AEIII EXAM 2 PRACTICE QUESTIONS

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia. b. Felty's syndrome. c. Joint deformity. d. Low-grade fever. e. Weight loss.

b. Felty's syndrome. c. Joint deformity. e. Weight loss.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

b. Notify the health care provider.

In assessing a client for emphysema, the nurse would know that a physical finding commonly associated with this condition is: a. barrel chest. b. bulbous nose. c. spider angiomas. d. varicose veins.

a. barrel chest.

In a bedtime routine for a palliative care client who is having difficulty falling asleep, the least helpful intervention to incorporate would be: a. black tea with sugar. b. massage. c. progressive muscle relaxation. d. warm milk.

a. black tea with sugar.

The interventions for a burn patient newly admitted to the emergency department include: (Select all that apply.): a. covering the burn with sterile saline-saturated towel. b. removing clothing stuck to burn. c. taking care not to disturb blisters. d. removing jewelry from injured limbs. e. assessing the cause of the burn.

a. covering the burn with sterile saline-saturated towel. c. taking care not to disturb blisters. d. removing jewelry from injured limbs. e. assessing the cause of the burn.

The nurse caring for a client with asthma would place the client in the: a. fowler position. b. lithotomy position. c. side-lying position. d. supine position.

a. fowler position.

A client using a new opioid analgesic for pain becomes drowsy after the first two doses. The nurse explains to the client and family that the dose may be too high if this persists for more than: a. 1 day. b. 2 to 3 days. c. 5 to 7 days. d. 7 to 10 days.

b. 2 to 3 days.

The nurse is teaching an asthma patient proper use of the peak flowmeter. The nurse determines further teaching is needed when observing which action by the patient? a. Repeating the procedure for a total of three readings. b. Breathing in deeply through the mouthpiece. c. Standing while performing the test. d. Recording the highest reading on the peak flow sheet.

b. Breathing in deeply through the mouthpiece.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

b. Change gloves between wound care on different parts of the client's body.

The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How will this finding be documented? a. Torticollis. b. Crepitation. c. Subluxation. d. Epicondylitis.

b. Crepitation.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

c. Administer oxygen to keep saturations greater than 94%. e. Administer prescribed albuterol (Proventil) inhaler.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

c. Auscultate breath sounds over the trachea and bronchi.

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents. b. Antibiotics. c. Barbiturates. d. Corticosteroids. e. Loop diuretics.

c. Barbiturates. d. Corticosteroids. e. Loop diuretics.

The nurse instructing a client at risk for osteoporosis would encourage the client to include which item in the client's diet? a. Beans. b. Citrus fruits. c. Dairy products. d. Red meat.

c. Dairy products.

After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance

c. "An advance directive will specify what I want done when I can no longer make decisions about health care."

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate. b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

c. Suggest the patient use over-the-counter (OTC) artificial tears.

A hospice client is clearly dehydrated and the family is arguing over whether or not the client should receive intravenous fluids. The nurse would guide this discussion based on what knowledge about dehydration in the terminally ill client? a. If the terminally ill client complains of thirst, he/she is dehydrated. b. Peripheral edema in the terminally ill client indicates fluid overload. c. The emphasis of all treatments should be on comfort and reduction of symptoms. d. The only choices for hy

c. The emphasis of all treatments should be on comfort and reduction of symptoms.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas. b. Orange gelatin. c. Vanilla milkshake. d. Whole grain bagel

c. Vanilla milkshake.

A client admitted to the emergency department (ED) with burns of the chest and neck exhibits a wet, shiny, weeping surface with some blistering. The nurse would document these burn injuries as: a. full thickness, fourth degree. b. full thickness, third degree. c. partial thickness, second degree. d. superficial, first degree.

c. partial thickness, second degree.

A nurse working with clients on a hospice service understands that a client's quality of life is often linked to: a. projections about the amount of time that the client can expect to live. b. strength and remaining physical ability to perform self-care. c. symptom distress and the meanings attached to these physical sensations. d. the number of family and friends who remain as a support system.

c. symptom distress and the meanings attached to these physical sensations.

A nurse evaluates that goals for self-care teaching have been met when the client with asthma states: a. "Coughing at night is an expected side effect of bronchodilators." b. "Follow up visits with the doctor every year are important for monitoring." c. "I won't change the dosages of my medications without talking to the doctor." d. "If my peak flow measurements drop I will increase my medications."

d. "If my peak flow measurements drop I will increase my medications."

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How should the nurse respond? a. "You are using the inhaler incorrectly. This medication should be taken daily." b. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." c. "Tell me more about your fears related to feelings of breathl

d. "It is important to use this type of inhaler every day. Let's identify potential community services to help you."

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a. "When the antibiotic therapy is complete." b. "As soon as his albumin levels return to normal." c. "Once we complete the fluid resuscitation process." d. "When all of his burn wounds have closed."

d. "When all of his burn wounds have closed."

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

d. The upper peak airway pressure limit alarm is on.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the client's hands. d. Use an abduction pillow.

d. Use an abduction pillow.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

d. Use pulse oximetry to check oxygen saturation.

A client near the end of life is experiencing dyspnea, which causes anxiety. To plan holistic care for this client, the best decision by the nurse would be to: a. get an order for liberal doses of anxiolytics. b. have the family stay with the client. c. prepare the client for a morphine infusion. d. use an interdisciplinary approach.

d. use an interdisciplinary approach.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time - Increased risk for loss of function from contracture formation. b. Reduced inflammatory response - Deep partial-thickness wound with minimal exposure. c. Reduced thoracic compliance - Increased risk for atelectasis. d. High incidence of cardiac impairments - Increased risk for acute kid

a. Slower healing time - Increased risk for loss of function from contracture formation. c. Reduced thoracic compliance - Increased risk for atelectasis. d. High incidence of cardiac impairments - Increased risk for acute kidney injury.

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5. b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes. c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions. d. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool.

a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5.

A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

a. Notify the health care provider.

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

a. Notify the health care provider.

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this client's pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the client's feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine.

a. Play music that the client enjoys. c. Rub lavender lotion on the client's feet.

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

a. Remove nonadherent clothing and wristwatch.

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider? a. Respirations are 36 breaths/min. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

a. Respirations are 36 breaths/min.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator - Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid - Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. d. Cromone

b. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating. b. Client with a red, hot, swollen right wrist. c. Client who has a puffy-looking area behind the knee. d. Client with a worse joint deformity since the last visit.

b. Client with a red, hot, swollen right wrist.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

b. Continue to measure the urine output.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules. b. Discomfort with joint movement. c. Redness and swelling of the knee joint. d. Stiffness that increases with movement.

b. Discomfort with joint movement.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

b. Draw blood for a carboxyhemoglobin level.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

b. Elevate the right arm and hand on pillows and extend the fingers.

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Encourage the patient to sit up at the bedside in a chair and lean forward. c. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. d. Place the patient in the Trendelenburg position with pillows behind the head.

b. Encourage the patient to sit up at the bedside in a chair and lean forward.

Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

b. Encourage the patient to take a nap in the afternoon.

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.

b. Ensure the weight for the traction is hanging freely.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction. b. Full-thickness skin destruction. c. Deep partial-thickness skin destruction. d. Superficial partial-thickness skin destruction.

b. Full-thickness skin destruction.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad. b. Ice packs. c. Splints. d. Wax dip.

b. Ice packs.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

b. Insert a feeding tube and initiate enteral feedings.

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions. b. Kussmaul respirations. c. Low oxygen saturation (SpO2). d. Decreased venous O2 pressure.

b. Kussmaul respirations.

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.

b. Maintain the pulse oximetry level at 90% or greater.

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent.

a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. d. Encourage reminiscence by both client and family members.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health

a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound.

A client had a total hip arthroplasty from the posterolateral approach. The nurse ensures correct positioning by placing the client with the operative leg: a. abducted with a triangular foam pillow. b. externally rotated to 90 degrees. c. in a flexed position with pillows between the knees. d. internally rotated to no more than 60 degrees.

a. abducted with a triangular foam pillow.

A client has been diagnosed with early osteoarthritis (OA) in the hips. The nurse explains that the first medical treatment that will be tried is administration of: a. acetaminophen (Tylenol). b. celecoxib (Celebrex). c. misoprostol (Citotec). d. nonsteroidal anti-inflammatory drugs (NSAIDs).

a. acetaminophen (Tylenol).

A client has received a meshed split-thickness skin graft for coverage of a burn wound. The nurse would explain that the graft is meshed in order to: a. allow fluid to escape from the wound. b. avoid the need for sutures to hold the graft in place. c. facilitate debridement of the wound. d. observe the wound more carefully.

a. allow fluid to escape from the wound.

A client on the hospice service develops dyspnea related to the disease process. The nurse checks the order sheet for a(n) (Select all that apply): a. anti-anxiety agent. b. bronchodilator. c. corticosteroid. d. opioid analgesic.

a. anti-anxiety agent. b. bronchodilator. c. corticosteroid.

A client on hospice service reports experiencing a "colicky" type of pain. To relieve this clinical manifestation, the hospice nurse would request an order for a(n): a. anticholinergic. b. nonsteroidal anti-inflammatory drug. c. opioid analgesic. d. salicylate.

a. anticholinergic.

Psychosocial implications of a diagnosis of osteoporosis the nurse should assess for can include (Select all that apply): a. anxiety over disfigurement. b. chronic pain. c. fear of falling. d. poor quality of life. e. self-esteem problems.

a. anxiety over disfigurement. b. chronic pain. c. fear of falling. d. poor quality of life. e. self-esteem problems.

A client has a circumferential third-degree burn on the upper left arm. The nursing assessments specific for this client would include: a. assessing capillary refill in the left hand. b. evaluating left hand strength. c. measuring left forearm circumference. d. monitoring blood pressure in the left arm.

a. assessing capillary refill in the left hand.

To prevent contractures in the burn patient, the nurse should: a. assist the patient to ambulate as soon as fluid shift has stabilized. b. leave the limbs in full extension. c. stop range-of-motion (ROM) exercises when the patient complains of pain. d. place the limbs in the flexion position.

a. assist the patient to ambulate as soon as fluid shift has stabilized.

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should: a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.

a. avoid activities requiring repetitive use of the same muscles and joints.

A nonsmoking client has been diagnosed with mild asthma. The nurse instructs the client to try to identify and reduce or eliminate exposure to triggers, which may include (Select all that apply): a. being overly excited. b. household pets. c. physical exercise. d. perfumes. e. second-hand smoke.

a. being overly excited. b. household pets. c. physical exercise. d. perfumes. e. second-hand smoke.

The nurse teaching a class on osteoarthritis (OA) stresses that this disorder is best described as: a. degeneration of articular cartilage in synovial joints. b. enzymatic breakdown of tissue in non-weight-bearing joints. c. joint destruction caused by an autoimmune process. d. overproduction of synovial fluid, resulting in joint destruction.

a. degeneration of articular cartilage in synovial joints.

The nurse explains to the patient on a mechanical ventilator that it is set on assist-control mode, which means that the machine will: (Select all that apply.): a. deliver a set tidal volume. b. deliver a set number of breaths if the patient's rate falls. c. automatically cuts off if the patient is breathing independently. d. deliver more oxygen at the end of an inspiration. e. help to correct respiratory acidosis.

a. deliver a set tidal volume. b. deliver a set number of breaths if the patient's rate falls.

The nurse performing a brief physical assessment of an anxious client with asthma would carefully inspect the chest wall primarily to: a. evaluate the use of intercostal muscles. b. gain time to calm the client. c. observe the client for diaphoresis. d. verify bilateral chest expansion.

a. evaluate the use of intercostal muscles.

To reduce contractures of the knee in a client with extensive burns of the knee and mid-leg, the nurse would position the client with the knee: a. extended. b. flexed. c. adducted. d. abducted.

a. extended.

A hospice nurse reevaluates the pain management plan for a client who requires more than: a. four rescue doses in a 24-hour period. b. one rescue dose in a 48-hour period. c. three rescue doses in a 48-hour period. d. two rescue doses in a 24-hour period.

a. four rescue doses in a 24-hour period.

Important health promotion measures the nurse should encourage the client with COPD to consider are: a. getting influenza and pneumonia vaccinations. b. increasing ambient humidity in the house or apartment. c. installing a UV filter in the heating and air conditioning system. d. moving to an area of the country with a dry climate.

a. getting influenza and pneumonia vaccinations.

The nurse would assure a family member that for the first 24 hours after a burn injury, pain is kept to a minimum by administering: a. intravenous narcotic agents. b. liquid narcotics via a nasogastric tube. c. narcotics via an intramuscular route into nonburned tissue. d. tepid soaks and oral morphine.

a. intravenous narcotic agents.

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg. b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg. c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg. d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg.

a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg.

The signs the nurse would expect to see in a patient with advanced emphysema are: (Select all that apply.): a. productive cough. b. dyspnea. c. barrel chest. d. wheezing. e. cyanotic skin tone.

a. productive cough. b. dyspnea. c. barrel chest. e. cyanotic skin tone.

The home health nurse recommends to the 60-year-old patient with emphysema who is anorexic to enhance her nutrition by the practices of: (Select all that apply.): a. resting before eating. b. avoiding gas-producing food. c. eating four to six small meals rather than three large ones. d. lying down after eating. e. taking small bites and chewing slowly.

a. resting before eating. b. avoiding gas-producing food. c. eating four to six small meals rather than three large ones. e. taking small bites and chewing slowly.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

b. Antibodies lead to inflammation. c. It consists of an autoimmune process.

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

b. Applying cold packs before exercise may decrease joint pain.

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

b. Ask about medications the client is currently taking.

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the client's body for the funeral home.

b. Ask family members if they would like to spend time alone with the client.

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

b. Briefly ask specific questions about this episode of respiratory distress.

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose. b. C-reactive protein. c. Serum electrolytes. d. Liver function tests.

b. C-reactive protein.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler'

b. Notify the health care provider and prepare for endotracheal intubation.

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. O2 saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.

b. O2 saturation is > 90%.

A nurse cares for a dying client. Which manifestation of dying should the nurse treat first? a. Anorexia. b. Pain. c. Nausea. d. Hair loss.

b. Pain.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. b. Place on heart monitor. c. Check potassium level. d. Assess oral temperature.

b. Place on heart monitor.

A client has a bone density score of -2.8. What action by the nurse is best? a. Asking the client to complete a food diary. b. Planning to teach about bisphosphonates. c. Scheduling another scan in 2 years. d. Scheduling another scan in 6 months

b. Planning to teach about bisphosphonates.

A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death? a. Level of consciousness. b. Respiratory rate. c. Bowel sounds. d. Pain level on a 0-to-10 scale.

b. Respiratory rate.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use pursed-lip breathing. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.

b. Teach the patient how to use pursed-lip breathing.

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large dos

b. The patient is trying to get pregnant before her disease becomes more severe.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull on shoes and socks. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

b. The patient leans over to pull on shoes and socks.

The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? a. The patient inhales slowly through the nose. b. The patient puffs up the cheeks while exhaling. c. The patient practices by blowing through a straw. d. The patient's ratio of inhalation to exhalation is 1:3.

b. The patient puffs up the cheeks while exhaling.

The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the Diskus. d. The patient performs huff coughing after inhalation.

b. The patient rapidly inhales the medication.

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

b. The patient's blood glucose is 165 mg/dL.

Which information in a 67-yr-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? a. The patient sprained her ankle at age 13. b. The patient's mother became shorter with aging. c. The patient takes ibuprofen for occasional headaches. d. The patient's father died of complications of miliary tuberculosis.

b. The patient's mother became shorter with aging.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

b. Urine output of 41 mL over past 2 hours.

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds.

b. Wear gown, cap, mask, and gloves during care.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with: a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

b. a warm bath followed by a short rest.

A client's burn wound is being treated with enzymatic debridement. At this time the nurse would assess the client for: a. allergic reactions. b. bleeding from the burn wound. c. increased fluid loss. d. serum electrolyte imbalances.

b. bleeding from the burn wound.

The nurse caring for a client with burns over 40% of the body notes a hematocrit of 55% at 12 hours after the injury. The nurse would explain that this finding is related to: a. cellular debris from burned tissue. b. decreased intravascular fluid. c. increased red blood cell (RBC) production. d. presence of carboxyhemoglobin (COHb).

b. decreased intravascular fluid.

The nurse caring for a client who has undergone total hip replacement (THR) assesses for manifestations of the most common and serious complication after hip surgery, which is: a. contractures. b. deep vein thrombosis. c. infection. d. prosthesis dislocation.

b. deep vein thrombosis.

The older client is at greater risk of death following a burn because the older client (Select all that apply): a. does not have immunity to infections seen in burned clients. b. has a combination of age-related functional impairments. c. has thinner skin than a younger person does. d. may live alone without any social support.

b. has a combination of age-related functional impairments. c. has thinner skin than a younger person does. d. may live alone without any social support.

The patient with asthma is prescribed a leukotriene modifier drug, montelukast (Singulair). The nurse points out that the major advantage of this drug is it: a. has no GI side effects. b. provides bronchodilation and anti-inflammatory effects. c. controls acute asthma episodes. d. can be substituted for all other asthma remedies.

b. provides bronchodilation and anti-inflammatory effects.

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."

c. "I will use the drug when I have an asthma attack."

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? a. "Tagamet stimulates intestinal movement so you can eat more." b. "It improves fluid retention, which helps prevent hypovolemic shock." c. "It helps prevent stomach ulcers, which are common after burns." d. "Tagamet protects the kidney from damage caused by dehydration."

c. "It helps prevent stomach ulcers, which are common after burns."

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is: a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease

c. "It is important to start methotrexate early to decrease the extent of joint damage."

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. "Let's ask the provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

c. "Try a paraffin wax dip 20 minutes before you quilt."

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercise to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while you exercise."

c. "Use the bronchodilator before you start to exercise."

The nurse is caring for a client with burns covering the entire surface of both arms and the anterior trunk. Using the rule of nines, the nurse would estimate the percentage of burn surface area to be: a. 18%. b. 27%. c. 36%. d. 45%.

c. 36%.

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece."

c. 4, 3, 5, 1, 2, 6.

A hospice nurse explains to a client that one of the underlying reasons for the underutilization of hospice services is the difficulty in determining life expectancy prognoses of: a. 1 year or less. b. 8 months or less. c. 6 months or less. d. 3 months or less.

c. 6 months or less.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219 mL/hr. b. 625 mL/hr. c. 938 mL/hr. d. 1875 mL/hr.

c. 938 mL/hr.

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial-thickness facial burns. b. A patient who has just returned from having a cultured epithelial autograft to the chest. c. A patient who has a weight loss of 15% from admission and will have enteral feedings started. d. A patient who has blebs under an autograft on the thigh and has an ord

c. A patient who has a weight loss of 15% from admission and will have enteral feedings started.

A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next? a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the scheduled follow-up appointment.

c. Administer a bronchodilator and recheck the peak flow.

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Have the patient repeat the instructions immediately after teaching. b. Accomplish the patient teaching just before the scheduled discharge. c. Arrange for the patient's caregiver to be pres

c. Arrange for the patient's caregiver to be present during the teaching.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature. b. Peripheral pulses. c. Extremity movement. d. Pupil reaction to light.

c. Extremity movement.

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position.

c. Give the prescribed albuterol (Ventolin HFA) before the therapy.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching

c. Increasing the rate of the ordered IV solution.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

c. Lose weight if needed.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching? a. Travel is not possible with the use of O2 devices. b. O2 flow should be increased if the patient has more dyspnea. c. O2 use can improve the patient's prognosis and quality of life. d. Storage of O2 requires large metals tanks that each last 4 to 6 hours.

c. O2 use can improve the patient's prognosis and quality of life.

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's intake of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.

c. Offer high-calorie protein snacks between meals and at bedtime.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

c. Raise the lower siderail on the affected side.

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? a. Use of long-acting beta-adrenergic medications. b. Side effects of sustained-release theophylline. c. Self-administration of inhaled corticosteroids. d. Complications associated with O2 therapy.

c. Self-administration of inhaled corticosteroids.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit of 53%. b. Serum sodium of 147 mEq/L. c. Serum potassium of 6.1 mEq/L. d. Blood urea nitrogen of 37 mg/dL.

c. Serum potassium of 6.1 mEq/L.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32. b. Hematocrit: 52%. c. Serum potassium: 6.5 mEq/L. d. Serum sodium: 131 mEq/L.

c. Serum potassium: 6.5 mEq/L.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings. b. Over age 85. c. Severe osteoporosis. d. Urinary tract infection.

c. Severe osteoporosis.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. b. Check the blood pressure. c. Stabilize the cervical spine. d. Assess alertness and orientation.

c. Stabilize the cervical spine.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a. Bowel sounds. b. Stool frequency. c. Stool occult blood. d. Abdominal distention.

c. Stool occult blood.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

Which medication information will the nurse identify as a potential risk to a patient's musculoskeletal system? a. The patient takes a daily multivitamin and calcium supplement. b. The patient takes hormone replacement therapy (HRT) to prevent "hot flashes." c. The patient has severe asthma requiring frequent therapy with oral corticosteroids. d. The patient has headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).

c. The patient has severe asthma requiring frequent therapy with oral corticosteroids.

Which information obtained during the nurse's assessment of a patient's nutritional-metabolic pattern may indicates increased risk for musculoskeletal problems? a. The patient takes a multivitamin daily. b. The patient dislikes fruits and vegetables. c. The patient is 5 ft, 2 in tall and weighs 180 lb. d. The patient prefers whole milk to nonfat milk.

c. The patient is 5 ft, 2 in tall and weighs 180 lb.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient indicates a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months every winter. d. The patient denies having respiratory problems until the past 12 months.

c. The patient reports a productive cough for 3 months every winter.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

c. The patient takes propranolol (Inderal) for hypertension.

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

c. The white blood cell (WBC) count is 1500/μL.

In the initial visit to a recently discharged client with osteoporosis, the home health nurse will reinforce the priority topic of: a. diet low in phosphates. b. exercise regimen. c. hazards to home safety. d. medication administration.

c. hazards to home safety.

After providing instructions to a client with newly diagnosed COPD who is learning to take a steroid medication by inhaler, the nurse would determine that proper technique has been learned when the client: a. breathes out forcefully with an open mouth. b. gently rolls the canister in the hands before use. c. holds the breath for 5 to 10 seconds after inhalation. d. starts to discontinue the medication once manifestations subside.

c. holds the breath for 5 to 10 seconds after inhalation.

The nurse alerts a family member about the client's imminent death because the nurse has assessed the cardiovascular indicator of: a. bradycardia. b. fluctuating blood pressure. c. irregular heart rate. d. narrowing pulse pressure.

c. irregular heart rate.

A nurse is auscultating the lungs of a client who presented to the emergency department complaining of an asthma attack. The nurse hears no wheezing. The nurse should conclude that the client: a. does not really have asthma. b. is not having a bad attack. c. may have severe airway constriction. d. needs increased IV fluids.

c. may have severe airway constriction.

A client on the hospice service is experiencing nausea and vomiting as the result of pain management using opioids. The nurse should attempt to minimize this adverse effect by using the: a. intramuscular route. b. intravenous route. c. oral route. d. subcutaneous route.

c. oral route.

A client receives a beta-adrenergic bronchodilator and supplemental oxygen when entering the ED for treatment of asthma, but the client's condition remains unchanged. The nurse would anticipate that the client will: a. be coached immediately in pursed-lip breathing. b. receive increased intravenous fluids. c. receive intravenous (IV) steroids. d. undergo "stat" pulmonary function tests.

c. receive intravenous (IV) steroids.

As a beneficial exercise program, the nurse teaching a group of clients with osteoarthritis would suggest: a. daily vigorous aerobic exercise followed by a warm shower or bath. b. minimal exercise several times daily, followed by rest periods. c. regular daily, low-impact exercise program. d. strength-building exercises with weights or resistance.

c. regular daily, low-impact exercise program.

The nurse dismissing a burn-injured client would evaluate that teaching goals have been met when the client says "I a. have to avoid any moisturizers on the burns so they 'toughen up'." b. can't wait to go home and throw out these pressure garments!" c. should use only alcohol-free skin moisturizers." d. will need to wear sunscreen for at least a year."

c. should use only alcohol-free skin moisturizers."

The hospice nurse requests the drug temazepam (Restoril) for a client who has difficulty in: a. falling asleep. b. falling asleep and staying asleep. c. sleeping without nightmares. d. staying asleep.

c. sleeping without nightmares.

The nurse would stress to the ancillary staff that the most important means of preventing the spread of infection in the burn unit is: a. prophylactic antibiotics. b. restricting visitors with respiratory tract infections. c. strict hand-washing. d. using clean gowns, gloves, and masks.

c. strict hand-washing.

The nurse is counseling a client at risk of osteoporosis that one of the most beneficial exercises is: a. cycling. b. swimming. c. walking. d. water aerobics.

c. walking.

Which finding for a 77-yr-old patient seen in the outpatient clinic requires further nursing assessment and intervention? a. Symmetric joint swelling of fingers. b. Decreased right knee range of motion. c. Report of left hip aching when jogging. d. History of recent loss of balance and fall.

d. History of recent loss of balance and fall.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

d. Measure hourly urine output.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

d. Notify the provider immediately.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon. b. Whole wheat toast and fresh fruit. c. Egg-white omelet and a half grapefruit. d. Oatmeal with skim milk and fruit yogurt.

d. Oatmeal with skim milk and fruit yogurt.

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

d. Perform chest physiotherapy every 4 hours.

The nurse admitting a patient with significant burns to the emergency department notes the presence of symptoms consistent with an inhalation burn. Which finding is the nurse most likely noting? a. Full-thickness burns to chest. b. Hypotension. c. Agitation. d. Persistent coughing.

d. Persistent coughing.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask.

d. Place the patient on 100% O2using a nonrebreather mask.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis. b. Metabolic alkalosis. c. Respiratory acidosis. d. Respiratory alkalosis.

d. Respiratory alkalosis.

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

d. The patient sleeps with two pillows under the head.

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.

d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.

The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).

d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent)

Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

d. Tremors are an expected side effect of rapidly acting bronchodilators.

The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? a. Pulse oximetry reading of 91%. b. Respiratory rate of 26 breaths/min. d. Use of accessory muscles in breathing. d. Peak expiratory flow rate of 240 L/min.

d. Use of accessory muscles in breathing.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Stop exercising when you feel short of breath. b. Walk until pulse rate exceeds 130 beats/minute. c. Limit exercise to activities of daily living (ADLs). d. Walk 15 to 20 minutes a day at least 3 times/week.

d. Walk 15 to 20 minutes a day at least 3 times/week.

A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman, the nurse explains that: a. with a family history of osteoporosis, there is no way to prevent or slow bone resorption. b. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. c. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. d. calcium

d. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

The nurse who notes that a 59-yr-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about: a. discography studies. b. myelographic testing. c. magnetic resonance imaging (MRI). d. dual-energy x-ray absorptiometry (DXA).

d. dual-energy x-ray absorptiometry (DXA).

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac. b. lorazepam (Ativan). c. gabapentin (Neurontin). d. hydromorphone (Dilaudid).

d. hydromorphone (Dilaudid).

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%. b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%. c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%. d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%.

d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%.

The nurse counseling a client with osteoporosis identifies one of the medications that may have contributed to the condition as: a. aspirin. b. colchicine. c. ibuprofen. d. prednisone.

d. prednisone.

The nurse is caring for a client with a continuous passive motion (CPM) machine after a total knee arthroplasty. An important safety measure the nurse should add to the plan of care is to: a. allow the client to use the machine 10-12 hours daily. b. keep the head of the bed elevated at least 30 degrees. c. position the client supine during CPM machine use. d. remove the CPM machine during meals.

d. remove the CPM machine during meals.

The nurse instructing a client on considerations regarding the medication calcium carbonate would include in the teaching plan that the client: a. has to wait 1 hour after meals to take the medication. b. may experience nausea or diarrhea. c. needs to take the calcium with an 8-ounce glass of water. d. should take the calcium carbonate with food.

d. should take the calcium carbonate with food.

The nurse caring for a burn client would monitor the client's stools for occult blood as assessment for development of: a. bleeding caused by bowel distention. b. gastric irritation related to smoke. c. intestinal ileus. d. stress ulcers.

d. stress ulcers.

A client with osteoporosis complains that avoiding coffee will be very difficult. To offset coffee consumption, the nurse might suggest that for every cup of coffee consumed, the client should: a. add 1 serving of leafy green vegetables. b. combine 20 minutes of exercise to the daily program. c. drink 1 glass of orange juice or grapefruit juice. d. take 40 mg of over-the-counter calcium.

d. take 40 mg of over-the-counter calcium.

When caring for a severely burned client, the nurse notes that the client's urine is dark brown. The priority action by the nurse would be to: a. check the urinary catheter for patency and irrigate it if needed. b. monitor vital signs more frequently to detect hypovolemia. c. notify the physician immediately and request an order for urinalysis. d. titrate intravenous (IV) fluids to maintain urine output of 75-100 ml/hour.

d. titrate intravenous (IV) fluids to maintain urine output of 75-100 ml/hour.

The nurse assesses that the individual most susceptible to osteoporosis is the: a. muscular 50-year-old man with diabetes. b. obese 50-year-old woman who is allergic to milk. c. thin 70-year-old man with gout. d. very slender 75-year-old woman.

d. very slender 75-year-old woman.

The physician orders 1% silver sulfadiazine cream applied to a client's burn wound two times daily. The nurse would be aware that this medication can affect: a. blood pH. b. hemoglobin level. c. serum electrolyte levels. d. white blood cell count.

d. white blood cell count.

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. b. Assess for contractures. c. Check peripheral pulses. d. Monitor for hip dislocation.

a. Assess for hip pain.

A nurse caring for an elderly client with COPD alters care knowing that in the older population (Select all that apply): a. COPD is not a common problem in the elderly. b. impaired nutrition is a common problem in the elderly. c. multiple co-morbidities may be present that complicate care. d. sensory disturbances may hinder their ability to provide self-care. e. there may be more problems with drug-drug interactions.

b. impaired nutrition is a common problem in the elderly. c. multiple co-morbidities may be present that complicate care. d. sensory disturbances may hinder their ability to provide self-care. e. there may be more problems with drug-drug interactions.

The nurse would explain to a client that when a major burn occurs, the body's initial systemic responses include: a. elevated pulse rate, decreased cardiac output, and polyuria. b. increased capillary permeability, decreased cardiac output, and oliguria. c. plasma leakage into surrounding tissue, decreased hematocrit, and oliguria. d. production of epinephrine, vasodilation, and increased cardiac output.

b. increased capillary permeability, decreased cardiac output, and oliguria.

The nurse is assessing a client with osteoporosis. The finding that is consistent with the nurse's understanding of the disease is: a. a stiff posture. b. kyphosis. c. pain in long bones. d. weight loss.

b. kyphosis.

When admitting a client who has sustained a burn injury, the nurse would inoculate against tetanus if the client has: a. been inoculated in the last 6 years. b. open wounds with copious debris embedded. c. second-degree burns with broken blisters. d. third-degree burns.

b. open wounds with copious debris embedded.

The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

d. "I can sleep in any position that is comfortable for me."

A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How should the nurse respond? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."

d. "I will have another nurse assist me to turn your husband on his side."

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis. b. Metabolic alkalosis. c. Respiratory acidosis. d. Respiratory alkalosis.

a. Metabolic acidosis.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV. b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer. c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI). d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI).

b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, r

a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day."

What information does the nurse teach a women's group about osteoporosis? a. "For 5 years after menopause you lose 2% of bone mass yearly." b. "Men actually have higher rates of the disease but are underdiagnosed." c. "There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis."

a. "For 5 years after menopause you lose 2% of bone mass yearly."

A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How should the nurse respond? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous cath

a. "Let him know that food is available if he wants it, but do not insist that he eat."

The patient with sleep apnea is fitted with a continuous positive airway pressure (CPAP) mask and asks the nurse how this device will help. The nurse correctly responds with which statement? a. "The device delivers constant positive pressure to keep your airway open." b. "The device will require you to be intubated to open your airway." c. "The device delivers oxygen only when you are apneic." d. "The device delivers negative pressure to stimulate your respirations."

a. "The device delivers constant positive pressure to keep your airway open."

A nurse discusses inpatient hospice with a client and the client's family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "

a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left."

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat

a. 4, 2, 1, 3, 5, 6, 7.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol). b. Cyclobenzaprine hydrochloride (Flexeril). c. Hyaluronate (Hyalgan). d. Ibuprofen (Motrin).

a. Acetaminophen (Tylenol).

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene. b. Administering anti-ulcer medication. c. Elevating the head of the bed. d. Providing oral care per protocol. e. Suctioning the client on a regular schedule.

a. Adherence to proper hand hygiene. b. Administering anti-ulcer medication. c. Elevating the head of the bed. d. Providing oral care per protocol.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

a. Administer the prescribed intravenous morphine sulfate.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol. b. Caffeine. c. Fat. d. Carbonated beverages. e. Vitamin D.

a. Alcohol. b. Caffeine. d. Carbonated beverages. e. Vitamin D.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

a. Apply oxygen and continuous pulse oximetry.

To minimize hypertrophic scarring of a client's burn wound, the nurse would anticipate providing which intervention? a. Applying continuous pressure with elastic wraps. b. Applying topical antimicrobial agents. c. Debridement with enzymatic products. d. Vigorous removal of all dead tissue.

a. Applying continuous pressure with elastic wraps.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospital's gift shop. e. Use aseptic

a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. e. Use aseptic technique and wear gloves when performing wound care.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

a. Ask the client about fear of falling.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. d. Use a vibrating positive expiratory pressure device.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

a. Assess neurovascular status in both legs.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

a. Assess the cause of the agitation.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

a. Auscultate the patient's lung sounds.

A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.) a. Bone changes lead to potential safety risks. b. Increased bone density leads to stiffness. c. Osteoarthritis occurs due to cartilage degeneration. d. Osteoporosis is a universal occurrence. e. Some muscle tissue atrophy occurs with aging.

a. Bone changes lead to potential safety risks. c. Osteoarthritis occurs due to cartilage degeneration. e. Some muscle tissue atrophy occurs with aging.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.) a. Can communicate his treatment preferences. b. Is able to read and write at an eighth-grade level. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information. e. Has completed an advance directive.

a. Can communicate his treatment preferences. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness. b. Decreased muscle strength. c. Inability to cooperate. d. Less lung elasticity. e. Poor vision and hearing.

a. Chest wall stiffness. b. Decreased muscle strength. d. Less lung elasticity.

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine. b. Red blood cells. c. Sodium. d. Magnesium.

a. Creatinine.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart. b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles. c. Increased number and size of mucus glands producing large amounts of thick mucus.

a. Increased pulmonary pressure creating a higher workload on the right side of the heart.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

a. Inspect the client's distal finger joints.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

b. Administer furosemide (Lasix) 40 mg IV push.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? a. Observe output from the surgical drain. b. Administer prescribed pain medication. c. Instruct the patient about benefits of early ambulation. d. Change the dressing and document the wound appearance.

b. Administer prescribed pain medication.

A client tells the nurse that he read something about "dead space" in an article about emphysema and asks the nurse to explain it to him. The nurse's most accurate answer would be the following: a. "Any part of your lungs that contains mucous secretions is called dead space." b. "Dead space is an area of your lung that does not participate in air exchange." c. "Parts of the lower airway that serve as a conduit for fresh air." d. "This is a small area of necrotic tissue that

b. "Dead space is an area of your lung that does not participate in air exchange."

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" e. "Have you lost any weight lately?"

A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this client's plan of care? a. "Is your advance directive up to date and notarized?" b. "Do you want to be at home at the end of your life?" c. "Would you like a physical therapist to assist you with range-of-motion activities?" d. "Have your children discussed resuscitation with your health care provider?"

b. "Do you want to be at home at the end of your life?"

A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this client's teaching? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer

b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms."

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire an around-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication al

b. "I have some of her favorite hymns on a CD that I could bring for music therapy."

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours."

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too

b. "It's true that your life may be different. What concerns you the most?"

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30-pack-year history of smoking. b. A 52-year-old in a tripod position using accessory muscles to breathe. c. A 68-year-old who has dependent edema and clubbed fingers. d. A 74-year-old with a chronic cough and thick, tenacious secretions

b. A 52-year-old in a tripod position using accessory muscles to breathe.

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job. c. A 38-yr-old man who plays on a summer softball team. b. A 56-yr-old woman who works on an automotive assembly line. a. A 38-yr-old woman who is newly diagnosed with diabetes mellitus.

b. A 56-yr-old woman who works on an automotive assembly line.

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes. b. A patient with a respiratory rate of 38 breaths/min. c. A patient who has a cough productive of thick, green mucus. d. A patient with jugular venous distention and peripheral edema.

b. A patient with a respiratory rate of 38 breaths/min.

Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain. b. A patient with smoke inhalation who has wheezes and altered mental status. c. A patient with full-thickness leg burns who is scheduled for a dressing change. d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr.

b. A patient with smoke inhalation who has wheezes and altered mental status.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching? a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer nee

c. "I will take this medication every morning to help prevent an acute attack."

The patient with acute bronchitis asks if antibiotics will be ordered for the condition. The best response by the nurse would be: a. "Yes. Antibiotics are the best treatment option." b. "No. Antibiotics will not help a viral condition." c. "Antibiotics will be given if the sputum culture indicates your bronchitis is caused by bacteria." d. "I don't think so because antibiotics will inhibit the inflammatory response of your body to the invasion of this infection."

c. "Antibiotics will be given if the sputum culture indicates your bronchitis is caused by bacteria."

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

c. "Do you experience shortness of breath with basic activities?"

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."

c. "Do you think dark beige makeup will cover this scar?"

A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"

c. "Have you taken any bronchodilators today?"

An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy wi

c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death."

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. "I can bend down to pick something up." b. "I no longer need to do my exercises." c. "I will not sit with my legs crossed." d. "I won't wash my incision to keep it dry."

c. "I will not sit with my legs crossed."

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the past year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." d. "I've been using my albuterol inhaler more frequently over the last 4 days."

d. "I've been using my albuterol inhaler more frequently over the last 4 days."

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

d. "It will prevent ulcers from the stress of mechanical ventilation."

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails. b. A 48-year-old client with an oxygen saturation level of 92% at rest. c. A 35-year-old client who has a longer expiratory phase than inspiratory phase. d. A 27-year-old client with a heart rate of 120 beats/min.

d. A 27-year-old client with a heart rate of 120 beats/min.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

d. Apply water-based cream to burned areas frequently.

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL. b. Client who recently fell and has vertebral compression fractures. c. Hypertensive client who takes calcium channel blockers. d. Client with a spinal cord injury who cannot tolerate sitting up.

d. Client with a spinal cord injury who cannot tolerate sitting up.

A nurse teaches a client's family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities. b. Long periods of insomnia. c. Increased respiratory rate. d. Decreased appetite. e. Congestion and gurgling.

d. Decreased appetite. e. Congestion and gurgling.

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for an emergency airway.

d. Gather appropriate equipment and prepare for an emergency airway.