Medsurg practice quiz

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A) Limit the client's intake of oral fluids and food. Feedback: INCORRECT B) Evaluate the effectiveness of narcotic analgesics. Feedback: CORRECT C) Encourage the client to ambulate as tolerated. Feedback: INCORRECT D) Teach the client about prevention of crises.

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The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2° F. Which intervention should the nurse implement? A) Document the temperature reading on the vital sign graphic sheet. Feedback: CORRECT B) Report the temperature to the healthcare provider immediately. Feedback: INCORRECT C) Instruct the UAP to take the client's temperature again in 30 minutes. Feedback: INCORRECT D) Advise the UAP to assist the client in returning to her bed.

A subnormal temperature of 97.2° F (orally) is a common finding in elderly clients, so the nurse should document the findings (A) and continue with the plan of care. (B, C, and D) are not indicated unless the temperature falls below 97° F or if other symptoms occur.

A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? A) Tell your friends and family so that they can help you. Feedback: INCORRECT B) Get involved with a support group. I will give you some names. Feedback: CORRECT C) Talk only to other friends who are infertile since only they can help. Feedback: INCORRECT D) Start adoption proceedings immediately since obtaining an infant is very difficult.

A support group (B) provides a safe haven for the couple to share experiences and gain insight from others experiences. Although talking about feelings may unburden the couple of negative feelings, infertility is a major stressor that affects the couple's relationships, so discussion with family and friends (A) should be minimal. Limiting interaction to other infertile couples (C) may address some psychosocial needs, but depending on where the other couples are in the recovery process, it may not be helpful. Giving an opinion about adoption (D) is not therapeutic nor supportive of the psychosocial needs.

The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What is the priority nursing action to implement? A) Prepare for intubation. Feedback: INCORRECT B) Defibrillate at 200 joules. Feedback: CORRECT C) Insert intravenous catheter. Feedback: INCORRECT D) Obtain arterial blood gases.

After confirming ventricular fibrillation, rapid defibrillation (B) is critical in re-establishing cardiac output and preserving vital organ function. After CPR is initiated and defibrillation attempted, airway intubation (A) and intravenous access (C) are indicated for successful resuscitation. Arterial blood gases (D) are obtained during or after resuscitation to determine medical management for metabolic acidosis which occurs secondary to anaerobic glycolysis during VF or cardiac arrest.

When observing a client for symptoms of a large bowel obstruction, the nurse should assess for which finding? A) Distention of the lower abdomen. B) Nausea with profuse vomiting. C) Upper abdominal discomfort. D) Fluid and electrolyte imbalances.

Among findings characteristic of a large bowel obstruction is the distention of the lower abdomen (A). (B, C, and D) are findings associated with small bowel obstruction.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A) A scalp laceration oozing blood. B) Serosanguineous nasal drainage. C) Headache rated 10 on a 0-10 scale. D) Dizziness, nausea and transient confusion.

Any nasal discharge should be evaluated (B) to determine the presence of cerebral spinal fluid which indicates a tear in the dura making the client susceptible to meningitis. The scalp is highly vascular and results in blood oozing from wounds (A). Pain is expected and can be treated after further assessment of the presence of nasal discharge (C). Dizziness, nausea, and transient confusion (D) are expected manifestations following a traumatic brain injury and need ongoing monitoring, but (B) is most important.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). This condition is most often related to which predisposing condition? A) Small cell lung cancer. B) Active tuberculosis infection. C) Hodgkin's lymphoma. D) Tricyclic antidepressant therapy.

Cancer is the most common cause of the syndrome of inappropriate antidiuretic hormone (SIADH), with small cell lung cancer (A) being the most common cancer that increases ADH, which causes dilutional hyponatremia and fluid retention. (B, C, and D) are also possible causes, but secondary to CNS trauma or disease.

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? A) Heart palpitations. B) Anorexia. C) Hypersomnia. D) Stress incontinence.

Characteristic features of premenstrual syndrome include heart palpitations (A), sleeplessness, increased appetite and food cravings, and oliguria or enuresis. (B, C, and D) are not consistent with symptoms of premenstrual syndrome.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) A) Vagal stimulation. B) An increased level of stress. C) Decreased duodenal inhibition. D) Hypersecretion of hydrochloric acid. E) An increased number of parietal cells.

Correct selections are (A, C, D, and E). Hypersecretion of gastric juices (D) and an increased number of parietal cells (E) that stimulate secretion are most often the causes of ulceration. Vagal stimulation (A) and decreased duodenal inhibition (C) also increase the secretion of caustic fluids. An increased stress level is not physiologic and is not a direct cause of ulceration (B).

A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) A) Only marijuana cigarettes affect sperm count. Feedback: INCORRECT B) Smoking can decrease the quantity and quality of sperm. Feedback: CORRECT C) The first semen analysis should be repeated to confirm sperm counts. Feedback: CORRECT D) Cessation of smoking improves general health and fertility. Feedback: CORRECT E) Sperm specimens should be collected in 2 subsequent days.

Correct selections are (B, C, and D). Use of tobacco, alcohol, and marijuana may affect sperm counts (B). Sperm counts vary from day to day and are dependent on emotional and physical status and sexual activity, so a single analysis may be inconclusive (C). A minimum of two analyses should be performed several weeks apart to assess male fertility, not (E). (A and D) contain inaccurate information.

Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)? A) Type 1 DM and a serum hemoglobin-A1c of 3.5%. Feedback: INCORRECT B) Type 1 DM and retinopathy and mild vision loss. Feedback: CORRECT C) Type 2 DM and hypertension controlled by metoprolol. Feedback: INCORRECT D) Type 2 DM and a history of morbid obesity for 5 years.

Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and retinopathy is most likely to develop nephropathy (B) and CKD. (A) is demonstrating compliance with therapy (H-A1c target level is below 7%), which indicates tight glucose control and reduces the risk for microvascular complications. The client with controlled hypertension (C) is less likely to develop CKD, although metoprolol, a beta adrenergic receptor antagonist, can mask the signs of hypoglycemia. A client with Type 2 DM is more likely at risk for complications associated with chronic obesity (D).

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? A) Palpate the pedal pulse volume. Feedback: INCORRECT B) Count the brachial pulse rate. Feedback: INCORRECT C) Measure the blood pressure. Feedback: CORRECT D) Assess for a carotid bruit.

Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure (C) should be determined. (A, B, and D) are less likely to provide data related to the client's tachycardia.

A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? A) Serum amylase of 132 units/L. B) Serum sodium of 134 mEq/L. C) Chest x-ray indicating a mediastinal shift. D) Abdominal x-ray air throughout intestines.

Immediate action is required for findings of a mediastinal shift (C), which can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to increasing air entrapment in the pleural space. (A and B) do not warrant action (normal levels for serum sodium level 135 to 145 mEq/L and amylase 30 to 220 units/L). (D) describes a normal gas pattern in the intestines.

The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? A) Kyphosis with a reduction in height. Feedback: INCORRECT B) Dilated superficial veins on both legs. Feedback: INCORRECT C) External hemorrhoids with itching. Feedback: INCORRECT D) Yellowish discoloration of the sclerae.

Jaundice, a yellowish discoloration of the sclerae (D), may indicate liver damage and requires further assessment. Kyphosis and height reduction (A) due to bone loss, varicose veins (B), and external hemorrhoids with itching (C) are common findings in the elderly that do not require immediate intervention.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). What is the most significant desired outcome for this client? A) Free from injury of drug side effects. Feedback: INCORRECT B) Return to pre-illness weight. Feedback: CORRECT C) Adequate oxygenation. Feedback: INCORRECT D) Maintenance of intact perineal skin.

MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight (B) using oral, enteral, or parenteral supplementation as needed. Drug schedules and side effects (A) remain a life long management problem. Client outcomes for adequate oxygenation (C) are often dependent on management of anemia, maintenance of activities without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity (D) is dependent upon resolution of diarrhea, which is not as significant as optimal nutrition.

A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis? A) Production of replacement cartilage is stimulated. B) Further destruction of the articular cartilage is prevented. C) Inflammation is reduced by inhibiting prostaglandin synthesis. D) Bradykinin is inhibited, thereby reducing acute and chronic pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis, inhibit the synthesis of prostaglandins and relieve associated pain (C), but they do not generate new cartilage (A). NSAIDs are not an effective treatment to inhibit bradykinin (D). Joint destruction is not preventable with this disease process (B).

The severity of diabetic retinopathy is directly related to which condition? A) Poor blood glucose control. B) Neurological effects of diabetes. C) Susceptibility to infection. D) Uncontrolled hypertension.

Poor glucose control (A) worsens diabetic retinopathy, where as tight glucose control can lessen its severity. (B, C, and D) do not affect the severity of diabetic retinopathy.

Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states, I guess we will never have sex again after this. Which response is best for the nurse to provide? A) Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife. Feedback: INCORRECT B) Sexual activity can be resumed whenever you and your wife feel like it because the sexual response is more emotional rather than physical. Feedback: INCORRECT C) You should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage. Feedback: INCORRECT D) Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities.

Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs (D), as long as other guidelines, such as limiting food and alcohol intake before intercourse, are followed. (A, B, and C) do not provide the best factual information to reduce the client's anxiety and misconceptions.

Which method elicits the most accurate information during a physical assessment of an older client? A) Ask the client to recount one's health history. Feedback: INCORRECT B) Obtain the client's information from a caregiver. Feedback: INCORRECT C) Review the past medical record for medications. Feedback: INCORRECT D) Use reliable assessment tools for older adults.

Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale), consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. (A and B) are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although (C) is a good resource to identify polypharmacy, a written record may not be available or currently accurate.

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? A) Obtain a prescription for an adjusted dose of insulin. B) Administer an oral anti-diabetic agent. C) Give an insulin dose using parameters of a sliding scale. D) Withhold insulin while the client is NPO.

Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin (A). (B, C, and D) are not indicated.

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? A) Upper chest subcutaneous emphysema. B) Tidaling (fluctuation) of fluid in the water-seal chamber. C) Constant air bubbling in the suction-control chamber. D) Pain rated 8 (0-10) at the insertion site.

Subcutaneous emphysema (A) is a complication and indicates air is leaking beneath the skin. Tidaling in the water-seal chamber and constant bubbling with suction in the suction-control chamber (B and C) are expected findings that indicate the closed drainage system is working. Pain at the insertion site is an expected finding (D) and the prescribed analgesia should be given to assist the client to breathe deeply and facilitate lung expansion.

A client is admitted to the Emergency Department with a tension pneumothorax. Which assessment should the nurse expect to identify? A) An absence of lung sounds on the affected side. Feedback: INCORRECT B) An inability to auscultate tracheal breath sounds. Feedback: INCORRECT C) A deviation of the trachea toward the side opposite the pneumothorax. Feedback: CORRECT D) A shift of the point of maximal impulse to the left, with bounding pulses.

Tension pneumothorax is caused by rapid accumulation of air in the pleural space, causing severely high intrapleural pressure. This results in collapse of the lung, and the mediastinum shifts toward the unaffected side, which is subsequently compressed (C). (A, B, and D) are not demonstrated with a tension pneumothorax.

The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? A) It is quickly digested. B) It does not cause diarrhea. C) It does not dilate the stomach. D) It is slow to leave the stomach.

This type of diet is slowly digested and is slow to leave the stomach (D). Because of its density from proteins and fats, and the reduction of fluids with the meal, the possibility of dumping syndrome is reduced. (A, B, and C) are incorrect rationales.

An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? A) Begin wearing the aids in quiet environments to experiment with adjustments. Feedback: CORRECT B) Wear the hearing aids for an hour a day at first, gradually increasing the time. Feedback: INCORRECT C) Keep the volume on low until the conditions with noises are audible. Feedback: INCORRECT D) Use one hearing aid until comfortable, then add the second aid.

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What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? A) Tell another staff member to bring extinguishing equipment to the bedside. B) Close the doors to the client's area when attempting to extinguish the fire. C) Use a bag-valve-mask resuscitator while removing the client from the area. D) Implement an emergency protocol to remove the client from the ventilator.

A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source (C). (A, B, and D) are not the priority in maintaining client safety during a fire in the client care area.

What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.) A) White patches. Feedback: INCORRECT B) Cherry angiomas. Feedback: INCORRECT C) Border irregularity. Feedback: CORRECT D) Lesion with asymmetry. Feedback: CORRECT E) Lesion with color variations. Feedback: CORRECT F) Lesion of 3 to 5 mm diameter. Feedback: INCORRECT

Correct selections are (C, D, and E). ABCDE is the acronym used by the American Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin cancer: A for asymmetry of the lesion (D); B for irregular border (C); C for color, usually dark (E); D for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of the characteristics of ABCDE should be evaluated by a healthcare provider. (A) lack the color variable. (B) are raised, dome-shaped, benign clusters of blood vessels that do not require treatment. Lesions of 3 to 5 mm diameter are small and may be monitored instead of treated (F).

The nurse is caring for a client with a nursing diagnosis of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? A) Limit visitors to immediate family to decrease exposure to infection. Feedback: INCORRECT B) Maintain "clean" technique in the change of wound dressing and IV site. Feedback: INCORRECT C) Assess and document skin condition around the incision and IV site at each shift. Feedback: CORRECT D) Require the use of a face mask by staff when providing care requiring close contact.

Early identification of infection leads to prompt treatment and decreased nosocomial transmission to others, so the condition of any invasive lines or breaks in the skin should be assessed and documented (C) during each shift. (A and D) are not indicated for care of this client. Sterile technique is used in the dressing change or IV site change, not (B).

cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? A) Administer medications for pain relief, shortness of breath, and nausea. Feedback: CORRECT B) Clarify family members' feelings about the meaning of client behaviors and symptoms. Feedback: INCORRECT C) Develop a plan of care after assessing the needs of the client and family. Feedback: INCORRECT D) Teach the family to recognize restlessness and grimacing as signs of client discomfort.

Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects (A) is within the scope of practice for the PN. Nursing actions that require the skills of the RN include assessing and clarifying the feelings of family members (B), planning care (C), and teaching symptom recognition (D).

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? A) Neisseria gonorrhoea. Feedback: INCORRECT B) Chlamydia trachomatis. Feedback: INCORRECT C) Herpes simplex virus. Feedback: INCORRECT D) Human papillomavirus.

Human papillomavirus (D) is known to alter cervical epithelium cytology, which is consistent with early changes of cervical cancer. Although STIs (A, B, and C) place the client at risk for exposure to HPV, these are likely to place the client at risk for pelvic inflammatory disease, infertility sequela, and painful reoccurrence.

A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? A) Obstruction at the urinary bladder neck. Feedback: CORRECT B) Ureteral calculi obstruction. Feedback: INCORRECT C) Ureteropelvic junction stricture. Feedback: INCORRECT D) Partial post-renal obstruction due to ureteral stricture.

Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed (A). A large residual urine does not occur with (B, C, and D) because the urine can not get to the bladder.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? A) Prevent the formation of effusion fluid. B) Remove fluid from the intrapleural space. C) Debulk tumor to maintain patency of air passages. D) Relieve empyema after pneumonectomy.

Instillation of a sclerosing agent to create pleurodesis (adherence of the parietal and visceral pleura) is aimed at preventing the formation of pleural effusion fluid (A). (B) refers to thoracentesis. (C) is achieved by surgical resection. (D) is treated by closed-chest drainage.

The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? A) Helps to minimize pain and anxiety. B) Maintains correct spinal alignment to protect the surgical area. C) Prevents dizziness while stabilizing the spine. D) Allows the nurse to move the client freely without assistance.

Log-rolling technique maintains the spine in a straight superior-inferior plane that aligns the spine without movement while protecting the surgical area (B), which is especially important when the procedure involves bone grafts that may several weeks for the bone to fuse. (A) is best managed with client teaching, preparation before procedures, relaxation techniques, and pain management, not log-rolling. (C and D) are not accurate.

A client with osteoarthritis requests information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information? A) Low impact exercise, walking, swimming and water aerobics. B) Repetitive strength-building exercises with weights or resistance bands. C) Circuit training alternating with frequent rest periods. D) High-impact aerobic exercise.

Low impact exercises such as walking or swimming (A), that do not cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics (B, C and D) may cause too much stress on the joint areas and subsequently increase inflammation and damage.

A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? A) Give the drug and allow the client to read and sign the consent form. Feedback: INCORRECT B) Counter-sign the client's initials on the consent form after giving the drug. Feedback: INCORRECT C) Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Feedback: CORRECT D) Call the healthcare provider to explain the surgical procedure before the client signs the consent.

Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered (C). The validity of legal documents will be in question if a client signs them while under the influence of any central nervous system-depressant drug (A and B). If indicated, (D) may need to be implemented but should be determined before the client arrives to the preoperative area.

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A) A description of inflammation, infection, and tumors. B) Continuous visualization of intracranial neoplasms. C) Imaging of tumors without exposure to radiation. D) An image that describes metastatic sites of cancer.

PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their aggressiveness. This diagnostic test scans the body to detect the spread of cancer (metastasis) (D). (A, B, and C) are not the purpose of PET.

Which signs and symptoms are associated with arterial insufficiency? A) Pallor, intermittent claudication. B) Pedal edema, brown pigmentation. C) Blanched skin, lower extremity ulcers. D) Peripheral neuropathy, cold extremities.

Pallor and intermittent claudication (A) are signs related to stage II of peripheral vascular disease, which results in arterial insufficiency. (B) are signs related to venous insufficiency. (C) are not specific to arterial disease. Although (D) may be related to complications of diabetes mellitus resulting in poor circulation, arterial insufficiency causes impaired perfusion resulting in hypoxic pain or intermittent claudication.

The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement? A) Encourage fluids to 3000 ml/day. Feedback: INCORRECT B) Check stools for occult blood. Feedback: CORRECT C) Provide oral hygiene every 2 hours. Feedback: INCORRECT D) Check for fever every 4 hours.

Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces (B), urine, nasogastric secretions, or wounds. (A) does not minimize the risk for bleeding associated with thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia. (D) assesses for infection, not risk for bleeding.

A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? A) Notify the client's healthcare provider. Feedback: CORRECT B) Document the finding in the client record. Feedback: INCORRECT C) Prepare a warm enema solution for rectal instillation. Feedback: INCORRECT D) Obtain a large bore needle for aspiration of the corpora cavernosa.

Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be notified immediately (A). Documentation (B) is not the first action that should be taken. Treatment may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa (C) and giving pain medications, but (A) has priority. If noninvasive measures do not work, (D) is implemented by the healthcare provider.

Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? A) Carotid stenosis. B) Steatosis hepatitis. C) Metastatic cancer. D) Clavicular fracture.

Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer (C) from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. (A, B, and D) do not result in SVC syndrome.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A) Assessment of the client's vital signs. Feedback: INCORRECT B) Document the finding as the only action. Feedback: INCORRECT C) Determine the time the client last voided. Feedback: CORRECT D) Insert a rectal tube for the passage of flatus.

Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided (C) should be determined next. Documentation (B) should be made, but the client's distended bladder requires additional intervention. (A and D) are not priority actions based on the client's abdominal findings.

The nurse is caring for a client who is two days postoperative.

The RRT should be called to intervene for a client with an acute life-threatening change, such as (B). (A) indicates possible hemorrhage and needs further investigation and monitoring. (B) indicates an infection and (D) may indicate post operative diuresis with corresponding hypotension. Although these symptoms needs prompt collaborative attention, they can be dealt with through normal channels such providing supportive care and calling the healthcare provider.

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? A) The xray procedure may last for several hours. B) A nasogastric tube (NGT) is inserted to instill the barium. C) Enemas are given to empty the bowel after the procedure. D) Nothing by mouth is allowed for 6 to 8 hours before the study.

The client should be NPO for at least 6 hours before the UGI (D). (A) is not typical for this procedure. A NGT is not needed to instill the barium (B) unless the client is unable to swallow. A laxative, not enemas (C), is given after the procedure to help expel the barium.

After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? A) Collect blood for hemoglobin and hematocrit. Feedback: INCORRECT B) Start the first transfusion of blood. Feedback: CORRECT C) Insert an indwelling urinary catheter. Feedback: INCORRECT D) Encourage alternate rest periods with activity.

The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started (B). (A) should be obtained after the client is transfused to evaluate its effectiveness. (C) is not indicated at this time. (D) should be included in the plan of care, but is not as essential as (B) at this time.

During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care? A) Promotion of comfort. Feedback: CORRECT B) Prevention of pregnancy. Feedback: INCORRECT C) Instruction in condom use. Feedback: INCORRECT D) Information about transmission.

The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority (A). Prevention of pregnancy (B), instruction in condom use (C), and information about transmission (D) are all important to teach the client, but the client's ability to learn is hindered until the pain is controlled.

A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? A) Keep the client on bed rest for eight hours. Feedback: INCORRECT B) Check vital signs every 15 minutes for two hours. Feedback: INCORRECT C) Allow the client nothing by mouth until the gag reflex returns. Feedback: CORRECT D) Encourage fluid intake to promote elimination of the contrast media.

The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns (C) to prevent aspiration from any oral intake or secretions. (A, B, and D) are not indicated after bronchoscopy.

A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? A) Determine the client's level of discomfort using a pain rating scale. Feedback: INCORRECT B) Ask the client about her past experience with chronic pain. Feedback: INCORRECT C) Observe the client's facial expressions for pain and discomfort. Feedback: INCORRECT D) Evaluate the client's ability to adjust the voltage to control pain.

The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage (D). The PN can collect data about the client's pain (A, B, and C).

The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? A) Asthma. Feedback: INCORRECT B) Myocardial infarction. Feedback: INCORRECT C) Chronic esophagitis with gastroesophageal reflux. Feedback: INCORRECT D) Pathologic fracture of two ribs on the right chest.

The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurence of two right-sided ribs with pathological fractures resulting without evidence of trauma (D) is related to radiation damage. The heart (B), esophagus (C), and larger bronchi (A) are not usually in the radiation path.

During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement? A) Notify the surgeon. Feedback: CORRECT B) Document the assessment. Feedback: INCORRECT C) Secure a colostomy pouch over the stoma. Feedback: INCORRECT D) Place petrolatum gauze dressing over the stoma.

The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately (A). Although (B, C, and D) may be implemented, the findings require immediate medical attention.

The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? A) An older man who is always happy and chooses to view only the good in every situation. Feedback: INCORRECT B) A single mother who seeks the support of her two teenage daughters during difficult times. Feedback: INCORRECT C) A successful businessman who is accustomed to handling highly-stressful situations. Feedback: INCORRECT D) A teacher who seeks information about her disease and wants to continue teaching.

Those who seek information about their disease while attempting to carry on with their lives as best they can (D) are likely to handle the diagnosis of cancer best. Those who use repression (A) to deal with traumatic events often have difficulty expressing their feelings. Depending on children for support (B), especially when the children are teenagers, may be disappointing. Someone who is used to handling high-stress situations (C) is used to being in control, and control over a life-threatening diagnosis is not always possible.

A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? A) Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. B) Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. C) Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. D) Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.

Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks (C). (A, B, and D) are incorrect antibiotic schedules for osteomyelitis.