hesi practice questions

A client is diagnosed with lesions in the right occipital lobe. Which clinical manifestation should the nurse expect to find? *a.* Loss of vision on the left side. *b.* Lack of coordination of movement on the right side. *c.* Inability to recognize bodily defects or diseases. *d.* Diminished response to verbal cues or pain on the left side.

*a.* Loss of vision on the left side. A client with lesions in the right occipital lobe may present with loss of vision on the left side.

The nurse is assessing a client with recent head trauma. Which physiological signs indicate increased intracranial pressure? *SATA* *a.* Bradycardia *b.* Corneal reflex present *c.* Hypotension *d.* Tachypnea *e.* Unilateral dilated pupil

*a.* Bradycardia *e.* Unilateral dilated pupil Head injuries can cause a drop in the pulse to compensate for the increased intracranial pressure. Respirations also decrease due to pressure on the respiratory center. Blood pressure increases and pupils unilaterally dilated and have an absent light reflex dependent upon which side of the brain is affected.

What self-management education by the nurse is important for clients diagnosed with systemic lupus erythematosus who are taking prednisone? *Select all that apply.* *A.* "Take calcium supplements to prevent osteoporosis from the steroid." *B.* "Stay away from crowds and people with infections." *C.* "Avoid being in the sun to prevent disease flare-ups." *D.* "Get up slowly to prevent dizziness from orthostatic hypotension." *E.* "Take your prednisone early in the morning before breakfast."

*A.* "Take calcium supplements to prevent osteoporosis from the steroid." *B.* "Stay away from crowds and people with infections." *C.* "Avoid being in the sun to prevent disease flare-ups." *E.* "Take your prednisone early in the morning before breakfast."

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? *Select all that apply.* *A.* Peripheral edema *B.* Crackles in both lungs *C.* Breathlessness *D.* Ascites *E.* Tachypnea

*B.* Crackles in both lungs *C.* Breathlessness *E.* Tachypnea

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? *A.* Call the ED physician immediately. *B.* Draw a serum digoxin level. *C.* Assess for signs of hypokalemia. *D.* Establish the client's airway.

*B.* Draw a serum digoxin level. can't find a rationale :(

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time? *A.* Assess the client's oxygen saturation level. *B.* Ask the laboratory to retest the potassium level. *C.* Give potassium as an IV infusion. *D.* Check the client's serum creatinine.

*D.* Check the client's serum creatinine. can't find a rationale :(

Which assessment finding indicates a client is progressing into stage II of shock? *a.* "Bowel sounds are diminished." *b.* "Skin is hot and flushed." *c.* "Slow, labored breathing begins." *d.* "Heart rate decreases."

*a.* "Bowel sounds are diminished." In stage II of shock, the body initiates a series of compensatory mechanisms. The endocrine system's compensatory mechanism releases a series of hormones to increase blood pressure and glucose levels in the body. During this stage, the client's bowel sounds may diminish.

The nurse is reviewing basic dietary guidelines with a client who is newly diagnosed with diabetes. Which statement by the client regarding macronutrients indicates a need for further education? *a.* "I should limit my carbohydrate intake to 80 grams a day." *b.* "I should try to eat salmon or tuna a few times a week." *c.* "Eating enough protein is important for improving my insulin response." *d.* "My total fat intake should be limited to about 50 or 60 grams a day."

*a.* "I should limit my carbohydrate intake to 80 grams a day." Individuals with diabetes should be advised to consume at least 45% of their total calories from carbohydrates, with a minimum of 130 g per day. The nurse should explain to the client that consuming 80 grams of carbohydrates per day is not sufficient.

The nurse is attending a lecture on cardiovascular pathology. Which statement by the nurse regarding aortic aneurysm indicates that the teaching has been effective? *a.* "They are classified as true or false." *b.* "They are most commonly located in the thoracic aorta." *c.* "They are classified based on their size and severity." *d.* "They can involve a single layer of the arterial wall."

*a.* "They are classified as true or false." An aortic aneurysm is an increase in the diameter of the vessel by at least 50%. Aortic aneurysms are classified as true or false. A true aneurysm involves all three layers of the arterial wall, whereas a false aneurysm involves only two layers.

The home health nurse revises a student's documentation statement from "reports eating an appropriate lunch for nutritional value" to be "reports eating nutritionally adequate lunch including yogurt, jello, pre-made beef-pie with vegetables, and orange juice." Which characteristic is the home health nurse concerned about? *a.* Accuracy *b.* Completeness *c.* Currency *d.* Organization.

*a.* Accuracy Quality documentation is important in home health care for reimbursement, continuity of care, avoiding errors or delays in care, and to improve outcomes. Five characteristics of quality documentation include accuracy, completeness, currency, factualness, and organizations. Accuracy is utilization of precise quantifications, which allows other providers to determine if outcomes are consistently being met ensuring continuity of care.

A client presents with swelling of bilateral lower extremities and darkening of the skin from the feet up into the lower legs. Which disease process should the nurse suspect? *a.* Chronic venous insufficiency. *b.* Arterial insufficiency. *c.* Deep vein thrombosis. *d.* Hypertension.

*a.* Chronic venous insufficiency. Chronic venous insufficiency causes pooling of blood and stasis in the lower extremities. This condition is often marked by hyperpigmentation and swelling of the lower legs.

What is the most important action for the nurse who is implementing a standing order? *a.* Compare the order with the client's current status. *b.* Confirm the order with the healthcare provider. *c.* Transcribe the order into the record. *d.* Verify the order with another nurse.

*a.* Compare the order with the client's current status. The implementation of standing orders requires the nurse to use clinical judgment. Comparing the client's current status with the order is one way to apply clinical judgment.

Which clinical finding should the nurse expect to find while assessing a client diagnosed with pyelonephritis? *a.* Costovertebral angle tenderness. *b.* Ascites. *c.* Enlarged liver. *d.* Abnormal bowel sounds.

*a.* Costovertebral angle tenderness. When assessing a client with pyelonephritis, the nurse should perform a costovertebral angle assessment. Costovertebral angle tenderness is used when a client has pain and tenderness located in the lower back just below the costovertebral angle of the ribs, adjacent to the spine. This is a classic clinical sign of pyelonephritis in a client with this condition.

A client with dementia has a diminished gag reflex. The nurse is instructing a caregiver in now to safety assist the client during feeding. What techniques should the nurse include in the teaching plan? *SATA* *a.* Do not rush the client and offer frequent rest periods. *b.* Check the client's open mouth for pocketed food. *c.* Verify that the client has swallowed the food between bites. *d.* Have the client drink an ounce of water (30mL) in between bites of food. *e.* Ensure the client sits in an upright position and extends the neck when swallowing.

*a.* Do not rush the client and offer frequent rest periods. *b.* Check the client's open mouth for pocketed food. *c.* Verify that the client has swallowed the food between bites. To help minimize the risk of aspiration with a client who has diminished gag reflex due to dementia, have the client sit upright and bend their chin towards the chest while swallowing, do not rush them, check their mouth for pocketed food and that the food has been swallowed before taking another bite of food.

The nurse is educating a client who is trying to become pregnant. Which physical sign should the nurse teach the client to interpret as a sign of ovulation? *a.* Elevated basal body temperature. *b.* Thin cervical mucus. *c.* Tender breast tissue. *d.* Increased fatigue.

*a.* Elevated basal body temperature. Basal body temperature increases slightly during ovulation and will remain increased until pregnancy or menstruation occurs. When teaching a client to monitor fertility, the nurse should instruct the client to check her basal body temperature every morning before getting out of bed.

A nurse is preparing discharge instructions for a woman who had a "Loop electrosurgical excision procedure" (LEEPs) of her cervix at the out-patient surgical clinic. Which information should be included in her discharge instructions? *SATA* *a.* For the next 14 days, do not lift or pull heavy objects. *b.* Do not place anything in the vagina for the next 2 weeks. *c.* Drink at least 2.5 -3.5 liters of fluid per day for the next 48 hours. *d.* You need to rest for at least 24 hours following the procedure. *e.* Excessive bleeding is expected, so change the perineum pads frequently.

*a.* For the next 14 days, do not lift or pull heavy objects. *b.* Do not place anything in the vagina for the next 2 weeks. *d.* You need to rest for at least 24 hours following the procedure. The discharge instructions status post- LEEPs should include: not to lift or pull heavy objects; rest for 24 hours post procedure; report bleeding more than a normal menstrual cycle because this is considered excessive bleeding; report signs of infection such as fever, increase pain or foul-smelling vaginal discharge; do not douche, use tampons, or have vaginal intercourse for two weeks; change out perineum pads frequently and use the antiseptic solution to keep the perineum area clean and pat dry.

Which sign should alert the nurse of a possible pneumothorax in a client with an acute asthma exacerbation? *a.* Hyperresonance found on percussion. *b.* Decreased tactile fremitus. *c.* Wheezing heard on auscultation. *d.* Hyperinflated chest.

*a.* Hyperresonance found on percussion. A pneumothorax is a possible complication of acute asthma exacerbation. The presence of hyperresonance upon percussion should alert the nurse to a possible pneumothorax.

Which medication is contraindicated for a client with renal failure? *a.* Ibuprofen. *b.* Coumadin. *c.* Lasix. *d.* Lipitor.

*a.* Ibuprofen. A care priority for this client is to avoid further deterioration in the client's renal status. The nurse should avoid giving ibuprofen because it impedes the blood flow to the kidneys, thus worsening the kidney disease.

The nurse is assessing a client who is experiencing shortness of breath, intercostal retractions, nasal flaring, inspiratory and expiratory wheezing, who has not not shown any respiratory improvement after two administrations of albuterol nebulizer treatments. Which is a common trigger for acute asthma exacerbation? *a.* Ingested allergen. *b.* Exposure to warm air. *c.* Hypocapnia. *d.* Inactivity.

*a.* Ingested allergen. Specific triggers for acute asthma exacerbation vary from client to client. In general, sudden changes in weather (especially exposure to cold air), allergens in the environment or food, expression of intense emotion, and exercise may all trigger acute asthma exacerbation.

During assessment of the thorax and lungs, which technique should the nurse use to assess the client's AP diameter? *a.* Inspection *b.* Percussion *c.* Palpation *d.* Auscultation.

*a.* Inspection The nurse uses inspection to observe and compare the antero-posterior (AP) diameter with the transverse diameter of the chest.

The nurse is caring for a client with exacerbation of asthma who is not responding to breathing treatments and medications. Which emergency intervention should the nurse be prepared for? *a.* Intubation and mechanical ventilation. *b.* Emergency tracheostomy. *c.* Bedside thoracotomy. *d.* Bronchoscopy.

*a.* Intubation and mechanical ventilation. Maintaining the client's airway is the nursing priority in clients with exacerbation of asthma. Interventions, such as intubation and mechanical ventilation, are performed to help restore normal breathing patterns.

The nurse is caring for a client who takes metoprolol. The nurse should monitor the client for which side effect? *a.* Low heart rate. *b.* Unexplained weight loss. *c.* Hypersalivation. *d.* Mania.

*a.* Low heart rate. Metoprolol belongs to a class of antihypertensive medications known as beta blockers, which lower heart rate and blood pressure. Use of beta blockers can cause an abnormally low heart rate. The client's blood pressure should be take periodically during initial treatment and an apical/radial pulse should be taken before administration and the medication should be held and healthcare provider notified if any significant or pulse rate less than 60 beats per minute.

The nurse is assessing a young adult client who reports joint discomfort and pain. Upon inspection the nurse notes the client has very long hands and feet, and a very tall, thin build. On physical assessment, the nurse identifies a mitral valve murmur and scoliosis. Which condition is consistent with the nurse's assessment? *a.* Marfan syndrome *b.* Cushing's syndrome *c.* Fibromyalgia syndrome *d.* Polymyalgia rheumatic syndrome

*a.* Marfan syndrome Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the body. Client's with this condition are extremely tall and thin, accompanied by very long hands and fingers and feet and toes. They often experience joint discomfort and pain. Scoliosis is often present due to the rapid growth. Visual acuity is decreased and many also develop glaucoma. They are afflicted with cardiovascular problems such as mitral valve prolapse and aortic aneurysms. Their life expectancy is their 30s where they often die from heart failure. There is no cure, but supportive care includes close monitoring and frequent echocardiograms to monitor cardiovascular status.

What actions should the nurse do when partnering with an interpreter to help teach a client about self-care instructions? *SATA* *a.* Match the gender of the interpreter to that of the client. *b.* Use short sentences when giving instructions. *c.* Brief the interpreter about the client and the purpose of the session. *d.* Question family members to verify the accuracy of the interpretation. *e.* Ask the interpreter to periodically check if the client understands.

*a.* Match the gender of the interpreter to that of the client. *b.* Use short sentences when giving instructions. *c.* Brief the interpreter about the client and the purpose of the session. *e.* Ask the interpreter to periodically check if the client understands. The relationship between the client and the interpreter is built more quickly when the interpreter matches the client's age, gender and background. Prior to meeting with the client, the interpreter should be briefed about relevant information about the client and the purpose of the session. The nurse should ask the interpreter to speak as if the nurse were doing the speaking directly to the client in the first person. The nurse should use short sentences to allow time for the interpreter to translate and to seek out clarification from the client about the counseling instructions, questions and concerns.

Which symptom should the nurse expect in a client with uremia? *a.* Metallic taste. *b.* Increased appetite. *c.* Excessive sleepiness. *d.* Clammy skin.

*a.* Metallic taste. Side effects of uremia may include insomnia, dry skin, anorexia, and a metallic taste in the mouth. The nurse should provide frequent oral hygiene to alleviate unpleasant tastes in the client's mouth.

Which assessment finding should the nurse expect during the second period of reactivity? *a.* Passage of meconium. *b.* Bradycardia. *c.* Fine crackles in the lungs. *d.* Slight nasal flaring.

*a.* Passage of meconium. Around 4 to 8 hours after birth, the second period of reactivity occurs. During this time, the passage of meconium is expected.

The nurse is assessing a 4-year old child. Which best describe this child's concept of illness? *a.* Possesses magical thoughts of how and why illness occurs. *b.* Demonstrates deep understanding of the cause of illness. *c.* Has a very concrete and rigid idea, but no abstract understanding. *d.* Little comprehension due to lack of life experiences, but can list the symptoms.

*a.* Possesses magical thoughts of how and why illness occurs. A pre-school age child possesses magical thoughts about the world around them.

Which nursing actions should be implemented to reduce the risk of the development of acute respiratory distress syndrome (ARDS)? *SATA* *a.* Practicing scrupulous infection control guidelines. *b.* Implementing a restricted intake and documenting all output. *c.* Placing a client with active tuberculosis client in a negative pressure room. *d.* Adhering to aspiration precautions for clients with impaired swallowing and gag reflex. *e.* Raising the head of the bed to 30-45° for clients receiving enteral feedings.

*a.* Practicing scrupulous infection control guidelines. *c.* Placing a client with active tuberculosis client in a negative pressure room. *d.* Adhering to aspiration precautions for clients with impaired swallowing and gag reflex. *e.* Raising the head of the bed to 30-45° for clients receiving enteral feedings. Both aspiration and systemic infections increase a client's chances of developing acute respiratory distress syndrome (ARDS). To reduce the risk of a client aspirating while receiving enteral feedings, the nurse should raise the head of the bed 30 to 45 degrees. If the client has impaired swallow or reduced gag reflex, aspirations precautions should be put in place and followed. To help decrease the risk of a systemic infection, the nurse should adhere to scrupulous infection control guidelines.

Which should the nurse interpret as a normal finding on the physical exam of a neonate? *a.* Pulsating anterior fontanelle *b.* Hypospadias *c.* Grunting *d.* Mottling

*a.* Pulsating anterior fontanelle The anterior fontanelle is located at the junction of the two parietal and two frontal bones. A pulsating anterior fontanelle is caused by the baby's heartbeat.

Which steps indicate that the nurse is following recommended procedure for handwashing? *a.* Rub hands together to create lather for at least 15 seconds. *b.* While washing, keep hands and forearms lower than the elbows. *c.* Starting from the elbows, dry in a downward direction towards the fingertips. *d.* Dry hands starting at the fingertips and work upward towards the elbows. *e.* While washing, keep hands and forearms in upward position with bent elbows.

*a.* Rub hands together to create lather for at least 15 seconds. *b.* While washing, keep hands and forearms lower than the elbows. *d.* Dry hands starting at the fingertips and work upward towards the elbows. Proper handwashing requires a lather to break down the natural oils on the skin which attract microbes. While washing, soap and water must flow from least contaminated to most contaminated. While drying, the action should be from least contaminated to most.

The nurse is administering IV fluid resuscitation to an elderly client diagnosed with sepsis. The nurse should be alert for which possible complication of this treatment? *a.* Shortness of breath. *b.* Facial droop. *c.* Decreased urine output. *d.* Confusion.

*a.* Shortness of breath. IV fluid resuscitation is administered to clients experiencing extreme dehydration or sepsis. When administering IV fluid resuscitation to an elderly client, the nurse should monitor for symptoms of fluid overload, which include shortness of breath and respiratory compromise.

Which condition is a complication of atrial fibrillation? *a.* Stroke *b.* Hypertension *c.* Liver failure *d.* Kidney disease

*a.* Stroke Clients with atrial fibrillation have an increased risk of stroke and heart failure. Stroke may manifest as facial drooping, paralysis, difficulty speaking, or extremity weakness.

A home health nurse talks with an older client and their family caregiver about the client's medications. The client has renal disease and hypertension. Which factor places the client at risk for worsening renal function? *a.* Taking a total of seven different daily medications. *b.* Taking more than one medication for hypertension. *c.* Having one health care provider review all medications. *d.* Involvement of the caregiver in helping with medication administration.

*a.* Taking a total of seven different daily medications. Polypharmacy, the concurrent use of many medications, increases the risk for adverse drug effects and inappropriate use of medications. Polypharmacy causes a higher incidence of drug-to-drug interactions, especially in older adults, which can lead to impairment of kidney function.

A client diagnosed with a cluster B personality disorder has a history of self-harm by cutting, threatening behavior towards other clients, and dichotomous thinking regarding interpersonal relationships. This behavior has caused disruption on the unit and strain upon staff members. The staff has decided to use a firm and consistent approach and enforce boundaries. Which client outcome reflects the effectiveness of the treatment plan? *a.* The client no longer demonstrates aggressive behavior during group therapy. *b.* The client accuses the treatment team of playing favorites with the clients. *c.* The client presents with a fresh burn after taking a smoke break and claims it was an accident. *d.* The client has come to idealize the social worker and wants to pursue that line of work.

*a.* The client no longer demonstrates aggressive behavior during group therapy. Individuals diagnosed with cluster B personality disorder have difficulties with relationships and boundaries. They use manipulative behavior in order to get their needs met in response to a lack of trust toward all individuals, including those in the health care setting. Goals need to be realistic and set one at a time. Personality change is a slow process, which takes time and repetition in order to produce results.

The nurse is preparing discharge instructions for a client diagnosed with acute coronary syndrome. Which is an expected outcome when effective client education is provided? *a.* The client will verbalize lifestyle changes that are needed. *b.* The client will require additional teaching. *c.* The client will question the need to take hypertensive medications. *d.* The client will refuse to adhere to a cardiac diet.

*a.* The client will verbalize lifestyle changes that are needed. Within the 24-hour period before discharge from the cardiac care step-down unit, the client should verbalize understanding of the disease, as well as the necessary lifestyle changes that may modify risk factors. It is important that the nurse be aware of expected outcomes and plan for the client's learning needs.

A client is taking beclomethasone (Beconase AQ) for seasonal allergies. Which factor has an impact on the effectiveness of the medication? *a.* The regular use of the medication as prescribed *b.* The concurrent use of an antihistamine with the medication *c.* The seasonal amount of allergens present in the environment *d.* The administration of medication when symptoms are present

*a.* The regular use of the medication as prescribed The effectiveness of beclomethasone (Beconase AQ) is dependent on the regular use of the medication as prescribed.

The client's lower extremity has an ulcer present. Which findings would indicate to the nurse that the ulcer is a venous ulcer? *SATA* *a.* The ulcer is located in the ankle area. *b.* The lower extremities pulses are decreased. *c.* The area with the ulcer is located is edematous. *d.* The ulcer bed is pink with granulation tissue present. *e.* Dependent rubor is present in the extremity with the ulcer.

*a.* The ulcer is located in the ankle area. *c.* The area with the ulcer is located is edematous. *d.* The ulcer bed is pink with granulation tissue present. Venous ulcers are a result of a faulty venous system. They are often chronic non-healing ulcers located in the ankle area with ankle or leg swelling often present. Pulses are present. The ulcer bed is pink with granulation tissue often present. There may be scarring present from previous ulcers and some ankle discoloration may be present.

The nurse performs a 12-lead electrocardiogram (ECG) on a client who is in the first hour of care after a myocardial infarction (MI). The client's T-waves appear tall and peaked. How should the nurse interpret this finding? *a.* This is a normal finding in the first hour after an MI. *b.* This is a warning sign for an impending massive heart attack. *c.* This as abnormal because T-waves are typically inverted during an acute MI. *d.* This tracing should be compared with a previous 12-lead ECG prior to interpretation.

*a.* This is a normal finding in the first hour after an MI. ECG changes are common after a client has experienced a myocardial infarction. Within the initial hour of infarction, T waves become tall, peaked, and upright. The nurse should interpret this as a typical finding in the setting of an acute MI.

The caregiver of a pediatric client states that the child has had a fever of 104° F (40° C), a runny nose, and a newly developed rash. The caregiver is concerned because there was a reported case of measles at the child's school. Which intervention should the nurse perform? *a.* Transfer the child to a negative-pressure room. *b.* Place a face mask on the child. *c.* Initiate contact precautions. *d.* Prepare to administer MMR vaccine.

*a.* Transfer the child to a negative-pressure room. The child presents with manifestations of measles and the caregiver confirms that there has been a reported case in the child's school. Because measles is an airborne disease, the nurse should initiate airborne precautions, which include placement of the child in isolation in a negative-pressure room (airborne infection isolation room) to prevent potential spread of the disease. It is important for the use of the negative-pressure room, so individuals who are either immune-compromised or has not been vaccinated with the measle vaccine are not exposed to this virus.

Which assessment finding is considered a positive sign of pregnancy? *a.* Visualization of the fetus on ultrasound. *b.* Positive pregnancy test. *c.* Amenorrhea. *d.* Nausea and vomiting.

*a.* Visualization of the fetus on ultrasound. The signs and symptoms of pregnancy may be categorized into three areas: presumptive, probable, and positive. Positive signs are those which can only be linked to the presence of a fetus; these include visualization of the fetus on ultrasound.

What are the best interventions that can be done in the hospital setting to reduce the risk of an immunocompromised client becoming infected and possibly septic? *SATA* *a.* When working with non-intact skin use aseptic technique. *b.* Changing out IV catheters and access lines every 24 hours. *c.* The removal of indwelling urinary catheters as soon as possible. *d.* Placing in negative pressure rooms with reverse airflow. *e.* Clients who are mechanically ventilate, when possible, weaned off the ventilators.

*a.* When working with non-intact skin use aseptic technique. *c.* The removal of indwelling urinary catheters as soon as possible. *e.* Clients who are mechanically ventilate, when possible, weaned off the ventilators. The practice of aseptic technique when dealing with immunocompromised clients with non-intact skin and/or mucous membranes is crucial for the safety of the client. The removal of indwelling urinary catheters and IV catheters and access lines should be done as soon as possible. When possible, weaned off ventilators as soon as possible. All are interventions that can help minimize the risk of infection and possibly infection. A client should be placed in a positive pressure room if their absolute neutrophil count (ANC) is below 500.

A client is diagnosed with benign prostatic hypertrophy (BPH) on the basis of their history, physical examination, and urinalysis results. While reviewing the client's urinalysis results, the nurse becomes concerned about which finding? *a.* White blood cells. *b.* Pale urine. *c.* Specific gravity of 1.025. *d.* Negative for nitrites.

*a.* White blood cells. A hypertrophic prostate can obstruct the urethra and impede the client's ability to void normally. The client is at risk for urinary retention, which may lead to a urinary tract infection (UTI). The presence of white blood cells in the urine may be indicative of a urinary tract infection (UTI).

A 72-year old client diagnosed with Lyme disease has been prescribed doxycycline (Vibramycin) for 21 days. Which statement by the client indicates a correct understanding of precautions when taking doxycycline? *a.* "I can take this with my iron pills." *b.* "I should take this with meals." *c.* "I should avoid the sun." *d.* "I should take this with milk."

*b.* "I should take this with meals." Doxycycline causes photosensitivity. Clients should be advised to avoid the sun due to increased susceptibility to sunburns.

The nurse is planning care for a client who was just diagnosed with acute pericarditis. Which screening test should the nurse educate the client about? *a.* Creatinine clearance. *b.* 12-lead electrocardiogram. *c.* Dobutamine stress test. *d.* Blood transfusion.

*b.* 12-lead electrocardiogram. Acute pericarditis is an inflammatory process involving the pericardium and epicardial surfaces of the heart. The nurse should provide client education about the 12-lead electrocardiogram, which will assess for any dysrhythmias.

The health care provider prescribes doxazosin (Cardura) to a 74-year-old client with benign prostate hypertrophy (BPH). The nurse should instruct the client to avoid driving or operating machinery for how many hours after taking the initial dose of the medicine? *a.* 2 *b.* 4 *c.* 12 *d.* 24

*b.* 4 The first dose of doxazosin (Cardura) may cause syncope. Clients should be instructed to avoid driving and operating machinery for 4 hours after their first dose and/or after an increase in their dosage.

The nurse is caring for a client with chronic hepatic failure who has developed refractory ascites who has not responded to traditional diuretics. Which action should the nurse take to manage the accumulation of ascites? *a.* Limit sodium intake to 2,000 mg per day. *b.* Administer mannitol. *c.* Prepare the client for a peritoneovenous shunt. *d.* Limit fluid intake to 500 ml per day.

*b.* Administer mannitol. Impaired liver function for six months or longer is a characteristic sign of chronic liver failure. According to a NIH study, if a client has not responded to traditional antidiuretics such as lasix or spirolactone, mannitol has shown to help the improving the response of diuretics in producing urinary output and lowering of sodium levels in refractory ascites. Therefore, in order to manage the client's ascites, the nurse should administer mannitol.

An emergency department nurse is triaging an unaccompanied, unconscious client. Upon inspection the nurse notices some paradoxical movement of the anterior lower chest area. The client's blood pressure is 88/54mmHg. The heart rate is 112 beats per minute and the client's oxygen saturation via pulse oximetry is 91% on room air. Based on these findings which condition should the nurse suspect? *a.* Lung tumor *b.* Broken ribs *c.* Pneumothorax *d.* Pulmonary infiltrates

*b.* Broken ribs The client's presenting symptom of paradoxical movement of the thorax cavity is indicative of broken ribs or one rib that is fractured in more than one place. This condition is referred to as a "flail chest". The paradoxical chest movement is often accompanied by client complaints of pain, especially when coughing or trying to breath deeply. Other symptoms include dyspnea, cyanosis, tachycardia and hypotension depending upon how severe the injury.

When applying restraints, which action is most important for the nurse to take to prevent contractures? *a.* Pad skin and any bony prominences that will be covered by the restraint. *b.* Correct anatomical positioning where restraint is applied and is restricting movement. *c.* Assess the neurovascular status of the area which is restrained or has movement restrictied. *d.* Inspect the area where restraint is to be placed, ensuring there are no tubing or devices present.

*b.* Correct anatomical positioning where restraint is applied and is restricting movement. Correct anatomical positioning where the restraint is to be applied and restricting movement will help prevent contractures. Other options are important but do not directly address prevention of contractures.

The nurse is reviewing a client's list of daily medications and supplements. Which type of medication, if used in combination with herbal supplements, has been known to cause an adverse reaction? *a.* Diuretics such as furosemide (Lasix). *b.* Antibiotics such as penicillin (Amoxil). *c.* Antidepressants such as phenelzine (Nardil). *d.* Antipyretics such as acetaminophen (Tylenol).

*c.* Antidepressants such as phenelzine (Nardil). Herbs such as valerian, St. John's Wort, and yohimbe may interfere with the therapeutic effects of MAOI antidepressants such as phenelzine (Nardil), and should not be used concurrently.

The homehealth nurse is visiting an older client who has trouble ambulating without assistance. The client is cognitively intact, but is often incontinent of urine, despite having normal urethra and bladder function and no evidence of infection. What should the nurse inform the caregiver is likely contributing to functional urinary incontinence in this client? *a.* Bladder spasms. *b.* Difficulty accessing a toilet. *c.* Detrusor muscle spasms. *d.* Weakened perineal muscles.

*b.* Difficulty accessing a toilet. Difficulty accessing a toilet due to physical limitation can lead to functional urinary incontinence. Functional urinary incontinence is likely to occur when toilets are difficult to access because of their location, when there are not enough caregivers to provide needed assistance, or when physical restraints prevent free movement. The homehealth nurse should contact the healthcare provider for a prescription for a bedside commode.

While assessing a child, the pediatric nurse notes a temperature of 103.6° F (39.7° C) and administers ibuprofen (Motrin) 10 mg/kg PO as ordered. Thirty minutes later, the nurse observes that the child is diaphoretic. Which action should the nurse perform? *a.* Administer an additional dose of ibuprofen. *b.* Document the findings. *c.* Request another antipyretic medication. *d.* Assess the child's oxygen saturation.

*b.* Document the findings. The administration of an antipyretic medication such as ibuprofen (Motrin) will decrease body temperature. Sweating is a normal physiological response following the administration of an antipyretic, as the body works to cool itself and achieve a lower temperature. Diaphoresis is a normal finding that should be documented; no additional action is required.

Which physical assessment finding should the nurse anticipate for a client diagnosed with sickle cell anemia when he or she exercises which may require some sort of medical intervention? *a.* Periods of bradycardia *b.* Dyspnea *c.* Heat intolerance *d.* Diffuse erythema

*b.* Dyspnea Sickle cell disease is a genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. One clinical assessment finding is dyspnea on exertion. The sickle cells of sickle cell anemia are misshapen and damaged and are not able to carry the hemoglobin necessary to carry the oxygen molecules to the tissues of the body. Dependent upon the severity of the client's compromise respiratory status, the nurse may need to intervene and administered prescribed oxygen as needed.

The nurse manager has been transferred to a new nursing unit and wishes to begin building a collaborative, interdisciplinary team. Which characteristics would contribute to effective teamwork? *SATA* *a.* Seriousness and focus. *b.* Effective and consistent communication. *c.* Trust and mutual respect. *d.* Recognition and valuation. *e.* Rigorousness and discrimination.

*b.* Effective and consistent communication. *c.* Trust and mutual respect. *d.* Recognition and valuation. Desirable traits of a collaborative teamwork are effective communication amongst its members, trust and respect of each other and recognition and valuation of each other's strengths and talents.

Which finding indicates that a client with hypertension may be experiencing a potential complication of the disease? *a.* Bradycardia. *b.* Elevated blood urea nitrogen. *c.* Polyuria. *d.* Dry skin.

*b.* Elevated blood urea nitrogen. Hypertension can cause vascular damage to the kidneys. An elevated blood urea nitrogen (BUN) level indicates kidney dysfunction, a complication associated with hypertension.

The nurse is giving discharge instructions to a client treated for an anaphylactic reaction to bee stings. The nurse should anticipate the need to educate the client on the use of which medication? *a.* Prednisone *b.* Epinephrine *c.* Chloroquine *d.* Ciprofloxacin

*b.* Epinephrine A client with a history of anaphylactic reaction to bee stings should be provided a prescription for an epinephrine injection kit and educated about the emergency use of this medication.

A 72-year-old man is brought to the emergency department by ambulance with fever and abdominal pain. He had a colon resection 1 week prior due to colon cancer, and his wife states that he seems "slower," and that he experiences dizziness upon standing. He had an IV placed prior to arrival, and the health care provider suspects sepsis. Which intervention is the priority? *a.* Initiate a sepsis bundle. *b.* Give a rapid crystalloid fluid bolus as ordered. *c.* Start broad-spectrum antibiotics as ordered. *d.* Replace the pre-hospital IV.

*b.* Give a rapid crystalloid fluid bolus as ordered. In clients with suspected sepsis, the primary concern is to maintain circulation. The nurse should prepare to administer crystalloid fluid boluses, as ordered.

An echocardiogram results revealed the client has an ejection fraction rate of 35%. The nurse should anticipate the client should be diagnose with which medical condition? *a.* Pancreatitis. *b.* Heart failure. *c.* Gallbladder disease. *d.* End stage renal disease.

*b.* Heart failure. An ejection fraction rate measures how well your heart is pumping. The normal ejection fraction rate is between 50-70% with ventricular dilation. An ejection fraction rate below 40% is indicative of heart failure.

The nurse is evaluating lab results in the client's electronic medical record. Which lab value may indicate a state of malnutrition? *a.* Low level of sodium. *b.* Low level of albumin. *c.* Low level of hemoglobin. *d.* Low level of magnesium.

*b.* Low level of albumin. Low level of albumin may indicate malnutrition.

A client is admitted to the coronary intensive care unit with a diagnosed acute heart failure (HF) and myocardial infarction (MI). Which medication would the nurse anticipate the healthcare provider to prescribed to the client to decrease the preload and afterload, slow down their respirations, and reduce their anxiety and pain due to the MI? *a.* Enalapril (Vasotec). *b.* Morphine sulfate (Contin, MSIR). *c.* Hydrochlorothiazide (HCTZ, Urozide). *d.* Diazepam (Valium, Diastat, Diazemuls).

*b.* Morphine sulfate (Contin, MSIR). Morphine sulfate is prescribed to decrease the preload and afterload, slow down respirations, and reduce anxiety and pain due to the MI in clients also diagnosed with acute heart failure.

The home health nurse is visiting an 75-year-old client and is assessing them for dehydration. Which is the best way to assess for dehydration? *a.* Gently pinch skin on their clavicle. *b.* Obtain the client's weight. *c.* Ask the client if they are thirsty. *d.* Assess the client's mental status.

*b.* Obtain the client's weight. As an individual ages their kidney function begins to decrease and the ability to conserve fluid. An elderly client's weight measurement is the most accurate way to determine their hydration status. A weight loss of 3% or more is indicative a fluid lost and dehydration.

The triage nurse is assessing a client with a six week history of a persistent cough producing rusty colored mucus, 10 pounds (4.54kg) weight loss, decreased appetite and night sweats. Based on the client's history which nursing action should the nurse do next? *a.* Request a prescription for chest x-ray and lab work. *b.* Place a mask on the client and place the client in a private room. *c.* Assess the client's vital signs to include a pulse oximetry reading. *d.* Auscultate the lung fields as the client takes deep and slow breaths.

*b.* Place a mask on the client and place the client in a private room. Based on the client's presenting history and complaints, the nurse needs to place a mask on the client and place the client in a private room, until tuberculosis (TB) can be ruled out. Clinical manifestations of TB are a persistent cough, weight loss, anorexia, night sweats, fevers or chills, dyspnea or hemoptysis.

The nurse is preparing to perform a tuberculin (TB) skin test on an older adult client. The nurse should know which information about TB testing on older adults? *a.* TB tests are contraindicated in older adults. *b.* TB tests may yield false negative results in older adults. *c.* TB test results are more accurate in older adults. *d.* TB tests may yield false positive results in older adults.

*b.* TB tests may yield false negative results in older adults. Tuberculosis antigens initiate a cell-mediated immune response in the body. Because older adults experience a decrease in cell-mediated immune response caused by decreased circulating T-lymphocytes, skin tests for TB in older adults may yield false negatives.

How is the client's confidentiality maintained when a nurse inputs client data into the electronic medical record? *a.* The client must give consent each time before the nurse inputs or retrieves any data. *b.* The nurse must log into the electronic medical record using a secured password prior to data entry. *c.* Because the client is admitted to the hospital, it is assumed consent is given to any employee of the hospital. *d.* The nurse must print a copy of the client data, date and sign the printed copy, and place it in client's chart.

*b.* The nurse must log into the electronic medical record using a secured password prior to data entry. To protect the client's rights and keep the client's record confidential, anyone who enters data into or consults a computerized record must log into the system using a secure password.

A nurse is assigned to care for a client diagnosed with Stage "1" seminoma testicular cancer with no protein markers found in their blood. The nurse should anticipate which treatment plan for this client? *a.* Bilateral orchiectomy followed up with adjuvant chemotherapy. *b.* Unilateral intact orchiectomy with prosthesis implant and active close surveillance follow-up. *c.* Before surgery external beam radiation therapy, followed up with chemotherapy post- orchiectomy. *d.* Orchiectomy of the diseased testicle with radical retroperitoneal lymph node dissection.

*b.* Unilateral intact orchiectomy with prosthesis implant and active close surveillance follow-up. The treatment plan for testicular cancer is based upon the stage of the cancer. Clients with seminoma testicular cancer have surgery to remove the diseased testicle with every effort to remove the diseased testis intact to prevent releasing or "seeding" of cancer cells at the surgical site. Testicle prosthesis is usually placed in the testicular sac at the same time or scheduled at a later date. The client is then followed very closely for any signs of returning cancer; this is known as " active surveillance".

Which therapeutic agent is indicated for treatment of all types of seizures? *a.* Oxcarbazepine (Trileptal) *b.* Valproic acid (Depakene) *c.* Felbamate (Felbatol) *d.* Ethosuximide (Zarontin).

*b.* Valproic acid (Depakene) Valproic acid (Depakene) is a broad-spectrum antiepileptic drugs (AEDs). Unlike narrow-spectrum AEDs, valproic acid is used to treat all types of seizures.

The nurse is speaking with the son of an older adult client who was admitted to the hospital for skin breakdown, malnutrition, and dehydration. The son states that he loves his mother and tries to do all he can for her, but he is struggling to care for her due to commitments with his own family. He is clearly upset that he might be responsible for his mother's condition. Which is the nurse's best response? *a.* "It sounds like you are doing the best you can." *b.* "You should go home and get some rest while we take care of your mother." *c.* "I realize this neglect is unintentional, but I must report it to the proper service agency." *d.* "Perhaps you can find a friend or relative to help you take care of your mother."

*c.* "I realize this neglect is unintentional, but I must report it to the proper service agency." Family members who provide care for an older relative may struggle with balancing their own personal and financial responsibilities. Their intentions may be good, but an older client may still experience profound, unintentional neglect. Although unintentional neglect is usually not viewed as a crime, it is still reportable to adult protective service agencies.

A client with a body mass index (BMI) of 27 asks the nurse how much weight she should gain during her pregnancy with a single fetus. Which range should the nurse recommend? *a.* 28-to-40 lbs (12.7 to 18.1 kg). *b.* 25-to-35 lbs (11.3 to 15.9 kg). *c.* 15-to-25 lbs (6.8 to 11.3 kg). *d.* 11-to-20 lbs (4.9 to 9.1 kg).

*c.* 15-to-25 lbs (6.8 to 11.3 kg). With a body mass index (BMI) of 27, the client is considered overweight. A woman who is overweight should aim to gain 15 to 25 lbs (6.8 to 11.3 kg) during a single-fetus pregnancy.

While assessing a client's health history, the nurse notes that the client has been prescribed an anti-diarrheal. The nurse should notify the healthcare provider of which health outcome found during the assessment ? *a.* Abdominal cramping. *b.* Flatulence and bloating. *c.* Absence of bowel sounds. *d.* Passage of hard, solid stools.

*c.* Absence of bowel sounds. The absence of bowel sounds could be indicative of paralytic ileus, a rare condition associated with anti-diarrheal use. Treatment of a paralytic ileus typically includes placement of a nasogastric tube, close medical management, and possible surgical intervention.

The nurse is caring for a client who just been brought into the emergency department after a myocardial infarction. Which action is the priority for this client? *a.* Administer pain medications. *b.* Begin educating the client about what to expect in the cath lab. *c.* Administer 2-4L oxygen by nasal cannula. *d.* Obtain an electrocardiogram.

*c.* Administer 2-4L oxygen by nasal cannula. Clients experiencing myocardial infarction often experience pain and discomfort. To relieve ischemic pain, the nurse can provide additional oxygen via nasal cannula, which will promote delivery of oxygen to the heart.

The healthcare provider has prescribed lisinopril 5mg to be added to a client's current medication plan of furosemide 60 mg PO BID to treat the client's heart failure and edema. Which action is most important for the nurse do first related to the client's new prescription for lisinopril? *a.* Reconcile the new prescription in the client's electronic medical administration record. *b.* Review the client's most recent serum potassium, magnesium, sodium and chloride levels. *c.* Check with the healthcare provider about reducing or discontinuing the dose of the diuretic before starting lisinopril. *d.* Assess the client's blood pressure every four hours at the beginning of treatment and periodically when administered.

*c.* Check with the healthcare provider about reducing or discontinuing the dose of the diuretic before starting lisinopril. For clients already taking a diuretic, severe hypotension may occur with lisinopril, an antihypertensive. This results from hypovolemia associated with the effect of the diuretic. This may be prevented by either reducing the diuretic dose or discontinuing the diuretic for three days prior to beginning lisinopril therapy.

Which statement is true regarding the effects of aging on glomerular filtration rate (GFR)? *a.* GFR declines due to age-related metabolic needs. *b.* GFR increases due to slight blood pressure increases caused by aging. *c.* GFR declines due to a loss of renal cortical tissue caused by aging. *d.* GFR increases due to age-related changes in the renal tubules.

*c.* GFR declines due to a loss of renal cortical tissue caused by aging. Aging is associated with a decline in renal function. One age-related factor that causes a decline in glomerular filtration rate is a decrease in renal cortical mass.

Which factor is most likely to contribute to the development of osteoarthritis? *a.* Atrophy of skeletal muscles. *b.* Calcium deficiency. *c.* High body mass index. *d.* Sedentary lifestyle.

*c.* High body mass index. Increased weight causes joint changes. For each pound of weight (0.45KG) there is four pounds (1.8KG) of pressure on the body's weight bearing joints.

Which action should the nurse take to prevent infection and sepsis in a client with renal failure? *a.* Use clean technique when managing central lines. *b.* Provide oral hygiene every 8 hours. *c.* Inspect all body secretions. *d.* Record the client's temperature once a day.

*c.* Inspect all body secretions. The nurse should carefully monitor clients with renal failure to prevent infection. Inspecting the color, odor, and appearance of all body secretions is a care priority for preventing infection and sepsis.

A client's assessment findings of hoarseness and audible wheezing noted at 2-3 feet (0.61-0.91 meters); trachea deviation towards the left; breathing pattern with prolonged exhalation followed by periods of shallow breathing; tenderness and increased fremitus with light palpation on the left side of the thorax cavity's base; and an occupation history as an oil refinery plant manager for the past ten years would be indicative of which condition? *a.* Flail chest *b.* Emphysema *c.* Lung cancer *d.* Pneumothorax.

*c.* Lung cancer Cigarette smoking is a major risk factor and responsible for 85% of all lung cancer deaths. The other 15% causes of lung cancer are due to environmental exposure to asbestos, petroleum distillates, radiation, tar, and uranium. Pulmonary signs and symptoms of lung cancer can be the presence of hoarseness; wheezing; decreased or absent breath sounds; prolonged exhalations alternating with periods of shallow breathing; rapid shallow breathing; areas of tenderness or masses palpated on chest wall; increase fremitus in areas of tumors; decreased or absent fremitus with bronchial obstruction; tracheal deviation; pleural friction rub; asymmetry of diaphragm movement and use of respiratory accessory muscles.

The nurse is caring for a client who is frequently hospitalized due to INR level management issues. The nurse recommends a home INR monitoring machine for the client as part of the discharge planning. Which step of the Predict, Prevent, Manage, Promote (PPMP) approach is the nurse using to proactively reduce future risk? *a.* Predict *b.* Prevent *c.* Manage *d.* Promote

*c.* Manage The Predict, Prevent, Manage, Promote (PPMP) approach proactively manages client health concerns and reduces risk through four stages. A home INR monitoring device allows a client more control over Coumadin dosing and INR levels, thereby decreasing hospitalizations and complications. The manage stage aims to implement technologies and interventions that can reduce risk, improve accuracy, and increase efficiency.

Which should the nurse include when planning discharge education for a client with end-stage renal disease? *a.* Increase dietary protein intake. *b.* Increase fluid intake. *c.* Monitor blood pressure and weight. *d.* Monitor 24-hour urine intake and output.

*c.* Monitor blood pressure and weight. Maintaining blood pressure conserves existing kidney function and slows down the progression of end-stage renal disease (ESRD). Fluid overload, a complication of ESRD, is reflected by a weight gain. Daily monitoring of blood pressure and body weight is the best way to obtain accurate data to monitor for problems.

Which teaching approach should the nurse use to facilitate learning and to reach client-centric goals? *a.* Encourage self-determination. *b.* Implement negative reinforcement. *c.* Reward positive behavior. *d.* Apply consequential punishment.

*c.* Reward positive behavior. Rewards for correct behavior reinforces learning and desired behaviors that are more likely to be repeated. This works better with immediate rewards than with delayed rewards.

The nurse is assessing a client for risk of falls. Which client behavior would be the most informative to the nurse? *a.* The client transfers unassisted from the bed to a chair next to the bed. *b.* The client changes positions in bed from a prone position to sitting upright at 45 degrees. *c.* The client is able to rise from a chair without using arms for support and walk 10 feet and turn around. *d.* The client with gait belt attached ambulates up and down the hallway with the physical therapist next to them.

*c.* The client is able to rise from a chair without using arms for support and walk 10 feet and turn around.

An older client has been diagnosed with pernicious anemia. The nurse should anticipate that the healthcare provider to prescribe which therapy? *a.* Blood transfusions *b. Dietary regimen of leafy green vegetables. *c.* Treatment with proton pump inhibitors. *d.* Monthly cobalamin (vitamin B12) injections.

*d.* Monthly cobalamin (vitamin B12) injections. Pernicious anemia is a type of vitamin B12 deficiency anemia caused by a lack of intrinsic factor, a substance normally secreted by the gastric mucosa that is needed for absorption of vitamin B12. This condition is generally diagnosed around the age of 60 years old. Clients with pernicious anemia are given vitamin B12 injections weekly at first, and then monthly thereafter.

How does angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) improve the cardiac function of a client diagnosed with heart failure? *SATA* *a.* They increase the heart rate and decrease the force of the contractions. *b.* They increase the resistance to the (L) ventricular ejection (afterload). *c.* They promote relaxing of the arterioles and arterial vasodilation. *d.* They help prevent sodium and water retention by blocking aldosterone. *e.* They improve the heart's stroke volume, thus improve cardiac output.

*c.* They promote relaxing of the arterioles and arterial vasodilation. *d.* They help prevent sodium and water retention by blocking aldosterone. *e.* They improve the heart's stroke volume, thus improve cardiac output. The purpose of the medications to manage heart failure is to improve the heart's stroke volume to improve the cardiac output. ACE inhibitors and ARBs do this by reducing the resistance of blood flow to the (L) ventricular ejection (afterload); this is done by the relaxation of the arterioles and arterial vasodilation. They help prevent sodium and water retention by blocking aldosterone.

When assessing a client after the administration of an albuterol inhaler, the nurse should be aware of what possible side effect of this medication? *a.* Lethargy *b.* Euphoria *c.* Tremors *d.* Low blood pressure.

*c.* Tremors Albuterol is included in the plan of care for clients with asthma. Albuterol is a sympathomimetic agent, which is a stimulant that can cause tremors in some clients.

What is the most reliable method a nurse should use to document the status of fluid retention in a client diagnosed with heart failure? *a.* Assess their skin turgor. *b.* Auscultate their lung sounds. *c.* Weigh them daily in the morning. *d.* Evaluate them for the presence of edema.

*c.* Weigh them daily in the morning. The best way to determine the fluid status of a client diagnosed with heart failure is measuring the client's weight early in the morning every day. Weight gain or loss is the most reliable way to assess the fluid status of these clients.

The nurse is educating a student nurse about collaborative care methods used with clients with increased intracranial pressure (IICP). Which method is appropriate treatment for clients with IICP? *a.* "Anti-hypertensives are considered first line therapy in client's with ICP." *b.* "Intravenous calcium antagonists increase perfusion." *c.* "Glycerin has been clinically proven to increase ICP and should not be used." *d.* "Clients given mannitol should be monitored for electrolyte imbalances."

*d.* "Clients given mannitol should be monitored for electrolyte imbalances." Mannitol lowers intracranial pressure by reducing fluid in the client's brain cells. After administering mannitol, the nurse should closely monitor the patient to be sure excessive dehydration does not occur.

What is the highest priority of nursing care in ventilator management of clients with acute respiratory distress syndrome? *a.* "The highest priority is nutrition support." *b.* "The highest priority is repositioning the client every 2 hours." *c.* "The highest priority is to reduce anxiety." *d.* "The highest priority is to protect the functional lung."

*d.* "The highest priority is to protect the functional lung." In ventilator management for clients with acute respiratory distress, the care concern of highest priority is maintaining adequate arterial oxygenation while also protecting the functional lung. The nurse should also evaluate the client for underlying causes of respiratory failure, such as neurologic conditions.

The nurse is assessing a newborn. The newborn appears pink with blue extremities, with arms and legs flexed. The nurse also notes that the child has a heart rate greater than 100 and is crying during the assessment. What APGAR score should the nurse assign? *a.* 4 *b.* 6 *c.* 7 *d.* 9

*d.* 9 The APGAR score is completed immediately (1) minute after birth to determine the initial health of the newborn and then again (5) minutes after birth. Based on the information provided, the correct APGAR score for this newborn is 9. APGAR scoring consists of: Heart rate- 0= absent; 1= less than 100; 2= over 100; Respiratory effort- 0= absent; 1= slow irregular; 2= good cry; Muscle tone- 0= limp; 1= some flexion; 2= active motion; Reflex irritability- 0= no response; 1= grimace; 2= cry; Color- 0= pale; 1= body pink, extremities blue; 2= all pink.

The nurse is conducting a health promotion presentation about stroke prevention for a group of residents in a retirement community. Which should the nurse identify as a modifiable risk factor for stroke? *a.* Gender *b.* Race *c.* Age *d.* Diet

*d.* Diet Diet is a modifiable risk factor. Choosing foods that are high in fiber and low in saturated fats, trans fats, and cholesterol can help prevent stroke.

Which nursing intervention should the nurse implement when caring for a client who is experiencing nocturia? *a.* Advise the client to stop drinking any liquids after 6:00 PM (1800 HR). *b.* Provide thorough perineal care after each voiding. *c.* Observe the client for urinary retention. *d.* Ensure adequate nighttime lighting and a hazard-free environment.

*d.* Ensure adequate nighttime lighting and a hazard-free environment. Nocturia occurs when a client has to get out of bed multiple times during the night to void. Ensuring adequate nighttime lighting and a hazard-free environment will help prevent falls and injuries.

A client has just been diagnosed with nephrogenic diabetes insipidus. Which assessment finding should the nurse interpret as a sign of electrolyte imbalance? *a.* Nocturia. *b.* Poor skin turgor. *c.* Increased thirst. *d.* Leg cramps.

*d.* Leg cramps. A chronic kidney disorder can result in nephrogenic diabetes insipidus which affects the kidney's ability to respond properly to the anti-diuretic hormone (ADH). This causes high urine output, increased thirst and electrolyte imbalances resulting in the client experiencing nausea, lethargy, muscle cramps and confusion. The nurse should interpret leg cramps are a sign of an electrolyte imbalance.

Which renal system change should the nurse anticipate to occur in an older adult client? *a.* Loss of renal blood flow. *b.* Increased glomerular filtration rate. *c.* Increased renal mass. *d.* Loss of functional nephrons.

*d.* Loss of functional nephrons. Decreased renal function occurs with age. Loss of functional nephrons, decrease in glomerular filtration rate (GFR), reduced renal mass, and diminished renal blood flow contribute to impaired renal function in the aging population.

A school nurse is assessing rashes on a child's lower shins and forearms that appear streaked and inflamed and are blistered with clear oozing substance present. The child reports that it is painful. Based on these signs and symptoms, what most likely caused this condition? *a.* Shellfish. *b.* Penicillin elixir. *c.* Laundry detergent. *d.* Poison ivy or oak.

*d.* Poison ivy or oak. Dermatitis reactions to plants that contain oil with urushiol, usually will cause localized rashes and are seen on areas of the skin that are not typically covered by clothing and appear to be streaky or spotty, inflamed, blisterd with oozing clear substance and painful. Three common plants which contain this substance are poison ivy, oak and sumac.

Which assessment finding should the nurse anticipate in a client experiencing an acute asthma exacerbation? *a.* Decreased nasal secretions. *b.* Frequent productive cough. *c.* Answering questions in full sentences. *d.* Prolonged phase of forced expiration.

*d.* Prolonged phase of forced expiration. The nurse should expect to observe a prolonged phase of force expiration, frequent unproductive cough, increased nasal secretions, and breathlessness in the client experiencing acute asthma exacerbation.

The nurse working at a community blood pressure screening health fair suggests that all the screenings should be performed by calibrated automated blood pressure cuff machines. Which screening test selection criterion concerns the nurse? *a.* Sensitivity *b.* Specificity *c.* Validity *d.* Reliability

*d.* Reliability Criteria for screening test selectivity and implementation include sensitivity, specificity, validity, and reliability. If the criterias are not met, the screening may do more harm than good. By using calibrated automated blood pressure cuff machines, it helps ensure the reliability and consistency of the blood pressure readings.

A nurse is assessing a client who is exhibiting bulging veins and 3+ pitting dependent peripheral edema. The nurse should anticipate the client to most likely be diagnosed with which medical condition? *a.* Atherosclerosis *b.* Coronary artery disease *c.* Left-sided heart failure *d.* Right-sided heart failure

*d.* Right-sided heart failure Right-sided heart failure can cause peripheral edema and increased pressure and volume in the venous system due to the right ventricle not emptying completely causing a back-up and emptying of the venous system.

A client is admitted for a thyroid scan to rule out Graves Disease. The nurse has delegated care of this client to an unlicensed assistive personnel (UAP). Which is the most important data that the UAP should report to the nurse immediately? *a.* Apical pulse of 110 beats per minute. *b.* Blood glucose reading of 150mg/dl. *c.* Presence of tremors and blurred vision. *d.* Temperature change from 99.1 to 100.1°F (37.3-37.8°C).

*d.* Temperature change from 99.1 to 100.1°F (37.3-37.8°C). For the client with Graves disease (hyperthyroidism), an increase in temperature may indicate worsening of the condition and the onset of a thyroid storm. An increase of 1° F should be reported immediately.

While assessing a client's health history, the nurse notes that the client has been prescribed enoxaparin (Lovenox). Which health outcome would indicate this medication is effective? *a.* The client maintains a hemoglobin A1C below 7%. *b.* The pulmonary embolus has lysed and the client's respiratory status improves. *c.* The client's hemoglobin remains above 14 g/dL throughout the rehabilitation. *d.* The client does not develop deep vein thrombosis (DVT) after abdominal surgery.

*d.* The client does not develop deep vein thrombosis (DVT) after abdominal surgery. Enoxaparin (Lovenox) is a low-molecular-weight heparin (LMWH) that is used to prevent DVT, pulmonary embolism, unstable angina, acute MI, and coronary artery thrombosis.

The nurse is caring for a client in acute respiratory failure. Which goal should the nurse include in the care plan? *a.* Respiratory rate will be 30 breaths/min within 24-48 hours after initiation of treatment. *b.* The client will be weaned from the ventilator within 24-48 hours after initiation of treatment. *c.* Blood pH will be between 7.50-7.60 within 2-4 hours after initiation of treatment. *d.* The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment.

*d.* The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment. Acute respiratory failure generally results from a primary lung dysfunction. When treating a client with acute respiratory failure, the client should have adequate gas exchange within 2 to 4 hours of initiating treatment. A PaO2 greater than 80 mmHg indicates adequate ventilation.

An ambulatory client has developed an ulcer as a result from chronic venous insufficiency that is non-healing and causing edema in the lower leg. The nurse should anticipate the healthcare provider's plan of care to include? *a.* Arterial revascularization. *b.* Cauterization of the wound bed. *c.* Surgical transplant of venous valves. *d.* Unna boot that has been moistened with zinc oxide.

*d.* Unna boot that has been moistened with zinc oxide. Surgical transplant of venous valves for chronic venous insufficiency is usually not done due to limited successful attempts in the past. The plan of choice for ambulatory clients is usually the application of an Unna boot that has been moistened with zinc oxide. The boot is usually applied by a healthcare provider and can be left in place for a week. The client is able to ambulate with the Unna boot in place.

Which finding should the nurse anticipate when assessing a client with a severe occipital lobe injury? *a.* Impaired judgment. *b.* Auditory impairment. *c.* Impaired temperature regulation. *d.* Visual impairment.

*d.* Visual impairment. The occipital lobe of the cerebral cortex assists in processing visual information. When the occipital lobe is damaged, the client may experience impaired vision.

When developing a research study, what information should the nurse consider when deciding populations? *a.* Adult male subjects should be the default study group for most studies. *b.* English-speaking subjects should be prioritized to reduce variables. *c.* Women who are pregnant should be excluded because fetuses cannot give consent. *d.* Vulnerable populations should be included in studies.

*d.* Vulnerable populations should be included in studies. Vulnerable populations have the right to have their issues, situations, and challenges studied, the same as other populations. The nurse should include vulnerable populations in the study as appropriate.

A client has a prescription for one liter of 0.9% Normal Saline solution to infuse over twelve hours. The IV administration set delivers 15 drops/ml. The nurse should set the drop rate at how many drops per minute?

Calculate as:Volume/Time (minutes) X drop factor (drops/mL)12 hours X 60 minutes = 720 minutes1000 mL/720 X 15 = 20.833 = *21 drops/minute*