission of HIV or any other sexually transmitted infection.

Question 11 of 19 A 44-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen (500 mg) every 8 hours." How does the nurse respond? 1-"More acetaminophen is needed to provide effective pain relief for you." 2-"You will need to have routine blood draws to monitor clotting time." 3-"That is the appropriate dose of acetaminophen for your pain." 4-"Aspirin would be a better, more effective choice for your pain relief."

3- "That is the appropriate dose of acetaminophen for your pain." In the healthy adult, a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults. The dose is appropriate; more is not indicated or advised.Acetaminophen is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding.

Question 13 of 19 The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? 1-Perform a cognitive assessment on the client. 2-Call the care provider for a change in the medication order. 3-Administer a dose of naloxone 0.4 mg slow IV push. 4-Change the order to every 6 hours rather than every 4 hours.

3- Administer a dose of naloxone 0.4 mg slow IV push. The priority nursing action is to administer a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone 0.4 mg over a 2-minute time period to reverse the action of the opioid analgesic.The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the health care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.

Question 8 of 19 A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? 1-PO 2-Rectal 3-IV 4-Transdermal

3- IV The intravenous route is the best choice for fast relief of nausea and pain.Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.

Question 10 of 19 The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? 1-"Older adults usually believe that pain is irrelevant and is to be expected." 2-"Older adults are at a very high risk for undertreated pain." 3-"Older adults typically believe that expressing pain is acceptable." 4-"I always assess older adults for present pain."

3-"Older adults typically believe that expressing pain is acceptable." The charge nurse will need to provide further education to the new nurse regarding the statement, "Older adults typically believe that expressing pain is acceptable."Older adults typically do not believe that expressing pain is acceptable. Many older adults believe that pain is irrelevant and is "just part of getting older."As a result, many older adults are at great risk for undertreated pain. In addition, some health care providers have outdated beliefs about older adults' pain sensitivity, tolerance, and ability to take opioids.

Question 1 of 19 The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? 1-Assess the level of pain. 2-Administer pain medication. 3-Accept the client's report of pain. 4-Call the health care provider for a medication order.

3-Accept the client's report of pain. The nurse's primary role in pain management is to advocate for the client by accepting reports of pain, as such, this is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain.Administering pain medication, assessing the pain level, and calling the provider are responses to the first response which is accepting that the client is in pain.

Question 4 of 19 A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? 1-Tolerance 2-Pseudoaddiction 3-Physical dependence 4-Addiction

3-Physical dependence The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms.Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.

Question 11 of 11 Which actions are priorities for the nurse to perform to prevent harm after a client has a bone marrow biopsy performed? (Select all that apply.) Select all that apply. 1-Sending the specimen to the laboratory 2-Measuring temperature 3-Advising the client to not drive for 24 hours 4-Inspecting the site for ecchymosis 5-Applying pressure to the biopsy site 6-Instructing the client to avoid vigorous activity

4, 5, 6 Prevention of harm after a bone marrow biopsy is to minimize postprocedure bleeding. The nurse applies pressure for 10 minutes to the site and evaluates for ecchymosis around the site. The client is instructed to avoid activities that could cause trauma to the procedure site.Measuring temperature does not prevent bleeding and is not a priority after bone marrow biopsy. Sending specimens to the laboratory is important but does not prevent harm. Unless the client had a sedative or anesthesia for the procedure, driving is not restricted.

Question 28 of 28 For which side effects of radiation therapy will the nurse prepare the client who has stage II lung cancer? (Select all that apply.) Select all that apply. 1-Scalp alopecia 2-Increased risk for infection 3-Increased bruising 4-Dry, peeling skin on the chest 5-Difficulty swallowing 6-Fatigue

4, 5, 6 Radiation therapy causes most side effects in the tissues within the radiation path. In this case the skin of the chest and the esophagus are likely to be affected, resulting in dry, peeling skin and reduced peristaltic movement of the esophagus, which makes swallowing more difficult. In addition to these local side effects, radiation therapy induces extreme fatigue.The most active blood cell forming bone marrow areas in adults are minimally affected by radiation therapy to the chest. Therefore, white blood cell numbers, red blood cell numbers, and platelet numbers remain normal. The client is not at increased risk for infection or bruising. The client's scalp hair is not in the radiation path and will be unaffected by this therapy.

uestion 27 of 29 Which lab values would the nurse expect to see for a client with sickle cell disease? (Select all that apply.) Select all that apply. 1-Decreased total bilirubin 2-Increased hematocrit 3-Decreased iron levels 4-Increased reticulocyte count 5-Elevated total white blood cell count 6-80% hemoglobin S

4,5, 6 The hemoglobin S levels in a client with SCD are always elevated because it is the basis of the disease. The reticulocyte is elevated because anemia of long duration stimulates the bone marrow to produce more red blood cells (RBCs) and release them at the less mature stage. The WBC count is usually high in clients with SCD related to chronic inflammation caused by tissue hypoxia and ischemia.Iron levels and bilirubin levels are increased in SCD because they are released from the damaged RBCs. The hematocrit is lower because of RBC loss.

Question 1 of 14 Which part of the HIV infection process is disrupted by the antiretroviral drug class of nucleoside reverse transcriptase inhibitors (NRTIs)? 1-Clipping the newly generated viral proteins into smaller functional pieces 2-Activating the viral enzyme "integrase" within the infected host's cells 3-Binding of the virus's gp120 protein to one of the CD4+ coreceptors 4-Forming counterfeit bases that prevent DNA synthesis and viral replication

4-Forming counterfeit bases that prevent DNA synthesis and viral replication The NRTIs have a similar structure to the four bases of DNA, making them "counterfeit" bases. They fool the HIV enzyme reverse transcriptase into using these counterfeit bases so that viral DNA synthesis and replication are suppressed.

Question 21 of 28 The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 62 year old with chronic obstructive pulmonary disease (COPD) being discharged with an oxygen saturation of 90% A 42 year old with lung cancer who needs an IV antibiotic administered before going to surgery A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min A 52 year old with end-stage pulmonary fibrosis and an oxygen saturation of 89%

A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min The client with CF with an elevated temperature and respiratory rate of 38 breaths/min is exhibiting signs of an exacerbation/infection and needs to be assessed first.The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications. This may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal and expected for a client with end-stage pulmonary fibrosis. There is no indication that this client is in distress. The nurse can delegate administration of the IV antibiotic to another RN, or it could be administered before the client is brought to the operating room.

Question 9 of 29 With which client will the nurse be most alert for the development of glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia? A 55-year-old man who had a myocardial infarction 5 years ago. A 28-year-old man Saudi Arabia whose mother had the disorder. A 55-year-old woman who had a partial gastrectomy for stomach cancer last year. A 28-year-old woman from Ireland whose father had the disorder.

A 28-year-old man Saudi Arabia whose mother had the disorder. The disorder is inherited as an X-linked recessive trait and is much more prevalent in men of Mediterranean descent. Men with the gene mutation only one X chromosome and the mutation is expressed as dominant. Women have two X chromosomes and if one X has the mutation, there are sufficient cells with a healthy X chromosome to avoid manifestations of the disease. The affected mother would have passed either of her affected X chromosomes to her son.

Question 3 of 18 For which hypersensitivity situation will the nurse prepare a client for management with plasmapheresis? A 35 year old with drug-induced hemolytic anemia A 30 year old with poison ivy lesions on 60% of the body A 25 year old with penicillin-induced anaphylaxis A 40 year old with angioedema and tongue swelling

A 35 year old with drug-induced hemolytic anemia Drug-induced hemolytic anemia is a type II hypersensitivity reaction in which the body makes autoantibodies directed against red blood cells that have foreign proteins from the drug attached to them. In this type of reaction, the autoantibody binds to red blood cells, forming immune complexes that destroy red blood cells along with the attached protein. Management starts with discontinuing the offending drug and, performing plasmapheresis (filtration of the plasma to remove specific substances) to remove the formed autoantibodies. Plasmapheresis is not beneficial with other types of hypersensitivity reactions.

Question 15 of 17 The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 45 year old with a peritonsillar abscess who can no longer swallow. A 65 year old with rhinosinusitis and a fever of 102° F (38.9° C) A 25 year old who had endoscopic sinus surgery 8 hours ago. A 55 year old with tuberculosis who is standard first-line therapy.

A 45 year old with a peritonsillar abscess who can no longer swallow. The client at greatest risk for a respiratory complication is the one with a peritonsillar abscess who is no longer able to swallow. This abscess is enlarging and could completely obstruct the client's airway. Rapid assessment is needed immediately to determine the degree of intervention urgency. No other client listed has indications of the need for potential emergency action.

Question 13 of 17 Which client will the nurse recognize as being at risk for bacterial sinusitis? A 45 year old with multiple dental caries and infected gums A 25 year old with seasonal pollen allergies A 65 year old who has a poor gag reflex after a stroke A 35 year old with a 20-pack-year smoking history who now vapes

A 45 year old with multiple dental caries and infected gums Dental infections of any kind greatly increase the risk for bacterial sinus infection. Smoking and vaping do not increase the risk for sinusitis although they do increase the risk for head and neck cancers. Allergies alone do not increase the risk. A poor gag reflect increases the risk for aspiration pneumonia but not sinusitis.

12 of 29 Which client will the nurse identify as having the greatest risk for development of acute leukemia? A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease. A 20 year old with cystic fibrosis who has been on continuous enzyme replacement therapy since infancy. A 55 year old with diabetes mellitus type 1 who has received insulin injections for 43 years. A 38 year old who has used combination oral contraceptives without a break for 15 years.

A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease. Cyclophosphamide is a cytotoxic agent that damages bone marrow and has been known to induce leukemia.Diabetes, long-term use of oral contraceptives, and enzyme replacement therapy for cystic fibrosis do not increase the risk for development of any type of leukemia

Question 23 of 29 Which client will the nurse monitor most closely for development of a febrile transfusion reaction? A 50 year old receiving multiple transfusions for severe hemorrhage A 60 year old receiving an intraoperative autologous transfusion A 40 year old receiving two units of fresh-frozen plasma A 70 year old receiving a rapid transfusion

A 50 year old receiving multiple transfusions for severe hemorrhage Febrile transfusion reactions, not related to infection or transfusion with contaminated blood, occur most often in the client with anti-WBC antibodies, which can develop when receiving multiple transfusions.The risk for febrile transfusion reactions is not age-related or related to the rate of transfusion delivery. Plasma transfusions do not have an increased risk for a febrile response. Febrile responses are nonexistent with autologous transfusions.

Question 17 of 29 Which observation by the home care nurse when visiting a client who had a stem cell transplant 2 months ago requires immediate action? The spouse is preparing a lettuce salad for lunch. The client's platelet count remains below 100,000 cells/mm3 (100 × 109/L). A dog is the household pet. A grandchild is visiting after receiving a measles, mumps, and rubella vaccine.

A grandchild is visiting after receiving a measles, mumps, and rubella vaccine. Although the client is discharged to home when the white blood cell count, especially the neutrophil count, is high enough to prevent general infections. However, antibody-mediated immunity takes at least a year to redevelop. During that time, exposure to anyone who has received a recent live-virus vaccination increases the client's risk for developing the disease caused by the live virus.By the time the client is discharged to home, there are no dietary restrictions beyond those recommended for all people. Dogs are not considered an infectious health hazard. Platelets usually remain low for months after stem cell transplantation.

Question 5 of 16 A client was recently diagnosed with osteoarthritis and asks the nurse which over-the-counter drug would be the best to take? What would the nurse's recommendation be? Ibuprofen Acetaminophen Tramadol Gabapentin

Acetaminophen Several major medical organizations, including the American Pain Society and OARSI committee recommend acetaminophen as the primary drug of choice.

Question 12 of 20 The nurse is planning desired outcomes for rehabilitation of a client with traumatic brain injury (TBI). What is the most important outcome for this client? Preventing skin breakdown Preventing further injury Achieving the highest level of functioning Increasing cerebral perfusion

Achieving the highest level of functioning The most important nurse's desired or expected outcome for the client having rehabilitation after TBI is to help him or her achieve the highest level of functioning possible.Prevention of injury from falls or skin breakdown, infection, or further impairment of cerebral perfusion is part of ongoing care for this client.

Question 17 of 21 A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? Surgical repair of the rotator cuff Patient-controlled analgesia with morphine Activity limitations for the affected arm Prescribed exercises of the affected arm

Activity limitations for the affected arm The immediate conservative treatment for this client is to limit activity in the injured arm.Surgical intervention is not considered immediate conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

Question 6 of 17 Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? High fever Profound bradycardia Acute confusion Coughing spasms

Acute confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Tachycardia is triggered by hypoxia, not bradycardia.

Question 5 of 17 Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? Administer oxygen to prevent hypoxemia and atelectasis. Administer the prescribed bronchodilator therapy to decrease bronchospasms. Encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration. Maintain semi-Fowler position to facilitate breathing and prevent further fatigue.

Administer the prescribed bronchodilator therapy to decrease bronchospasms. Although all actions are helpful and important, bronchodilator therapy is performed first to increase the size of the airways to improve clearance.

Question 22 of 22 The nurse is caring for a client who has Parkinson disease (PD). What assessment findings would the nurse expect? (Select all that apply.) Select all that apply. 1-Stooped posture 2-Masklike facial expression 3-Drooling at times 4-Shuffled gait 5-Dysarthria 6-Muscle rigidity

All of these signs and symptoms commonly occur in clients who have PD.

Question 4 of 22 A client visits the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. What action would the nurse take next? Turn on the lights for a neurologic assessment. Assess the client's vital signs. Remove the cloth because it can harbor microorganisms. Allow the client to remain undisturbed.

Allow the client to remain undisturbed. The next action by the nurse is to allow the client to remain undisturbed. The client may be able to alleviate pain by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she would remain undisturbed until awakening.Assessing the client's vital signs, although important, will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it would be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

Question 21 of 29 The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 32 year old with pernicious anemia who needs a vitamin B12 injection A 40 year old with iron deficiency anemia who needs an iron dextran infusion A 67 year old with acute myelocytic leukemia with petechiae on both legs An 81 year old with thrombocytopenia and an increase in abdominal girth

An 81 year old with thrombocytopenia and an increase in abdominal girth The nurse needs to first assess the 81-year-old client with thrombocytopenia and an increase in abdominal girth. An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage, and warrants further assessment immediately.The 32 year old with pernicious anemia, the 67 year old with acute myelocytic leukemia, and the 40 year old with iron deficiency anemia do not have indications of any acute complications and their assessments can be delayed.

Question 7 of 18 The nurse administered a prescribed dose of natalizumab for a client who is diagnosed with multiple sclerosis. For what adverse drug event will the nurse assess as the priority for this client within the first hour after administration? Anaphylactic or allergic reaction Elevation of liver enzymes Infection Neurologic changes such as confusion

Anaphylactic or allergic reaction While all of these adverse drug events are associated with natalizumab, the one that can occur within the first hour after administration is anaphylaxis. Infection can also cause fatality if it becomes systemic or the client develops progressive multifocal leukoencephalopathy (PML) which can cause mental and other neurologic changes.

Question 1 of 22 The nurse is assessing a client who was diagnosed with Alzheimer disease (AD) and notes the client has difficulty finding the correct words at times during conversation. What communication alteration would the nurse document? Aphasia Apraxia Anomia Agnosia

Anomia Anomia is the inability to find words for objects, places, and events, and is a common assessment finding in clients with early AD. Aphasia is a general problem with speaking, understanding, to both. Apraxia is the inability to use an object correctly and agnosia, a later AD finding, is a lack of sensory comprehension.

Health Promotion and Maintenance Which supplement will the nurse recommend to a client who wishes to enhance eye health? A. Lutein* B. Vitamin D C. Magnesium D. Saw palmetto

Answer: A Rationale: Lutein, zeaxanthin, and beta carotene have been shown to enhance eye health. Vitamin D, Magnesium, and saw palmetto are not associated with enhancement of eye health. Cognitive Level: Application Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation/Therapeutic Nursing Intervention

Health Promotion and Maintenance When caring for a 28-year old healthy client, how frequently does the nurse recommend a clinical breast examination (CBE)? A. Every 3 years B. At each annual physical C. Not until age 30 as the risks are low D. To begin at age 40 when risks increase

Answer: A Rationale: The American Cancer Society recommends that women age 20-29 receive a clinical breast examination (CBE) every 3 years, unless the client is at a higher risk for development of cancer. Cognitive Level: Understanding Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

Safe and Effective Care Environment When reviewing the laboratory results for a client in the emergency department, which finding does the nurse report immediately to prevent harm? A. International Normalized Ratio (INR) is 5.2 B. Platelet count of 180,000/mm3 (180 x 109/L) C. Hematocrit of 27% (0.27 volume fraction) D. Reticulocyte value of 4%

Answer: A Rationale: While many of the values are abnormal, the INR is greatly increased indicating that the client is a high risk for harm from excessive bleeding even without trauma. The elevated reticulocyte value 2% does not meet a value that is critical but does support the possibility that bleeding is already occurring somewhere. This client has a low hematocrit and is anemic. The platelet values are normal. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

17-3. The client at stage HIV-III (AIDS) reports a large painful "pimple" in the perineal area. How does the nurse respond to this report? A. Inspect the area for indications of infection. B. Ask the client whether this causes pain during intercourse. C. Remind the client to clean the area carefully after every stool. D. Explain that this is a small matter and document the report as the only response.

Answer: A Rationale: With the greatly reduced immunity response of AIDS, even an infected "pimple" can lead to cellulitis and systemic infection. The nurse must determine the degree of infection and inform the immunity health care provider so proper interventions can be initiated to prevent a more serious infection. Cognitive Level: Applying or higher Client needs category: Physiological Integrity Nursing Process Step: Assessment

Physiological Integrity The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? A. "Persistent pain is a warning in my body that alerts the sympathetic nervous system." B. "Acute pain has a quick onset and is usually isolated to one area of my body." C. "My frozen-shoulder causes musculoskeletal or somatic pain." D. "Nociceptive pain follows a normal and predictable pattern."

Answer: A Rationale: Acute pain, not persistent (chronic) pain serves as a warning signal to alert the sympathetic nervous system. Persistent or chronic pain serves no biologic purpose. The other answer options are all correct and do not require additional teaching. Cognitive Level: Application Integrative Process: Teaching/Learning

1. A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the healthcare provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."

Answer: A Rationale: Gabapentin is commonly used for neuropathic pain. The most common side effect is dizziness which will generally decrease with use. It is not appropriate to tell the client to stop taking the medication and it is unlikely that the neuropathic pain or another medication is causing the dizziness. Cognitive Level: Application

Physiological Integrity During a client's neurologic assessment, the nurse finds that the client who is arousable only with vigorous or painful stimulation How does the nurse document this client's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Alert

Answer: A Rationale: The client who is stuporous is only arousable with vigorous stimulation. The lethargic client (Choice B) is drowsy but is easily awakened. The comatose client (Choice C) is unconscious and not arousable.

Physiological Integrity Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.

Answer: A Rationale: The nurse will document that the client reports acute pain at the surgical site. Acute pain is commonly associated with surgical procedures and lasts for a short duration. The client does not demonstrate persistent or chronic pain, nor is the pain neuropathic in nature. Acute pain that is poorly controlled and lasts longer than it should can lead to chronification of pain. Cognitive Level: Apply Integrative Process: Nursing Process

1. The nurse is teaching a client who has osteopenia about alendronate. Which statement by the client indicates a need for further teaching? A. "I will take this drug at night to prevent nausea." B. "I need a dental checkup before taking the drug." C. "I need to sitting up for 30 minutes after taking the drug." D. "I will drink plenty of water after I take the drug."

Answer: A Rationale: This drug is a bisphosphonate and can cause esophageal irritation or damage. Therefore, it is taken on an empty stomach in the morning followed by plenty of water while sitting or standing upright for at least 30 minutes.

1. The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness

Answer: A Rationales: Osteoarthritis indicates a joint disease in which bone cartilage degenerates causing joint pain and secondary inflammation (Choice A). The client often experiences muscle stiffness which is not as uncomfortable as joint pain (Choice D). Clients who have severe osteoarthritis are not necessarily dependent in ADLs or at risk for falling (Choice B and C).

Physiological Integrity A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

Answer: A Rationales: The client wearing a halo device for a complete spinal cord injury cannot move his or her legs of feet which makes Choice C an incorrect response. An oxygen saturation of 95% on room air is normal and does not require a report to the primary health care provider. Choice B is incorrect because a halo device is not the same as a hard cervical collar. Instead, Choice A is correct because the halo is put in place with four pins into the skull which can become infected. This change needs to be reported to the primary health care provider.

Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse? A. "I'm glad I can keep eating protein like red meat." B. "I'll try to walk at least 20-30 minutes each day." C. "I'm going to talk to my doctor about a weight loss plan." D. "I plan to include more fruits and vegetables in my diet."

Answer: A Rationales: The client who has had a TIA needs to modify his or her lifestyle to promote health and prevent a stroke. Choices B, C, and D all indicate that the client realizes the need to exercise more, lose weight, and eat a healthy diet. Choice A shows that the client believes that red meat is also healthy but it contains high levels of saturated fat which can clog arteries and decrease Perfusion.

Physiological Integrity A client has a new synthetic leg cast for a right fractured tibia. What health teaching will the nurse include before discharge to home? Select all that apply. A. "Elevate your right leg as often as possible to reduce swelling." B. "Report increased pain or burning sensation under your cast." C. "Use ice on the affected leg for the first 24-36 hours." D. "Do not bear weight on the affected leg until instructed to do so." E. "Do not cover the cast when you are in bed; keep it open to air to dry."

Answer: A, B, C, D Rationales: Ice and elevation of the affected leg can decrease swelling which is needed to prevent pressure from the cast (Choices A and C). The purpose of the cast is to immobilize the foot such that the tibia can heal. Therefore, no weight-bearing is allowed (Choice D). Increased pain and burning are indicators that the cast may be too tight and the skin under the cast may break down. These changes need to be reported promptly to the primary health care provider (Choice B). A synthetic cast dries immediately (unlike a plaster cast) and therefore Choice E is an incorrect response.

Health Promotion and Maintenance A nurse is performing a musculoskeletal assessment on an older adult. What normal physiologic changes of aging does the nurse expect? Select all that apply. A. Muscle atrophy B. Slowed movement C. Kyphosis D. Arthritis E. Widened gait F. Decreased joint range-of-motion

Answer: A, B, C, D, E, F Rationale: As listed in the Older Adult Health Considerations box, all of these assessment findings are common physiologic changes associated with the aging process

Physiological Integrity Which assessment data are factors increase the risk for osteoporosis for an older Euro-American female? Select all that apply. A. Drinks 3-4 glasses of wine each day B. Sits at a desk all day in her job C. Smokes a pack of cigarettes a day D. Takes a mile-long walk 5 days a week E. Takes 1000 mg acetaminophen for arthritis daily F. Weighs 110 pounds (50 kg)

Answer: A, B, C, F Rationales: Regular exercise helps to prevent or slow osteoporosis; Choice D suggests that the client includes exercise in her life style. Acetaminophen is not a drug that causes bone loss, so Choice E is not a risk factor. However, excessive alcohol (Choice A), sedentary job (Choice B), smoking (Choice C), and being a petite, thin woman (Choice F) increases the client's risk for osteoporosis.

Health Promotion and Maintenance The nurse performs an initial neurologic assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all that apply. A. Decreased coordination B. Hearing loss C. Long term memory loss D. Recent memory loss E. Decreased balance control

Answer: A, B, D, E Rationale: All of the choices can occur as a result of normal aging except for long term memory. Many older adults often reminisce about their earlier years and life events but often cannot recall what occurred the day before.

Physiological Integrity A client had a left noncemented posterolateral total hip arthroplasty 2 days ago. Which statements will the nurse include in health teaching for the client? Select all that apply. A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." C. "Be sure to cross your legs to be more comfortable in a chair." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."

Answer: A, B, D, E Rationales: The client who had a posterolateral surgical approach is at risk for hip dislocation and should be taught NOT cross his or her legs which cause adduction. Therefore, Choice C is an incorrect response. All clients having a total hip arthroplasty are at risk for clotting and leg exercises can help reduce that risk (Choice A). Taking deep breaths and using incentive spirometry are important for all surgical clients to prevent pneumonia or ateletasis (Choice B). Choice D is important for client teaching because these signs and symptoms may indicate hip dislocation. Clients with noncemented implants should not initially bear weight on the affected leg (Choice E

Physiological Integrity The nurse is preparing to teach a client who has been prescribed a levodopa-carbidopa preparation for Parkinson's disease. What health teaching will the nurse include for the client and family? Select all that apply. A. "Move slowly when changing positions from sitting to standing." B. "Take your medication after meals to help prevent nausea." C. "Report any hallucinations that the client may have." D. "Note any changes in mental or emotional status." E. "Pay attention to whether your tremors improve or worsen."

Answer: A, C, D, E Rationales: Choice B is an incorrect response because levodopa drugs should be taken with meals to help with absorption. The other choices are all correct.

1. The nurse reassesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? Select all that apply. A. Blood pressure increase to 196/100 B. Heart rate of 88 beats per minute C. Respiratory rate of 22 breaths per minute D. New onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently F. Urine output of 360 mL since admission

Answer: A, D, E Rationale: The client's increase in blood pressure, intense headache, and decreasing level of consciousness implies that the client is most likely experiencing either an increase in intracranial pressure or is presenting with stroke symptoms. In either case, the nurse would report these new findings (Choices A, D, E) to the primary health care provider or Rapid Response Team. The client's heart and respiratory rate are within normal limits (Choices B and C), and the client is producing an adequate amount of urine given the minimum output should be at least 30 mL/hour.

Physiological Integrity Which assessment findings will the nurse expect for the client with early-stage rheumatoid arthritis? Select all that apply. A. Joint inflammation B. Subcutaneous nodules C. Severe weight loss D. Fatigue E. Thrombocytosis F. Anorexia

Answer: A, D, F Rationales: Subcutaneous nodules (Choice B), severe weight loss (Choice C) and thrombocytosis (Choice E) are all commonly seen in clients with late-stage, advanced RA. Joint inflammation (Choice A) is common in early disease and often occurs with client reports of fatigue and anorexia (Choices D and F).

Psychosocial Integrity The nurse assesses a client with a diagnosis of early-stage Alzheimer's disease. Which assessment findings would the nurse expect for this client? Select all that apply. A. Forgetfulness B. Hallucinations C. Wandering D. Urinary incontinence E. Difficulty eating F. Personality changes

Answer: A, F Rationales: Early-stage AD assessment findings are mild and often evident through a client and/or family history (Choice A and F). Psychotic behaviors, such as hallucinations (Choice B), wandering (Choice C); incontinence (Choice D); and becoming dependent in ADLs, such as eating (Choice E); are assessment findings that commonly occur in clients with middle-stage or moderate AD.

28-1. A nurse interviewing an 82-year-old somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

Answer: B Rationale: A is incorrect because each year's influenza vaccine is composed of some different strains of antigen and is not really a booster. C is incorrect because the older vaccination may not contain the viral antigens most likely to cause influenza this season. The nasal mist vaccination is not recommended for anyone over age 49 years. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

Physiological Integrity Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the healthcare provider? A. Temperature of 99°F B. Tingling sensation in the right arm C. Impaired range of motion in the right arm D. Drainage of 20 mL collected over 24 hours

Answer: B Rationale: A tingling sensation in the affected arm can indicate the onset or presence of lymphedema. The nurse will report this finding to the healthcare provider. All other findings are expected in the client who has had a right mastectomy. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Implementation

17-1. Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

Answer: B Rationale: Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attach to the CD4 receptor and have its gp41 bind to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

Health Promotion and Maintenance Which dietary change does the nurse suggest for the client who has esophageal candidiasis? A. Avoid drinking alcoholic beverages. B. Eat soft, cool food such as pudding and smoothies. C. Limit your intake of fluid to no more than 1 liter daily. D. Increase your intake of cooked leafy green vegetables.

Answer: B Rationale: Esophageal candidiasis not only makes food "taste funny" but it is painful and irritating. Eating soft food and liquids is less likely to irritate the esophagus further. Cooler and cold food can reduce discomfort by numbing sensations somewhat. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Implementation

Health Promotion and Maintenance A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? A. "This year I will get the pneumonia vaccination in addition to a flu shot." B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." C. "Maybe drinking a supplement will help me retain weight and have more energy." D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."

Answer: B Rationale: Many clients mistakenly believe that performing no exercise will reduce COPD symptoms. Exercising did not cause the increase in disease severity, but inactivity can by making muscles weaker, including the muscles used in breathing. Exercise for conditioning and pulmonary rehabilitation can improve function and endurance in clients with COPD, even those at a GOLD 3 class. The client should receive the pneumonia vaccination and should have an annual influenza vaccination. Drinking supplements can add calories to the diet and may have a positive effect on both weight and energy levels. Using a spacer with an MDI is the preferred method for this type of drug delivery system and can improve the likelihood that the drug will reach the lower airways. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention

27-5. A client newly diagnosed with Stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in client's whose lung cancer has metastasized not for early stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon."

Answer: B Rationale: Pembrolizumab is a type of immunotherapy that helps control lung cancer but does not cure it. It is approved only for use in clients whose cancers are positive for PD-L1 or 2 and have metastasized to the extent that they are at Stage IV. Although this client's cancer cells may have been tested for PD-L levels, his cancer stage does not qualify for the therapy. His best chances for cure at a stage I is complete tumor removal by surgery. Although C sounds like a correct response, it sounds very judgmental. The nurse can give accurate information to the client about the immunotherapy drug. It is not necessary to keep the information from him until he speaks to the oncologist or the surgeon. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention

Health Promotion and Maintenance When caring for four clients, which individual does the nurse identify at the highest risk for development of breast cancer? A. 33-year-old male with gynecomastia and obesity B. 45-year-old female whose mother has breast cancer C. 60-year-old male whose father died from colon cancer D. 72-year-old female who was treated for breast cancer 3 years ago

Answer: B Rationale: The client who is 45 years old with a first degree relative who has breast cancer is at the highest risk for development of breast cancer. Cognitive Level: Application Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Assessment/Evaluation

18-3. Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

Answer: B Rationale: The drug is a monoclonal antibody given parenterally. It is composed of some foreign proteins and has been known to cause anaphylaxis even 2 hours after administration. Thus, it must be given by a health care professional in a setting capable of handling an anaphylactic emergency. It must not be self-administered. The drug is not available in tablet form. Belimumab does not induce drowsiness and can be administered at any time of day. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

36-1. Which statement regarding erythrocytes is true? A. Reticulocytes represent the final stage of mature erythrocytes. B. The lack of a nucleus in a mature erythrocyte increases its life span. C. Each erythrocyte can carry up to a maximum of four molecules of oxygen. The main trigger for erythrocyte production is the secretion of thrombopoietin

Answer: B Rationale: The lack of a nucleus gives the mature erythrocyte a biconcave disk shape that makes it flexible, which allows it to squeeze through small blood vessels and remain intact. Reticulocytes are a less mature form of erythrocytes. Each hemoglobin molecule can carry up to four molecules of oxygen and each erythrocyte contains hundreds of thousands of hemoglobin molecules. The trigger for erythrocyte production is the secretion of erythropoietin. Thrombopoietin triggers platelet production. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: NA

Safe and Effective Care Environment A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and re-assess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.

Answer: B Rationale: The low oxygen saturation and the client's confusion suggests hypoxia and a possible worsening of the client's condition. The increased respiratory rate supports this possibility. Increasing the oxygen flow rate and re-assessing in 5 minutes helps the nurse to determine whether the hypoxia responds to increased oxygen. If more oxygen is going to help, it will do so quickly. Even if the oxygen saturation increases with more oxygen, the health care provider needs to be informed of these events urgently. The incentive spirometer is not likely to be performed correctly with a confused client and would not immediately improve the client's hypoxia. Increasing the flow rate of the antibiotic also is not going to help the hypoxia immediately. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment/Evaluation

Safe and Effective Care Environment The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling. C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. D. No action is needed because these responses are normal for the first post-op day after lobectomy.

Answer: B Rationale: The tip of the chest tube could be lying against tissue, becoming occluded and causing the burning pain. Repositioning the client can change the position of the chest tube tip, relieving the pain and allowing drainage to continue. A is incorrect because although no bubbling means no drainage and could lead to a tension pneumothorax, troubleshoot quickly before call the rapid response team. If repositioning does not solve the problem, then call the rapid response team. C is incorrect. Identifying the cause of the pain is critical in this situation. Although it is important to relieve pain, wait to see how the repositioning affects the problem. The client needs to be completely alert to report how the sensation has changed (or not changed) as a result of the repositioning. D is incorrect. Neither the burning pain nor the lack of bubbling in the water seal chamber are normal at this stage of postoperative recovery. Cognitive level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation/Evaluation

2.A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds. B. Manage the client's airway. C. Check oxygen saturation level. D. Perform a neurologic assessment.

Answer: B Rationale: Although all of these actions are appropriate, Choice B is the priority because the client needs a patent airway as the first desired outcome.

2. The nurse is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the primary health care provider? A. Discomfort at the injection site B. Bleeding from the injection site C. Fatigue and weakness D. Mild headache

Answer: B Rationale: Discomfort is expected at the injection site (Choice A), but the client should not have bleeding from the site, which could be life-threatening. Fatigue, weakness, and a mild headache is not an immediate concern because these findings are not potentially life-threatening (Choice C and D).

Physiological Integrity The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider? A. Client has a mild headache. B. Client's blood pressure is 194/120. C. Client has left hemiparesis. D. Client continues to be drowsy.

Answer: B Rationales: The assessment findings in Choices C and D are not new and are likely related to the client's stroke. Having a mild headache is not unusual for clients who have a stroke but a severe headache during or after fibrinolytic therapy would be a major concern. During or after alteplase administration, the expected outcome for the client's blood pressure is to keep it below 185/110. The blood pressure in Choice B is very high and needs to be immediately reported to the primary health care provider who will likely prescribe a rapid-acting anti-hypertensive drug.

Physiological Integrity A client returns from the postanesthesia care unit (PACU) after a surgical removal of a frontal lobe tumor. In what position will the nurse place the client at this time? A. Turn the client from side to side to prevent aspiration. B. Elevate the head of the bed to at least 30 degrees at all times. C. Keep the client flat in bed or up 10 degrees and reposition from side to side. D. Keep the client in a high-Fowler's position in bed at all times.

Answer: B Rationales: The frontal lobe tumor that was removed is considered a supratentorial tumor. Positioning for a postoperative client who has a tumor removed from the supratentorium requires the head of the bed to be elevated to a 30 degree, or semi-Fowler's position. Therefore, Choice B is the best response. Choices A and C do not imply an elevation of the head of the bed and are therefore incorrect responses. Choice D suggests a higher sitting position but if the head is too high, the client may become hypotensive. Therefore, Choice D is an incorrect response

1. The nurse is assigned to care for a postoperative client who had an open reduction, internal fixation of the right tibia yesterday. The client reports increased right leg pain, numbness, and tingling. What would be the nurse's first action at this time? A. Elevate the surgical leg on a pillow. B. Perform a neurovascular assessment. C. Administer pain medication. D. Call the primary health care provider.

Answer: B Rationales: The nurse would suspect neurovascular compromise which is causing the client's reported signs and symptoms. Therefore, the first nursing action is to perform a complete neurovascular assessment, also called a "circ" or "CMS check" to validate the client's condition (Choice B). Neurovascular compromise results in decreased arterial perfusion and elevating the leg would decrease it further (Choice A). Although the nurse would report the client's complication to the primary health care provider and give the client an analgesic, these actions would not be performed first (Choices C and D).

Physiological Integrity The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long term pain control? Select all that apply. A. "Take the prescribed drug before breakfast each day." B. "Report any sign of bleeding, including bloody or dark, tarry stool." C. "Do not take other NSAIDs while on celecoxib." D. "Report any major changes in the amount of urine you excrete each day." E. "Follow up with lab tests to assess liver function."

Answer: B, C, D Rationales:Celecoxib is a COX-2 inhibiting NSAID and therefore can cause many adverse effects including GI symptoms, such as bleeding (Choice B), and acute kidney injury which is manifested by decreased urinary output (Choice D). Other NSAIDs should be avoided to reduce potential adverse effects (Choice C). All NSAIDs should be taken with meals or food to decrease GI effects, making Choice A the wrong response. Lab tests to measure liver function are more likely requested for patients taking acetaminophen, so Choice E is not appropriate for celecoxib therapy

1. The nurse is caring for a client who was admitted to the Emergency Department (ED) with report of left knee pain and swelling after playing baseball with friends. Which nursing actions are appropriate when caring for the client? Select all that apply. A. Apply heat to the affected area. B. Assess the severity and quality of pain. C. Perform a neurovascular assessment. D. Elevate the affected extremity. E. Immobilize the injured knee joint.

Answer: B, C, D, E Rationales: The nurse always performs an assessment as part of nursing care, including pain and neurovascular assessments (Choice B and C). Musculoskeletal injuries are usually treated using RICE (rest/immobilization, ice, compression, and elevation) Choice D and E). Therefore, Choice A using heat for the new injury is contraindicated.

Health Promotion and Maintenance The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or food additives that may trigger a migraine and should be avoided will the nurse include in the teaching? Select all that apply. A. Sugar B. Beer C. Smoked sausage D. Pickles E. Caffeine F. Wine

Answer: B, C, D, E, F Rationales: Clients who have migraines should avoid food and beverages that contain tyramine. Choices B, C, and D contain tyramine. However, caffeine and wine do not contain tyramine but can cause headaches in many patients (Choices E and F). Artificial sweeteners, not sugar, can cause a migraine headache, so Choice A is an incorrect response.

Physiologic Integrity A nurse is assessing a client with a suspected diagnosis of multiple sclerosis. Which assessment findings will the nurse expect? Select all the apply. A. Resting tremors B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria

Answer: B, C, D, E, F Rationales: The client with MS often has intention tremors rather than tremors at rest. Therefore, Choice A is an incorrect response. The remaining choices are very typical findings that result from loss of myelin (white matter) and the presence of a chronic disease.

Physiological Integrity A client had an open reduction internal fixation (ORIF) of the right wrist. What health teaching is appropriate for the nurse to provide for this client before returning home? Select all that apply. A. "Keep your right arm below the level of your heart as often as possible." B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Report coolness or discoloration of your right hand to your doctor." D. "Don't place any device under the cast to scratch the skin if it itches." E. "Move the fingers of the right hand frequently to promote blood flow."

Answer: B, C, E Rationales: An ORIF requires an open surgical procedure to reduce and immobilize the fracture. As a result, the client is at risk for swelling and neurovascular compromise. Therefore, keeping the affected arm above the heart is preferred rather than below the heart. Choice A is an incorrect response. Ice and moving the fingers can help to decrease swelling (Choice B and Choice E). The client should report any sign of decreased circulation, such as discoloration or coolness (Choice C). Choice E is incorrect because the client has a surgical incision and would not have a cast.

1. The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply. A. Joint inflammation B. Severe weight loss C. Bony nodules D. Joint deformities E. Sjogren's syndrome

Answer: B, D, E Rationales: Although rheumatoid arthritis (RA) is an inflammatory disease, clients with late-stage disease have joint deformity rather than inflammation (Choice A and D). Bony nodules occur in clients who have osteoarthritis; subcutaneous nodules are more common in clients with RA (Choice C). Severe weight loss and possibly Sjogren's syndrome are common in clients with late-stage RA (Choice B and E).

Integrative Process: Communication and Documentation or Nursing Process 2. A client has been receiving the same dose of an intravenous opioid for two days to manage post-surgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid-naïve.

Answer: B. Rationale: A client who has been receiving the same dose of an opioid for several days and now reports that the drug is not controlling the pain is likely developing tolerance. This is not the same thing as addiction or physical dependence. Physical dependence is manifested when a drug is stopped and the client shows withdrawal symptoms. Tolerance means the body has adapted to the drug and the client may require an increased dose or switching to a different drug for pain control. An opioid-naïve person has not recently taken enough opioid on a regular basis to become tolerant to the effects of an opioid. Tolerance does not indicate addiction or a history of addiction. Cognitive Level: B Integrative Process: Nursing Process

Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 X 109/L) to 400 cells/mm3 (0.2 X 109/L) indicates to the nurse that more teaching is needed? A. "Now my viral load is also probably lower." B. "I am so relieved that my drug therapy is working." C. "Although I am still HIV positive, at least I no longer have AIDS." D. "This change means I am less likely to develop an opportunistic infection."

Answer: C Rationale: A diagnosis of AIDS (HIV-III) requires that the adult be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 X 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3 [0.2 X 109/L]) or an opportunistic infection. Once HIV-III (AIDS) is diagnosed, even if the patient's T-cell count improves or if the percentage rises above 14%, or the infection is successfully treated, the AIDS diagnosis remains. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F (39.7 degrees C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated

Answer: C Rationale: A major and relatively common complication of severe seasonal influenza is development of pneumonia. It is likely this client's influenza was severe because hospitalization was required. The client would no longer be receiving the antiviral drug after discharge. A second strain of influenza is not likely in this context. Temperature elevation from dehydration is usually less dramatic. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Assessment

18-2. Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

Answer: C Rationale: All actions are appropriate interventions for the client having an anaphylactic reaction. The first and most important action is to inject the epinephrine to stop the attack. Administering oxygen is helpful in supporting the client but will not stop this extremely rapid response and will take time away from administering the epinephrine. Giving diphenhydramine is a second line therapy for anaphylaxis. Initiating IV access is important but may not even be possible if the blood pressure is too low during anaphylaxis. Time should not be wasted on this action. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation

Safe and Effective Care Environment When performing a medication reconcilliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? A. Record and display the information in a prominent place within the client's medical record. B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled. C. Collaborate with the surgeon to arrange for continuation of this therapy in the postoperative period. D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.

Answer: C Rationale: Asthma is a common disorder and adults admitted to the hospital for other health problems or surgery may also have asthma. For optimal control continuing the asthma drug therapy, is a priority regardless of setting. Although the length and effectiveness of therapy are important for evaluating an asthma treatment plan, the information is not the priority for this situation. Ensuring this information is included in the client's medical record is important but ensuring that the drugs are continued as prescribed during this client's hospitalization has a higher priority. The drugs are administered by inhalation and a parenteral form is not needed for a client who is NPO. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Intervention

36-3. Which precaution has the highest priority for prevention of harm when the nurse teaches the client about home care after a bone marrow aspiration? A. Clean the suture line daily with soap and water. B. Drink at least 4 L of fluid to ensure adequate hydration. C. Avoid taking any aspirin or aspirin-containing products. D. Stay in bed and only get up to use the bathroom for the next 2 days.

Answer: C Rationale: Bleeding at the site and throughout the tissues from the bone marrow to the skin is possible after a bone marrow aspiration and can be quite severe, especially if a hematologic problem is present. All aspirin or any other drug that disrupts clotting is to be avoided. A bone marrow aspiration does not involve a suture line (a biopsy usually does). Dehydration is not likely as a result of a bone marrow aspiration. Unless active bleeding is present, clients may resume most low intensity activities but should avoid those that may cause trauma to the site. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

Psychosocial Integrity The family of a client receiving a blood transfusion excitedly report to the nurse that although the the blood bag hanging has the client's name on it, the bag label says B negative and the client's blood type is B positive. What is the nurse's priority action? A. Alert the blood bank and Rapid Response team to a potential error. B. Thank the family for being alert and preventing a serious complication. C. Explain that a person who is Rh positive can receive Rh negative blood. D.Immediately go and stop the infusion but keep the IV line open with normal saline

Answer: C Rationale: Clients with Rh negative blood types can receive O negative blood because they do not have antibodies against this type of blood. Therefore, the transfusion does not need to be stopped nor does the blood bank need to be notified. The family should be thanked for their observation and helped to understand and encouraged to always report or question something that does not seem right to them. The transfusion can proceed. Cognitive Level: Applying or higher Client Needs Category: Psychosocial Integrity Nursing Process Step: Implementation

Physiological Integrity Which change in laboratory test results of a client with sickle cell disease who was started on therapy with Endari 2 months ago indicates to the nurse that the therapy is effective? A. Increased HbF from 2% to 10% B. Increased HbA from 3% to 5% C. Decreased reticulocyte count from 12% to 4% D. Decreased white blood cells from 8,200/mm3 to 7,000/mm3 (8.2 x 109/L to 7.0 x 109/L)

Answer: C Rationale: Endari is a drug that is composed of the amino acid glutamine. Higher levels of glutamine in RBCs appears to lower oxidative stress in these cells. This cellular response to glutamine both decreases sickling rates and increases mature RBC lifespans. As a result the percentage of circulating mature RBCs increases and the percentage of circulating reticulocytes decreases. It does not increase fetal hemoglobin or adult hemoglobin levels, and does not affect white blood cell levels directly. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluation

Physiological Integrity What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug? A. "Do you have glaucoma or any other problem with your eyes?" B. "Do you take medications for a seizure disorder?" C. "Are you allergic to sulfa drugs?" D. "Are you a diabetic?"

Answer: C Rationale: Fosamprenavir, a protease inhibitor, contains sulfa. A client who is allergic to sulfa drugs is highly likely to also be allergic to fosamprenavir and have a serious or life-threatening reaction to the drug. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment

Physiological Integrity What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma? Seeing "shooting stars" Decrease in central vision Gradual loss of visual fields Abrupt onset of excruciating pain

Answer: C Rationale: Glaucoma is a condition in which onset is gradual and slow; therefore, the nurse will anticipate this type of assessment data collected from a client with a new diagnosis. Glaucoma is not characterized by seeing "shooting stars", experiencing a decrease in central vision, nor an abrupt onset of excruciating pain. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: Assessment/Evaluation

Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

Answer: C Rationale: HIV particles are made within the infected CD4+ T-cell, using the host cell's protein synthesis processes. The new virus particle is made as one long inactive protein strand. The strand is clipped by the enzyme HIV protease into smaller active pieces. Protease inhibitors block the enzyme from creating active viral pieces that can leave the cell and infect other cells. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

18-3. Which new onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

Answer: C Rationale: Hydoxychloroquine can be toxic to retinal cells, especially near the macula. This would result in decreased or lost central vision such as would be seen as "missing" letters in the center of a word being read. Bruising is an expected side effect of the drug because is decreases clotting. Although foamy urine is an early indicator of protein in the urine and would need to be addressed, it is not as pressing a problem as the decreased central vision, which is irreversible and an indication that the drug must be stopped immediately. Nausea, although unpleasant, does not have a high risk for causing harm. Cognitive Level: Applying or Higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluation

28-2. A nursing home client who has completed a 2 week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheel chair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

Answer: C Rationale: The client is no longer contagious after completing the course of antibiotics and is just in the recovery phase of the illness. If he feels rested enough to be up in a wheel chair, there is no reason he must be isolated physically or socially. A face mask is not needed to protect others. Cognitive Level: Applying or higher Client Needs Category: Psychosocial Integrity Nursing Process Step: Intervention

27-2. A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. PaCO2 from 45 mmHg to 68 mmHg D. PaO2 from 88 mmHg to 86 mmHg

Answer: C Rationale: The rise in PaCO2 represents acute hypercapnia that could rapidly lead to respiratory failure. Although the oxygen level has dropped slightly, which is never good, it is the dramatic rise in carbon dioxide level that requires immediate action to determine the cause and intervene to prevent a worsening of the client's condition. The decrease in pH supports the identification of hypercapnia but this change alone does not warrant immediate action. The bicarbonate level is unchanged, which supports that the hypercapnia is an acute problem. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

A client returning to clinic 7 weeks after hematopoietic stem cell transplantation for leukemia has a total White blood cell (WBC) count of 5,200/mm3 (5.2 x 109/L) and a neutrophil count of 3000/mm3 (3 x 109/L). What is the nurse's priority action in view of these values? A. Notify the health care provider immediately. B. Assess the client for other symptoms of infection. C. Document the laboratory report as the only action. D. Obtain a urine specimen, sputum specimen, and chest X-ray.

Answer: C Rationale: The white blood cell count is now within the normal range (5,000 to 10,000/mm3 [5-10 x 109/L]) and the neutrophils represent more than 50% of the count. These values are indicators of successful engraftment. The client is not at any particular risk for infection at this time, nor is this cause to believe that an infection is present. (At any post-transplantation check-up, the client is assessed for infection.) Cognitive Level: Applying (Application or higher) Client Needs Category: Physiological integrity Nursing Process Step: Evaluation

1. The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the immediate concern of the nurse? A. Disorientation B. Numbness in both arms C. Decreased level of consciousness D. Report of headache

Answer: C Rationale: A decreased level of consciousness is the first sign of neurologic deterioration and can be life-threatening more than the other changes in the client's condition. Disorientation and headache are expected findings for a brain injury (Choices A and D). Numbness in the arms is not life-threatening Choice B).

Safe and Effective Care Environment A client returns to the post-anesthesia care unit (PACU) after an arthroscopy to repair a shoulder injury. What is the nurse's priority when caring for this client? A. Keep the affected arm elevated and immobilized. B. Ensure that the patient uses the patient-controlled analgesia (PCA) pump. C. Check the neurovascular status of the affected arm. D. Instruct the client to stay in bed for 24 hours.

Answer: C Rationale: Choice C is the best answer because postoperative swelling or bleeding can compress arterial and nerve supply to the entire arm. Therefore, performing a neurovascular assessment on the affected arm can detect any vascular or nerve changes that may need medical treatment. Choice A is also important to prevent increased swelling, but is not as important of a concern for the nurse. The client may or may not have a PCA pump (choice B) and would not need to stay in bed for 24 hours (choice D).

Physiological Integrity The nurse assesses a client recently diagnosed with metastatic vertebral bone cancer. Which intervention is the priority when caring for this client? A. Consult with rehabilitative therapy B. Referral to hospice care C. Drug therapy to manage persistent pain D. Oxygen therapy to prevent dyspnea

Answer: C Rationale: Metastatic vertebral bone pain is very painful, which is the priority in this client situation. Therefore, Choice C is the best answer because the client is expected to have persistent pain that needs to be well managed. Physical or occupational therapy (Choice A) may also be needed to help the client with ADL function, but it is not as important as pain control. Severe pain can cause shallow breathing and dyspnea, and therefore, the client may require oxygen therapy (Choice D). However, the situation does not provide information that suggests the need for oxygen. Choice B may be needed later, but this client has recently been diagnosed and very likely may not meet hospice care criteria at this time.

Physiological Integrity The nurse is caring for a client immediately after a bunionectomy. What is the nurse's priority action? A. Relieve or reduce the client's pain. B. Maintain the client's airway. C. Assess neurovascular status in the surgical foot. D. Apply a hot compress to the surgical area.

Answer: C Rationale: The client's situation does not suggest any problem with breathing and, therefore, Choice B is not correct. Assessing circulation in the surgical foot is more important than managing pain (Choice A). Choice D is incorrect because cold would reduce local pain and swelling. Heat would increase circulation but increase pain and swelling to the surgical site.

Safe and Effective Care Environment An unlicensed assistive personnel (UAP) is assigned to care for a client who had a cemented total knee arthroplasty yesterday. Which observation by the UAP indicates a need for follow-up by the nurse? A. "The client's surgical knee is very swollen and discolored." B. "The client states that the surgical knee is very painful when moving it." C. "The client's lower leg on the surgical side is painful and red." D. "The client needs assistance with walking to the bathroom."

Answer: C Rationales: A client who had a TKA one-day ago is expected to have a swollen and discolored surgical knee that is very painful when moving. The client is also expected to need assistance with a walker and possibly a staff member when ambulating. Therefore, Choices A, B, and D do not require follow-up by the nurse. However, redness, pain, and possibly swelling of the lower leg may indicate deep vein thrombosis which requires follow-up and assessment by the nurse (Choice C).

Safe and Effective Care Environment What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output.

Answer: C Rationales: Choices A, B, and C all apply for postoperative care for carpal tunnel syndrome (CTS). However, the most important priority action is to check for adequate circulation, movement, and sensation (neurovascular assessment). Therefore, Choice C is the best answer. Monitoring intake and output are not relevant for CTS surgery

1. The nurse teaches assistive personnel (AP) how to position a client who had an above-the-knee amputation (AKA) last week. Which statement by the AP indicates understanding of the teaching? A. "We should keep the surgical leg elevated on two pillows at all times." B. "We should keep the client in a sitting position as long as possible." C. "We should keep the surgical leg as flat on the bed as possible." D. "We should keep the client in a prone position most of the day."

Answer: C Rationales: One of the complications of an AKA is flexion hip contracture of the affected leg. The flexor muscles become spastic which causes hip flexion; therefore, the surgical leg ("stump") should be positioned as flat as possible in an extended position to prevent that complication (Choice C). Elevation would promote flexion (Choice A). Placing the client occasionally in a prone position can help promote hip extension but the client cannot remain in that position for a prolonged period of time (Choice D). Prolonged sitting can lead to sacral or buttock pressure injuries and would not be the best client position (Choice B).

Physiological Integrity The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client? A. Refer the client to the speech-language pathologist (SLP). B. Speak loudly to help the client interpret what is being said. C. Provide pictures to help the client understand. D. Ask the client to read messages on a white board.

Answer: C Rationales: The client who has receptive (sensory) aphasia cannot understand either verbal or written words. Therefore, Choice D is an incorrect response. Speaking loudly does not help the client better understand what is being said, so Choice B is also an incorrect response. While it is feasible to refer the client to the SLP, that action will not help now with communication (Choice A). Choice C is the most appropriate action to help the client understand what is being communicated.

Psychosocial Integrity A client with moderate dementia asks the nurse to find her son who is deceased. What is the nurse's most appropriate response? A. "We can call him in a little while if you want." B. " Your son died over 20 years ago." C. "What did your son look like?" D. "I'll ask your husband to find him when he visits."

Answer: C Rationales: The client with moderate dementia cannot be reoriented to reality, so validation therapy is the best approach. Choice C acknowledges the client's concern about her son, even though he is deceased. Choices A and D affirm that the son is alive which is not true. Choice B may cause an argument which should be avoided.

Safe Effective Care Environment A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110. What is the nurse's priority action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Place the patient in a sitting position. D. Turn on a fan to cool the patient

Answer: C Rationales: The patient's high blood pressure (BP) is causing the headache and flushing. If the BP continues to remain elevated, the patient is at risk for stroke. Therefore, sitting the patient up will help to lower the blood pressure and is the first priority action for the nurse. The other choices would be the next actions to determine and relieve the cause of the autonomic dysreflexia.

Health Promotion and Maintenance For insurance coverage a client who has been taking apixaban for 2 years for long-term anticoagulation is being changed to warfarin. Which precaution has the highest priority for the nurse to teach the client to prevent harm as a result of this prescription change? A. Apply an ice pack to any body area that you bump or otherwise injure to reduce bleeding. B. Check with your primary health care provider before taking any vitamin supplements. C. Always take your medication within an hour of the same time every day. D. Avoid taking aspirin or any aspirin-containing product.

Answer: D Rationale: A client who has taken an anticoagulant for 2 years should already understand the need to take the drug at the same time every day and to apply ice to any injured areas. The unique precaution for warfarin is to take care with the amount of vitamin K taken daily as a supplement or in the diet because warfarin is a vitamin K antagonist and taking exogenous vitamin K can reduce the drug's effectiveness as an anticoagulant. However, avoiding aspirin and aspirin-containing products is still the most important precaution to teach and reinforce to a client taking ANY anticoagulant. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

36-2. Which response or health problem does the nurse expect to be present for a client who has a life-long deficiency of antithrombin III? A. Chronic fatigue resulting from reduced production of normal hemoglobin B. Failure to produce and maintain normal circulating levels of platelets C. Prolonged bleeding and hematoma formation at sites of tissue injury D. Increased risk for clot formation and disruption of perfusion

Answer: D Rationale: Antithrombin III is an intrinsic protein that serves to inactivates thrombin and clotting factors IX and X. These actions prevent clots from becoming too large or forming in an area where Clotting is not needed. Deficiency of antithrombin III is a genetic clotting disorder that increases the risk for forming clots easily when they are not needed, contributing to an increased risk for thromboembolic events such as pulmonary embolism, myocardial infarction, and strokes. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Assessment

Physiological Integrity Which patient does the nurse identify at highest risk for development of dry age-related macular degeneration (AMD)? A. 55-year old client who recently began wearing glasses B. 59-year old client who has controlled hypertension C. 62-year old client with hypothyroidism 65-year old client with diabetes

Answer: D Rationale: Individuals over the age of 60 and that have hypertension, diabetes, or high cholesterol are at the highest risk for development of dry age-related macular degeneration (AMD). The client who is 55 and recently began wearing glasses is at lower risk than the other three patients, since he or she is not over 60, and wearing glasses is not associated with AMD. The 59-year old client with controlled hypertension is at lower risk due to age, and since the hypertensive condition is treated and controlled. The 62-year-old individual is at lower risk, as hypothyroidism is not associated with AMD. The 65-year old individual is at highest risk having two risk factors: age, and the condition of diabetes. Cognitive Level: Analysis Client Needs Category: Physiological Integrity Nursing Process Step: Assessment/Evaluation

Health Promotion and Maintenance What is the appropriate nursing response when a 66-year-old healthy client asks how often a visit to the eye care provider is recommended? A. "Annually." B. "Every 6 months." C. "Only if you have vision problems." D. "Every 1 to 2 years if you have no eye problems."

Answer: D Rationale: Per organizations such as Prevent Blindness and the American Academy of Ophthalmology, clients who are 65 years of age and over should have an eye examination every 1-2 years if they have no other eye problems. Cognitive Level: Application Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Assessment/Evaluation

18-2. A client who is six feet two inches tall and weighs 205 lb is having an anaphylactic reaction. Which dose of epinephrine will the nurse prepare for this client? A. 0.3 mL of a 1:10,000 solution B. 0.5 mL of a 1:10,000 solution C. 0.3 mL of a 1:1000 solution D. 0.5 mL of a 1:1000 solution

Answer: D Rationale: The dosage of epinephrine needed to be of benefit during an anaphylactic reaction is based on size. Adults are prescribed doses ranging from 0.3 mL to 0.5 mL of a 1:1000 solution. A solution of 1:10,000 will be ineffective unless the dose is massive. This client is larger than average and needs a larger dose of the solution. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation

37-2. Which intervention is a priority for the nurse to teach the client with polycythemia vera to prevent harm related to injury as a result of impaired platelet function? A. Wear gloves and socks outdoors in cool weather. B. Elevate your feet whenever you are seated. C. Drink at least 3 liters of liquids per day. D. Use a soft-bristled toothbrush.

Answer: D Rationale: The other interventions focus on preventing venous stasis and clot formation as a result of hypercellularity. Although the number of platelets may be elevated, their function is impaired and the client is at risk for bleeding. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding. Cognitive Level: Applying or higher Client Needs Category: Health promotion and maintenance Nursing Process Step: Implementation

17-2. Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? A. Caffeinated beverages B. Grapefruit juice C. Dairy products D. St. John's Wort

Answer: D Rationale: Tipranavir is a protease inhibitor. St. John's Wort changes the activity of metabolizing enzymes resulting in more rapid elimination of all the protease inhibitors and reducing their effectiveness. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

3.Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries? A. "I need to lose weight because I'm too big." B. "I should not stand or sit for a long period of time." C. "It would be best if I could get ergonomic office furniture." D. "Exercise is not going to help my back very much."

Answer: D Rationale: All of the choices are correct except for Choice D. Regular exercise, especially strengthening exercises can be very helpful in preventing back injuries and pain.

Physiological Integrity The nurse is teaching a client about what to expect immediately after a cerebral angiographic examination. Which statement by the client indicates a need for further teaching? A. "I'll have a pressure dressing on my groin for a couple of hours." B. "I'll have to keep my leg straight for a while after the procedure." C. "The nurses will check circulation in my injected leg frequently." D. "I can use heat on my groin to decrease any discomfort."

Answer: D Rationale: Ice is used to decrease swelling after the procedure. Heat could increase swelling and may cause the injection site to bleed due to vasodilation. Choices A, B, and C are part of expected post-procedure care after a cerebral angiogram.

.Which serum laboratory finding is of concern for the nurse and should be reported to the primary health care provider? A. Calcium = 9 mg/dL (2.10 mmol/L) B. Phosphorus = 4.5 mg/dL (1.45 mmol/L) C. Lactate dehydrogenase = 150 units/L (150 IU/L) D. Alkaline phosphatase = 210 units/L (210 IU/L)

Answer: D Rationale: The laboratory values for the Choices A, B, and C are all within normal limits. However, the normal value of alkaline phosphatase is 30-120 units/L (40-160 IU/L) and the value is much higher than the normal range value.

1. A client is admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia which resulted from a traumatic brain injury. Which of the following interventions is a priority for the client at this time? A. Contact the physical therapist (PT) to plan care to increase the client's mobility. B. Contact the occupational therapist (OT) to assess the client's ADL ability. C. Contact the unit social worker (SW) to talk with the family about his discharge. D. Contact the speech/language pathologist (SLP) to schedule a swallowing study.

Answer: D Rationale: The nurse will likely need to collaborate with all of these interprofessional health care team members. However, the priority at this time is to ensure that the client remains NPO until a bedside swallowing study can be conducted to prevent possible aspiration when the client eats food or drinks liquids. If there is a swallowing problem, the SLP makes recommendations for special swallowing precautions and communicates those interventions to the members of the health care team.

1. The nurse is caring for a client who had a posterolateral total his arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Surgical hip dislocation

Answer: D Rationales: Even with aggressive preventive interventions, the client who has a total hip arthroplasty (THA) is at most risk for the common complication of venous thromboembolism. The other choices are much less common for clients having a THA, and would be seen in clients having other types of surgery.

1.The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug? A. "Report changes in urinary and bowel elimination immediately." B. "Follow up for annual lab testing to monitor for liver toxicity." C. "Rotate the sites for your self-administered injections." D. "Avoid crowded places such as malls and large public gatherings."

Answer: D Rationales: Mitoxantrone is administered by IV infusion and therefore Choice C is not the correct response. This drug can cause leukemia, infection, and cardiac toxicity. Therefore, Choices A and B are incorrect. Choice D is correct because the drug can suppress the bone marrow and immunity. Clients taking this drug are therefore at risk for infection and should avoid large crowds.

Psychosocial Integrity A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases." B. "That's phantom limb pain, and every amputee has that." C. "Your foot has been amputated, so it's in your head." D. "On a scale of 0 to 10, how would you rate your pain?"

Answer: D Rationales: Nurses should treat any pain as real to the patient, even if the pain is perceived in a part of the body that is no longer there. Choice D demonstrates that the nurse acknowledges that the pain is real and further assesses is intensity. Choices A, B, and C dismisses the client's report of pain.

1.The nurse is caring for a client who is diagnosed with early-stage Alzheimer's disease who has periods of lucidity. What is the best principle for the nurse to use when communicating with this client? A. Use validation therapy to prevent upsetting the client. B. Encourage pet therapy to help allay the client's anxiety. C. Use aromatherapy and other integrative therapies to relax the client. D. Re-orient the client frequently to foster reality.

Answer: D Rationales: The client is in the early stage of the disease and has periods where she is not confused or has memory loss. Therefore, re-orientation is the best action to help the client maintain reality. Choices B, C, and D are more appropriate for clients with late-stage Alzheimer's disease

1. The nurse is caring for a client who was admitted with a draining diabetic ulcer on the lower extremity. What personal protective equipment will the nurse teach the staff to use? Select all that apply. A. Gown B. Gloves C. Mask D. Foot covers E. Goggles

Answers: A, B Rationale: The client with an open draining wound likely has a local or possibly a systemic infection. Therefore, Contact Precaution are needed to prevent contact with the drainage. Gloves and gowns are the most appropriate personal protective equipment to prevent infection transmission.

Physiological Adaptation Which symptoms will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0 degrees F E. Pupil that constricts in response to light

Answers: A, B, C Rationale: Pain, pus, or decreased visual acuity in an eye that recently underwent correction for a retinal detachment must be immediately reported to the eye care provider, as they can indicate a post-surgical complication. A temperature 99 degrees F is not cause for alarm, unless the temperature elevates to 100.6 degrees F or above. A pupil that constricts in response to light is a normal finding. Cognitive Level: Application Client Needs Category: Physiological Adaptation Nursing Process Step: Assessment/Evaluation

2. A client experiences a seizure that is observed by the nurse. What will the nurse document in the client's medical record? Select all that apply. A. Time that seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to pre-seizure status

Answers: A, B, C, D Rationales: All of the choices are correct except for E because drugs are not given during a single seizure.

.The nurse is preparing to teach a client about how to promote musculoskeletal health. Which statements will the nurse include in the teaching plan? Select all that apply. A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and Vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."

Answers: A, B, C, D, E Rationales: All of these choices are correct because they can help promote musculoskeletal health.

3.The nurse is admitting a client with a probable diagnosis of meningitis. What signs and symptoms might the nurse expect when assessing this client? Select all that apply. A. Photophobia B. Nystagmus C. Decreased level of consciousness D. Decreased movement, such as hemiparesis E. Disorientation to person, place, and time

Answers: A, B, C, D, E Rationales: Any of these neurologic changes may be seen in clients with meningitis. Therefore, all choices are correct

27-4. The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply. A. Ambrisentan B. Bosentan C. Epoprostenol D. Iloprost E. Macitentan F. Riociguat G. Selexipag H. Sildenafil I. Tadalafil J. Treprostinil

Answers: A, B, E, F Rationale: All the endothelin-receptor antagonists, including ambrisentan, bosentan, and macitentan, have been demonstrated to have teratogenic properties that can cause birth defects. Riociguat also has teratogenic properties. These drugs are contraindicated for use in women who are pregnant and when used by women of child-bearing age who are sexually active, two reliable methods of contraception are needed. The prostacyclin agonists (epoprostenol, iloprost, treprostinil, and selexipag), as well as the phosphodiesterase inhibitor-based guanylate cyclase inhibitors (sildenafil and tadalafil), are not associated with an increased risk for birth defects. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

Safe and Effective Care Environment Which assessment data does the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye that started 30 minutes prior? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

Answers: A, C, D, E Rationale: The nurse will anticipate that a client who has a foreign body in the eye will report some level of pain or discomfort, tearing (as the foreign body irritates the tissue within the eye), photophobia (as it may be difficult to see if there is the presence of a foreign body and the automatic response is to close the eye), and blurred vision (if the foreign body obstructs the line of sight). Fever is not associated with a foreign body that has been in the eye for such a short amount of time; this symptom may be present if infection arose from a foreign body that had been present for a longer period of time. Cognitive Level: Application Client Needs Category: Physiological Adaptation Nursing Process Step: Assessment/Evaluation

Safe and Effective Care Environment Which client history information is most relevant for the nurse to document when assessing for a possible hematologic problem? Select all that apply. A. Eats a vegan diet B. Participates in basketball twice weekly C. Mother has pernicious anemia D. Has a sister with Down syndrome E. Sprays fertilizers and weed-killers for a lawn care company F. Takes aspirin or NSAIDs occasionally for minor muscle pain G. Uses a vaping device instead of cigarette smoking for the past 2 years

Answers: A, C, E Rationale: A vegan diet can contribute to anemia and other hematologic problems if iron, protein, and nutrients involved in blood formation are absent from the diet. Pernicious anemia is an autoimmune disorder that has a genetic component. This information can be especially important if the client is female. Sprayed fertilizers and weed-killers contain many toxic chemicals and may be absorbed through skin and mucous membranes. Adults who work with these chemicals may not be using appropriate protection to prevent particulate matter exposure. Playing sports does not increase the risk for hematologic problems. Although adults with Down syndrome may be at greater risk for some hematologic problems, this risk is not present among family members who are chromosomally normal. Taking aspirin or NSAIDs occasionally does not create a hematologic health problem. Although the chemicals in vaping devices are not innocuous, as this time there is no link between exposure to them and the development of hematologic problems. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment

Physiological Integrity With which types of anemia does the nurse ask the client about the presence of the disorder in other family members? Select all that apply. A. Sickle cell anemia B. Folic acid deficiency anemia C. Glucose-6-phosphate dehydrogenase deficiency anemia D. Iron deficiency anemia E. Pernicous anemia F. Vitamin B12 deficiency anemia

Answers: A, C, E Rationale: Sickle cell anemia (sickle cell disease) is inherited as an autosomal recessive disorder. The client may have inherited one allele and have sickle cell trait, which does increase the risk for clot development under some circumstances. Glucose-6-phosphate dehydrogenase deficiency anemia is caused by an X-linked recessive mutation that is inherited. Thus it is often present in other family members, especially men. Pernicious anemia are both autoimmune disorders that have a genetic contribution to the problems and may be present in other family members. Pernicious anemia is the only type of vitamin B12 deficiency anemia that is an autoimmune disorder. Iron deficiency anemia and folic acid deficiency anemia represent dietary problems rather than genetic or autoimmune problems. Cognitive Level: Applying or higher Client Needs Category: Physiological integrity Nursing Process Step: Assessment

Which new symptoms in a client who is being managed for sickle cell crisis does the nurse report immediately to prevent harm? Select all that apply. A. Decreased handgrip strength on one side B. Diffuse abdominal pain C. Fever of 102.2 F (39 C) D. Increased urine output E. Shortness of breath F. Sore throat

Answers: A, C, E Rationale: Two serious and potentially lethal complications of sickle cell crisis are acute chest syndrome and stroke. Acute chest syndrome often results from a pulmonary infection and a major symptom is shortness of breath. Although not all clients have a fever, a sudden increase may indicate a pulmonary infection. Acute chest syndrome can progress rapidly to multiple organ dysfunction syndrome and death if interventions are not immediately instituted. New onset unilateral decreased handgrip strength is an indication of poor cerebral perfusion and must be managed quickly to prevent more brain damage. Diffuse abdominal pain is common in crises and does not indicate an emergency. Increased urine output is most likely related to the increased hydration therapy used to manage the crisis episode. Sore throat is not an emergency problem for a client in sickle cell crisis. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

Physiological Integrity The nurse has delegated care for a client with a radical left mastectomy for breast cancer to assistive personnel (AP). Which AP action requires nursing intervention? Select all that apply. A. Obtains blood pressure via left arm B. Reports client's pain level to the nurse C. Applies gait belt prior to walking with the client D. Records vital signs in the electronic health record E. Assists client to administer patient-controlled analgesia (PCA)

Answers: A, E Rationale: The AP is acting within scope when reporting the pain level to the nurse, applying a gait belt prior to walking the client, and recording vital signs in the electronic health record. The nurse needs to intervene when the AP obtains a blood pressure in the affected arm (as blood pressure should always be taken in the unaffected arm) and when the AP attempts to assist the client with PCA, as only the patient is authorized to control the PCA. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Implementation

18-1. Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply. A. Type III responses are usually directed against self cells and tissues. B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance. C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction. D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity. F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

Answers: A, E Rationale: Type III reactions are responsible for the generation of autoantibodies that attack self cells and tissues as part of autoimmune disorders. Rheumatoid arthritis is a classic example of a type III response generating autoimmunity. Although this type of reaction results from a genetic susceptibility combined with a triggering event, the pattern of inheritance is not discernable and most likely represents a polygenic effect. A type II response is generated by a foreign cell or protein that attaches to a normal body cell. When the antigen is attacked, the normal cell attached to it also is attacked. It does not progress to a type III autoimmune response. Although macrophages may be involved in some aspect of tissue injury with autoimmune disorders, the main mechanism is the development of autoantibodies from B-cells. Bradykinin and angioedema are features of a type I hypersensitivity and are not associated with type III responses. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

A client who is 5 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia comes to the clinic with a swollen belly and weight gain. Which additional assessment data supports the nurse's suspicion of possible sinusoidal obstructive syndrome (SOS)? Select all that apply. A. Jaundiced skin and sclera B. Platelet count is 28,000/mm3 C. Skin peeling on the hands and feet D. Mixed chimerism by laboratory finding E. Slightly below normal body temperature F. Pain in the upper right abdominal quadrant

Answers: A, F Rationale: SOS (formerly called veno-occlusive disease [VOD]) is the blockage of liver blood vessels by Clotting and inflammation (phlebitis) and occurs in about one fifth of patients with HSCT, especially those who received high-dose chemotherapy with alkylating agents. The problem can lead to fatal liver failure and supportive management must occur quickly. Symptoms include jaundice, pain in the right upper quadrant, ascites, weight gain, and liver enlargement. Skin peeling is a symptom of graft vs host disease, not SOS. Mixed chimerism is unrelated to the complication of SOS and indicates some degree of engraftment. The slightly low body temperature is not related to the SOS. The rising platelet count (although not yet to normal values) is a result of engraftment and not SOS. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environmenty Nursing Process Step: Evaluation

Health Promotion and Maintenance A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

Answers: A, G Rationale: The drug ethambutol can cause optic neuritis that can lead to blindness. The drug should be stopped and the patient's vision evaluated immediately. Yellowing of the sclera is associated with jaundice from liver problems, which can be serious and life-threatening. The client's liver status must be evaluated immediately. Although nausea when drinking alcohol is an expected side effect of ethambutol, it is a priority to report this change to the health care provider at this time. The nurse needs to explain the side effect to the client and remind him or her that alcohol must be avoided during TB therapy to prevent liver problems. This change only needs to be reported to the health care provider if the client continues to consume alcohol. Difficulty sleeping may or may not be associated with the TB drug therapy. It does not require immediate attention. Red-tinged urine is an expected side effect of rifampin. The nurse reinforces this information to the client to relieve his or her anxiety. The drug pyrazinamide increases photosensitivity. Sunburn is a common side effect that the nurse needs to instruct the client to prevent but does not require immediate attention from the healthcare provider. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention

28-3. Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. A, 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

Answers: B, C, D, E Rationale: Active tuberculosis is most likely to develop in adults who are heavily exposed to the organism, such as those living in crowded conditions (prison), from less affluent foreign countries, and anyone who is immunosuppressed (has AIDS and is not taking antiretroviral therapy). Adults who use/abuse injection drugs are also at increased risk because of life style and reduced cognition while under the influence of the drugs. This can result in choices that increase his or her exposure to the organism and may reduce immunity. A healthy 21-year-old living in a dorm in an affluent country is not at increased risk for TB. Having moderate to severe COPD alone does not increase risk for TB unless immunity is greatly reduced. Cognitive Level: Applying or higher Client Needs Category: Physiological integrity

Physiological Adaptation: Reduction of Risk Potential Which client statement affirms that nurse teaching about instillation of multiple different eye drops has been effective? Select all that apply. A. "It will be very easy for me to instill all of the drops at one time." B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eye drops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."

Answers: B, C, D, E Rationale: Teaching has been effective when a client can verbalize the need to create a schedule to remember when to instill eyedrops, to use a device if self-instillation is not possible, to label eyedrops by color to distinguish them, and to refrain from touching the dropper to the eye to reduce the chance of infection and contamination. Drops cannot be instilled all at one time, as each prescription will have its own dosing schedule. Even when taking drops around the same time, the client must be taught to pause between instillation of different drops. Cognitive Level: Analysis Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Assessment/Evaluation

Psychosocial Integrity; Psychosocial Integrity Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? Select all that apply. A. Encourage client to accept her new body image B. Provide self-care resources to the primary caretaker C. Teach client about birth control options that are available D. Refer to support groups for people who have had mastectomy E. Involve partner in discussions about sexuality if client desires

Answers: B, C, D, E Rationale: The nurse appropriately intervenes by providing self-care resources to the primary caretaker (as caretaking can be stressful); when teaching the client about birth control options (as pregnancy and chemotherapy are not compatible); when referring the client to support groups (which can increase support systems); and when involving the partner in discussions about sexuality, if the client desires (as body image changes can affect sexuality). Encouraging the client to accept her new body image at this time is nontherapeutic; this takes time and the client should be permitted time to grieve her former body image. Cognitive Level: Application Client Needs Category: Psychosocial Integrity; Psychosocial Integrity Nursing Process Step: Implementation

18-1. Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply. A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation. C. Type I responses are usually directed against nonself but the response is excessive. D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus. F. Responses always occur within minutes of exposure to the allergen. G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

Answers: B, C, G Rationale: Type I responses Type I reactions result from the increased production of the immunoglobulin E (IgE) antibody class that cause the release of mediators including histamine, bradykinin, leukotriene, and others that result in the five cardinal symptoms of inflammation (pain, swelling, warmth, redness, and loss of function). The reactions are directed against appropriate nonself targets rather than against self cells but the responses are excessive. The second phase of type I reactions are caused by accumulation of bradykinin deep within the skin tissue layers, which is the major mechanism of angioedema. Antihistamines are helpful with a type I hypersensitivity reaction because the major mediator is histamine. Although the susceptibility to type I reactions is genetic, no specific pattern of inheritance has been identified. Many type I reactions do occur rapidly after exposure to the allergen; however, angioedema is a pure type I reaction and may not occur until days, weeks, months, and even years after continual exposure to the allergen. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

Psychosocial Integrity Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply. A. Administering prescribed drug therapy B. Ambulating in the hall C. Culturing suspected infectious drainage D. Performing pulmonary hygiene E. Performing oral care F. Providing a complete bed bath G. Teaching about nutrition therapy

Answers: B, F, G Rationale: Although the patient is fatigued, some nursing care actions are essential to prevent immediate and potentially lethal complications. Most of these involve infection prevention activities and include administering prescribed drug therapy, culturing body fluids or lesions when infection is suspected, performing pulmonary hygiene to prevent or manage respiratory infections, and performing meticulous oral care to prevent infections. It is not immediately helpful to have the client ambulate in the hall or receive a complete bed bath (just inspect and clean the perineal and axillary areas). Teaching performed when the client is extremely fatigue has little effect or retention. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluating

A client with primary pulmonary arterial hypertension (PAH) receiving treprosinil by continuous IV infusion now has a fever of 101.6 degrees F (38.7 degrees C). Which actions will the nurse perform to prevent harm? Select all that apply. A. Administer the prescribed antipyretic B. Ask the client whether a productive cough is present C. Apply oxygen by nasal cannula D. Culture the IV site E. Determine whether a durable power of attorney has been signed F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic H. Place the client in protective isolation

Answers: D, F, G Rationale: Clients with PAH receiving continuous IV drug therapy are at high risk for developing sepsis because of the long-term direct access line. Any client with a fever is considered to have sepsis until proven otherwise, not pneumonia or any other respiratory infection. Also, clients with PAH who develop sepsis are less likely to survive it. The critical actions to prevent harm are to give oxygen to promote better gas exchange, initiate a second IV (only the prostacyclin agonist is administered through the long-term continuous line) and give the prescribed antibiotic immediately, increase the treprostinil flow rate (as prescribed) to prevent the pulmonary pressure from becoming higher. Culturing the IV site instead of the blood is unlikely to provide useable information in a timely manner. Placing the client in protective isolation will not help fight the sepsis. A durable power of attorney is not going to prevent harm. Administering the antipyretic will not prevent harm and is not the priority. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Health Care Environment Nursing Process Step: Implementation

Question 15 of 18 Which type of drug therapy will the nurse prepare a client in the early disseminated stage of Lyme disease to take for control or cure of this disease? Convalescent serum Corticosteroids Biological response modifiers Antibiotics

Antibiotics The goal of therapy during the initial and disseminated stages of Lyme disease is to eradicate the organism causing the infection with antibiotic therapy. Common antibiotics prescribed, sometimes for up to 30 days, include doxycycline, amoxicillin, and erythromycin. None of the other types of therapy listed are focused on this outcome.

Question 12 of 17 Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? Arranging for a health care worker to directly observe the client take the drugs Giving the client written instructions about how and when to take the drugs Instructing the client about the consequences of not taking the drugs Having the client repeat the drug names and side effects

Arranging for a health care worker to directly observe the client take the drugs The most effective action for the nurse to take to ensure that the client complies with the treatment regimen is to arrange for the client to be directly observed during therapy. The heroin addiction reduces the client's likelihood of adherence to long-term treatment unless closely supervised while taking the drugs.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Even if the client can state the names and side effects of the drugs does not indicate understanding of the importance of this therapy.

Question 5 of 12 A client who has undergone breast surgery is struggling her sexuality. How will the nurse address the client's concerns? Remind the client the she needs to avoid sexual intercourse at this time. Ask the client if she is using her surgery as an excuse not to avoid intercourse. Give the client a business card for a local counselor. Ask the client about satisfaction with sexual relations with her partner.

Ask the client about satisfaction with sexual relations with her partner. The appropriate way the nurse will address the client's concerns about sexuality after undergoing breast surgery is to ask the client about her satisfaction with sexual relations with her partner.It is inappropriate to insinuate or ask if the client is using surgery as an excuse. Reminding the client that she needs to avoid intercourse for a period of time after surgery is accurate information, yet this does not address her concern. Giving the client a business card for a local counselor may be a later intervention; at this time, it does not address the client's concern.

Question 13 of 18 A client returns to the neurosurgical floor after undergoing a traditional anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Check the client's ability to void. Administer pain medication. Assist with ambulation. Assess airway and breathing.

Assess airway and breathing. The nurse's first action when a client returns to the neurosurgical floor after having an anterior cervical diskectomy is to assess the airway and breathing. Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing.Administration of pain medication, ambulation, and assessing the client's ability to void are important but are not the highest priority.

Question 2 of 20 A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What would the nurse do first? Perform a focused neurologic assessment. Position the client in a sitting position. Assess airway, breathing, and circulation. Call the primary health care provider.

Assess airway, breathing, and circulation. When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team (RRT), not the primary health care provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for the RRT to assess and begin treatment. This does not need to be a seated position.

Question 15 of 21 A client who had a right elective above-the-knee amputation reports severe pain in the right lower leg and foot. What is the nurse's best action at this time? Assess the level of the client's pain. Change the subject and talk about the client's hobbies. Distract the client with stories about the nurse's family. Remind the client that the lower leg was removed.

Assess the level of the client's pain. The nurse should recognize that the pain (phantom limb pain) is real to the client and perform a pain assessment in preparation for pain management. The other options are not examples of acknowledging the client's concern or therapeutic responses to the client in this situation.

Question 14 of 22 A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? Strict monitoring of hourly intake and output Decreasing environmental stimuli Managing pain through drug and nondrug methods Assessing neurologic status at least every 2 to 4 hours

Assessing neurologic status at least every 2 to 4 hours The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2 to 4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status.Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority; however, intake and output must be monitored.

15 of 29 What is the appropriate action for the nurse to take when a client's leukocyte count is 8200/mm3 (8.2 × 109/L) 8 weeks after hematopoietic stem cell transplantation for leukemia? Notifying the hematologic health care provider immediately Reminding the client to avoid crowds and people who are ill Documenting the report as the only action Assessing the client for other symptoms of infection

Assessing the client for other symptoms of infection The leukocyte (white blood cell) count is now within the normal range (5000 to 10,000/mm3) [5 to 10 × 109/L) and is an indicator of successful engraftment. The client is not at any particular risk for infection at this time, nor is this cause to believe that an infection is present. (At any posttransplantation checkup, the client is assessed for infection.)

Question 13 of 20 The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign or symptom would the nurse be most concerned about? Head laceration Headache Asymmetric pupils Amnesia

Asymmetric pupils The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache, and a head laceration can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.

Question 3 of 20 The nurse is caring for a client diagnosed with a vertebrobasilar artery stroke. What assessment finding would the nurse expect for this client? Ataxia Amnesia Unilateral neglect Aphasia

Ataxia Aphasia, amnesia, and unilateral neglect are common assessment findings associated with cerebral strokes. Clients who have vertebrobasilar artery strokes have dysfunctions of the cerebellum, such as ataxia, and possibly the brainstem. Clients with this type of stroke typically have weakness in all four extremities rather than one-sided weakness.

16 of 29 Which precaution is most important for the nurse to teach a patient with leukemia to prevent an infection by cross-contamination? Reporting any burning on urination immediately Taking antibiotics exactly as prescribed Avoiding crowds and people who are ill Performing mouth care three times daily

Avoiding crowds and people who are ill Infection by cross-contamination occurs when organisms from another person are transmitted to the client. This risk can be reduced for the neutropenic client by avoiding crowds and people who are ill (social distancing).Auto-contamination is the overgrowth of the client's own normal flora or the translocation of his or her normal flora from its normal location to a different one. Taking antibiotics does not prevent cross-contamination and neither does reporting symptoms of an infection. Performing mouth care frequently can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from auto-contamination but not cross-contamination.

Question 6 of 12 A client is struggling with body image after breast cancer surgery. Which behavior indicates to the nurse that the client's coping is maladaptive? Requesting a temporary prosthesis Avoiding eye contact with staff Saying, "I feel like less of a woman" Saying, "This is the ugliest scar ever"

Avoiding eye contact with staff Avoiding eye contact may be an indication of decreased self-image.The client stating that she feels like less of a woman or that her scar is ugly illustrates an expected emotional state. By verbalizing her frustration, the client suggests a willingness to discuss and express feelings. Requesting a prosthesis can be a sign of healing and working through body image changes.

Question 10 of 21 The nurse is teaching a client about the use of crutches following a foot fracture. When adjusting the crutches to ensure a correct fit, what action will the nurse take? Ensure that each crutch fits firmly into the client's armpit. Be sure that the top of each crutch is well padded. Use the crutch on the affected side only. Check to see how many steps the client can take with the crutches.

Be sure that the top of each crutch is well padded. The crutches are used a set and require that the nurse ensure that the client does not develop axillary nerve damage. The tops of the crutches should be well padded and should be at least 2 to 3 finger-breadths below the armpit.

Question 5 of 29 Which condition or event within the past 24 hours will the nurse identify as a possible cause of the current crisis episode in a client with sickle cell disease (SCD)? Participating in an archery tournament Spraining a wrist while stopping a fall Binge-drinking wine at a party Engaging in sexual intercourse

Binge-drinking wine at a party Common conditions that cause sickling that may lead to crises include hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, high altitudes, low or high environmental or body temperatures, acidosis, strenuous exercise, emotional stress, tobacco use (especially cigarettes), and anesthesia. Therefore binge-drinking is a strong possible trigger for the client's current crisis.Although strenuous exercise can induce a crisis, archery is not a strenuous activity that causes hypoxemia or acidosis. Sustaining a sprained wrist or engaging in sexual intercourse does not commonly induce a crisis.

Question 16 of 22 The nurse is reviewing the history of a client who has been prescribed topiramate for prevention of migraines. The nurse plans to contact the primary health care provider if the client has which condition? Diabetes mellitus Hypothyroidism Bipolar disorder Glaucoma

Bipolar disorder The nurse contacts the primary health care provider after reviewing the history of a client with bipolar disorder who has been prescribed topiramate. Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder.Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

Question 3 of 12 A 48-year-old woman with the BRCA genetic mutation requests information about early detection for her daughter due to genetic risk. Which information will the nurse convey? Breast self-examination (BSE) beginning at 20 years of age is the best way to detect breast cancer. Hormone replacement therapy (HRT) combining estrogen and progesterone may be recommended by your daughter's primary health care provider. Cancer screening for the daughter would begin at age 38. The health care provider will discuss prophylactic mastectomy as the definitive option for prevention.

Cancer screening for the daughter would begin at age 38. Women with a high family history risk for developing breast cancer need to begin cancer screening at an age that is 10 years younger than the age at which the affected cancer client was initially diagnosed. For the daughter of a 48-year-old woman, her screening should begin at 38 years old.BSE is an option for everyone, not just those at high genetic risk for breast cancer. However, it is not the best way to detect breast cancer. Use of HRT containing both estrogen and progestin increases risk, but risk diminishes after 5 years of discontinuation. Although prophylactic mastectomy may be discussed with the daughter, it is not a definitive option. That is left to the client's choice.

Question 9 of 16 The nurse is preparing a client for a total hip arthroplasty today. What IV antibiotic would the nurse likely administer if the client has no drug allergies? Penicillin Clindamycin Vancomycin Cefazolin

Cefazolin Cephalosporins are the drug class of choice for clients without allergies who are having a total joint arthroplasty.

Question 11 of 16 The nurse is caring for a client who has a continuous femoral nerve blockade following a total knee arthroplasty. What nursing assessment does the nurse need to perform to ensure client safety? Monitor vital signs frequently to detect early complications. Perform focused cardiovascular and respiratory assessments. Check that the client can dorsiflex and plantar flex the foot on the operative leg. Monitor for excessive blooding and bruising during the infusion.

Check that the client can dorsiflex and plantar flex the foot on the operative leg. To ensure that the client is not receiving excessive anesthesia, the client should be able to dorsiflex and plantar flex the foot on the operative leg. The purpose of the continuous femoral nerve blockade is to help control postoperative pain.

Question 18 of 21 A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is essential for the nurse to take first? Check the dorsalis pedis pulses. Administer the prescribed analgesic. Place a dressing on the affected area. Immobilize the left leg with a splint.

Check the dorsalis pedis pulses. The essential nursing action is to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised.Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

Question 3 of 17 Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? Chest tightness and SpO2 of 86% Productive cough and yellow-colored sputum Anorexia and weight loss Intermittent fever and sweating

Chest tightness and SpO2 of 86% Symptoms of COVID-19 are similar to those of seasonal asthma. However, the inflammatory responses occurring in the lungs with serious COVID-19 infection causes lung stiffness with chest tightness and greatly reduced gas exchange. The other symptoms are not specific to COVID-19 or other pandemic respiratory infections.

Question 14 of 17 Which drug will the nurse expect to teach about to a client who has been exposed to inhalation anthrax but does not have symptoms? Vancomycin Oseltamivir Rifampin Ciprofloxacin

Ciprofloxacin The most recommended drug therapy for prophylaxis after exposure to inhalation anthrax is oral ciprofloxacin. Vancomycin is an intravenous drug used for treatment of actual anthrax infection. Oseltamivir is an antiviral agent, and rifampin is a first-line drug for treatment of tuberculosis.

Question 10 of 22 A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What health problem does the nurse suspect may be occurring? West Nile virus Stroke Meningitis Classic migraine

Classic migraine The nurse suspects that a classic migraine could be present when an ED client complains of frontal-temporal pain preceded by a visual disturbance. These symptoms are most typical of a classic migraine.Meningitis may present with a headache and visual disturbance but is usually accompanied by nuchal rigidity (neck stiffness) and fever. The symptoms of stroke will vary depending upon the area affected. Mild cases of West Nile virus may be asymptomatic or present with flulike symptoms, whereas severe cases may lead to loss of consciousness and death.

Question 9 of 17 Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? Client has been afebrile for 48 hours. Oxygen saturation ranges between 90% and 92% on room air. White blood cell count is 16, 000 cells/mm3 (16 × 109/L). Bronchial breath sounds present in lung periphery.

Client has been afebrile for 48 hours. A positive outcome is indicated by the client having been afebrile for 48 hours.Bronchial breath sounds in lung peripheral areas are abnormal. The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The listed count is elevated and indicates continuing infection. The normal oxygen saturation is expected to be above 95%.

Question 10 of 12 Which client being cared for on the medical-surgical unit is appropriate for the nurse to assign to a nurse who has floated from the intensive care unit (ICU)? Recent radical mastectomy client requiring chemotherapy administration Modified radical mastectomy client needing discharge teaching Client with a Jackson-Pratt drain who had a mastectomy yesterday Stage III breast cancer client requesting information about radiation and chemotherapy

Client with a Jackson-Pratt drain who had a mastectomy yesterday The appropriate client to assign to a nurse who has been floated from the ICU to the medical-surgical unit is the one with a Jackson-Pratt drain who had surgery yesterday. This nurse would be most familiar with postoperative monitoring and care of surgical clients.The other clients are better served by the nurse who regularly cares for those who have cancer, receive radiation and or chemotherapy, and/or have mastectomy.

Question 6 of 11 The nurse is caring for four clients with eye concerns. Which client, who has a family history of an eye disorder, does the nurse identify at risk for increased intraocular pressure (IOP)? Client with family history of diabetic retinopathy Client with family history of anisocoria Client with family history of presbyopia Client with family history of glaucoma

Client with family history of glaucoma Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year.Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population. This condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects. Increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

Question 2 of 21 A client had a fractured tibia repair several weeks ago and tells the nurse that she has persistent burning pain, ongoing edema, and muscle spasms in her affected leg. For which chronic complication is the client at risk? Chronic osteomyelitis Complex regional pain syndrome Severe osteoporosis Compartment syndrome

Complex regional pain syndrome When pain is not managed appropriately or interventions are not implemented to prevent complex regional pain syndrome (CRPS), the client is at risk for developing CRPS, a chronic debilitating complication of traumatic injury.

Question 6 of 11 Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast? Arthroscopy Electromyography (EMG) Computed tomography (CT) Tomography

Computed tomography (CT) A CT scan creates three-dimensional images and may be done with iodine-based contrast.Arthroscopy, EMG, and tomography do not use iodine-based contrast.

Question 2 of 11 Which body area on a client with darker skin is most appropriate for the nurse to examine for indications of pallor and cyanosis? Earlobes and bridge of the nose Palms and soles Conjunctiva of the eyes Tongue

Conjunctiva of the eyes Pallor and cyanosis are more easily detected in adults with darker skin by examining the oral mucous membranes and the conjunctiva of the eye, not the palms of the hands or soles of the feet (although petechiae may be more apparent there). The tongue is a poor indicator of pallor or cyanosis although changes in texture and color may indicate other hematology problems.

Question 8 of 20 A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How would the nurse help the client compensate? Approach the client on the affected side. Place objects in the client's field of vision. Encourage turning the head from side to side. Cover the affected eye, if possible.

Cover the affected eye, if possible. The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch may help reduce diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.

Question 18 of 22 The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse? Severe unrelenting headaches Photophobia during the day Periodic nystagmus Decreased level of consciousness

Decreased level of consciousness Unlike the other assessment findings, decreased level of consciousness is life threatening and would be of greatest concern to the nurse.

Question 11 of 20 The nurse is monitoring a client admitted with a closed traumatic brain injury for indications of increasing intracranial pressure. Which assessment finding would the nurse report to the primary health care provider immediately? Decreased level of consciousness (LOC) Blood pressure of 140/88 Temperature of 100° F (37.8° C) Apical pulse of 90 and regular

Decreased level of consciousness (LOC) The first and most important assessment finding associated with increased intracranial pressure that should be reported immediately to the primary health care provider is a decrease in LOC. The vital signs in the choices are near normal and not of great concern.

uestion 4 of 29 Which assessment finding will the nurse associate as a complication of a client having three episodes of sickle cell crisis in the past 3 months? Deeply yellowed sclera Worsening hypertension Several episodes of priapism Increased deep tendon reflexes

Deeply yellowed sclera Many red blood cells are lysed and destroyed during crises, which can greatly increase the bilirubin concentration in the blood. After three crises close together, the elevated bilirubin levels result in jaundice, which may manifest as deeply yellowed sclera.Clients with sickle cell disease are more likely to be hypotensive because of the anemia, not hypertensive. Priapism is a random event not associated with a crisis. When crises cause brain infarctions or strokes, deep tendon reflexes are reduced.

Question 9 of 11 How will the nurse interpret a client's laboratory finding of an increased total iron-binding capacity (TIBC)? Increased risk for clot formation Deficient circulating and stored iron levels Iron excess Decreased bone marrow function

Deficient circulating and stored iron levels TIBC measures how much iron could be bound to transferrin. When this value increases, a client is deficient in serum iron and stored iron levels and less is bound to the transferrin.Changes in TIBC do not reflect actual bone marrow function. Clot formation does not increase with higher TIBC.

Question 4 of 16 The nurse is assessing an older adult client who has severe kyphosis. What psychosocial client problem would the nurse anticipate? Dementia Bipolar disorder Psychosis Depression

Depression Clients who have severe kyphosis often have poor self-esteem and body image. Many clients are afraid to go out of their homes and socially interact and are concerned about possible falls. As a result, depression can occur.

25 of 29 Which drugs does the nurse anticipate giving as premedication to client who is to receive a pooled platelet transfusion and has had a previous transfusion reaction? Vitamin K and a diuretic Diphenhydramine and acetaminophen Aspirin and hydroxyurea Hydrocortisone and antihypertensives

Diphenhydramine and acetaminophen A client who has had a transfusion reaction in the past may be given diphenhydramine and acetaminophen before the transfusion to reduce the fever and severe chills (rigors) that often occur during platelet transfusions.

14 of 29 What is the nurse's interpretation of when the blood laboratory values a client who has chronic myelogenous leukemia (CML) shows a high percentage of blast cells and promyelocytes? Infection risk is decreasing. Disease is progressing. Leukemia type is now lymphocytic.

Disease is progressing. The leukemia is progressing and drug therapy is no longer effective. CML has three phases: The chronic phase is often a slowly progressing (indolent) course with fewer than 10% blast cells at this time. The accelerated phase has progressive symptoms with 10% to 30% blast cells and poor response to therapy. The blast phase indicates transformation to a very aggressive acute leukemia with more than 30% blast cells that commonly spread to other tissues and organs. The leukemia becomes more like acute leukemia than chronic leukemia but does not change from myelogenous to lymphocytic. With so many blast cells that are immature and do not function properly, the client is now at greatly increased risk for infection.

Question 3 of 29 Which new-onset symptom in a client with sickle cell disease (SCD) will the nurse report immediately to the health care provider to prevent harm? Distention of neck veins in the sitting position Itching of the extremities Priapism lasting 30 minutes Increased urinary output

Distention of neck veins in the sitting position Clients with SCD are at risk for heart failure. One of the major symptoms of heart failure, which can be a life-threatening complication, is distention of the neck veins when the client is in the upright position. The nurse will report this change immediately so that proper management of heart failure can begin to prevent multiple organ system dysfunction and death.Although prolonged priapism is a condition requiring urgent intervention, 30 minutes is not considered prolonged. An increased urinary output may indicate decreased concentrating function of the kidney, but is not an emergent change. Most clients with SCD have skin dryness on the extremities as a result of reduced perfusion. This could also be related to increased bilirubin in the skin resulting from red blood cell lysis; however, it does not require urgent management.

Question 7 of 11 What action will the nurse take when a client's laboratory results indicate the platelet count is 180,000/mm3 (180 × 109/L)? Apply oxygen to improve gas exchange. Document the result as the only action. Instruct assistive personnel (AP) to handle client gently. Immediately inform the health care provider because of possible spontaneous bleeding.

Document the result as the only action. The client's platelet count is within the normal limits and requires no action beyond ensuring documentation. This value is at the lower end of the normal range but does not increase the client's risk for excessive bleeding or bruising even after trauma.

Question 25 of 28 Which action is most appropriate for the nurse to take first when the water seal chamber of the chest drainage device in a client who had a lobectomy has small bubbles when the client coughs the appropriate action by the nurse? Add additional sterile water to the water seal chamber Checking the tubing for blood clots Briefly increasing the amount of suction Documenting the finding in the medical record

Documenting the finding in the medical record The nurse recognizes that gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. This indicates air is leaving the pleural space which is the intended purpose of the chest drain.Bubbling in the water seal chamber is absent if a kink or a blockage is present because air would not be able to escape from the chest cavity. Increasing the amount of suction without an order could damage lung tissue. There is no indication that the level of fluid in the water seal chamber is low.

Question 8 of 17 Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? Assessing the need for an immediate dose of lorazepam Requesting a referral to a social worker for alcohol counseling Drawing blood for aerobic and anaerobic blood cultures Administering intravenous antibiotic

Drawing blood for aerobic and anaerobic blood cultures The nurse will first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed to identify the specific causative organism. Initiating antibiotic therapy before cultures are obtained could affect the results of the culture and possibly delay identification an antibiotic more for the infection. Thus, antibiotic therapy is started after blood for cultures is obtained.Unless this client is a danger to self or staff, giving lorazepam for agitation is not the first action. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

13 of 29 Which action will the nurse perform first when caring for a client with neutropenia who has a suspected infection? Administering prescribed antibiotics Administering IV normal saline for hydration Placing the client on Contact Precautions Drawing blood for cultures

Drawing blood for cultures The priority action for the nurse to take is to draw blood cultures for cultures to identify the infectious agent. This must be done before administering prescribed antibiotics.Placing the client on Contact Precautions is unnecessary because the neutropenic client is not contagious to others. Hydration is important but not the first priority.

Question 12 of 18 A client with severe muscle spasticity has been prescribed tizanidine. The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hypertension Tachycardia Hirsutism

Drowsiness Adverse effects of tizanidine include drowsiness and sedation because the drug is a centrally acting skeletal muscle relaxant. It does not cause hirsutism, hypertension, or tachycardia.

Question 8 of 16 The nurse assesses a client diagnosed with Sjögren syndrome. The nurse anticipates that the client will also have which symptom? Excessive production of saliva in the mouth Intermittent episodes of diarrhea Abdominal bloating after eating Dry eyes

Dry eyes Clients with Sjögren syndrome experience dry eyes (keratoconjunctivitis sicca), dry mouth, and if female, dry vagina.

Question 5 of 16 The nurse is teaching a postmenopausal client about the need for bone health and screening. What diagnostic test would the nurse recommend? Serum Vitamin D Dual x-ray absorptiometry (DXA) Serum calcium and phosphorus Vertebral x-rays

Dual x-ray absorptiometry (DXA) The DXA scan screens for bone loss and provides a score to indicate the amount of loss, if any. It is a noninvasive test performed every 2 years to monitor for bone loss as one ages.

Question 2 of 14 Which signs and symptoms does the nurse expect to find in a client diagnosed with Pneumocystis jiroveci infection? Dyspnea, tachypnea, persistent dry cough, and fever Substernal chest pain and difficulty swallowing Fever, persistent cough, and vomiting blood Cough with copious thick sputum, fever, and dyspnea

Dyspnea, tachypnea, persistent dry cough, and fever P. jiroveci causes pneumonia with dry cough, shortness of breath, breathlessness, and fever. Thick sputum and vomiting blood are not present. Substernal chest pain and difficulty swallowing are associated with an oral and esophageal candida infection. Vomiting blood is not associated with any type of pneumonia.

Question 2 of 12 A client tells the nurse in the gynecology clinic that she doesn't get a yearly mammogram because she is afraid of what might be found. Which teaching will the nurse provide? People with low breast cancer risk can obtain an MRI instead. Detection of breast cancer before or after axillary node invasion yields the same outcome. Mammography is needed only if the client has a first-degree relative with breast cancer. Early detection is important, as localized breast cancer has a 99% 5-year survival rate

Early detection is important, as localized breast cancer has a 99% 5-year survival rate The purpose of screening is early detection of breast cancer before it spreads. Early detection is the key to effective treatment and survival. The nurse will teach that the 5-year survival rate for localized breast cancer is 99%, so early detection is critical.MRI is used for screening high-risk women and better examination of suspicious areas found by a mammogram. Recommending the client to an MRI does not address her fear. Detection of breast cancer before axillary node invasion increases the chance of survival. Mammography is recommended for all women, not just those with a first-degree relative with breast cancer.

Question 11 of 16 The nurse is reviewing the laboratory test results of a client with a recently diagnosed osteosarcoma. What abnormal laboratory finding would the nurse expect for this client? Elevated alkaline phosphatase Decreased hematocrit Increased calcium Increased white blood cell count

Elevated alkaline phosphatase An osteosarcoma is a type of primary malignant bone tumor. Alkaline phosphatase is an enzyme that is released from the bone when it is diseased or damaged. All of these lab values would be expected in clients who have bone metastasis.

Question 4 of 20 The nurse is caring for a client who has a left middle cerebral artery stroke. During shift assessment, the client begins to cry unexpectedly after laughing. What would the nurse suspect that the client is experiencing? Anxiety Delirium Emotional lability Depression

Emotional lability Emotional lability is present when the client's emotions change quickly and are not necessarily reflective of the client's mood or a particular situation. This problem is common in clients who have cerebral artery strokes.

Question 12 of 22 A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What would the nurse do first? Administer phenytoin. Draw the client's blood. Start an intravenous (IV) line. Establish an airway.

Establish an airway. When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure.Phenytoin is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

Question 16 of 20 A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A-V-P-U F-A-S-T K-I-N-D P-Q-R-S-T

F-A-S-T The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.

Question 14 of 21 The nurse is caring for a client immediately after a vertebroplasty. In what position would the nurse most likely place the client? Prone for the first 1 to 2 hours High-Fowler for the first hour Side-lying for the first 2 hours Flat supine for the first 1 to 2 hours

Flat supine for the first 1 to 2 hours The flat supine position provides support for the percutaneous or minimally invasive surgical procedure.

Question 2 of 11 Which eye procedure requires the nurse to assure that informed consent has been obtained from the client? Ophthalmoscopy Fluorescein angiography Snellen test Eyedrop instillation

Fluorescein angiography Fluorescein angiography is an invasive test and requires informed consent from the client.Eyedrop instillation, ophthalmoscopy, and the Snellen test are not invasive procedures and do not require informed consent from the client.

Question 5 of 22 Which is the most effective way for a college student to minimize the risk for bacterial meningitis? Avoid large crowds. Get the meningococcal vaccine. Take a high dose vitamin C daily. Take prophylactic antibiotics.

Get the meningococcal vaccine. The most effective way for a college student to minimize the risk for bacterial meningitis is to get the meningococcal vaccine. Individual's ages 16 to 21 years have the highest rates of meningococcal infection and need to be immunized against the virus.Avoiding large crowds is helpful, but is not practical for a college student. Taking a high dose of vitamin C every day does not minimize the risk of bacterial meningitis. However, maintaining a healthy lifestyle, with adequate sleep and nutrition, can improve immunity. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

Question 3 of 16 The nurse is caring for a client with an inflamed, reddened, and severely painful first metatarsal joint. With what type of arthritis are these signs and symptoms associated? Rheumatoid arthritis Infectious arthritis Gouty arthritis Osteoarthritis

Gouty arthritis Clients who have gout (also called gouty arthritis) experience severe inflammation in small joints, especially the metatarsal of the great (first) toe. Gout results when urate crystals created by errors in purine metabolism deposit in small synovial joints

Question 17 of 22 The nurse is providing medication instructions for a client for whom phenytoin has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Grape juice Grapefruit juice Apple juice Prune juice

Grapefruit juice The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity.Apple, grape, and prune juices are not contraindicated for a client taking phenytoin.

Question 15 of 18 A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Help the client sit up. Check for fecal impaction. Loosen the client's clothing. Insert a straight catheter.

Help the client sit up. The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

Question 1 of 20 The nurse is caring for a client who has a cerebral artery aneurysm. For what complication is the client at risk? Traumatic brain injury Brain cancer Hemorrhagic stroke Embolic stroke

Hemorrhagic stroke Aneurysms cause the arterial wall to be weak and thin which can lead to blood vessel rupture or hemorrhage. Therefore, an aneurysm in the brain can rupture and cause a hemorrhagic stroke.

Question 6 of 16 The nurse is caring for a client with osteoarthritis who reports severe pain in both knees. What nonpharmacologic intervention is the most appropriate for the nurse to recommend for this client? Massage and hypnosis. Hot compresses or moist heating pad. Glucosamine and chondroitin combination. Ice packs used every 3 to 4 hours during the day.

Hot compresses or moist heating pad. Heat sources such as compresses and heating pads cause vasodilation which promotes healing in the affected joints. Ice is best for inflamed joints rather than those that are degenerative. Glucosamine and chondroitin are integrative therapies that help some clients but their effectiveness has not been validated. Massage would be painful and hypnosis may or may not be helpful, depending on the client.

Question 22 of 28 Which laboratory finding does the nurse expect in a client who has metastatic lung cancer and new-onset back pain? Hypernatremia Hypercalcemia Hyperglycemia Hyperkalemia

Hypercalcemia Hypercalcemia is the result of increasing parathyroid hormone as a paraneoplastic complication of lung cancer as well as bone metastasis, which is suspected in the presence of back pain.Paraneoplastic syndromes are manifested by Cushing's syndrome, weight gain and dilution of electrolytes (SIADH) with resulting hyponatremia. Gynecomastia and hypoglycemia may also occur. Hyperkalemia most typically occurs with tumor lysis syndrome where multiple electrolyte imbalances develop impaired renal function and oliguria.

uestion 11 of 29 Which electrolyte imbalance will the nurse expect to find in a client with polycythemia vera (PV)? Hyperkalemia Hypokalemia Hyponatremia Hypernatremia

Hyperkalemia The actual number of circulating red blood cells is greatly increased in PV, but the cells are not normal and have shorter cell life spans. This problem leads to rapid cell turnover and excessive release of intracellular substances, including potassium. The increased potassium level is hyperkalemia, not hypokalemia. Blood sodium levels are unaffected by high turnover of red blood cells.

24 of 29 Which signs and symptoms in an older client receiving a blood transfusion indicate to the nurse that the client is experiencing transfusion-associated circulatory overload (TACO)? Urticaria, itching, and bronchospasm Hypertension, bounding pulse, and distended neck veins Headache, chest pain, and hemoglobinuria Fever, chills, and tachycardia

Hypertension, bounding pulse, and distended neck veins Older clients are much more at risk for TACO than younger clients. Common symptoms include hypertension, bounding pulse, distended jugular veins, dyspnea, restlessness, and confusion.Headache, chest pain, and hemoglobinuria are symptoms of a hemolytic transfusion reaction. Urticaria, itching, and bronchospasm are symptoms of allergic transfusion reactions. Fever, chills, and tachycardia are symptoms of bacterial transfusion reactions.

Question 7 of 17 Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? Productive cough and normal temperature Flushed cheeks and increased respiratory rate Hypotension and rapid, weak pulse SpO2 of 86% and confusion

Hypotension and rapid, weak pulse Hypotension and a rapid, weak pulse are indications of dehydration with possible impending sepsis and shock. This condition all result in poor perfusion and can progress to extreme hypoxemia and death. These symptoms require immediate attention and intervention.The other symptoms are expected with pneumonia and do not represent rapid progression to a more serious problem.

Question 4 of 12 The nurse is instructing a client with breast cancer who will be undergoing chemotherapy about the side effects of doxorubicin. Which teaching will the nurse provide? Report any symptoms of fatigue, cough, or edema to the oncologist. There are very few side effects associated with this agent. Doxorubicin is a type of selective estrogen receptor modulator (SERM). If side effects arise, they begin within 2 days of chemotherapy administration.

If side effects arise, they begin within 2 days of chemotherapy administration. Doxorubicin has cardiotoxic effects; clients must be instructed to be aware of and to report edema, shortness of breath, chronic cough, and excessive fatigue right away.There are indeed side effect associated with doxorubicin. The side effects of fatigue, cough, and edema can manifest even up to 2 years posttreatment. Doxorubicin is not a SERM; it is a topoisomerase inhibitor antineoplastic agent.

Question 5 of 20 A client has been admitted with a diagnosis of stroke. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Quick to anger and frustration Inability to discriminate words Aphasia and cautiousness Impulsiveness and smiling

Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.

Question 7 of 29 Which laboratory trend indicates to the nurse that drug therapy with hydroxyurea is effective in the client who has sickle cell (SCD)? Increasing hemoglobin-F levels Decreasing blood osmolarity Increasing platelet levels Increasing blood iron levels

Increasing hemoglobin-F levels Hydroxyurea has been successfully used to reduce the number of sickling and pain episodes. Hydroxyurea works by stimulating fetal hemoglobin (HbF) production. HbF is present during fetal development, but production of hemoglobin F is turned off before birth. Increasing the level of HbF reduces sickling of red blood cells in persons with sickle cell disease.Hydroxyurea does not reduce blood osmolarity or increase platelet numbers. Clients with SCD are not iron-deficient and do not need therapy to increase blood iron levels.

Question 10 of 17 What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? Increasing the flow rate of the IV piggy-back antibiotic Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes Assisting the client to a more upright position Reporting the change in status to the client's primary health care provider

Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes The client is becoming increasingly hypoxemic and needs more supplemental oxygen. After oxygen delivery is increased, the nurse will determine the client's response to this action.Although moving the client to a more upright position is not harmful and can increase oxygenation, it is not as effective in managing hypoxemia as increasing the oxygen flow rate. It should be the second action, not the first. Although the pneumonia may be worsening, giving the IV antibiotic at a faster rate is not going to make an immediate difference. In addition, infusing it faster may increase the risk for side effects and adverse effects. Before notifying the primary health care provider, the nurse will assess the client's response to increased oxygen flow rate. If the oxygen saturation has not improved or has decreased further in 5 minutes, the nurse would then immediately notify the primary health care provider.

Question 9 of 21 The nurse is caring for a client who has an external fixator for an open fracture of the tibia and fibula. What is the nurse's priority for care related to the fixator? Inspect the pins to monitor for infection and do not remove crusts. Make sure that the wound is managed using a moist wound healing method. Keep the leg covered to keep the extremity warm to promote circulation. Keep the extremity elevated to three pillows while in bed or in a chair.

Inspect the pins to monitor for infection and do not remove crusts. An external fixator is a series of pins attached to a metal frame to hold the bone ends in place while the wound can be managed. The nurse would frequently monitor the pin insertion sites for signs and symptoms of infection. Crusting that occurs at the sites should not be removed because it helps seal the open pin site areas to prevent infection. Leg elevation is important but the client would not necessarily need three pillows.

Question 12 of 21 A client is in skeletal traction for a complex femoral fracture. Which nursing intervention ensures proper care of this client? Ensure that weights are placed on the floor. Remove the traction weights only for bathing. Ensure that pins are not loose and tighten as needed. Inspect the skin at least every 8 hours.

Inspect the skin at least every 8 hours. The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown.Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

Question 6 of 29 Which medication will the nurse prepare to administer to a client who is in sickle cell crisis and requests "something for pain"? Intramuscular (IM) meperidine Intravenous (IV) hydromorphone Oral ibuprofen Oral morphine sulfate

Intravenous (IV) hydromorphone The client with sickle cell crisis needs immediate pain relief, usually an opioid, which is most effective when administered intravenously.NSAIDs may be used for clients with SCD for pain relief once their pain is under control, but not during a crisis. Meperidine is no longer a first-line drug for pain management.

Question 7 of 22 A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? Telling his wife what the client needs Involving the client and his wife in developing a plan of care Writing up a detailed plan of care according to standards Setting up visitations by a home health nurse

Involving the client and his wife in developing a plan of care The discharge plan most effective when discharging a client home with his spouse is to involve both the client and his wife in developing the plan of care. Involving the client and spouse in drawing up a plan of care is the best way to ensure success with the management plan.Home health nurse visitations are generally helpful but may not be needed for this client. The management plan must be collaborative and include not only the spouse but also the client to ensure buy-in. Evidence-based guidelines would be utilized.

Question 6 of 21 An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? Keep the client's heels off the bed at all times. Reposition the client every 3 to 4 hours. Avoid the use of antiembolism stockings. Administer pain medication before deep-breathing exercises.

Keep the client's heels off the bed at all times. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area.Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings or sequential compression devices are used for older adults to help prevent venous thromboembolism (VTE).

Question 13 of 21 A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse would instruct the client to notify the primary health care provider immediately if which change occurs? Absence of erythema and tenderness at the surgical site Ability to flex and extend the right knee Large amount of serosanguineous or bloody drainage Mild to moderate pain controlled with prescribed analgesics

Large amount of serosanguineous or bloody drainage A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention.Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

Question 4 of 11 When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor would be the priority for client teaching? Low calcium intake Postmenopausal status Positive family history Previous use of steroids

Low calcium intake The client's calcium and vitamin D intake is the priority risk factor that the client can change. The nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake.Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the client can change. These risk factors should be discussed but are not the priority for this client.

Question 3 of 22 The nurse is planning health teaching for a client starting on donepezil for Alzheimer disease (AD). For which side effect will the nurse teach the family to monitor? Low pulse rate Elevated body temperature Low oxygen saturation High blood pressure

Low pulse rate Donepezil and other cholinesterase inhibitors can cause bradycardia and possible heart failure. Therefore, the family needs to monitor the client's pulse rate for a decrease.

Question 7 of 11 A client is admitted to the emergency department with metal shards in the right eye. Which diagnostic test ordered by the health care provider does the nurse question? Radioisotope scanning Snellen chart Magnetic resonance imaging (MRI) Ophthalmoscopy

Magnetic resonance imaging (MRI) Because the client has metal in the eye, MRI is an absolute contraindication.Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

Question 14 of 20 A client has had a traumatic brain injury and is mechanically ventilated. Which technique would the nurse use to prevent increasing intracranial pressure (ICP)? Place the client in the Trendelenburg position. Suction the client frequently and as needed. Maintain neutral head position. Assess for Grey Turner sign.

Maintain neutral head position. To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.

Question 15 of 20 The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone Mannitol Phenytoin Hydrochlorothiazide

Mannitol In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema.Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.

Question 11 of 21 A client sustains a fracture of one arm and the primary health care provider applies a synthetic cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? Monitor neuromuscular status for decreased circulation and sensation in the extremity. Check the fit of the cast by inserting a tongue blade between the cast and the skin. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. Keep the cast covered with a soft towel to help it to dry quickly.

Monitor neuromuscular status for decreased circulation and sensation in the extremity. The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. The cast dries quickly because it is made of synthetic materials.

Question 3 of 21 A client in the emergency department receives moderate sedation while having a closed reduction of a fractured ankle. What is the nurse's priority assessment during this procedure? Check the client's blood pressure frequently. Monitor the client's pain level. Monitor the client's respiratory rate. Perform circulation checks before and after the procedure.

Monitor the client's respiratory rate. The drugs used for moderate sedation can suppress respiratory rate which requires constant monitoring during the procedure. The client should not feel any pain.

Question 10 of 20 A client is admitted with a stroke. Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Intracranial pressure monitor Mini-Mental State Examination (MMSE) National Institutes of Health Stroke Scale (NIHSS) Glasgow Coma Score (GCS)

National Institutes of Health Stroke Scale (NIHSS) The nurse uses the NIHSS tool to perform a focused neurologic assessment. Primary health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a nonspecific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.

Question 14 of 16 A client is admitted to the same-day surgical center PACU after a bunionectomy. After assessing the client's ABCs, what is the priority assessment for the client? Muscle strength assessment Joint assessment Neurovascular assessment Neurologic assessment

Neurovascular assessment The client had foot surgery and would have a bulky surgical dressing placed on the area to prevent bleeding. The nurse would want to frequently assess the neurovascular status of the operative foot as the priority.

Question 14 of 18 The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? Nifedipine Dopamine hydrochloride Ziconotide Methylprednisolone

Nifedipine The nurse anticipates that the primary health care provider will prescribe nifedipine or nitrates for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride is an inotropic agent used to treat severe hypotension. Methylprednisolone is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

Question 7 of 12 The nurse at the gynecology clinic is examining a woman's breasts. Which assessment finding requires immediate notification of the primary health care provider? Backache and breast fungal infection Ill-defined painful rubbery lump in the outer breast quadrant A 1-cm freely mobile rubbery mass discovered by the client Nipple discharge and dimpling

Nipple discharge and dimpling Nipple discharge and dimpling are high-risk assessment findings for a malignant breast lesion that requires immediate notification of the primary health care provider.On clinical examination, fibroadenomas as benign lesions are oval, freely mobile, rubbery masses usually discovered by the woman herself. Breast pain and tender lumps or areas of thickening in the breasts are typical symptoms of a fibrocystic breast condition. The lumps are rubbery, ill-defined, and commonly found in the upper outer quadrant of the breast. Many large-breasted women develop fungal infection under the breasts, especially in hot weather, because it is difficult to keep this area dry and exposed to air. Backaches from the added weight are also common. All of these findings will be documented and discussed with the health care provider; however, they do not require immediate notification.

Question 5 of 11 While reading a client's optical chart, the nurse notices that the client has emmetropia. Which assessment findings does the nurse anticipate? No corrective lenses; this is a normal finding Reading glasses Contact lenses Bilateral eye patches

No corrective lenses; this is a normal finding Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment.Eye patches, contact lenses, and reading glasses are not needed.

Question 19 of 29 Which assessment finding of a newly admitted client with thrombocytopenia requires immediate action by the nurse? Elevated temperature Pain rating of 8 on a 0 to 10 scale Nosebleed Decreased urine output

Nosebleed The assessment finding on a newly admitted client with thrombocytopenia that needs immediate action by the nurse is bleeding from the nose. The client with thrombocytopenia has a high risk for hemorrhage with any bleeding.The client's report of pain, decreased urine output, and temperature elevation are not the highest priority.

Question 23 of 28 Which problem experienced by a man with late-stage lung cancer is the priority for immediate action by the nurse? Anorexia and weight loss Pain rating of 9 on a 0-10 scale Constipation for 2 days Extreme fatigue

Pain rating of 9 on a 0-10 scale Although all the client problems list are distressing, effective pain management is the most important issue for this client. The constipation can be helped after pain control is achieved. The anorexia, weight loss, and extreme fatigue may not respond to any interventions in late-stage lung cancer.

Question 2 of 28 How will the nurse categorize the level of asthma control for a client who reports usually waking at night with wheezing once weekly and needing to use the prescribed reliever inhaler to stop the episode? Minimally controlled Partly controlled Controlled Uncontrolled

Partly controlled The client meets the criteria for partly controlled asthma, which are that any of these symptoms occur one to two times per week:Daytime symptoms of wheezing, dyspnea, coughingWaking from night sleep with symptoms of wheezing, dyspnea, coughingReliever (rescue) drug needed no more than twice weekly

Question 6 of 20 A client completed an alteplase infusion following a thrombotic stroke. What nursing action is appropriate? Insert an indwelling urinary catheter. Perform frequent neurologic assessments. Notify Radiology to schedule an MRI. Administer an antiplatelet agent.

Perform frequent neurologic assessments. After administering an alteplase infusion, the nurse performs a focused neurologic assessment, including vital signs, every 15 to 30 minutes, depending on agency protocol and the client's condition. Antiplatelet therapy is not started for at least 24 hours after infusion. A urinary catheter or other invasive tube can cause bleeding and should be avoided. The client would have a CT angiogram or perfusion scan before antiplatelet therapy is initiated.

Question 1 of 29 Which nursing action is most effective in reducing the potential for sepsis while caring for a client who has sickle cell disease (SCD)? Monitoring for abnormal laboratory values Checking vital signs every 4 hours Performing frequent and thorough handwashing Administering prophylactic drug therapy

Performing frequent and thorough handwashing The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia is to perform frequent and thorough handwashing. Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance.Taking vital signs every 4 hours will help with early detection of infection but is not prevention. Drug therapy is a major defense against infections that develop in the client with sickle cell disease but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention.

Question 1 of 11 Why does an abnormally low erythrocyte count reduce gas exchange? Pulmonary ventilation is reduced. Circulation to the peripheral tissues is reduced. Blood flow is obstructed from increased clot formation. Peripheral oxygen transport is reduced.

Peripheral oxygen transport is reduced. The major component of erythrocytes is hemoglobin, which is responsible for transporting oxygen through the blood to the tissues for tissue gas exchange. Fewer erythrocytes result in decreased oxygen transport although circulation to the peripheral tissues is unaffected.Clot formation is not increased, and pulmonary ventilation (movement of atmospheric air into and out from the lungs) is not affected.

Question 5 of 11 Which aspect of postoperative management will the nurse plan to discuss with a client about to undergo an arthroscopic repair of the knee? Pharmacy for client medications Physical therapy for exercises Social work for care coordination Registered dietitian for nutrition

Physical therapy for exercises The nurse and the physical therapist will discuss postoperative physical therapy with the client and will assess and collaborate on the postoperative exercises which will be necessary to establish ROM after the procedure.It is the nurse's responsibility to assess which medications the client is currently taking. Nutritional assessment is performed by the nurse, but this might also involve a dietitian if special needs exist. Unless there are postoperative complications or if the client has a variety of special needs, care coordination is not necessary.

Question 9 of 22 A client with Parkinson disease (PD) reports having auditory hallucinations. What drug would the nurse anticipate may be prescribed for the client? Ubrogepant Pimavanserin Phenytoin Levodopa

Pimavanserin Pimavanserin is a drug that is used when clients with PD have hallucinations. Phenytoin is used to manage seizures and ubrogepant is used for clients who have migraine headaches. Levodopa, usually in combination with carbidopa, is a commonly used drug for most clients at some time for their PD.

Question 2 of 17 Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? Tuberculosis Pneumonia Emphysema Heart failure

Pneumonia Pneumonia is the most common complication of seasonal influenza, especially among older clients. The symptoms of pneumonia include fever that does not resolve and acute confusion.Although heart failure is a complication of pneumonia, it is less common and not accompanied by fever. Neither emphysema nor tuberculosis is a complication of seasonal influenza.

Question 1 of 18 A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for the client at this time? Positioning the client to maximize ventilation potential Taking vital signs every 2 hours Inserting an indwelling urinary catheter Monitoring the client's nutritional status

Positioning the client to maximize ventilation potential The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3 to C5) innervate the phrenic nerve, controlling the diaphragm.

Question 13 of 22 The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? Positions the client on the side. Restrains the client. Forces a tongue blade in the mouth. Documents the length and time of the seizure.

Positions the client on the side. When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway.Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

tion 26 of 29 Which serum electrolyte will the nurse monitor most closely in a client who receiving four units of packed red blood cells (PRBCs) over the next 12 hours? Chloride Sodium Calcium Potassium

Potassium The electrolyte imbalance the nurse needs to monitor in a client after transfusing four units of PRBCs is hyperkalemia. During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

Question 2 of 22 The nurse is caring for a client with early stage (stage 1) Alzheimer disease (AD). Which nursing action is most appropriate when caring for this client? Provide a structured environment. Use validation therapy. Give a cholinesterase inhibitor. Refer the client to the social worker.

Provide a structured environment. The client who has stage 1 AD needs reality orientation rather than validation. A structured, consistent environment assists the client in self-care and prevents anxiety that could result from unfamiliar routines or environments. Drug therapy and social work referrals are appropriate for some clients, but all clients need structure.

Question 18 of 29 Which collaborative problem will the nurse consider to have the highest priority when caring for a client with multiple myeloma? Minimizing the side effects of chemotherapy Helping the client conserve energy Providing pain control Protecting the client from infection

Providing pain control All the listed collaborative problems are important; however, pain control has the highest priority for these clients. This disorder destroys bone and causes intense pain that interferes with mobility and greatly reduces all aspects of the client's quality of life.

Question 2 of 29 Which action will the nurse to perform first when caring for a female client who is in sickle cell crisis? Asking the client about possible triggers Teaching the client about barrier forms of contraception Ensuring adequate oral and IV fluid intake Providing pain medication

Providing pain medication The action the nurse would perform first for a client in sickle cell crisis is to provide pain medications as needed because the pain is often severe. Although ensuring adequate fluid intake is important, pain is managed first. Assessing for possible triggers and teaching about contraception are not priorities at this time.

Question 8 of 11 Which laboratory blood test results for a client undergoing hematologic assessment does the nurse report immediately to the prescriber? Platelets 185,000/mm3 INR 1.2 Red blood cell count 1.2 million/mm3 Hematocrit 36%

Red blood cell count 1.2 million/mm3 All of these test results are in the low to low-normal range. However, the parameter most abnormal is the red blood cell count. The normal range is 4.2 to 6.1 × 106/micL (4.2 to 6.1 × 1012cells/L. This client's value is dangerously below normal.

Question 10 of 29 Which foods will the nurse help the client with vitamin B12 deficiency to increase in the diet? Grains Unsaturated fats Red meat Starchy vegetables

Red meat The nurse encourages the client to increase foods such as animal proteins, fish, eggs, nuts, dairy products, dried beans, citrus fruit, and leafy green vegetables, as sources of vitamin B12.The other food items listed contain little, if any vitamin B12.

Question 8 of 29 With which member of the interprofessional team will the nurse collaborate when providing instructions for a client who has anemia cause by vitamin B12 acid deficiency? Registered dietitian nutritionist Mental health professional Physical therapist Wound care specialty nurse

Registered dietitian nutritionist The most common type of vitamin B12 acid deficiency anemia is caused by poor nutrition. This anemia is primarily managed is managed by teaching the client to increase his or her intake of foods rich in vitamin B12, although additional vitamin supplementation may be needed initially. A physical therapist is needed only in severe cases in which permanent nerve damage is present that interferes with mobility.

Question 10 of 18 Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injury? Special pressure-relief devices Frequent ambulation Encouraging nutrition Regular turning and repositioning

Regular turning and repositioning Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems.A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

Question 12 of 16 The nurse is caring for a female client who has a right wrist ganglion which is interfering with her ability to do her job as an administrative assistant. What collaborative treatment would the nurse anticipate for this client? Physical therapy Occupational therapy Removal of the ganglion Intravenous antibiotic therapy

Removal of the ganglion Because the ganglion cyst is interfering with the client's ability to work, the ganglion cyst would likely be removed rather than aspirated. Antibiotics are not appropriate and rehabilitation is not going to help remove her cyst.

Question 9 of 28 Which point is most important to prevent harm for the nurse to teach a client with chronic obstructive pulmonary disease (COPD) who is being discharged on home oxygen th Correct performance when setting up the oxygen delivery system Understanding the signs and symptoms of hypoxemia Demonstrating how to use a pulse oximetry device Removing combustion hazards present in the home

Removing combustion hazards present in the home The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards will be present in a room where oxygen is in use.The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client's oxygenation status and the visiting nurse or respiratory therapy partner can assess this.

Question 12 of 28 Which action is most important for the nurse to take when a client with chronic obstructive pulmonary disease who is taking a cholinergic antagonist now reports nausea, blurred vision, headache, and inability to sleep? Reporting the symptoms to the primary health care provider immediately Asking the client to explain the exact techniques he or she uses when taking the drug Requesting an order to draw blood to determine the drug level Reminding the client that these side effects are normal and not to worry

Reporting the symptoms to the primary health care provider immediately The symptoms the client describes represent a drug overdose placing the client in danger of even more adverse effects.It is possible that the client is taking the drug more frequently or at higher doses than prescribed; however, the first priority is to notify the primary health care provider. The drug is only taken as an inhalation and blood levels will not provide any useful information.

Question 1 of 21 The nurse is caring for an older client who has a large bulky lower leg dressing with posterior splint to maintain alignment after closed reduction for an ankle fracture. Which client assessment finding would the nurse report to the primary health care provider or Rapid Response Team immediately? Affected foot slightly cooler than the other foot. Reports pain level is 4 on a 0-10 pain intensity scale. Pedal pulse on affected foot is 1+ and regular. Reports tingling and numbness in affected foot.

Reports tingling and numbness in affected foot. This client is at risk for neurovascular compromise or compartment syndrome from the external dressing. Pain and a slightly cooler foot is to be expected. However, the client should not have tingling and numbness suggesting that arterial blood flow is diminished.

Question 2 of 18 To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? Nutritional therapy Physical therapy Respiratory therapy Occupational therapy

Respiratory therapy To help prevent death for a client with spinal cord injury, collaboration with the respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with respiratory therapy is crucial.Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

Question 10 of 11 Which client laboratory trend indicates to the nurse that the prescribed erythropoietin therapy is effective? Rising reticulocyte count Rising platelet count Decreasing albumin levels Decreasing white blood cell count

Rising reticulocyte count Erythropoietin stimulates the bone marrow to produce more new red blood cells. A rising reticulocyte count reflects bone marrow release of new and less mature erythrocytes.

Question 13 of 16 The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding? Dorsiflexion of any metatarsophalangeal (MTP) joint, with plantar flexion of the adjacent proximal interphalangeal (PIP) joint A small tumor in a digital nerve of the foot Severe pain in the arch of the foot, especially when getting out of bed Lateral deviation of the great toe; first metatarsal head becomes enlarged

Severe pain in the arch of the foot, especially when getting out of bed Severe pain in the arch of the foot, especially when getting out of bed, is an indication of plantar fasciitis.Lateral deviation of the great toe with an enlarged first metatarsal head describes a bunion of the foot. Dorsiflexion of any MTP joint with plantar flexion of the adjacent PIP joint is a description of a hallux valgus and hammertoe of the foot. A small tumor in a digital nerve of the foot describes Morton neuroma of the foot.

Question 4 of 11 Which symptom reported by a client suggests to the nurse that anemia is a possibility? Chronic headaches Shortness of breath Cold hands and feet Difficulty sleeping

Shortness of breath Shortness of breath is very common with anemia because the blood is not efficient at providing enough oxygen. Thus, to maintain adequate oxygenation to tissues, the person has to increase his or her respiratory rate. Although cold hands/feet and headaches are associated with anemia, these symptoms are not specific enough to suggest anemia.

Question 15 of 22 A client receiving propranolol as preventive therapy for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? Warm sensation Tingling feelings Slow heart rate Dry mouth

Slow heart rate The side effect that is the greatest concern for a client taking propranolol for migraine headaches is a slow heart rate. Beta blockers such as propranolol may be prescribed as a preventive medication for migraines. Propranolol causes blood vessels to relax and improves blood flow although the exact mechanism of action in migraines is unclear. The client would be taught how to monitor his or her heart rate and appropriately report any deviations to the primary care provider.Dry mouth is typically associated with tricyclic antidepressants such as nortriptyline. Skin flushing, tingling feelings, and a warm sensation are common side effects with triptan medications and are not indications to avoid using this group of drugs. Nortriptyline may be used as a preventive medication. Triptans are utilized as abortive medications after a migraine begins.

Question 9 of 12 The nurse is caring for a client undergoing mastectomy who asks the nurse about breast reconstruction. Which of these will the nurse include in the discussion? Reconstruction of the nipple-areola complex is the first stage in reconstruction. Prostheses are not recommended because of the nature of the surgery. Reconstruction cannot take place until several months after a mastectomy. Some women want breast reconstruction using their own tissue.

Some women want breast reconstruction using their own tissue. The correct statement reflects that some women do wish to have breast construction with their own tissue.Prostheses can be recommended if the client desires. Reconstruction of the nipple-areola complex is the last stage in breast reconstruction surgery. Breast reconstruction surgery would be discussed before mastectomy takes place.

Question 1 of 17 Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? Starting an IV line to begin hydration therapy Administering IM influenza vaccination Asking the client when symptoms began Placing the client in a negative air pressure room

Starting an IV line to begin hydration therapy The nurse's first priority is to start an IV line and begin intravenous hydration to maintain perfusion. Older clients with influenza symptoms can develop dehydration quickly because of fever, vomiting, and possible diarrhea.Asking when the symptoms first started is not important. A negative airflow room is not required and is usually in short supply. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority because it takes weeks for full immunity to develop.

Question 22 of 29 Which action is the first priority for the nurse to take when a client who is receiving a blood transfusion suddenly says, "I don't feel right!"? Applying oxygen Obtaining vital signs and monitoring for changes Initiating the Rapid Response Team Stopping the transfusion

Stopping the transfusion The nurse's first action when a client receiving a blood transfusion says, "I don't feel right," is to stop the transfusion. The client may be experiencing a transfusion reaction, so the nurse must stop the transfusion immediately.Calling the Rapid Response Team, applying oxygen, or obtaining vital signs is not the first thing that must be done.

Question 19 of 22 The nurse is caring for a client diagnosed with vascular dementia. The nurse recognizes that which health problem is associated with this type of dementia? Epilepsy Stroke Meningitis Migraines

Stroke Vascular dementia is typically caused by strokes or other cranial vascular disease. The exact cause of Alzheimer disease is not known.

Question 11 of 17 Which action to prevent harm is has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? Be sure to drink at least 2 L of fluids daily. Take these drugs daily exactly as prescribed. Expect a change in urine color. Wear use sunscreen and wear protective clothing when you are out-of-doors.

Take these drugs daily exactly as prescribed. The most important action is to take the drugs as prescribed to be effective and to prevent development of drug-resistant tuberculosis organisms. One drug in the regimen does change urine to a reddish color, but this is harmless. Two other drugs cause some degree of photosensitivity and increase the risk for sunburn; however, this is not a reason to stop the therapy.

Question 8 of 21 Which intervention would the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation Talking with an amputee close to the client's age who has a similar amputation Drawing a picture of how the client sees him- or herself

Talking with an amputee close to the client's age who has a similar amputation Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation.Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.

Question 10 of 16 The nurse is preparing to give apixaban for a client who recently had a total knee arthroplasty. What does the nurse recognize as the advantage of this drug over other anticoagulants? The client does not need to have labs drawn for PT or INR. The client only needs to take the drug while in the hospital. The client is not at risk for bleeding or bruising. The client does not need to wear sequential compression devices.

The client does not need to have labs drawn for PT or INR. Apixaban is a newer factor Xa inhibitor that helps to prevent venous thromboembolism in clients who have a total knee arthroplasty. The client taking this drug will need to continue for several weeks after surgery and is at risk for bleeding or bruising. However, the drug does not affect PT or INR, so that the client does not need to have labs drawn.

Question 1 of 12 A client who has been diagnosed with breast cancer tells the nurse she wishes to use only natural and complementary interventions. What teaching will the nurse provide? This type of therapy would not replace standard treatment. If chemotherapy has been recommended, complementary therapies are contraindicated. Complementary therapies can only be used after surgery. There are many natural herbs that have been shown to treat cancer.

This type of therapy would not replace standard treatment. The nurse would explain that complementary and integrative therapies cannot replace standard treatment for breast cancer. Complementary and integrative health options include prayer, herbal therapy, cancer diets, guided imagery, acupuncture, and others. Encourage clients to seek evidence-based information and to notify their health care provider if they choose to use any of these methods.Complementary therapies are not contraindicated when chemotherapy is recommended, but it is important to ensure that the client's choices can be safely integrated with conventional treatment for breast cancer. To date, no herbal treatments have been shown to treat cancer. If approved by the primary health care provider, complementary and integrative therapies can be used before surgery, as well as after surgery.

Question 9 of 20 A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What would the nurse suspect that the client is most likely experiencing? Transient ischemic attack Thrombotic stroke Embolic stroke Hemorrhagic stroke

Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

Question 2 of 16 The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor does the nurse suspect is the most likely cause of this client's OA? Trauma to the joint Aging Osteoporosis Familial history

Trauma to the joint The client has OA in one knee which suggests that the client has secondary OA rather than primary disease. Secondary OA occurs as a result of joint injury or obesity.

Question 19 of 21 Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? Lungs for bilateral normal breath sounds Urine specimen to assess for the red blood cells Pain score and level of alertness Skin to evaluate lacerations and abrasions

Urine specimen to assess for the red blood cells It is most important for the nurse to determine the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

Question 9 of 18 The nurse is collaborating with the rehabilitation therapist to improve mobility skills for a client with a complete high-level spinal cord injury. Which technique is appropriate for this client? Use of a mechanical lift to get the client out of bed Use of a sliding board (slider) to transfer from bed to a chair Use of parallel bars to facilitate ambulation Use of a walker to promote balance and prevent muscle atrophy

Use of a sliding board (slider) to transfer from bed to a chair The client who has a complete high-level, or cervical, spinal cord injury is tetraplegic (quadriplegic) meaning that he or she does not have control over any extremity. The client has shoulder movement allowing the client to use a sliding board as a "bridge" between the bed and chair.

Question 20 of 28 Which action is most important to teach a client living with progressing idiopathic pulmonary fibrosis? Maintaining an oral fluid intake of at least 2 L daily Taking oral temperature daily Using oxygen by nasal cannula whenever dyspnea is present Using energy conservation measures

Using energy conservation measures The client with progressing pulmonary fibrosis is extremely fatigued and has little energy. Using energy conservation measures helps the client have more energy to perform the work of breathing.

Question 7 of 14 Which laboratory test does the nurse analyze to determine the effectiveness of combination antiretroviral drug therapy in an HIV-positive client? Viral load testing Enzyme-linked immunosorbent assay Fourth generation testing Western blot analysis

Viral load testing Only viral load testing directly measures the actual amount of HIV viral RNA particles present in 1 mL of blood. Changes in the number indicate therapy effectiveness. Higher numbers indicate lack of effectiveness and lower numbers indicate the drugs are working. The other tests are used to determine whether the client is infected with HIV and do not change with therapy.

Question 1 of 16 The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the primary health care provider will request which supplement? Vitamin D3 Vitamin C Calcium Phosphorus

Vitamin D3 Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol (Calciferol).Vitamin C is not indicated for the treatment of osteomalacia, which is related to vitamin D deficiency. Phosphorus interferes with the absorption of calcium. Calcium is not indicated in the treatment of osteomalacia.

Question 6 of 16 What will the nurse recommend as the most appropriate way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? Increase nutritional intake of phosphorus. Walk for 30 minutes three times a week. Increase nutritional intake of calcium. Engage in high-impact exercise, such as running.

Walk for 30 minutes three times a week. Walking for 30 minutes three to five times a week is the best and single most effective exercise for osteoporosis prevention. Osteoporosis occurs most often in older, lean-built Euro-American and Asian women, particularly those who do not exercise regularly. Walking is a safe way to promote weight bearing and muscle strength.A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis. High-impact exercise and overtraining, such as running, may cause vertebral compression fractures and should be avoided. Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day (over 40 ounces [1.2 L]) are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender.

Question 3 of 11 The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider? Allergy to shellfish and iodine Knee pain at a level of 9 (0-10 scale) Previous surgery on the other knee Warm, red, and swollen knee

Warm, red, and swollen knee Findings such as swelling, heat, and redness may indicate infection in the knee joint and is most essential for the nurse to report to the health care provider. These findings will help the health care provider determine whether there may be a need to cancel the procedure.Having knee pain before surgery is not unexpected but will not affect whether the client will have surgery. Having previous surgery on the other knee does not preclude the client from having this surgery.

Question 1 of 11 A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what is the appropriate nursing action? Test the visual field. Obtain informed consent. Wash the hands. Don sterile gloves.

Wash the hands. Hands must always be washed, and clean gloves donned, before touching the external eye structures to prevent infection.The eye care provider will test the visual field. An informed consent or sterile gloves is not needed for the nurse to examine the client's eye.

Question 1 of 16 The nurse is developing a health teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Take up knitting to slow down joint degeneration. Eat at least 2 yogurts every day. Wear supportive shoes at all times. Begin a jogging or running program

Wear supportive shoes at all times. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running and running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended.

Question 4 of 17 What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza? Performing oral care before, as well as after, suctioning the oropharynx Wearing a disposable particulate mask N95 respirator with face shield or goggles Washing hands and donning gloves prior to the procedure Keeping the door to the client room closed

Wearing a disposable particulate mask N95 respirator with face shield or goggles The most important infection control precaution the nurse must take before suctioning a client with any pandemic influenza is to wear a particulate mask respirator with protective eyewear or a face shield to prevent infectious organisms from entering the nurse's mucous membranes and respiratory tract.The door to the room needs to be closed during any care of the client with a pandemic influenza. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.

Question 10 of 16 A middle-age female client has osteoporosis and is at risk for developing vertebral fractures. She asks the nurse about exercises to help minimize this risk. Which exercise will the nurse recommend? Cycling Running Walking Yoga

Yoga Yoga helps to strengthen abdominal and back muscles which improves posture and support for the spine.Cycling, running, and walking help to develop range of motion and muscle strengthening but do not have specific effects on posture and spinal stability.

Question 8 of 16 The nurse is caring for a client who is diagnosed with osteopenia. Which T-score will the nurse expect to see for this client after a bone mineral density (BMD) test? −2 −3 0 to −1 +1.5

−2 The T-score represents the standard deviations above or below the average BMD for young, healthy adults. A T-score of −1 to −2.5 represents osteopenia.The T-score in a young, healthy adult is 0. A normal T-score is between +1 and −1. A score of +1.5 is not a part of the T-score. A T-score of −3 represents osteoporosis.

Question 18 of 18 Which assessment findings will the nurse expect to see in a client who is suspected to have systemic lupus erythematosus (SLE)? (Select all that apply.) Select all that apply. 1-Anemia 2-Joint pain and swelling 3-Hair loss 4-Fever 5-Fatigue 6-Facial redness

1, 2, 3, 4, 5, 6 Each of these assessment findings has been associated with systemic lupus erythematosus (SLE).

Question 7 of 19 A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? 1-Teaching key points of the relaxation response 2-Incorporating activities of daily living as soon as possible 3-Encouraging diversional activities 4-Using preemptive analgesia

4- Using preemptive analgesia The nursing intervention with the highest priority in the client's care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay.Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.

Question 8 of 18 Which client with persistent joint and muscle pain will the nurse consider as most likely to have a systemic lupus erythematosus (SLE) diagnosis? A 33-year-old African-American man whose father died from a myocardial infarction. A 33-year-old white woman whose sister has Grave disease. A 33-year-old African-American woman whose mother has psoriasis. A 33-year-old man whose identical twin brother has acute myelogenous leukemia.

A 33-year-old African-American woman whose mother has psoriasis. SLE is an autoimmune disorder that is much more common in women than in men and has a genetic predisposition related to tissue type. A client with SLE is very likely to have another close relative who also has an autoimmune disorder, such as psoriasis (myocardial infarction, type 2 diabetes mellitus, and thrombotic stroke are not autoimmune disorders). In addition, the incidence of SLE is about eight times greater for African-American women than for white women.

Question 6 of 19 A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? 1-Oxycodone 2-Hydromorphone 3-Midazolam 4-Acetaminophen

Acetaminophen The nurse will administer acetaminophen as prescribed. Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain.Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Oxycodone is an opioid and is not needed for a mild headache.

Physiological Integrity Which statement about the genetics of cystic fibrosis is true? A. Recessive disorder affecting chloride transport B. Recessive disorder affecting alpha1-antitrypsin levels C. Dominant disorder inhibiting alveoli formation D. Dominant disorder increasing production of interleukin-5

Answer: A Rationale: Cystic fibrosis is caused by a mutation in both alleles of the CFTR gene, which results in the inhibition of chloride transport in epithelial cells, especially of the lungs, allowing thick, stick mucus to plug the airways. Although alpha1-antitrypsin deficiency is inherited in an autosomal pattern, this problem is associated with emphysema, not CF. Alveolar formation are not affected by CF, nor is interleukin-5 production increased. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

Health Promotion and Maintenance The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane and he missed all of yesterday's dosages. What action does the nurse recommend? A. Take today's dosages as normally prescribed and continue to follow your therapy program. B. Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem. C. Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days. D. Go to the nearest emergency department and have an immediate blood test for assessment of viral load.

Answer: A Rationale: One day of missing the drugs is not good but is unlikely to cause drug resistance if 90% of the drugs within any 1 month are taken on time and at proper dosages. The client should not be taught that anything under 4 days of missing drugs is okay. Doubling the next day's doses does not make up for missing doses. The viral load will not change in this short of a time period. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

27-3. Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy? A. Examine your skin and the whites of your eyes daily for a yellow appearance. B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum. C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination. D. Go to your primary health care provider immediately if you develop a fever or other sign of infection.

Answer: A Rationale: This combination gene therapy drug is an oral medication taken once daily. Both drugs used in the combination can impair liver function. Thus a priority precaution for patients on this drug is to be aware of and report any symptom specific for impaired liver function. Jaundice of the skin or sclera is a major symptom of liver impairment. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

17-4. A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? A. Abacavir B. Darunivir C. Tripanavir D. Raltegravir

Answer: D Rationale: Raltegravir is teratogenic and can cause birth defects. Although most cART drugs are prescribed during pregnancy and significantly reduce the risk for transmitting HIV to the infant, raltegravir is suspended during pregnancy. Cognitive Level: Understanding Client Needs Category: Safe and Effective Care Environment

Question 4 of 18 Which action is the priority for the nurse to take to prevent harm for the alert 58-year-old client who is admitted to the emergency department with wheezing, dyspnea, angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122 beats/min? Asking about exposure to possible allergens Applying oxygen via a high-flow nonrebreather mask at 90% to 100% Reassuring the client that appropriate interventions are being instituted Starting an IV infusion of normal saline

Applying oxygen via a high-flow nonrebreather mask at 90% to 100% The immediate priority is to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

Question 5 of 28 Which assessment findings in a client with asthma indicate to the nurse that the client's asthma condition is deteriorating and progressing toward respiratory failure? Audible wheezing with use of accessory muscles on inhalation Crackles, rhonchi, and productive cough with yellow sputum Tachypnea, thick and tenacious sputum, and hemoptysis Respiratory alkalosis; slow, shallow respiratory rate

Audible wheezing with use of accessory muscles on inhalation Normal exhalation is passive. When airways narrow, wheezing is first heard on exhalation. Wheezing on inhalation along with the use of accessory muscles for inhalation indicates more severe airway problems and a worsening of asthma.Worsening asthma would cause acidosis, not alkalosis. Hemoptysis is not associated with asthma. Crackles are not present because asthma is an airway problem, not an alveolar problem.

Question 14 of 18 What is the pathophysiologic basis for Lyme disease progression to stage III? Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels Failure of the immune system to recognize the causative organism as non-self, allowing it to become a systemic infection Triggering of antibodies against infected cells that lead to autoimmune disease The special ability of Borrelia burgdorferi to burrow deeply into joint, cardiac, and neurons causing direct damage to these tissues.

Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels The causative organisms can switch out parts of its unique surface proteins, which changes the ability of immune sensitized system cells and antibodies to recognize the existing infecting organism allowing it to "hide." Every time a switch occurs, the immune system treats them like a new infection, and develops new antibodies and inflammatory responses to them, resulting in keeping all general and specific immunity actions in continual but ineffective attack mode through all stages of the disease process. This prolonged and continuous process results in persistent and enhanced damage to a variety of tissues and organs.

Question 6 of 14 Which concept is the highest priority for the nurse to consider in planning care for the client with HIV-III who has candidial stomatitis? Cellular regulation Gas exchange Comfort Nutrition

Comfort Candidial stomatitis causes considerable oral discomfort and difficulty eating and swallowing. Ice chips and cool liquids can help reduce the discomfort until prescribed antifungal agents have reduced the infection symptoms. Some clients may have pain to the point that opioid analgesics are needed. Gas exchange and cellular regulation are not directly affected by the problem. Although nutrition is negatively affected, it is the pain that interferes most with nutrition.

Question 11 of 28 Which complication does the nurse suspect when a client with severe chronic obstructive pulmonary disease COPD has new-onset increased fatigue, dependent edema, neck vein distension, and oral cyanosis? Lung cancer Cor pulmonale Pneumonia Asthma

Cor pulmonale The client with long-term COPD develops higher pressures in pulmonary blood vessels making the right ventricle of the heart work harder to generate pressures that are high enough to perfuse the lungs. This persistent over-working of the right ventricle leads to right-sided heart failure that is not related to independent cardiac damage (cor pulmonale). This complication remains a constant risk for anyone with COPD.These symptoms are not related to asthma or pneumonia. Although some are also associated the lung cancer, they would appear slowly over time.

27-1. Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes.

Correct Answer: B Rationale: The drug is a monoclonal antibody given parenterally. It is composed of some foreign proteins and has been known to cause anaphylaxis even 2 hours after administration. Thus it must be given by a health care professional in a setting capable of handling an anaphylactic emergency. It must not be self administered. The drug is not in an inhaled or tablet form. Benralizumab does not induce drowsiness and can be administered at any time of day. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Implementation

Question 10 of 28 Which changes in arterial blood gas (ABG) values will the nurse expect in a client with long-term chronic obstructive pulmonary disease (COPD)? Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level Increased pH; increased PaO2; increased PaCO2; Increased bicarbonate level Increased pH; increased PaO2; increased PaCO2; decreased bicarbonate level Decreased pH; decreased PaO2; decreased PaCO2; decreased bicarbonate level

Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level Hallmark changes in ABGs for long-term COPD is respiratory acidosis (increased arterial carbon dioxide [Paco2]); metabolic alkalosis (increased arterial bicarbonate) as compensation by kidney retention of bicarbonate (seen as an elevation of HCO3− although pH remains lower than normal); and lower-than-normal PaO2 from poor gas exchange.

Question 9 of 18 What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 45 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? Check all your stools for the presence of blood or a black, tarry appearance. Do not suddenly stop taking the drug when your flare is over. Be sure to take this drug with food. Take 30 mg in the morning and 15 mg at night.

Do not suddenly stop taking the drug when your flare is over. All of the precautions are correct and important. However, the most critical precaution is to not suddenly stop taking the drug, which could lead to acute adrenal insufficiency and even death. This dose of the drug (45 mg daily) would need to be tapered down over a period of weeks to prevent adrenal insufficiency.

Question 7 of 28 Which action will the nurse teach a client with chronic bronchitis to use to mobilize secretions? Drinking at least 2 L of fluid daily Avoiding triggers that cause coughing Elevating the head of the bed 45 degrees Assuming the tripod position as often as possible

Drinking at least 2 L of fluid daily Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 L of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. If health issues require fluid restriction, the client would attempt to consume the total amount permitted.Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.

Question 7 of 18 Which of the drugs or supplements taken daily taken by a client who is newly diagnosed with drug-induced systemic lupus erythematosus (SLE) does the nurse suspect is most likely to have caused this problem? Vitamin D Lisonopril Aspirin Hydralazine

Hydralazine Hydralazine is a blood pressure medication that has been found to cause drug-induced SLE. None of the other drugs are associated with drug-induced SLE, although lisinopril, an angiotensin-converting enzyme inhibitor, is associated with development of angioedema.

Question 17 of 28 For which side effect will the nurse monitor a client with pulmonary arterial hypertension (PAH) who is receiving endothelin receptor antagonist therapy? Hypotension Increased clot formation Sepsis Decreased urine output

Hypotension Endothelin receptor antagonists cause vasodilation of systemic as well as pulmonary blood vessels, which can lead to severe hypotension.These oral drugs do not increase clot formation or lead to sepsis. Urine output is only affected when hypotension becomes profound.

Question 8 of 14 With which antiretroviral drug class will the nurse teach clients to prevent harm by reporting any new onset muscle weakness and muscle pain to the immunity health care provider? Fusion inhibitors Integrase inhibitors Nucleoside reverse transcriptase inhibitors Protease inhibitors

Integrase inhibitors The integrase inhibitor class of drugs can cause muscle breakdown (rhabdomyolysis) especially in adults taking a "statin" (type of lipid-lowering drug). The first symptoms of rhabdomyolysis are muscle pain and weakness. None of the other classes of antiretroviral drugs have this side effect.

Question 8 of 28 Which action is most important for a nurse to take to prevent complications for a client with a history of chronic obstructive pulmonary disease (COPD) is admitted for a surgical procedure that is unrelated to the respiratory system? Assessing the client's respiratory system every 8 hours Instructing the client to use a tissue when coughing or sneezing Monitoring for signs and symptoms of pneumonia Ensuring the client remains in bed for a full 24 hours after surgery

Monitoring for signs and symptoms of pneumonia The client with COPD is always at greater risk for development of a respiratory infection, especially after any surgery requiring anesthesia. The nurse would assess the client's respiratory system at least every 2 hours. The client with COPD alone does not pose an infection risk to others, although everyone is urged to use a tissue to cover the mouth and nose when sneezing or coughing. Remaining in bed is avoided because it promotes atelectasis and pneumonia.

Question 5 of 18 What is the most important action to prevent harm for the nurse to perform after a client's oral and facial swelling from an angiotensin-converting enzyme inhibitor (ACEI) have resolved? Teaching the client about symptoms to report immediately to the primary health care provider Instructing the client to discard the offending drug after being discharged Monitoring the client for return of symptoms for at least the next 2 to 4 hours Assessing the vein above the IV infusion site for a firm, cordlike texture

Monitoring the client for return of symptoms for at least the next 2 to 4 hours All actions are important, although phlebitis is not likely to occur from IV therapy for angioedema. The ACEI class of drugs have a longer half-life and remain in the body longer than does the corticosteroid infusion used to treat the angioedema. As a result, symptoms can recur after first resolving when corticosteroid therapy is stopped. The client remains at risk and must be monitored for at least 2 to 4 hours for return of angioedema.

Question 1 of 28 Which action will the nurse teach an older client with a respiratory problem to make as an accommodation to promote adequate gas exchange? Notify your primary health care provider at the first sign of respiratory infection. If you must walk any distance in cool weather move quickly to keep warm. Replace at least one meal each day with a high-calorie liquid food supplement. Avoid any nonessential physical activity or exercise.

Notify your primary health care provider at the first sign of respiratory infection. A respiratory infection can become serious very quickly in an older client with a pre-existing respiratory problem and must be addressed as early as possible before complications occur.Older clients with respiratory problems are encouraged to perform low-impact exercises, such as walking, daily but should not rush through it. The client is taught to pace the exercise and stop and rest as often as needed. High-calorie liquid food drinks are meant to supplement meals, not replace them.

Question 3 of 28 What is the priority action for the nurse to take when a client comes to the emergency department with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers? Establishing IV access to give emergency medications. Asking the client how long he or she has had asthma and what triggered this attack Preparing the client for intubation Placing the client in a high-Fowler position, and starting oxygen

Placing the client in a high-Fowler position, and starting oxygen With labored breathing, the client is most likely hypoxemic and the first priority is ensuring gas exchange by placing the client in a high-Fowler position and starting oxygen.The length of time the client has had asthma and the probably trigger for this attack are not important and will not affect how this attack is managed. Establishing IV access is important but not the first priority. Preparing a client for intubation is not needed unless all other methods to improve gas exchange are not effective.

Question 14 of 28 Which complication will the nurse assess for first in any client with cystic fibrosis (CF)? Respiratory infection Pneumothorax Weight loss Osteoporosis

Respiratory infection In addition to respiratory failure, the most common cause of death for any client with CF is respiratory infection. Recognizing infections early and initiating appropriate therapy are essential life-saving strategies.Although weight loss and osteoporosis are complications of CF, they are not immediately life threatening. Pneumothorax is not a common complication of CF.

Question 11 of 18 Which precaution is a priority to prevent harm for the nurse to teach a client with systemic lupus erythematosus (SLE) who is newly prescribed to take hydroxychloroquine for disease management? See your ophthalmologist for visual field testing every 6 months. Report a reduction of joint swelling to your rheumatology health care provider immediately. Report a worsening of joint swelling to your rheumatology health care provider immediately. See your ophthalmologist for intraocular pressure measurement every 6 months.

See your ophthalmologist for visual field testing every 6 months. Hydroxychloroquine has both immunomodulating and anticlotting effects that can be beneficial to clients with SLE. A major complication of this drug is its toxicity to retinal cells causing retinitis that can lead to an irreversible loss of central vision. Clients prescribed hydroxychloroquine are instructed to have frequent eye examinations with visual field testing (before starting the drug and every 6 months thereafter). If retinal toxicity is suspected, the drug is discontinued to preserve the remaining vision.

Question 6 of 28 Which outcome indicates to the nurse that oxygen therapy for the client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia is effective? PCO2 is within normal range. Finger clubbing has resolved. Client reports decreased distress. SpO2 is between 88% and 90%.

SpO2 is between 88% and 90%. Clients with hypoxemia, even those with COPD and hypercarbia, need to receive oxygen therapy at rates appropriate to reduce hypoxia and maintain SpO2 levels between 88% and 92%.Gases diffuse independently, therefore applying oxygen will not decrease the carbon dioxide level and hypoxemia may still be present. A report of less distress is appropriate but not an objective indicator of therapy effectiveness. Finger clubbing in a client with long-term COPD does not resolve.

Question 18 of 28 Which action with the nurse take to prevent harm when prescribed to administer an IV antibiotic to a client with pulmonary artery hypertension (PAH) who is being managed with a continuous prostacyclin agonist infusion? Requesting a prescription for an oral antibiotic Starting a peripheral IV access to use for administering the antibiotic Stopping the prostacyclin agonist infusion for 15 minutes to administer the IV antibiotic Administering the IV antibiotic through the continuous infusion's side port

Starting a peripheral IV access to use for administering the antibiotic The prostacyclin agonist infusion cannot be stopped for even 15 minutes without endangering the client's life. The drug also cannot be mixed with any other drug. Clients with PAH are at high risk for sepsis. Thus, the antibiotic must be administered intravenously and the safest action is to insert a separate peripheral IV access for this purpose.

Question 15 of 28 Why will the nurse administer vitamin supplements to a client who has cystic fibrosis (CF)? Clients are too fatigued to ingest sufficient vitamins and nutrients. Steatorrhea causes a deficiency of fat-soluble vitamins. Increased blood levels of vitamins enhance chloride transport activity. High doses of vitamins can slow the progression of the disease.

Steatorrhea causes a deficiency of fat-soluble vitamins. The stool of clients with CF contains large amounts of fat (steatorrhea), which promotes loss of fat-soluble vitamins, leaving the client deficient of such vitamins and malnourished.Vitamins are important for general health and nutrition and play no role in the disease or its progression.

Question 16 of 28 Which action is most important for the nurse to take when preparing a client with cystic fibrosis (CF) for a lung transplantation procedure? Teaching the client how to perform pulmonary muscle strengthening exercises Collaborating with the registered dietitian nutritionist to provide high-calorie, high-protein meals Reminding the client to continue taking prescribed vitamin supplementation Using aseptic technique when assisting the client to perform pulmonary hygiene

Teaching the client how to perform pulmonary muscle strengthening exercises Surgery for lung transplantation involves large "clam-shell" incisions that cut through ribs and muscle. This procedure is very painful and clients have a difficult time breathing deeply enough to wean from the ventilator. A critical factor in the outcome of the surgery and prevention of atelectasis and pneumonia in the new lungs is the strength of the muscles used for ventilation. These muscles must be strengthened before the transplantation.

Question 19 of 28 What is the primary indication for the nurse to apply supplemental oxygen to the client with pulmonary artery hypertension (PAH)? Oxygen therapy is part of the client's ongoing clinical management and is applied continuously. The client determines when oxygen supplementation is needed. The nurse applies oxygen when the client's respiratory rate is decreased. The nurse applies oxygen when the client's respiratory rate is increased.

The client determines when oxygen supplementation is needed. The nurse applies supplemental oxygen when the client finds the dyspnea to be uncomfortable. This action is not dependent on a particular respiratory rate. It is also not a continuous therapy.

Question 3 of 14 What is the first action a nurse should take after sustaining a needlestick injury after injecting a client who is known to be HIV positive? Send the syringe and needle to the laboratory for analysis of viral load. Inform the charge nurse. Thoroughly scrub and flush the puncture site. Go to the employee clinic for postexposure prophylaxis.

Thoroughly scrub and flush the puncture site. Although the nurse would also inform the charge nurse and go to the employee clinic to initiate postexposure prophylaxis, the first action is to clean the puncture site by washing it thoroughly with soap and water for at least 1 minute as recommended by the CDC. Viral load cannot be determined by analyzing the syringe and needle.

Question 2 of 18 Which type of hypersensitivity reaction will the nurse suspect in a client who develops as circular rash on the skin underneath a new necklace worn for 3 days? Type IV Type I Type II Type III

Type IV A type IV delayed hypersensitivity reaction occurs when sensitized T-cells respond to an antigen by releasing chemical mediators and triggering macrophages. This reaction causes a rash as seen in a metal allergy exposure.A type I reaction occurs rapidly after exposure and is mediated by immunoglobulin E (IgE). Type II reactions occur when the body makes autoantibodies directed against self-cells and attack those cells. Type III reactions occur when an abundance of immune complexes are made and they get stuck in small vessels causing inflammation.