Module 10: Physiological Health Problems Module Tests

The nurse is providing information about foods that are high in sodium to a client who must restrict sodium intake. Which foods should the nurse tell the client to avoid? Select all that apply. A. Ketchup B. Broccoli C. Baked Ham D. Cantaloupe E. Watermelon F. American cheese

A. Ketchup C. Baked Ham F. American cheese

A nurse provides self-care instructions to a client with hypertension who will be taking an antihypertensive medication daily. Which statement by the client indicates a need for further instruction? A. "I need to cut down on my smoking." B. "I'm going to have to take this medicine for the rest of my life." C. "I can use relaxation techniques to help control my blood pressure." D. "I need to check food labels for the sodium content when I'm shopping."

A. "I need to cut down on my smoking."

The nurse provides discharge instructions to a client who has undergone mechanical valve replacement. Which statement by the client indicates an understanding of the instructions? A. "I'll have to take a blood thinner for the rest of my life." B. "If I hear a clicking sound I need to call the surgeon immediately." C. "I need to avoid lifting anything heavier than 30 lb for at least 6 weeks." D. "I shouldn't worry if I see redness at the incision site or clear drainage, because it's normal."

A. "I'll have to take a blood thinner for the rest of my life."

A client with sepsis has been receiving intravenous antibiotics, and acute kidney injury has developed as a result. The nurse assesses the client and reviews the laboratory results. Which findings should the nurse expect to note during the oliguric stage of acute kidney injury? Select all that apply. A. A calcium level of 8.0 mg/dL B. A creatinine level of 2.0 mg/dL C. A serum sodium level of 159 mEq/L D. A serum potassium level of 3.1 mEq/L E. A blood urea nitrogen level of 30 mg/dL

A. A calcium level of 8.0 mg/dL B. A creatinine level of 2.0 mg/dL E. A blood urea nitrogen level of 30 mg/dL

Which of the following clients are at risk for pulmonary embolism? Select all that apply. A. A pregnant client B. A client who is underweight C. A client under the age of 30 years D. A client who is in traction and immobilized E. A client who has undergone abdominal surgery

A. A pregnant client D. A client who is in traction and immobilized E. A client who has undergone abdominal surgery

Which of the following measures should the nurse implement in the immediate management of the care of a client experiencing angina? Select all that apply. A. Administering oxygen B. Assessing the client's pain C. Administering nitroglycerin D. Placing the client in a side-lying supine position E. Helping the client identify anxiety-precipitating events or experiences

A. Administering oxygen B. Assessing the client's pain C. Administering nitroglycerin

A nurse is having dinner with a friend at a restaurant when a woman at a nearby table suddenly clutches her neck with both hands. Suspecting that the woman is choking, the nurse quickly approaches her. What action should the nurse take first? A. Asking the woman whether she can speak B. Helping the woman into a supine position C. Striking the woman's back forcefully with a fist D. Opening the woman's airway and attempting to perform ventilation

A. Asking the woman whether she can speak

The nurse obtains a cardiac rhythm strip from a client and sees the rhythm depicted in the image. How does the nurse interpret the pattern? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Normal sinus rhythm

A. Atrial fibrillation

A nurse is preparing a list of home care instructions for a client with peripheral artery disease (PAD). Which instructions should the nurse include on the list? Select all that apply. A. Avoid crossing the legs. B. Report signs of skin breakdown. C. Avoid ambulation to help prevent pain. D. Inspect the skin of the extremities daily. E. Elevate the legs above the level of the heart when in bed or in a chair. E. Avoid exposure to cold and place a heating pad on the legs to improve blood flow.

A. Avoid crossing the legs. B. Report signs of skin breakdown. D. Inspect the skin of the extremities daily.

A nurse provides home care instructions to a client who has been hospitalized for acute diverticular disease. Which instruction should the nurse give the client to prevent the occurrence of an acute episode? A. Avoid lifting, straining, or coughing. B. Restrict fluid intake to 1000 mL daily. C. Avoid foods that contain whole grains. D. Restrict consumption of fruits and vegetables.

A. Avoid lifting, straining, or coughing.

The nurse is caring for a client with acute coronary syndrome. Which of the following manifestations would lead the nurse to suspect that cardiogenic shock is developing? Select all that apply. A. BP of 88/60 mm Hg B. Pulmonary congestion C. Flushed, diaphoretic skin D. Heart rate of 58 beats/min E. Respiratory rate of 18 beats/min F. Urine output of 90 mL in the past 4 hours

A. BP of 88/60 mm Hg B. Pulmonary congestion F. Urine output of 90 mL in the past 4 hours

The nurse is conducting a class on testicular cancer for young men. The nurse should include which description of the late signs of testicular cancer? Select all that apply. A. Bone pain B. Fluid in the scrotum C. Painless testicular swelling D. Presence of abdominal masses E. Dragging sensation in the scrotum

A. Bone pain B. Fluid in the scrotum D. Presence of abdominal masses

Jean runs to John, who is lying supine on the sand, and kneels at his side. Number the following actions that Jean will take in the order of priority, with number 1 as the first action and number 4 as the last. A. Checking John's carotid pulse B. Opening John's airway with a jaw-thrust maneuver C. Delivering compressions D. Tapping or gently shaking John and shouting, "Are you OK?"

A. Checking John's carotid pulse B. Opening John's airway with a jaw-thrust maneuver C. Delivering compressions D. Tapping or gently shaking John and shouting, "Are you OK?"

A nurse is monitoring a client who sustained a closed head injury in a motor vehicle accident for signs of increased intracranial pressure (ICP) . Which early sign does the nurse watch for? A. Confusion B. Slowed pulse rate C. Widened pulse pressure D. Increased systolic blood pressure

A. Confusion

A client hospitalized with prostate cancer is undergoing chemotherapy. While the nurse is helping the client with hygiene care, the client suddenly complains of severe back pain. The nurse should take which initial action? A. Contact the healthcare provider. B. Administer pain medication. C. Take the client's blood pressure. D. Allow the client to rest and complete the bath later.

A. Contact the healthcare provider.

The mother of a child with leukemia who has not had varicella (chickenpox) receives a telephone call from the school nurse, who tells her that one of her child's classmates has contracted chickenpox. Which instruction to the mother by the nurse is most appropriate? A. Contacting the child's pediatrician B. Monitoring her child closely for signs of infection C. Encouraging her child to wear a mask while in school D. Keeping her child out of school until the child with varicella recovers

A. Contacting the child's pediatrician

A nurse is monitoring a client who has returned from colostomy surgery with an ostomy pouch system in place. On checking the stoma, the nurse notes that it is purple and firm. Which initial action by the nurse is appropriate? A. Contacting the healthcare provider B. Documenting the findings C. Placing warm packs over the stoma D. Changing the ostomy pouch system

A. Contacting the healthcare provider

A nurse is assessing the patency of an AV fistula in the left arm of a client who is undergoing hemodialysis for the treatment of chronic kidney disease. Which finding indicates that the fistula is patent? A. Palpation of a thrill over the fistula B. Presence of a radial pulse in the left wrist C. Absence of a bruit on auscultation of the fistula D. Capillary refill time of less than 3 seconds in the nail beds of the fingers on the left hand

A. Palpation of a thrill over the fistula

A Mantoux skin test is administered to a child infected with HIV. Forty-eight hours after the test is administered, the nurse checks the skin test site and notes an area of induration 5 mm in diameter. How does the nurse interpret this finding? A. Positive result B. Negative result C. Inconclusive result D. Inaccurate result requiring a repeat test

A. Positive result

A nurse monitoring the 24-hour fluid balance of a client with diarrhea calculates the client's intake as 2500 mL and notes that urine output is 1500 mL and fecal output 150 mL. What is the additional expected maximal amount of insensible fluid loss the nurse should determine the client is experiencing? A. Skin, 800 mL; lungs, 600 mL B. Skin, 400 mL; lungs, 500 mL C. Skin, 200 mL; lungs, 300 mL D. Skin, 100 mL; lungs, 100 mL

A. Skin, 800 mL; lungs, 600 mL

The nurse collects data from a client who has experienced an episode of chest pain. The client tells the nurse that the chest pain started shortly after he started raking leaves but went away after he rested and took a nitroglycerin tablet. Which type of angina most closely corresponds to the client's description? A. Stable B. Variant C. Unstable D. Intractable

A. Stable

Following a kidney, ureters, and bladder (KUB) x-ray, the client has been diagnosed with urolithiasis. The nurse provides home care instructions to the client and provides the client with which instruction(s)? Select all that apply. A. Strain all urine for stones. B. Drink plenty of fluids daily. C. Avoid walking or other activity. D. Apply ice to the area where the pain is located. E. Restrict food intake until the stone has passed.

A. Strain all urine for stones. B. Drink plenty of fluids daily.

A nurse receives a telephone call from a neighbor, who asks for assistance because her husband has sustained an eye injury. The nurse rushes to the neighbor's house and discovers that the husband has a piece of metal embedded in and protruding from the eye. What should the nurse do first? A. Tape a paper cup over the eye. B. Irrigate the eye with tap water. C. Cover the eye with a gauze pad. D. Sterilize a pair of tweezers and remove the metal.

A. Tape a paper cup over the eye.

Which of the following risk factors for MI are modifiable? Select all that apply. A. The client smokes four or five cigarettes a day. B. The client reports a sedentary lifestyle. C. The client is 5 feet 1 inch tall and weighs 232 lb. D. The client's blood pressure consistently ranges between 148/88 and 170/96 mm Hg. E. The client reports that her mother has a history of severely increased cholesterol levels that cannot be controlled with diet or medication.

A. The client smokes four or five cigarettes a day. B. The client reports a sedentary lifestyle. C. The client is 5 feet 1 inch tall and weighs 232 lb. D. The client's blood pressure consistently ranges between 148/88 and 170/96 mm Hg.

A nurse arrives at the home of a neighbor, who called for help when her husband fell off a ladder during a seizure. The neighbor tells the nurse that she called 911 and that an ambulance is on the way. The nurse assesses the man and determines that he is unconscious without a pulse. After performing 30 chest compressions, the nurse prepares to deliver rescue breaths and uses which method to open the man's airway? A. The jaw-thrust maneuver B. The head tilt-chin left method C. Lifting the chin and using the fingers to open the mouth D. Placing the fingers in the victim's mouth, using a hooking action

A. The jaw-thrust maneuver

Which clinical manifestations of hypokalemia will the nurse expect to note while assessing Martha? Select all that apply. A. Weak peripheral pulses B. Orthostatic hypotension C. Decreased urine output D. An absence of deep tendon reflexes E. Decreased bowel sounds and constipation

A. Weak peripheral pulses B. Orthostatic hypotension D. An absence of deep tendon reflexes E. Decreased bowel sounds and constipation

A nurse provides self-care instructions to a client who has had a permanent pacemaker inserted. Which statements by the client indicate a need for further instruction? Select all that apply. A. "I'll start keeping a pacemaker identification card in my wallet." B. "I can expect some swelling and drainage from the pacemaker insertion site." C. "I need to call the doctor if I have any weakness, dizziness, or shortness of breath." D. "I need to let all my healthcare providers know that I've had this pacemaker inserted." E. "I don't need to worry about airport security scanners, because the pacemaker won't be affected by them at all."

B. "I can expect some swelling and drainage from the pacemaker insertion site." E. "I don't need to worry about airport security scanners, because the pacemaker won't be affected by them at all."

A hearing aid has been prescribed for a client with presbycusis, and the nurse provides instructions to the client about its use. Which statement by the client indicates to the nurse that additional instruction is required? A. "I need to keep extra batteries on hand." B. "I need to clean the ear mold with alcohol every day." C. "I need to keep the hearing aid turned off when I take it out." D. "I need to keep the hearing aid in a safe place when I'm not using it."

B. "I need to clean the ear mold with alcohol every day."

The nurse provides postoperative instructions to a client who has undergone ear surgery. Which statements by the client indicate an understanding of the instructions? Select all that apply. A. "I can shower as long as I put cotton in my ears." B. "I need to move my head slowly so that I don't end up getting dizzy." C. "I need to avoid flying for a while because of the changes in pressure." D. "My hearing should improve within a week, and if it doesn't I need to call the surgeon." E. "I need to stay away from people with colds because of the risk of getting their infections."

B. "I need to move my head slowly so that I don't end up getting dizzy." C. "I need to avoid flying for a while because of the changes in pressure." E. "I need to stay away from people with colds because of the risk of getting their infections."

The nurse provides information to the client about measures to treat GERD. Which statement by the client indicates the need for further instruction? A. "I should stop drinking caffeinated coffee." B. "I should lie down for at least an hour after I eat." C. "I should prop up the head of my bed." D. "I shouldn't eat or drink anything for 2 hours before bedtime."

B. "I should lie down for at least an hour after I eat."

George has been discharged from the hospital but is experiencing frequent "fluttering beats" and has also lost consciousness at home. He has returned to the hospital for the insertion of an automatic implantable cardioverter-defibrillator (AICD). Which statement by George shows that he needs further preoperative teaching on this device? A. "I'll call the doctor if it gives me a shock." B. "I won't have any dysrhythmias after the AICD is implanted." C. "The doctor will put the device in my chest, like my friend's pacemaker." D. "I'll have to make follow-up visits to make sure the device is working and check the battery life."

B. "I won't have any dysrhythmias after the AICD is implanted."

A nurse is teaching a certification course in cardiopulmonary resuscitation to a group of nursing students. How many breaths per minute does the nurse instruct the students to deliver to an adult victim? A. 6 B. 10 C. 18 D. 20

B. 10

Which of the following findings are specific characteristics of right-sided heart failure? Select all that apply. A. Cough B. Allow sips of clear fluids only. C. Crackles on auscultation D. Pitting dependent edema E. Abdominal pain and bloating

B. Allow sips of clear fluids only. D. Pitting dependent edema E. Abdominal pain and bloating

A nurse is preparing a list of home care instructions for a client with COPD. Which instructions should the nurse include on the list? Select all that apply. A. Avoid immunizations. B. Alternate periods of rest with activity. C. Sleep on the right side. D. Avoid exposure to people with infections. E. Perform pursed-lip and diaphragmatic breathing exercises. F. Increase the oxygen flow rate if breathing becomes difficult.

B. Alternate periods of rest with activity. D. Avoid exposure to people with infections. E. Perform pursed-lip and diaphragmatic breathing exercises.

A client has sustained superficial partial-thickness burns of the anterior surfaces of the thighs. On assessment, which of these characteristics would the nurse expect to see? Select all that apply. A. Mild erythema B. Blistering and edema C. Blackening without edema D. Yellow discoloration with severe edema E. Wet, shiny, weeping surface F. Red base and broken epidermis

B. Blistering and edema E. Wet, shiny, weeping surface F. Red base and broken epidermis

Which of the following prescriptions would the nurse question for a client experiencing an acute hypertensive crisis? Select all that apply. A. Administering 40 mg furosemide (Lasix) IV B. Checking the BP and heart rate every 4 hour C. Keeping the client in a supine position at all times D. Administering oxygen E. Monitoring a patient who is receiving IV antihypertensives to maintain a diastolic blood pressure under 90 mm Hg

B. Checking the BP and heart rate every 4 hour C. Keeping the client in a supine position at all times

EMS has arrived. Which actions should Jean take at this time? Select all that apply. A. Helping the emergency medical technicians (EMTs) with the AED B. Continuing CPR until she is asked to stop C. Talking to John's wife while the EMTs work on John D. Going for a run to relieve the stress of the situation E. Preparing to go with John and his wife to the hospital F. Telling the EMTs what has happened since she has been there

B. Continuing CPR until she is asked to stop C. Talking to John's wife while the EMTs work on John F. Telling the EMTs what has happened since she has been there

A community health nurse is preparing a poster for an educational session for a group of women with whom she will be discussing the risk factors for breast cancer. Which of the following factors increase the risk for breast cancer and should be listed on the poster? Select all that apply. A. Multiparity B. Early menarche C. Early menopause D. Family history of breast cancer E. Exposure of the chest to high-dose radiation F. Previous cancer of the breast, uterus, or ovaries

B. Early menarche D. Family history of breast cancer E. Exposure of the chest to high-dose radiation F. Previous cancer of the breast, uterus, or ovaries

A nurse is providing self-care instructions to a client whose serum phosphorus level is 2.3 mg/dL. Which information should the nurse provide to the client? A. Eat foods high in calcium B. Eat foods high in phosphorus, such as diary products, nuts, and legumes. C. Take phosphate-binding medications daily with meals or immediately after meals. D. Read the labels on over-the-counter medications and avoid phosphate-containing medications such as laxatives and enemas.

B. Eat foods high in phosphorus, such as diary products, nuts, and legumes.

A nurse provides instructions to a client with type 1 diabetes mellitus about home care measures to treat hypoglycemia. The nurse determines that the client understands the instructions, if the client states that if a hypoglycemic episode occurs, he will perform which action? A. Call the healthcare provider. B. Eat six saltine crackers. C. Report to the emergency department. D. Take an additional dose of regular insulin.

B. Eat six saltine crackers.

The nurse is monitoring a client with renal failure who is at risk for fluid volume excess. Which assessment finding is indicative of this fluid imbalance? A. Flat neck veins B. Increased blood pressure C. Poor skin turgor with tenting D. Diminished peripheral pulses

B. Increased blood pressure

Which of the following are characteristics of Brown-Séquard syndrome? Select all that apply. A. The injury affects the entire spinal cord. B. It is a type of injury that results from penetrating injuries. C. Pain sensation is lost on the same side of the body as the injury. D. Motor function is lost on the same side of the body as the injury. E. Light touch sensation is affected on the opposite side of the body from the injury.

B. It is a type of injury that results from penetrating injuries. D. Motor function is lost on the same side of the body as the injury. E. Light touch sensation is affected on the opposite side of the body from the injury.

George remains in the hospital, and the list of assessment findings grows to include poor appetite, pale skin, hypotension and tachycardia, and fatigue. The nurse suspects decreased cardiac output. For which findings characteristic of decreased cardiac output should the nurse assess George? Select all that apply. A. Weight loss B. Lung crackles C. Mental status change D. Increased urine output E. Decreased peripheral pulses

B. Lung crackles C. Mental status change E. Decreased peripheral pulses

A nurse is preparing a list of instructions regarding stoma and laryngectomy care to a client who has undergone laryngectomy. Which instructions should be included in the list? Select all that apply. A. Restrict fluid intake. B. Obtain a MedicAlert bracelet. C. Keep humidity in the home low. D. Avoid wearing high-collared clothing. E. Prevent debris from entering the stoma. F. Avoid swimming and use care when showering.

B. Obtain a MedicAlert bracelet. E. Prevent debris from entering the stoma. F. Avoid swimming and use care when showering.

Which interventions should the for a client undergoing intermittent ambulatory peritoneal dialysis? Select all that apply. A. Maintaining the client in a flat position B. Obtaining the client's weight before the procedure C. Warming the dialysate solution before infusing it D. Using aseptic technique when connecting the dialysate tubing to the catheter E. Recording a deficit of outflow on the fluid balance record F. Notifying the healthcare provider if the outflow fluid is brown

B. Obtaining the client's weight before the procedure C. Warming the dialysate solution before infusing it D. Using aseptic technique when connecting the dialysate tubing to the catheter E. Recording a deficit of outflow on the fluid balance record F. Notifying the healthcare provider if the outflow fluid is brown

The nurse is monitoring a client who is undergoing treatment for acute respiratory failure. Which finding on arterial blood gas analysis indicates that treatment is effective? A. pH of 7.28 B. PaCO2 of 45 mm Hg C. PaO2 of 58 mm Hg D. Oxygen saturation of 88%

B. PaCO2 of 45 mm Hg

A client who was exposed to cold for a prolonged period is brought to the emergency department. The nurse, conducting an assessment of the client, notes acute frostbite of the fingers of the left hand. Which action should the nurse take immediately? A. Placing the client's fingers in cold water for 15 to 20 minutes B. Placing the client's fingers in warm water for 15 to 20 minutes C. Placing the client's fingers in warm water for 5 minutes, then debriding any obvious blisters D. Placing the client's fingers in cold water for 10 minutes and then warm water for 10 minutes and continuing this pattern for 1 hour

B. Placing the client's fingers in warm water for 15 to 20 minutes

A nurse provides information to a client who has undergone a Billroth II procedure about dietary measures to prevent of dumping syndrome. Which menu choices by the client indicate to the nurse that the client has understood the instructions? Select all that apply. A. Milk B. Rice C. Eggs D. Beef E. Apple pie

B. Rice C. Eggs D. Beef

George's dysrhythmias and cardiac output are resistant to treatment measures, and acute kidney injury occurs. Hemodialysis is being performed to cleanse the blood temporarily, until the kidneys recover. Which access does the nurse expect the healthcare provider to prescribe for hemodialysis? A. Peritoneal B. Subclavian catheter C. Internal arteriovenous graft D. Internal arteriovenous fistula

B. Subclavian catheter

A nurse is reading the medical record of a client admitted to the hospital with a diagnosis of diabetes insipidus. Which of these clinical manifestations would the nurse expect to see documented in the client's record? Select all that apply. A. Anuria B. Tachycardia C. Complaints of thirst D. Moist mucous membranes E. Complaints of muscle weakness F. Blood pressure of 168/98 mm Hg

B. Tachycardia C. Complaints of thirst E. Complaints of muscle weakness

A nurse provides instructions to a client with type 1 diabetes mellitus with regard to foot care. The nurse determines that the client needs further instruction if the client says that she will perform which action? A. Inspect her feet daily. B. Walk barefoot only at home. C. Wash her feet with warm water and a mild soap. D. Check her shoes for foreign objects before putting them on.

B. Walk barefoot only at home.

The nurse notes documentation in a client's record that the client has a stage IV pressure ulcer. What does the nurse expect to see during assessment? A B C D

C

The nurse provides self-care instructions to a client with a venous disorder. Which of these statements by the client indicate the need for further instruction? Select all that apply. A. "I need to order a MedicAlert bracelet." B. "I should watch my legs and ankles for swelling." C. "I can massage my leg gently when it's sore." D. "I can put pillows under my knees if it's more comfortable." E. "I should elevate my legs above the level of my heart when I'm in bed."

C. "I can massage my leg gently when it's sore." D. "I can put pillows under my knees if it's more comfortable."

A nurse provides home care instructions to a client with acute hepatitis. Which statement by the client indicates a need for further instruction? A. "I need to eat frequent small meals." B. "I need to eat foods high in carbohydrates and low in fat." C. "I need to maintain my normal physical activity and daily routine." D. "I have to avoid physical contact with other people until my test results are negative."

C. "I need to maintain my normal physical activity and daily routine."

A client with hyponatremia accompanied by a fluid-volume deficit is being treated with IV normal saline solution. Which serum sodium laboratory finding indicates to the nurse that the treatment has been effective? A. 120 mEq/L B. 130 mEq/L C. 140 mEq/L D. 150 mEq/L

C. 140 mEq/L

The nurse is monitoring Martha's serum potassium level while administering the IV potassium. Which serum potassium reading tells the nurse that the treatment has been effective? A. 3.0 mEq/L B. 3.3 mEq/L C. 4.0 mEq/L D. 5.6 mEq/L

C. 4.0 mEq/L

Which of the following clients are at risk for venous thrombosis? Select all that apply. A. A client with a diagnosis of hypothyroidism B. A client who reports that he is a marathon runner C. A client who sustained a pelvic fracture after falling from a horse D. A client with a seizure disorder who is taking phenytoin (Dilantin) E. A client who reports using oral contraceptives as a means of birth control

C. A client who sustained a pelvic fracture after falling from a horse E. A client who reports using oral contraceptives as a means of birth control

A nurse is reviewing the medical records of the clients for whom the nurse will be caring. Which of these clients does the nurse identify as being at risk for a fluid-volume deficit? Select all that apply. A. A client with congestive heart failure B. A client with syndrome of inappropriate ADH C. A client with a nasogastric tube attached to suction D. A client undergoing long-term corticosteroid therapy E. A client with a fever who is experiencing severe diaphoresis

C. A client with a nasogastric tube attached to suction E. A client with a fever who is experiencing severe diaphoresis

A nurse is reviewing the medical records of the clients the nurse has been assigned to care for. Which client is at the greatest risk for hypercalcemia? A. A client with Crohn disease B. A client with lactose intolerance C. A client with severe dehydration D. A client who has undergone thyroidectomy

C. A client with severe dehydration

The nurse should include which of the following in the preoperative plan of care for a client with appendicitis? Select all that apply. A. Administer a Fleet enema. B. Allow sips of clear fluids only. C. Apply an ice bag to the abdomen. D. Administer 15 mL milk of magnesia orally. E. Monitor the client who is receiving prescribed IV fluids.

C. Apply an ice bag to the abdomen. E. Monitor the client who is receiving prescribed IV fluids.

Jean determines that John is unconscious. John's wife cries, "I want to help! What can I do? Just tell me what to do and I'll do it!" What is the appropriate response? A. Asking her to perform chest compressions on John B. Quickly teaching her how to perform mouth-to-mouth resuscitation C. Asking her to call 911 to get help and an automatic external defibrillator (AED) D. Tell her that there is nothing that she can do unless she knows how to perform CPR

C. Asking her to call 911 to get help and an automatic external defibrillator (AED)

A nurse reviewing a client's laboratory results sees a magnesium level of 1.0 mg/dL. Which clinical manifestation would the nurse expect to note in this client in light of this laboratory finding? A. Bradycardia B. Hypotension C. Chvostek sign D. Diminished deep tendon reflexes

C. Chvostek sign

The school nurse receives a telephone call from a physical education teacher, who says that a student with diabetes mellitus is feeling shaky and weak. Which action should the nurse tell the teacher to take immediately? A. Laying the student on the floor B. Staying with the student until the nurse arrives C. Giving the student a glass of orange juice or non-diet soda D. Calling for an ambulance to bring the student to the emergency department

C. Giving the student a glass of orange juice or non-diet soda

Which interventions should the nurse expect to see included in the plan of care for a client with hypothyroidism? Select all that apply. A. Providing a cool environment for the client B. Instructing the client to consume a high-fat diet C. Instructing the client about thyroid-replacement therapy D. Encouraging the client to consume fluids and high-fiber foods E. Instructing the client to contact the healthcare provider if chest pain occurs F. Informing the client that radioactive iodine preparations may be prescribed to treat the disorder

C. Instructing the client about thyroid-replacement therapy D. Encouraging the client to consume fluids and high-fiber foods E. Instructing the client to contact the healthcare provider if chest pain occurs

A nurse is hiking in the woods with some friends when one of the friends sustains a snakebite on the ankle. What action should the nurse take first? A. Immobilizing the affected extremity B. Removing jewelry and constricting clothing C. Moving the victim to a safe area away from the snake D. Covering the victim with available items to keep him warm

C. Moving the victim to a safe area away from the snake

A nurse is reviewing the laboratory results of a client with Addison disease. Which finding would the nurse expect to note? A. Calcium level of 8.6 mg/dL B. Sodium level of 145 mEq/L C. Potassium level of 5.5 mEq/L D. Blood glucose level of 110 mg/dL

C. Potassium level of 5.5 mEq/L

An electrocardiogram (ECG) is performed on Martha. Which ECG findings would the nurse expect to note? Select all that apply. A. Flat P waves B. Peaked T waves C. Prominent U wave D. Prolonged PR interval E. Depressed ST segment F. Widened QRS complexes

C. Prominent U wave E. Depressed St segment

Flail chest is diagnosed in a client who sustained injury in a high-speed motor vehicle crash. Which findings does the nurse expect to note when assisting with data collection? Select all that apply. A. Bradycardia B. Hypertension C. Severe chest pain D. Diminished breath sounds E. An inward movement of the loose chest area during inspiration F. Puffing out of the loose chest area during expiration

C. Severe chest pain D. Diminished breath sounds E. An inward movement of the loose chest area during inspiration F. Puffing out of the loose chest area during expiration

Despite her attempts to ventilate John, Jean is unable to deliver the breaths. As Jean repositions John's head, his wife asks, "Could this have happened because of his cancer?" Which of the following oncologic emergencies could precipitate this situation? A. Hypercalcemia B. Tumor lysis syndrome (TLS) C. Superior vena cava (SVC) syndrome D. Syndrome of inappropriate antidiuretic hormone (SIADH)

C. Superior vena cava (SVC) syndrome

A client with CKD has a serum potassium level of 6.1 mEq/L. Which finding in the electrocardiographic (ECG) reading would the nurse expect to note? A. U waves B. Elevated P waves C. Tall, peaked T waves D. Shortened PR interval

C. Tall, peaked T waves

A client undergoes transplantation of a kidney from her brother. Which information should the nurse, in home care instructions to the client about graft rejection, provide to the client? A. Rejection always occurs during the 48 hours after surgery. B. Rejection is not a problem when the donor is a direct family member. C. The client should contact the healthcare provider if she notices weight gain or edema. D. The client should not be concerned about rejection, because immunosuppressive medications prevent its occurrence.

C. The client should contact the healthcare provider if she notices weight gain or edema.

A client who is hospitalized with active TB asks the nurse how long it will take before the disease is no longer communicable. What should the nurse tell the client? A. The disease is communicable until the cough subsides. B. The disease is no longer communicable once medication has been started. C. The disease is usually no longer communicable after medication has been taken for 2 to 3 weeks. D. The disease is communicable for the duration of medication therapy, which is usually 9 months.

C. The disease is usually no longer communicable after medication has been taken for 2 to 3 weeks.

A client who is experiencing chest pain is brought to the emergency department by a family member. Assessing the client, the nurse obtains a description of the client's chest pain. Which information from the client causes the nurse to determine that the client's pain is most likely angina? A. The pain is unrelieved by rest. B. The pain is unrelieved by nitroglycerin. C. The pain was precipitated by a stressful event. D. The pain is accompanied by nausea, vomiting, diaphoresis, and dyspnea.

C. The pain was precipitated by a stressful event.

The nurse is monitoring a client who has undergone abdominal aneurysm repair for signs of graft occlusion. Which findings might be indicative of graft occlusion, requiring the nurse to notify the healthcare provider? A. Warm legs and feet B. Strong peripheral pulses with a rate of 80 beats/min C. Urine output of 25 mL per hour, decreased from 40 mL/hr D. A reported pain level of 3 on a 1-to-10 pain scale, with 10 representing the most severe pain

C. Urine output of 25 mL per hour, decreased from 40 mL/hr

The nurse prepares to care for a client who has undergone supratentorial cranial surgery. In which position does the nurse plan to place the client in the postoperative period? A. Flat B. Flat on the side that has been operated on C. With the head of the bed elevated 30 degrees D. On the back, with a small pillow under the head for support

C. With the head of the bed elevated 30 degrees

A nurse performs an assessment of a client with a serum calcium level of 8.0 mg/dL. Which clinical manifestations of this electrolyte imbalance would the nurse expect to note? Select all that apply. A. Tachycardia B. Hypertension C. Bounding peripheral pulses D. Presence of the Trousseau sign E. Hyperactive deep tendon reflexes

D. Presence of the Trousseau sign E. Hyperactive deep tendon reflexes

The nurse provides home care instructions to a client who has undergone cataract surgery. Which statement by the client indicates the need for further instruction? A. "I need to put on an eye shield at bedtime." B. "I should increase my fluid intake and eat high-fiber foods." C. "I need to call the doctor if I have any severe eye pain." D. "I can pick up my 12-lb dog as long as I don't bend forward to do it."

D. "I can pick up my 12-lb dog as long as I don't bend forward to do it."

The nurse provides information to a client treated for cystitis about measures to prevent its recurrence. Which statement by the client indicates a need for further instruction? A. "I should wear cotton underpants." B. "I should urinate and drink a glass of water after sex" C. "I need to wipe from front to back when I use the bathroom." D. "I can soak in a bathtub to relieve the pain and prevent infections in the future."

D. "I can soak in a bathtub to relieve the pain and prevent infections in the future."

A nurse provides home care instructions to a client with bacterial infective endocarditis. Which statement by the client indicates a need for further instruction? A. "I need to let my dentist know that I had this infection." B. "I need to take antibiotics before I have any invasive procedures." C. "I should check my temperature every day and call the doctor if I have a fever." D. "I need to be sure to floss my teeth and use an electric toothbrush."

D. "I need to be sure to floss my teeth and use an electric toothbrush."

Martha's serum potassium level has returned to normal. She will be discharged with a prescription for oral potassium supplementation in addition to the previously prescribed Lanoxin (Digoxin) and furosemide (Lasix). Which comment indicates that Martha understands the discharge instructions? A. "I may get black stools." B. "I'll start using a salt substitute." C. "I can take an extra pill if I forget to take one." D. "I will call my doctor if I suddenly get weak."

D. "I will call my doctor if I suddenly get weak."

An adult client who recently underwent surgery suddenly experiences sharp chest pain and dyspnea and lapses into unconsciousness. The client is not breathing and does not have a pulse. The nurse calls a code and begins CPR. How many chest compressions per minute does the nurse deliver? A. 40 B. 50 C. 70 D. 100

D. 100

After demonstrating the correct procedure for CPR in an infant during a CPR recertification course, the nurse asks a student to perform the procedure on a mannequin. Which ratio of chest compressions to ventilations performed by the student indicates to the nurse that the student is performing the procedure correctly? A. 5:1 B. 15:1 C. 15:2 D. 30:2

D. 30:2

The nurse is asked to perform ear irrigation. Which of the following steps should the licensed practical/vocational nurse perform first in preparing for the procedure? A. Warming the irrigating solution to body temperature B. Placing a towel over the client's shoulder on the side being irrigated C. Filling an irrigation syringe with 50 to 70 mL of irrigating solution D. Ask the registered nurse or health care provider to assess the tympanic membrane for intactness

D. Ask the registered nurse or health care provider to assess the tympanic membrane for intactness

A nurse is monitoring a client with hyperparathyroidism for signs of hypocalcemia and prepares to test the client for the Trousseau sign. Which item would the nurse obtain to perform this test? A. Cotton B. Tongue blade C. Reflex hammer D. Blood pressure cuff

D. Blood pressure cuff

The healthcare provider prescribes a continuous intravenous (IV) infusion of 250 mL of normal saline solution with 40 mEq of potassium chloride to be infused at a rate of 50 mL/hour by way of an infusion device. Which laboratory result is most important for the nurse to check before administering the infusion? A. Sodium B. Hematocrit C. Hemoglobin D. Blood urea nitrogen (BUN)

D. Blood urea nitrogen (BUN)

While holding his airway open, Jean assesses John for spontaneous respiration and notes that it is absent. Which action should Jean take next? A. Turning John on his side B. Calling emergency medical services C, Maintaining an open airway until EMS arrives D. Blowing two slow, full breaths into John's mouth, ensuring that his chest rises with each breath

D. Blowing two slow, full breaths into John's mouth, ensuring that his chest rises with each breath

A nurse caring for a client with acute pancreatitis looks for the Cullen sign. Which finding is the nurse looking for? A. Increased lipase level B. Abdominal tenderness and guarding C. Gray-blue discoloration of the flanks D. Bluish discoloration of the abdomen and periumbilical area

D. Bluish discoloration of the abdomen and periumbilical area

A client with an ocular melanoma has undergone enucleation. Which postoperative finding indicates the need for follow-up? A. The client is sleepy but arousable. B. The apical pulse rate is 78 beats/min. C. The blood pressure reading is 118/72 mm Hg. D. Bright-red drainage is noted on the dressing.

D. Bright-red drainage is noted on the dressing.

The licensed practical nurse (LPN) is monitoring the client following escharotomy on the lower extremity and reporting changes to the registered nurse. Which parameter should the nurse monitor specifically related to this procedure? A. Blood pressure B. Apical pulse rate C. Body temperature D. Dorsalis pedis pulses

D. Dorsalis pedis pulses

A nurse is watching for indications of autonomic dysreflexia in a client who sustained a spinal cord injury in a fall from a roof. For which sign of this complication should the nurse monitor the client closely? A. Constricted pupils B. Tachycardia C. Hypotension D. Nasal stuffiness

D. Nasal stuffiness

A nurse is gathering subjective data from a client with suspected bladder cancer. Which early manifestation of bladder cancer the nurse would expect the client to report? A. Flank pain B. Groin discomfort C. Lower back pain D. Painless hematuria

D. Painless hematuria

When George is first admitted to the unit, his electrocardiographic (ECG) monitoring strip shows the following rhythm: George's heart rate is 48 beats/min and his blood pressure is 82/60 mm Hg, and George complains of dizziness. Which of the following orders does the nurse anticipate will be given by the healthcare provider? A. Defibrillate the client. B. Administer digoxin (Lanoxin). C. Continue monitoring the client. D. Prepare for transcutaneous pacing.

D. Prepare for transcutaneous pacing.

A nurse is reading the results of a biopsy of cervical lymph nodes from a client with suspected Hodgkin's lymphoma. Which of the following findings would the nurse expect see documented in the results if Hodgkin's lymphoma is confirmed? A. Blast cells in the blood B. Increased platelet count C. Bence-Jones protein in the urine D. Reed-Sternberg cells in the lymph nodes

D. Reed-Sternberg cells in the lymph nodes

A nurse is conducting the admission interview of a client with cholecystitis who is scheduled for laparoscopic cholecystectomy. Which finding does the nurse expect the client to report? A. Heartburn B. Hiccups C. Right upper quadrant abdominal pain that is relieved when the client eats high-protein food D. Right upper quadrant abdominal pain that radiates to the back and right shoulder after the client eats fatty food

D. Right upper quadrant abdominal pain that radiates to the back and right shoulder after the client eats fatty food

A client whose father has polycystic kidney disease reports to the clinic for a physical examination. The client tells the nurse that she is concerned about the possibility of inheriting the disease. Which information should the nurse provide to the client? A. She shouldn't worry about inheriting the disorder. B. It is unlikely that she will inherit the disease, because it always skips a generation. C. She needs to get on with her life, because there is no known way to prevent the disease. D. She should be aware of the signs of the disease and seek medical attention if they occur.

D. She should be aware of the signs of the disease and seek medical attention if they occur.

The nurse, reviewing George's current ECG rhythm strip, finds an irregular rhythm of 82 beats/min. The P wave is missing at intervals, and the wide T wave of these beats runs in the direction opposite that of the QRS. The PR interval is 0.14 seconds or absent and the QRS complex measures 0.26 second on these unusual beats. How should the nurse interpret this rhythm? A. Sick sinus syndrome B. Ventricular tachycardia C. Sinus bradycardia with premature atrial contractions (PACs) D. Sinus rhythm with premature ventricular contractions (PVCs)

D. Sinus rhythm with premature ventricular contractions (PVCs)

The nurse is teaching a client at risk for hypokalemia about foods that are high in potassium. Which foods should the nurse tell the client to be sure to consume? Select all that apply. A. Eggs B. Cocoa C. Cheese D. Spinach E. Tomatoes F. Strawberries

D. Spinach E. Tomatoes F. Strawberries

A nurse is grocery shopping when a woman screams, "Help me! He's choking on a piece of candy!" On rushing to the scene, the nurse sees that the woman's 4-year-old son is having respiratory difficulty and hears high-pitched inspiratory noises from the child. Which action should the nurse immediately take? A. Calling 911 on a cell phone B. Laying the child on the floor C. Placing the child across her lap and delivering five back blows D. Standing behind the child and administering abdominal thrusts

D. Standing behind the child and administering abdominal thrusts

A nurse in the cardiac telemetry unit is reviewing a client's laboratory results and notes that the potassium level is 5.8 mEq/L. In light of this laboratory value, which finding would the nurse expect to note while looking at the client's cardiac monitor? A. Inverted T waves B. Prominent U wave C. ST-segment depression D. Widened QRS complexes

D. Widened QRS complexes

A supratentorial craniotomy is performed on a child who has a brain tumor. In which position does the nurse plan to place the child after the surgery? A. Trendelenburg B. Flat on left side C. Flat on the right side D. With the head elevated

D. With the head elevated