NUR 120 (Med/Surg - Test 3) NCLEX STYLE PRACTICE QUESTIONS
The nurse assesses the dietary education provided to a client with pernicious anemia. The client's selection of which food indicates the teaching is EFFECTIVE? A) Cheese B) Popcorn C) Spinach D) Red meat **K**
D (Red meat)
The nurse provides care for a client days after a mastectomy. Which activity does the nurse suggest to facilitate mobility on the affected side? A) Weeding the garden B) Walking C) Swimming D) Combing hair **K**
D (Combing hair)
In which age group is diabetes mellitus type 2 MOST likely to occur? A) Children B) Adolescents C) Older Adults D) Adults **K**
D (Adults)
The nurse completes a client's admission history and physical exam. The client has a diagnosis of pernicious anemia. Which question does the nurse ask to obtain information related to potential risk factors for development of this disorder? A) "How much stress do you encounter in the workplace?" B) "Do any other members of your family have pernicious anemia?" C) "How much alcohol have you been consuming over the past year?" D) "Can you tell me how long have you been dieting?" **K**
"Do any other members of your family have pernicious anemia?"
The nurse instructs a group of clients about dietary habits to reduce the risk of cancer. Which statement, if made by a client to the nurse, indicates further teaching is necessary? A) "Eating polyunsaturated fats will decrease my changes of developing cancer." B) "I should increase my intake of food high in fiber." C) "I should eat apricots, carrots, leafy vegetables, and citrus fruits." D) "I should eat turkey on my sandwich rather than bologna." **K**
A ("Eating polyunsaturated fats will decrease my changes of developing cancer.")
The nurse, teaching a class to a group of community members about the importance of weight loss in decreasing the risk of type 2 diabetes mellitus, is asked why weight loss reduces the risk associated with the development of this health problem. Which response by the nurse is most appropriate? A) "Excess body weight impairs the body's release of insulin." B) "The amount of food taken in by those who are overweight requires more insulin to adequately metabolize, resulting in diabetes." C) "The physical inactivity associated with obesity causes a reduced ability by the body to produce insulin." D) "Thin people are less likely to become diabetic." **P-12**
A ("Excess body weight impairs the body's release of insulin.")
A dark-skinned client tells the nurse of plans to bask in the sun on an upcoming vacation. The nurse questions the client about sunscreen use. Which response indicates the client needs further education? A) "I don't need sunscreen because I am dark-skinned already." B) "I will avoid the sun between the peak hours of 10 a.m. and 4 p.m." C) "I can still experience sun damage despite my dark skin tones." D) "The melanocytes in my skin provide me with increased protection from the sun." **P-2**
A ("I don't need sunscreen because I am dark-skinned already.")
The nurse provides care for a client diagnosed with type 2 diabetes. Which statement indicates the client understands the diagnosis? A) "I need to follow my diet and take my pills." B) "If I don't take my insulin pills, I will go blind." C) "I should not eat anything that contains glucose." D) "I am ready to learn how to give myself shots." **K**
A ("I need to follow my diet and take my pills.")
The nurse instructs a client recovering from a mastectomy on ways to prevent lymphedema. Which client statement indicates that teaching has been successful? A) "I should do the exercises on my affected arm every day." B) "I have to take no special precautions." C) "I should avoid cleansing my skin with soap." D) "Eating fresh fruits and vegetables will prevent my arm from swelling." **P-2**
A ("I should do the exercises on my affected arm every day.")
An adolescent client is diagnosed with type 1 diabetes. Which statement BEST indicates the client understand the effects of strenuous exercise on blood glucose levels and insulin needs? A) "I will need to eat a snack before I go to swim team practice" B) "I can go out for ice cream after the game with the rest of the team" C) "I should eat more calories all the time, since I play sports" D) "Since exercise burns up calories, I won't need my insulin on days I swim" **K**
A ("I will need to eat a snack before I go to swim team practice")
A client is newly diagnosed with type 1 diabetes. The nurse talks with the client prior to discharge and discovers the client lives alone. Discharge planning should include arranging home visits by which health care provider? A) A home health nurse B) A physical therapist C) An occupational therapist D) A respiratory therapist **K**
A (A home health nurse)
A client has undergone a thyroidectomy. Which equipment is MOST important for the nurse to keep at the client's bedside during the immediate postoperative period? A) A tracheostomy tray B) Dressing equipment C) An ampule of D50W D) A central venous catheter tray **K**
A (A tracheostomy tray)
Which race is at highest risk of inheriting sickle cell disease? A) African American B) Caucasian C) Hispanic D) Asian **P-2**
A (African American)
A client reports increased thirst, frequent urination, and hunger. The client is diagnosed with type 1 diabetes. Which symptom reported by the client causes the nurse the MOST concern when planning care for the client? A) Constant thirst B) Difficulty sleeping C) Fatigue D) Perineal itching **K**
A (Constant thirst)
The nurse provides care for a client diagnosed with a severe head injury. The client's urine output is 150 mL/hour, blood pressure 92/68 mm/Hg, and increased serum osmolality is present. The nurse suspects the client has which condition? A) Diabetes insipidus B) Increased intracranial pressure C) Pulmonary edema D) Acute kidney injury **K**
A (Diabetes insipidus)
The nurse takes the medical history of a client diagnosed with hypothyroidism. Which signs and/or symptoms does the nurse expect the client to exhibit? A) Dry skin and constipation B) Weight loss and diarrhea C) Hirsutism and palpitations D) Increased energy level and exophthalmos **K**
A (Dry skin and constipation)
Which is the MOST important for the nurse to consider when planning the care for the client receiving chemotherapy? A) Instructing individuals who are visiting the client to wash hands B) Minimizing or preventing alopecia by using an ice cap C) Maintaining adequate gastrointestinal function to ensure adequate nutrition D) Minimizing hemorrhagic cystitis by increasing intravenous (IV) fluids **K**
A (Instructing individuals who are visiting the client to wash hands)
Which form of anemia can be prevented by a change in diet? A) Iron deficiency anemia B) Aplastic anemia C) Blood loss anemia D) Hemolytic anemia **P-2**
A (Iron deficiency anemia)
Which intravenous solution does the nurse use before and after administration of a blood transfusion? A) Isotonic saline B) Dextrose 5% in Water (D5W) C) Lactated Ringer solution D) Any solution may be used **K**
A (Isotonic saline)
The nurse is planning care for a young child who is admitted with sickle cell crisis. The parents are with the child, and neither has much information about the disease. When planning care for this family, the nurse will set which goal with this family? A) The child will drink adequate amounts of fluid each day. B) The child will play outside in the sun. C) The family will not have the child vaccinated. D) The family will plan vacations in high-altitude areas. **P-2**
A (The child will drink adequate amounts of fluid each day)
A client is diagnosed with breast cancer after a positive breast biopsy. The client refuses to believe the diagnosis and says, "I do not have the C-disease." When planning nursing interventions, which is an INITIAL short-term goal? A) The client will say the word "cancer" B) The client will admit to having cancer C) The client will attend a cancer support group D) The client will sign an advance directive **K**
A (The client will say the word "cancer")
The nurse is preparing an educational program on risk factors for the development of prostate cancer. Which information will the nurse include as being the greatest risk factor for developing prostate cancer? A) The client's age B) A family history C) A history of a vasectomy D) A diet high in fat **P-2**
A (The client's age)
A client who presents with complaints of easily bruising, bleeding gums, and petechiae may be suffering from what complication of leukemia? A) Thrombocytopenia B) Anemia C) Hepatomegaly D) Neutropenia **P-2**
A (Thrombocytopenia)
The nurse is assessing the vital signs of a client experiencing hypoparathyroidism. While monitoring the blood pressure, the nurse notes the client's hand begins to spasm. Which term is appropriate for the nurse to use when documenting this assessment finding? A) Trousseau sign B) Chvostek sign C) Turner sign D) Cullen sign **P-12**
A (Trousseau sign)
The nurse is caring for an adolescent client with a strong family history of breast cancer. What should the nurse instruct the client regarding cancer prevention? (Select all that apply A) Encourage the client to learn more about the disease. B) Talk to family members who have the disease. C) Perform monthly breast self-examination. D) Teach the side effects of cancer treatment. E) Discuss cancer fears with the healthcare provider. **P-2**
A & C (Encourage the client to learn more about the disease.) (Perform monthly breast self-examination.)
A nurse is caring for an adult client recently diagnosed with hypothyroidism. After reviewing the nursing admission assessment, on which documented findings should the nurse plan care for this client? (Select all that apply) A) Hypothermia B) Hot flashes C) Nausea D) Constipation E) Tachycardia **P-12**
A & D (Hypothermia) (Constipation)
The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members of the group indicate retention and application of the material presented by the nurse to reduce the risk of developing cancer? (Select all that apply) A) "I started using sunscreen when I work outside." B) "I began drinking two glasses of red wine a day with dinner." C) "I have reduced my intake of fiber." D) "I have increased the amount of fried fish in my diet." E) "I am trying to quit smoking." **P-2**
A & E ("I started using sunscreen when I work outside.") ("I am trying to quit smoking.")
A client with a history of anemia has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this client has adequate amounts of iron in the diet? (Select all that apply) A) Legumes B) Orange juice C) Yeast D) Okra E) Peas **P-2**
A, B, & E (Legumes) (Orange juice) (Peas)
A nurse is screening a client for prostate cancer. Which assessment findings would cause the nurse to suspect that the client has prostate cancer? (Select all that apply) A) Fatigue B) Upper extremity weakness C) Back pain D) Hematuria E) Scrotal edema **P-2**
A, C, & D (Fatigue) (Back pain) (Hematuria)
The nurse is reviewing data collected during a health history and physical assessment and determines that a client is at risk for developing breast cancer. Which data supports this client's risk for developing breast cancer? (Select all that apply) A) Age 60 B) Breastfed both children C) Sister had breast cancer D) Body mass index 22 E) Menopause at age 58 **P-2**
A, C, & E (Age 60) (Sister had breast cancer) (Menopause at age 58)
Type 2 diabetes mellitus is characterized by which underlying pathophysiology? A) Excessive insulin production B) Insulin resistance C) Inability of the pancreas to produce insulin D) Impaired insulin uptake **P-12**
B (Insulin resistance)
The nurse understands which is the MOST common type of anemia? A) Aplastic anemia B) Iron-deficiency anemia C) Pernicious anemia D) Sickle cell anemia **K**
B (Iron-deficiency anemia)
Which goal would be most appropriate to include in the nursing care plan of a client with type 2 diabetes? A) The client will record daily fat intake. B) The client will use hand hygiene when toileting. C) The client will monitor fasting glucose levels. D) The client will inspect feet at least once daily. **P-12**
D (The client will inspect feet at least once daily)
A toddler client diagnosed with sickle cell anemia comes to the clinic with the parent. Which statement demonstrates to the nurse that the parent understands the information provided? A) "When my child gets a fever and looks pale, I'll wait a few days to call the health care provider to see if these symptoms will first resolve on their own." B) "My child should drink fluids throughout the day and have frequent bathroom breaks to stay healthy." C) "I'll get cold compresses to apply to the painful areas to help decrease the pain during child's sickle cell crisis episodes." D) "All of my child's future children will have sickle cell anemia, and those children will have children with sickle cell anemia too." **K**
B ("My child should drink fluids throughout the day and have frequent bathroom breaks to stay healthy.")
A spouse of a client diagnosed with pernicious anemia asks why vitamin B12 cannot be given in pill form. Which response by the nurse is BEST? A) "Your spouse's symptoms of deficiency are quite severe, and large doses can only be given by injection." B) "Your spouse's stomach doesn't secrete the necessary substance for B12 to be absorbed orally." C) "I can ask the health care provider to change the medication to a pill if your spouse does not want an injection." D) "The intramuscular route is the fastest way for the vitamin B12 to be absorbed" **K**
B ("Your spouse's stomach doesn't secrete the necessary substance for B12 to be absorbed orally.")
Which signs and/or symptoms should the nurse anticipate in the client diagnosed with Addison Disease? A) Clubbing of the fingers B) A bronze skin tone C) Shortness of breath D) Intermittent claudication **K**
B (A bronze skin tone)
The nurse assesses the skin of the client who has skin lesions. Which assessment finding does the nurse associate with basal cell carcinoma? A) A red, scaly lesion on the back of the hand B) A small, crusty nodule on the face C) An irregular, bluish-black lesion on the back D) A red, scaly raised plaque on the knee with pruritus **K**
B (A small, crusty nodule on the face)
The home healthcare nurse is preparing a care plan for a client with severe anemia. The client currently lives alone and states, "I can't even walk to the kitchen without getting winded." What would be the priority nursing diagnosis for this client? A) Hopelessness B) Activity Intolerance C) Imbalanced Nutrition, Less than Body Requirements D) Anxiety **P-2**
B (Activity Intolerance)
The nurse is caring for a 78-year-old woman who was recently diagnosed with breast cancer. What consideration may the nurse need to make for this woman that she may not need to make for younger women with breast cancer? A) Discussing the woman's life expectancy B) Arranging transportation to appointments C) Ensuring the woman has adequate emotional support D) Providing teaching related to breast-conservation treatments **P-2**
B (Arranging transportation to appointments)
The nurse provides care for a client diagnosed with sickle cell anemia who is scheduled for a splenectomy. Which nursing action is most ESSENTIAL to include in the postoperative plan of care for this client? A) Assess for diarrhea due to increased gastric motility" B) Assess for signs of infection C) Assess of palpitation and hypertension D) Assess for increased intracranial pressure **K**
B (Assess for signs of infection)
During a routine physical examination of a client's lungs, the nurse notes a pink papule that is flat and erythematous with surface crusting on the client's upper chest. The nurse should notify the physician of this finding because the nurse suspects the papule might indicate what? A) Squamous cell carcinoma B) Basal cell carcinoma C) Actinic keratosis D) Malignant melanoma **P-2**
B (Basal cell carcinoma)
Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which action is MOST appropriate for the nurse to take INITIALLY? A) Leave the blood at the client's bedside until the health care provider checks it B) Check the type and cross-match with another nurse C) Run first 50 mL of blood rapidly to check for any reaction D) Flush tubing with normal saline and hang next unit **K**
B (Check the type and cross-match with another nurse)
Which is the correct nursing procedure for administering a blood transfusion? A) Allowing the blood to remain at room temperature no more than one hour before administration B) Comparing the laboratory blood type record with ABO group and Rh type on the blood bag label C) Using a 22-gauge needle with intravenous tubing D) Avoiding inversion of the bag, which may damage the blood cells **K**
B (Comparing the laboratory blood type record with ABO group and Rh type on the blood bag label)
The nurse provides care for a client with Addison disease. The nurse assesses for which of the following conditions? A) Urinary retention B) Dysrhythmias C) Glycosuria D) Water intoxication **K**
B (Dysrhythmias)
A client with hyperthyroidism reports feeling irritable to the nurse. The nurse understand which about this symptom? A) Irritability is usually the result of temporary mental confusion B) Irritability is commonly observed in clients with hyperthyroidism C) Irritability is fairly typical when a client thinks an illness is irreversible D) Irritability is frequently associated with decreasing serum thyroxine **K**
B (Irritability is commonly observed in clients with hyperthyroidism)
An older client is diagnosed with iron deficiency anemia. The client states that even though an "iron pill" is taken daily, the client is feeling more and more fatigued. Which action does the nurse take FIRST? A) Instruct the client to balance rest and activity B) Obtain a stool specimen to test for occult blood C) Contact the health care provider D) Instruct the client about eating food high in iron **K**
B (Obtain a stool specimen to test for occult blood)
Which action does the nurse perform when administering packed red blood cells to a client through a peripheral intravenous line? A) Prime the tubing with a D5W solution B) Obtain the client's vital signs and document findings C) Infuse the blood slowly over a period of five to six hours D) Initially infuse blood at a rapid rate and check pulse frequently **K**
B (Obtain the client's vital signs and document findings)
The nurse is caring for a client with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this client? A) Replace hand hygiene with gloves. B) Restrict visitors with communicable illnesses. C) Restrict fluid intake. D) Insert an indwelling urinary catheter to prevent skin breakdown. **P-2**
B (Restrict visitors with communicable illnesses)
The nursing instructor presents a class about inherited autosomal recessive disorders. Which disorders does the instructor include in the presentation? A) Childhood leukemia B) Sickle cell anemia C) Spina bifida D) Tracheoesophageal fistula **K**
B (Sickle cell anemia)
When teaching a client with Addison disease about dietary needs, the nurse should emphasize the importance of consuming which nutrient? A) Potassium B) Sodium C) Magnesium D) Chloride **K**
B (Sodium)
The nurse teaches a client diagnosed with iron deficiency anemia about dietary management of the anemia. At the end of the session, the client's selection of food indicates the client understands the teaching? A) Milk and raisins B) Spinach and eggs C) Cheese and broccoli D) Poultry and beans **K**
B (Spinach and eggs)
The client has a transfusion reaction. Which is the nurse's FIRST action? A) Slow down the transfusion B) Stop the transfusion C) Notify the health care provider D) Recheck the type and cross-match **K**
B (Stop the transfusion)
The nurse performs a postoperative assessment after a client's thyroidectomy. Which should the nurse assess FIRST? A) The client's position B) The client's respiratory status C) The client's level of activity tolerance D) The condition of the dressing **K**
B (The client's respiratory status)
The nurse in the outpatient clinic provides care for a client with the diagnosis of Cushing disease. The nurse expects to observe which symptoms? A) Weight loss B) Thin legs and arms C) Hypoglycemia D) Hypotension **K**
B (Thin legs and arms)
A client complaining of mouth soreness had gastric bypass surgery 1 year ago. During the assessment, the nurse notes the client's tongue is beefy, red, and smooth and the client's skin appears yellowish. Which additional information is most likely needed before diagnosing this client? A) Vitamin B6 levels B) Vitamin B12 levels C) Potassium levels D) Iron levels **P-2**
B (Vitamin B12 levels)
A client is receiving chemotherapy for acute lymphocytic leukemia. While providing care for this client, which clinical manifestations would indicate tumor lysis syndrome? (Select all that apply) A) Thrombocytopenia B) Cardiac arrhythmia C) Respiratory distress D) Changes in urine output E) Upper-extremity edema **P-2**
B & D (Cardiac arrhythmia) (Changes in urine output)
A client diagnosed with iron deficiency anemia receives ferrous gluconate daily. The client asks the nurse, "Why do I have to dilute this iron and drink more fluids?" Which response by the nurse is BEST? A) "This facilitates the production of intrinsic factor" B) "Iron cause dehydration" C) "Undiluted iron stains teeth and causes constipation" D) "Fluids are necessary to maintain fluid and electrolyte balance." **K**
C "Undiluted iron stains teeth and causes constipation"
The nurse does discharge teaching for a client after a right mastectomy. The nurse determines the teaching is effective if the client makes which statement? A) "I should eat a full liquid diet for 3-4 days." B) "I can take a shower as soon as I get home." C) "I should empty the drain reservoir twice a day." D) "I should eat with my left hand until the stitches are removed." **K**
C ("I should empty the drain reservoir twice a day.")
The nurse provides care for a client newly diagnosed with type 1 diabetes. The nurse instructs the client about the diabetic regimen. Which statement by the client indicates the need for further instruction? A) "I will substitute brown rice for whole wheat bread because I dislike bread." B) "I will always have to take insulin by injection." C) "I will increase my insulin dose on holidays so I can eat more." D) "I will program my glucometer every time I open a new bottle of test strips." **K**
C ("I will increase my insulin dose on holidays so I can eat more."
A client diagnosed with Cushing Syndrome had a bilateral adrenalectomy. After the operation, the nurse discusses the medication plan with the client. Which client statement indicates the nurse's postoperative teaching is successful? A) "I will call the health care provider if I need a medication holiday." B) "I can stop taking the medication as soon as I feel better." C) "I will set a timer or an alarm to make sure that I take my medication every day." D) "I will be glad to get home so I don't have to take all this medication." **K**
C ("I will set a timer or an alarm to make sure that I take my medication every day.")
The nurse is caring for a client who is undergoing diagnostic tests to rule out lung cancer. The client asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? A) "The doctor prefers this test." B) "To rule out the possibility that your problems are caused by pneumonia." C) "It is more specific in diagnosing your condition." D) "Why are you concerned about this test?" **P-2**
C ("It is more specific in diagnosing your condition.")
The nurse is caring for a client who has recently been diagnosed with skin cancer. The client is tearful and states, "How did I get skin cancer? I don't believe in tanning!" Which response by the nurse is indicated at this time? A) "Can you tell me more about your feelings?" B) "This is unusual, as skin cancer normally only occurs in sunbathers." C) "Sun exposure can happen as we carry out our daily activities." D) "We frequently never find out why cancer strikes." **P-2**
C ("Sun exposure can happen as we carry out our daily activities.")
Parents of a newborn infant are concerned that their baby may have sickle cell disease. The nurse reviews the medical record and finds that both parents have the sickle cell trait. Which is the best response for the nurse to give the parents? A) "Since neither of you actually has sickle cell disease, your baby is not at risk." B) "Your baby has the disease, as you both carry the trait." C) "We are required to test all babies for sickle cell disease." D) "Have you talked to a genetic counselor about your concerns?" **P-2**
C ("We are required to test all babies for sickle cell disease.")
An older client is diagnosed with anemia. The client lives in a two-story house, and the bedrooms are on the second floor. Prior to discharge, it is IMPORTANT for the nurse to ask which question? A) "How often does your adult child plan to visit?" B) "Shall I arrange Meals-on-Wheels for you?" C) "Where do you plan to sleep?" D) "Is your laundry in the basement?" **K**
C ("Where do you plan to sleep?"
A client will receive a unit of whole blood. Which intravenous solution does the nurse obtain for infusion with the blood? A) D5W B) D5W1/2NS C) 0.9% NS D) 0.45% NS **K**
C (0.9%NS)
The nurse is teaching a group of community members about preventing skin cancer. Which participant would be at the greatest risk for skin cancer? A) A 25-year-old lifeguard at the community pool who wears sunscreen B) A baby underneath a large beach umbrella C) A 60-year-old farmer who wears a cap when working D) A teenager who wears a ski outfit when skiing **P-2**
C (A 60-year-old farmer who wears a cap when working)
The nurse provides care for a patient with Addison disease. How would the nurse expect the client's skin to appear? A) Ruddy and oily B) Puffy C) Abnormally dark and pigmented D) Pale, dry, and scaly **K**
C (Abnormally dark and pigmented)
A client has undergone a thyroidectomy. The nurse is conducting a post operative assessment. Which procedure must the nurse perform to assess for bleeding for this client? A) Remove the dressing and observe the incision every 15 minutes for one hour B) Reinforce the existing pressure dressing as needed C) Check the dressing and the back of the client's neck D) Change the surgical dressing within two hours of the surgery to assess for hematoma formation **K**
C (Check the dressing and the back of the client's neck)
The nurse is speaking with a client who wants information regarding colorectal cancer. Which statement indicates the client understood the information presented by the nurse? A) The risk of colorectal cancer decreases with age. B) Colorectal cancer can be detected in early stages by measuring the level of the carcinogenic embryonic antigen (CEA). C) Colorectal cancer occurs more frequently in clients who have a history of inflammatory bowel disease. D) Colorectal cancer has no symptoms in the early stage and there are no definitive diagnostic tests. **P-2**
C (Colorectal cancer occurs more frequently in clients who have a history of inflammatory bowel disease)
The nurse performs a postoperative assessment of a client recovering from a thyroidectomy. The nurse notes that the client can only whisper. Which is the CORRECT action for the nurse to take? A) Thoroughly suction the oropharyngeal area B) Elevate the head of the bed, administer oxygen at two liters per minute, and check the client in 15 minutes C) Ensure that a tracheostomy set is at the bedside and notify the health care provider immediately D) Prepare a weakened solution of warm salt water and ask the client to gargle **K**
C (Ensure that a tracheostomy set is at the bedside and notify the health care provider immediately)
The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines teaching is effective if the client selects which menu? A) broiled fish, green vegetables, and milk B) Fried chicken, yellow vegetables, and fruit juice C) Flank steak, green leafy vegetables, and prunes D) Grilled cheese sandwich, creamed soup, and tomato salad **K**
C (Flank steak, green leafy vegetables, and prunes)
The nurse is instructing a group of women between the ages of 40 and 50 about early detection of breast cancer. What should the nurse include in this teaching? A) Perform monthly breast self-exams. B) See a healthcare provider if there is a strong family history of breast cancer. C) Have a yearly mammogram. D) Have a clinical breast exam performed by a healthcare provider every 5 years. **P-2**
C (Have a yearly mammogram)
After having a total knee replacement, a client receives a blood transfusion. Ten minutes after the transfusion starts, the client reports chills, chest tightness, lower back pain, and nausea. The nurse determines the client is experiencing which complication of blood transfusion? A) A myocardial infarction B) Circulatory overload C) Hemolytic transfusion reaction D) Septic shock **K**
C (Hemolytic transfusion reaction)
The nurse is assisting the healthcare provider with a bone marrow aspiration and biopsy on a client who has leukemia. The client also has thrombocytopenia. Upon completing the test, which intervention is a priority for the nurse? A) Dispose of the equipment used, and clean the area properly. B) Label and refrigerate the specimen obtained by the physician. C) Hold pressure on the wound for approximately 5 minutes. D) Make certain the client understands the purpose of the test. **P-2**
C (Hold pressure on the wound for approximately 5 minutes)
The nurse knows that a client with a blood sugar level of 40 mg/dL indicates which condition? A) Ketoacidosis B) Normal serum blood glucose C) Hypoglycemia D) Glycosuria **K**
C (Hypoglycemia)
A client is evaluated in the outpatient clinic for hypothyroidism. The nurse expects the client to exhibit which symptoms? A) Joint pain B) Urinary frequency C) Increasing fatigue D) Muscular twitching **K**
C (Increasing fatigue)
The nurse provides care for a conscious client with severe ketoacidosis. The nurse anticipates which treatment modality? A) Orange juice B) Glucose tablets C) Insulin D) Exercise **K**
C (Insulin)
The nurse teaches a client diagnosed with iron deficiency anemia about diet. The nurse determines teaching is successful if the client selects which menu items? A) Chicken salad, lettuce, tomatoes, and an apple B) Roast beef sandwich, coleslaw, and ice cream C) Liver and onions, spinach, and rice pudding with raisins D) Cheese omelet, toast, and fruit cocktail **K**
C (Liver and onions, spinach, and rice pudding with raisins)
The nurse care for client receiving chemotherapy. The nurse recognizes which nursing intervention is of PRIMARY importance for the prevention or early detection of bleeding in these clients? A) Obtaining results of electrolyte counts B) Assessing red blood cell counts C) Monitoring platelet counts D) Evaluating white blood cell and differential counts **K**
C (Monitoring platelet counts)
The nurse instructs the client recently diagnosed with type 1 diabetes about proper meal planning. Which action should the nurse take FIRST? A) Instruct the client about the importance of eating regular meals B) Inform the client that 50-60% of calories should come from carbohydrates C) Obtain a diet history that includes the client's favorite foods and usual meal patterns D) Teach the client how to use the Exchange List for Meal Planning **K**
C (Obtain a diet history that includes the client's favorite foods and usual meal patterns)
A client diagnosed with iron deficiency anemia says to the nurse, "I have always been a picky eater." The client's menstrual flow is normal and no sources of occult bleeding were identified in the client's diagnostic workup. The nurse understand that which is the MOST likely cause of anemia? A) Gastrointestinal malabsorption B) Hereditary predisposition C) Poor nutrition D) Bone marrow dysfunction **K**
C (Poor nutrition)
The nurse provides care for client diagnosed with a goiter. The client reports weakness, fatigue, increased sensitivity to heat, and feeling nervous and jittery. Which nursing intervention is the MOST appropriate in the care of this client? A) Encourage the client's family to remain with the client and provide diversion B) Assist the client to ambulate in the halls as frequently as possible C) Provide the client with rest periods between activities D) Encourage the client to eat three large well-balanced meals and choose menu items from all food groups **K**
C (Provide the client with rest periods between activities)
The nurse provides care for a client diagnosed with diabetes insipidus. The client receives desmopressin. Which action is MOST important for the nurse to include in the client's care plan? A) Record daily weights B) Test urine for glycosuria C) Reduce fluid intake D) Monitor client for constipation **K**
C (Reduce fluid intake)
Which diagnostic study does the nurse expect to confirm the diagnosis of pernicious anemia? A) Serum folic acid B) Bone marrow biopsy C) Schilling test D) Serum iron **K**
C (Schilling test)
The nurse provides care for a client diagnosed with Addison disease. Which is the CORRECT reason the nurse protects the client from stressors such as noise, environmental changes, and light? A) The client is hypercalcemic B) The client may develop Curling ulcers C) The client is not producing corticosteroids D) The client is overproducing antidiuretic hormone **K**
C (The client is not producing corticosteroids)
The nurse cares for the client diagnosed with adrenal hypersecretion (Cushing syndrome). The expects to observe which findings? A)Hypoglycemia and hypertension B) Anorexia and weight loss C) Truncal obesity and increased facial fat D) Symptoms of dehydration and hyponatremia **K**
C (Truncal obesity and increased facial fat)
The nurse suspects that a client with severe shortness of breath in the absence of cyanosis is experiencing anemia. Which laboratory tests should the nurse review to confirm anemia? (Select all that apply) A) Serum electrolytes B) Cardiac enzymes C) Hemoglobin D) Blood sugar E) Hematocrit **P-2**
C & E (Hemoglobin) (Hematocrit)
The nurse is preparing to perform a health assessment on an adult client who has a family history of cancer. Which questions should the nurse ask the client to assess for the early warning signs of cancer? (Select all that apply) A) "Do you have a cough that is associated with seasonal allergies?" B) "Have you noticed a change in your appetite?" C) "Have you noticed any cuts that have not healed?" D) "Have you had any changes in bowel or bladder habits?" E) "Have you experienced any problems swallowing?" **P-2**
C, D, & E ("Have you noticed any cuts that have not healed?") ("Have you had any changes in bowel or bladder habits?") ("Have you experienced any problems swallowing?")
Which intervention does the nurse include when teaching a client how to prevent skin cancer? A) Use a tanning booth rather than go out in the sun B) Limit tanning to the hours between 1000 and 1500 C) Use sunscreen with SPF of less than 15 D) Wear a heat and opaque clothing when out in the sun **K**
D (Wear a heat and opaque clothing when out in the sun)
The nurse is caring for a client with Graves disease. When observing the facial features of the client (pictured below), the nurse notes that the client is exhibiting which associated sign of the disease? A) Conjunctivitis B) Lacrimation C) Periorbital edema D) Exophthalmos **P-12**
D (Exophthalmos)
The nurse provides care for a client diagnosed with pernicious anemia. Which treatment does the nurse expect to be prescribed? A) Oral administration of vitamin B12 supplements daily B) Oral administration of ferrous gluconate 325mg 3 times daily C) Oral administration of 1mg folic acid daily D) Parenteral administration of vitamin B12 once a month **K**
D (Parenteral administration of vitamin B12 once a month)
Which complaint by the client should the nurse report to the physician as a potential indication of colorectal cancer? A) Abdominal pain B) Constipation C) Diarrhea D) Rectal bleeding **P-3**
D (Rectal bleeding)
The nurse suspects that a client is experiencing hypothyroidism. Which question should the nurse ask during the health history? A) "Is your skin often clammy?" B) "Do you have brown, shiny patches on your legs?" C) "Are you intolerant to heat?" D) "Have you had unexplained weight gain?" **P-12**
D ("Have you had unexplained weight gain?")
The nurse educates a client diagnosed with iron deficiency anemia. Which client statement indicates the client needs further teaching? A) "I cook my food in iron pots" B) "I am a vegetarian and eat every type of fruit and vegetable" C) "I will increase my intake of meats and leafy green vegetables" D) "I don't have to worry about diet because I take iron pills" **K**
D ("I don't have to worry about diet because I take iron pills")
The nurse is completing an assessment interview with an older adult client being seen for a yearly physical examination. Which client statement would indicate a possible diagnosis of diabetes mellitus? A) "I'm slightly winded when I walk up a flight of stairs, but it passes quickly." B) "I feel a bit tired by mid-afternoon and take a 30-minute nap most days." C) "I sometimes have muscle aches in my upper legs at night." D) "I've been experiencing increased thirst during the past several months." **P-12**
D ("I've been experiencing increased thirst during the past several months.")
A client is diagnosed with hypoparathyroidism. The nurse teaches the importance of taking calcium replacements. Which client statement indicates FURTHER teaching is required? A) "If I don't take my calcium tablets, I could develop irregular heartbeats." B) "I will call my health care provider if my hands or feet start tingling and become numb." C) "If i have difficulty swallowing my food, I will seek medical attention promptly." D) "If I have an extra glass of milk each day, I don't have to take my calcium tablets." **K**
D ("If I have an extra glass of milk each day, I don't have to take my calcium tablets.")
The nurse counsels a client diagnosed with type 2 diabetes. The client states, "I don't think I can follow this diet!" Which response by the nurse is MOST appropriate? A) "You have to follow the diet that your health care provider prescribed." B) "What makes you cheat on this diet?" C) "If you don't follow the diet, you might go blind." D) "Tell me what you find frustrating about the diet." **K**
D ("Tell me what you find frustrating about the diet.")
A client with pernicious anemia asks the nurse how long injections of Vitamin B12 will be needed. Which response by the nurse is BEST? A) "Ask your health care provider" B) "Six months to a year" C) "That will be determined by your blood count" D) "You may need lifelong injections" **K**
D ("You may need lifelong injections")
The nurse monitors a client diagnosed with type 1 diabetes. The client tells the nurse, "I jog 30 minutes every day but today after my jog I felt nervous, hungry, and had tremors." Which statement by the nurse is BEST? A) "You should walk rather than jog." B) "How do you feel before you begin exercising?" C) "What do you think is causing these feelings?" D) "You should eat cheese and crackers prior to jogging." **K**
D ("You should eat cheese and crackers prior to jogging.")
What approach is appropriate for interpreting the prostate-specific antigen (PSA) level as a diagnostic factor for prostate cancer? A) A PSA level higher than 4.0 ng/mL indicates prostate cancer. B) A PSA level lower than 4.0 ng/mL indicates prostate cancer. C) A fluctuating PSA level indicates prostate cancer. D) An abnormal PSA level alone is not enough to diagnose prostate cancer. **P-2**
D (An abnormal PSA level alone is not enough to diagnose prostate cancer)
