Med Surg Final

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5. The nurse is preparing to administer erythromycin to a patient who takes digoxin. The nurse will plan to monitor the patient for a. digoxin toxicity. b. decreased digoxin effects. c. erythromycin toxicity. d. decreased erythromycin effects.

ANS: A Intestinal flora have the ability to metabolize digoxin, and any drug that destroys or inhibits growth of these gastrointestinal microflora can increase digoxin levels leading to toxicity.

5. The nurse is caring for a patient who is diagnosed with tuberculosis. The patient tells the nurse that the provider plans to order a prophylactic antitubercular drug for family members and asks which drug will be ordered. The nurse will expect the provider to order which drug? a. Isoniazid (INH) b. Pyrazinamide c. Rifampin (Rifadin) d. Streptomycin

ANS: A INH is the drug of choice for prophylactic treatment of patients who have had close contact with a patient who has tuberculosis.

4. An adult patient is brought to the emergency department for treatment of an asthma exacerbation. The patient uses inhaled albuterol as needed to control wheezing. The nurse notes expiratory wheezing, tremors, restlessness, and a heart rate of 120 beats per minute. The nurse suspects that the patient has a. over-used the albuterol. b. not been using albuterol. c. taken a beta-adrenergic blocker. d. taken a monoamine oxidase (MAO) inhibitor.

ANS: A High doses of albuterol may affect beta1 receptors, causing an increase in heart rate. Patients having an asthma exacerbation may over-use their albuterol inhalers when seeking relief. Patients may have wheezing and increased heart rate during an untreated asthma exacerbation, but they will not have tremors and restlessness.

1. The nurse is caring for a patient recently diagnosed with mild emphysema and provides teaching about the disease and medications for treatment. Which statement by the patient indicates understanding of the medication regimen? a. I should use albuterol when my symptoms worsen. b. I will need to take oral prednisone on a daily basis. c. My provider will prescribe prophylactic antibiotics. d. My symptoms are reversible with proper medications.

ANS: A Albuterol is used to treat bronchospasm during symptom flares. Oral prednisone is given for acute flares but not generally on a daily basis until symptoms are chronic and severe because of the risk of adrenal suppression. Prophylactic antibiotics are not given regularly because of the risk of antibiotic resistance. Symptoms of emphysema are not reversible.

4. A patient will begin using ipratropium bromide (Atrovent), albuterol (Proventil), and an inhaled glucocorticoid medication (steroid) to treat chronic bronchitis. When teaching this patient about disease and medication management, the nurse will instruct the patient to administer these medications in which order? a. Albuterol, ipratropium bromide, steroid b. Albuterol, steroid, ipratropium bromide c. Ipratropium bromide, albuterol, steroid d. Steroid, ipratropium bromide, albuterol

ANS: A Patients who use a beta agonist should be taught to use it 5 minutes before administering ipratropium bromide, and ipratropium bromide should be given 5 minutes prior to an inhaled glucocorticoid. This helps the bronchioles to dilate so the subsequent medication can be deposited in the bronchioles for improved effect.

5. The nurse is caring for a patient who is receiving warfarin (Coumadin) and notes bruising and petechiae on the patients extremities. The nurse will request an order for which laboratory test? a. International normalized ratio (INR) b. Platelet level c. Partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) d. Vitamin K level

ANS: A The INR is the test used most frequently to report prothrombin time results in patients taking warfarin. Warfarin is not an antiplatelet drug, so platelet levels are not indicated. PTT and aPTT are used to monitor heparin therapy. Vitamin K is an antidote for warfarin; levels are not routinely checked.

6. A patient who takes digoxin to treat heart failure will begin taking a vasodilator. The patient asks the nurse why this new drug has been ordered. The nurse will explain that the vasodilator is used to a. decrease ventricular stretching. b. improve renal perfusion. c. increase cardiac output. d. promote peripheral fluid loss.

ANS: A Vasodilators are given to decrease venous blood return to the heart, resulting in decreased cardiac filling and decreased ventricular stretching, in turn reducing preload, contractility, and oxygen demand on the heart.

5. The nurse is caring for a patient who develops marked edema and a low urine output as a result of heart failure. Which medication will the nurse expect the provider to order for this patient? a. Digoxin (Lanoxin) b. Furosemide (Lasix) c. Hydrochlorothiazide (HydroDIURIL) d. Spironolactone (Aldactone)

ANS: B Furosemide is a loop diuretic and is given when the patients condition warrants immediate removal of body fluid, as in heart failure. Digoxin improves cardiac function but does not remove fluid quickly. The other diuretics may be used when immediate fluid removal is not necessary.

4. A patient is being treated with isoniazid (INH), rifampin, and pyrazinamide in phase I of treatment for tuberculosis. The organism develops resistance to isoniazid. Which drug will the nurse anticipate the provider will order to replace the isoniazid? a. Ciprofloxacin (Cipro) b. Ethambutol (Myambutol) c. Kanamycin d. Streptomycin sulfate

ANS: B If there is bacterial resistance to isoniazid, the first phase may be changed to ethambutol, rifampin, and pyrazinamide. Ciprofloxacin, kanamycin, and streptomycin are not generally first-line antitubercular drugs.

65. The nurse is preparing to administer insulin intravenously. Which statement about the administration of intravenous insulin is true? a. Insulin is never given intravenously. b. Only regular insulin can be administered intravenously. c. Insulin aspart or lispro can be administered intravenously, but there must be a 50% dose reduction. d. Any form of insulin can be administered intravenously at the same dose as that is ordered for subcutaneous administration.

ANS: B Regular insulin is the usual insulin product to be dosed via intravenous bolus, intravenous infusion, or even intramuscularly. These routes, especially the intravenous infusion route, are often used in cases of diabetic ketoacidosis, or coma associated with uncontrolled type 1 diabetes.

4. The nurse is preparing to administer digoxin to a patient who has heart failure. The patient reports nausea, vomiting, and a headache. The nurse notes a respiratory rate of 18 breaths per minute, a heart rate of 58 beats per minute, and a blood pressure of 120/78 mm Hg. What will the nurse do next? a. Administer the next dose as ordered since these are mild side effects. b. Hold the dose and notify the provider of possible digoxin toxicity. c. Reassure the patient that these are common, self-limiting side effects. d. Request an order for an antiemetic and an analgesic medication.

ANS: B Nausea, vomiting, and headache are common signs of digoxin toxicity as is a heart rate less than 60 beats per minute. The nurse should hold the dose and notify the provider.

6. The nurse receives the following order for insulin: IV NPH (Humulin NPH) 10 units. The nurse will perform which action? a. Administer the dose as ordered. b. Clarify the insulin type and route. c. Give the drug subcutaneously. d. Question the insulin dose.

ANS: B Only regular insulin can be given intravenously. The nurse should clarify the order. It is not correct to give Humulin NPH insulin IV. The nurse should not administer the drug by a different route without first discussing with the provider.

3. A patient has been receiving intravenous heparin. When laboratory tests are drawn, the nurse has difficulty stopping bleeding at the puncture site. The patient has bloody stools and is reporting abdominal pain.The nurse notes elevated partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT). Which action will the nurse perform? a. Ask for an order for oral warfarin (Coumadin). b. Obtain an order for protamine sulfate. c. Request an order for vitamin K. d. Suggest that the patient receive subcutaneous heparin.

ANS: B Protamine sulfate is given as an antidote to heparin when patients clotting times are elevated. Oral warfarin will not stop the anticoagulant effects of heparin. Vitamin K is used as an antidote for warfarin. Administering heparin by another route is not indicated when there is a need to reverse the effects of heparin.

6. The nurse is preparing to give a dose of trimethoprim-sulfamethoxazole (TMP-SMX) and learns that the patient takes warfarin (Coumadin). The nurse will request an order for a. a decreased dose of TMP-SMX. b. a different antibiotic. c. an increased dose of warfarin. d. coagulation studies. ANS: D Sulfonamides can increase the anticoagulant effects of warfarin. The nurse should request INR levels. An increased dose of warfarin would likely lead to toxicity and to undesirable anticoagulation. 7. A patient has been taking warfarin (Coumadin), which is highly protein-bound. The patient will begin taking gemfibrozil, which is also highly protein-bound. The nurse will observe the patient closely for a. decreased effects of warfarin. b. increased effects of warfarin. c. decreased effects of gemfibrozil. d. decreased effects of both drugs.

ANS: B The addition of a highly protein-bound drug will compete with warfarin for protein- binding sites, releasing more free warfarin into the system, increasing drug effects and increasing the chance of toxicity.

6. The nurse is preparing to administer clarithromycin to a patient. When performing a medication history, the nurse learns that the patient takes warfarin to treat atrial fibrillation. The nurse will perform which action? a. Ask the provider if azithromycin may be used instead of clarithromycin. b. Obtain an order for continuous cardiovascular monitoring. c. Request an order for periodic serum warfarin levels. d. Withhold the clarithromycin and notify the provider.

ANS: C Macrolides can increase serum levels of other drugs such as warfarin. If these drugs are used with macrolides, serum drug levels should be monitored. All macrolides have this drug interaction. Cardiovascular monitoring is not indicated. The drug may be given as long as serum drug levels are monitored.

60. The nurse is reviewing instructions for a patient with type 2 diabetes who also takes insulin injections as part of the therapy. The nurse asks the patient, "What should you do if your fasting blood glucose is 47 mg/dL?" Which response by the patient reflects a correct understanding of insulin therapy? a. "I will call my doctor right away." b. "I will give myself the regular insulin." c. "I will take an oral form of glucose." d. "I will rest until the symptoms pass."

ANS: C Hypoglycemia can be reversed if the patient eats glucose tablets or gel, corn syrup, or honey, or drinks fruit juice or a nondiet soft drink or other quick sources of glucose, which must always be kept at hand. She should not wait for instructions from her physician, nor delay taking the glucose by resting. The regular insulin would only lower her blood glucose levels more.

5. A provider has prescribed ipratropium bromide/albuterol sulfate (Combivent) for a patient who has chronic obstructive pulmonary disease (COPD). The nurse explains that this combination product is prescribed primarily for which reason? a. To be more convenient for patients who require both medications b. To improve compliance in patients who may forget to take both drugs c. To increase forced expiratory volume, an indicator of symptom improvement d. To minimize the side effects that would occur if the drugs are given separately

ANS: C Combivent is more effective and has a longer duration of action than if either agent is used alone, and the two agents combined increase the FEV1. While it is more convenient and may improve compliance, this is not the primary reason for using it. The combination does not alter drug side effects.

5. The nurse is caring for a patient who is taking digoxin to treat heart failure. The patients electrocardiogram shows a ventricular dysrhythmia. The nurse will notify the provider and will anticipate an order for which medication? a. Digoxin immune Fab (Digibind) b. Furosemide (Lasix) c. Phenytoin (Dilantin) d. Potassium

ANS: C The antidysrhythmics phenytoin and lidocaine are effective in treating digoxin-induced ventricular dysrhythmias. Digoxin immune Fab is used to treat severe digitalis toxicity, characterized by bradycardia, nausea, and vomiting. Unless a potassium deficit is present, giving potassium could worsen the dysrhythmia.

6. The nurse caring for a patient who has tuberculosis and who is taking isoniazid, rifampin, and streptomycin reviews the medical record and notes the patients sputum cultures reveal resistance to streptomycin. The nurse will anticipate that the provider will take which action? a. Add ethambutol (Myambutol). b. Change the streptomycin to clarithromycin. c. Change the streptomycin to kanamycin. d. Order renal function tests.

ANS: C The patients current regimen is first-phase treatment. If resistance to streptomycin develops, the provider can change to kanamycin or to ciprofloxacin. Ethambutol is added if there is resistance to isoniazid. Clarithromycin is used during phase II. Renal function tests are not indicated.

6. A patient who is taking warfarin has an international normalized ratio (INR) of 5.5. The nurse will anticipate giving a. fresh frozen plasma. b. intravenous iron. c. oral vitamin K. d. protamine sulfate.

ANS: C Vitamin K is an antagonist against warfarin, an oral anticoagulant. Patients with an INR of 5.5 should be given a low dose of oral vitamin K. Too much vitamin K may reduce the effectiveness of warfarin for up to 2 weeks. Fresh frozen plasma and intravenous iron are given for anemia caused by blood loss. Protamine sulfate is given for heparin overdose.

2. The nurse is preparing to administer doses of hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin) to a patient who has heart failure. The patient reports having blurred vision. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 140/78 mm Hg. Which action will the nurse take? a. Administer the medications and request an order for serum electrolytes. b. Give both medications and evaluate serum blood glucose frequently. c. Hold the digoxin and notify the provider. d. Hold the hydrochlorothiazide and notify the provider.

ANS: C When thiazide diuretics are taken with digoxin, patients are at risk of digoxin toxicity because thiazides can cause hypokalemia. The patient has bradycardia and blurred vision, which are both signs of digoxin toxicity. The nurse should hold the digoxin and notify the provider. Serum electrolytes may be ordered, but the digoxin should not be given.

2. A patient is diagnosed with heart failure, and the prescriber has ordered digoxin. The patient asks what lifestyle changes will help in the management of this condition. The nurse will recommend which changes? a. Aerobic exercise and weight lifting 2 or 3 times weekly b. Changing from cigarette smoking to pipe smoking c. Consuming 2 teaspoons or less of salt every day d. Having no more than one alcoholic beverage per day

ANS: D Alcohol should either be completely avoided or restricted to no more than one per day. Mild exercise, such as walking, is recommended. All nicotine deprives the heart of oxygen. Salt should be limited to no more than one teaspoon per day.

1. A patient who has atrial fibrillation is taking digoxin. The nurse expects which medication to be given concurrently to treat this condition? a. Hydrochlorothiazide (HydroDIURIL) b. Inamrinone (Inocor) c. Milrinone (Primacore) d. Warfarin (Coumadin)

ANS: D Digoxin is given for atrial fibrillation to restore a normal heart rhythm. To prevent thromboemboli, warfarin is given concurrently. Hydrochlorothiazide is a diuretic medication. Inamrinone and milrinone are inotropic agents that would be used instead of digoxin.

7. The nurse performs a medication history and learns that the patient takes a thiazide diuretic and digoxin (Lanoxin). The nurse will question the patient to ensure that the patient is also taking which medication? a. Cortisone b. Lidocaine c. Nitroglycerin d. Potassium

ANS: D If a patient is taking digoxin and a potassium-wasting diuretic such as thiazide, the patient should also take a potassium supplement to prevent hypokalemia that could result in digoxin toxicity. It is not necessary to take cortisone, lidocaine, or nitroglycerin unless the patient has symptoms that warrant these drugs.

7. The nurse is teaching a patient who will begin taking warfarin (Coumadin) for atrial fibrillation. Which statement by the patient indicates understanding of the teaching? a. I should eat plenty of green, leafy vegetables while taking this drug. b. I should take a nonsteroidal anti-inflammatory drug (NSAID) instead of acetaminophen for pain or fever. c. I will take cimetidine (Tagamet) to prevent gastric irritation and bleeding. d. I will tell my dentist that I am taking this medication.

ANS: D Patients taking warfarin should tell their dentists that they are taking the medication because of the increased risk for bleeding. Patients should avoid foods high in vitamin K, which can decrease the effects of warfarin. Patients should not take NSAIDs or cimetidine (Tagamet) because they can displace warfarin from protein-binding sites.

56. The nurse is teaching a group of patients about self-administration of insulin. What content is important to include? a. Patients need to use the injection site that is the most accessible. b. If two different insulins are ordered, they need to be given in separate injections. c. When mixing insulins, the cloudy (such as NPH) insulin is drawn up into the syringe first. d. When mixing insulins, the clear (such as regular) insulin is drawn up into the syringe first.

ANS: D If mixing insulins in one syringe, the clear (regular) insulin is always drawn up in to the syringe first. Patients always need to rotate injection sites. Mixing of insulins may be ordered.

61. The nurse is teaching patients about self-injection of insulin. Which statement is true regarding injection sites? a. Avoid the abdomen because absorption there is irregular. b. Choose a different site at random for each injection. c. Give the injection in the same area each time. d. Rotate sites within the same location for about 1 week before rotating to a new location.

ANS: D Patients taking insulin injections need to be instructed to rotate sites, but to do so within the same location for about 1 week (so that all injections are rotated in one area—for example, the right arm—before rotating to a new location, such as the left arm). Also, each injection needs to be at least to 1 inch away from the previous site.

3. A patient will be discharged home with albuterol (Proventil) to use for asthma symptoms. What information will the nurse include when teaching this patient about this medication? a. Failure to respond to the medication indicates a need for a higher dose. b. Monitor for hypoglycemia symptoms when using this medication. c. Palpitations are common with this drug even at normal, therapeutic doses. d. Overuse of this medication can result in airway narrowing and bronchospasm.

ANS: D Excessive use of an aerosol drug can occasionally cause severe paradoxical airway resistance, so patients should be cautioned against overuse. Excessive use can also lead to tolerance and loss of drug effectiveness, but patients should not increase the dose because of the risk of bronchospasm and the increased incidence of adverse effects such as tremors and tachycardia. Hyperglycemia can occur. Palpitations are common with increased doses but not at therapeutic doses.

5. A patient is admitted to the hospital, and the provider orders gemfibrozil (Lopid) 600 mg twice daily, 30 minutes prior to meals. The nurse learns that the patient takes warfarin (Coumadin) once daily. The nurse will contact the provider to discuss a. decreasing the dose of gemfibrozil. b. giving the warfarin at noon. c. increasing the dose of warfarin. d. ordering frequent INR levels.

ANS: D Gemfibrozil is highly protein-bound and competes for receptor sites with drugs such as warfarin. The anticoagulant dose should be decreased, and the INR should be closely monitored. Decreasing the dose of gemfibrozil is not recommended. Giving the warfarin at a different time of day does not change this drug interaction. The warfarin dose should be decreased not increased.

7. The nurse will administer parenteral insulin to a patient who will receive a mixture of NPH (Humulin NPH) and regular (Humulin R). The nurse will give this medication via which route? a. Intradermal b. Intramuscular c. Intravenous d. Subcutaneous

ANS: D Insulin is given by the subcutaneous route. Only regular insulin may be given IV.

7. A patient who is taking isoniazid (INH) as part of a two-drug tuberculosis treatment regimen reports tingling of the fingers and toes. The nurse will recommend discussing which treatment with the provider? a. Adding pyrazinamide b. Changing to ethambutol c. Increasing oral fluid intake d. Taking pyridoxine (B6)

ANS: D Peripheral neuropathy is an adverse reaction to INH, so pyridoxine is usually given to prevent this. It is not necessary to change medications. Increasing fluids will not help with this.

6. A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? A) Preparing to assist with intubating the patient B) Setting up oxygen at 5 L/minute by nasal cannula C) Performing deep suctioning D) Setting up a nebulizer to administer corticosteroids

Ans: A Feedback: A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.

5. A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? A) Arrange for a portable x-ray machine to be used. B) Have the patient wear a mask to the x-ray department. C) Ensure that the radiology department has been disinfected prior to the test. D) Send the patient to the x-ray department, and have the staff in the department wear masks.

Ans: A Feedback: A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patients room. This confers more protection than disinfecting the radiology department or using masks.

40. A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A) Prepare the patient for opening or bivalving of the cast. B) Obtain an order for a different analgesic. C) Encourage the patient to wiggle and move the fingers. D) Petal the edges of the patients cast.

Ans: A Feedback: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Ordering different analgesics does not address the underlying problem. Encouraging the patient to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.

17. A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? A) Administer antidiarrheal medications on a scheduled basis, as ordered. B) Encourage the patient to eat three balanced meals and a snack at bedtime. C) Increase the patients oral fluid intake. D) Encourage the patient to increase his or her activity level.

Ans: A Feedback: Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the patients diarrhea is not caused by an infectious microorganism. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the patient has frequent diarrhea.

7. A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A) Make sure you dont bring your knees close together. B) Try to lie as still as possible for the first few days. C) Try to avoid bending your knees until next week. D) Keep your legs higher than your chest whenever you can.

Ans: A Feedback: After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the patients legs do not need to be higher than the level of the chest.

6. The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck. While providing patient education, what potential adverse effects should the nurse discuss with the patient? A) Impaired nutritional status B) Cognitive changes C) Diarrhea D) Alopecia

Ans: A Feedback: Alterations in oral mucosa, change and loss of taste, pain, and dysphasia often occur as a result of radiotherapy to the head and neck. The patient is at an increased risk of impaired nutritional status. Radiotherapy does not cause cognitive changes. Diarrhea is not a likely concern for this patient. Radiation only results in alopecia when targeted at the whole brain; radiation of other parts of the body does not lead to hair loss.

8. A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystispneumonia (PCP). Which nursing diagnosis has the highest priority for this patient? A) Ineffective Airway Clearance B) Impaired Oral Mucous Membranes C) Imbalanced Nutrition: Less than Body Requirements D) Activity Intolerance

Ans: A Feedback: Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns.

23. The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness

Ans: A Feedback: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness.

25. A patient with a diagnosis of HF is started on a beta-blocker. What is the nurses priority role during gradual increases in the patients dose? A) Educating the patient that symptom relief may not occur for several weeks B) Stressing that symptom relief may take up to 4 months to occur C) Making adjustments to each days dose based on the blood pressure trends D) Educating the patient about the potential changes in LOC that may result from the drug

Ans: A Feedback: An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.

19. A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy? A) Administer an antiemetic. B) Administer an antimetabolite. C) Administer a tumor antibiotic. D) Administer an anticoagulant.

Ans: A Feedback: Antiemetics are used to treat nausea and vomiting, the most common adverse effects of chemotherapy. Antihistamines and certain steroids are also used to treat nausea and vomiting. Antimetabolites and tumor antibiotics are classes of chemotherapeutic medications. Anticoagulants slow blood clotting time, thereby helping to prevent thrombi and emboli.

28. The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF? A) HF ultimately affects oxygen transportation to the brain. B) Patients with HF are susceptible to overstimulation of the sympathetic nervous system. C) Decreased LOC causes an exacerbation of the signs and symptoms of HF. D) The most significant adverse effect of medications used for HF treatment is altered LOC.

Ans: A Feedback: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.

10. An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patients plan of care? A) Suction the patients airway secretions. B) Immobilize the ribs with an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate and intubate the patient.

Ans: A Feedback: As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.

14. The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A) A resident who suffered a severe stroke several weeks ago B) A resident with mid-stage Alzheimers disease C) A 92-year-old resident who needs extensive help with ADLs D) A resident with severe and deforming rheumatoid arthritis

Ans: A Feedback: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.

39. An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture B) Loss of estrogen C) Negative calcium balance D) Dowagers hump

Ans: A Feedback: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowagers hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

36. The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient? A) Leukopenia B) Metabolic acidosis C) Hyperphosphatemia D) Respiratory alkalosis

Ans: A Feedback: Chemotherapy is usually administered IV on an outpatient basis using a combination of platinum and taxane agents. Paclitaxel (Taxol) plus carboplatin (Paraplatin) are most often used because of their excellent clinical benefits and manageable toxicity. Leukopenia, neurotoxicity, and fever may occur. Acidbase imbalances and elevated phosphate levels are not anticipated.

38. Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment? A) Chest auscultation B) Pulmonary function testing C) Chest percussion D) Thoracic palpation

Ans: A Feedback: Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.

7. A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation

Ans: A Feedback: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

27. The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg C) Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg

Ans: B Feedback: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg.

20. A nurse is caring for a patient who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the patient for which of the following clinical manifestations? A) Copious sputum production B) Pain on inspiration C) Pigeon chest D) Dry cough

Ans: A Feedback: Clinical manifestations of bronchiectasis include hemoptysis, chronic cough, copious purulent sputum, and clubbing of the fingers. Because of the copious production of sputum, the cough is rarely dry. A pigeon chest is not associated with the disease and patients do not normally experience pain on inspiration.

18. A pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. What potential causative agent should the nurse describe? A) Pets B) Lack of sleep C) Psychosocial stress D) Bacteria

Ans: A Feedback: Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Lack of sleep, stress, and bacteria are not common triggers for asthma attacks.

19. A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk? A) Utilize a pressure-reducing mattress. B) Limit the patients physical activity. C) Apply antibiotic ointment to dependent skin surfaces. D) Avoid contact with synthetic fabrics.

Ans: A Feedback: Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Activity should be promoted, not limited, and contact with synthetic fabrics does not necessary threaten skin integrity. Antibiotic ointments are not normally used unless there is a break in the skin surface.

7. While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action? A) Stopping the administration of the drug immediately B) Notifying the patients physician C) Continuing the infusion but decreasing the rate D) Applying a warm compress to the infusion site

Ans: A Feedback: Doxorubicin hydrochloride is a chemotherapeutic vesicant that can cause severe tissue damage. The nurse should stop the administration of the drug immediately and then notify the patients physician. Ice can be applied to the site once the drug therapy has stopped.

40. When assessing venous disease in a patients lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography

Ans: A Feedback: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.

29. Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following? A) Perform at least 100 chest compressions per minute. B) Pause to allow a colleague to provide a breath every 10 compressions. C) Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D) Perform high-quality chest compressions as rapidly as possible.

Ans: A Feedback: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitators goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring.

29. The nurse is caring for a patient who has just been told that her ovarian cancer is terminal and that no curative options remain. What would be the priority nursing care for this patient at this time? A) Provide emotional support to the patient and her family. B) Implement distraction and relaxation techniques. C) Offer to inform the patients family of this diagnosis. D) Teach the patient about the importance of maintaining a positive attitude.

Ans: A Feedback: Emotional support is an integral part of nursing care at this point in the disease progression. It is not normally appropriate for the nurse to inform the family of the patients diagnosis. It may be inappropriate and simplistic to focus on distraction, relaxation, and positive thinking.

18. The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)? A) Early ambulation B) Increased dietary intake of protein C) Maintaining the patient in a supine position D) Administering aspirin with warfarin

Ans: A Feedback: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patients risk for bleeding.

1. Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? A) Gay, bisexual, and other men who have sex with men B) Recreational drug users C) Blood transfusion recipients D) Health care providers

Ans: A Feedback: Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients.

6. A nurse is evaluating the diagnostic study data of a patient with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis? A) Elevated sweat chloride concentration B) Presence of protein in the urine C) Positive phenylketonuria D) Malignancy on lung biopsy

Ans: A Feedback: Gene mutations affect transport of chloride ions, leading to CF, which is characterized by thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. Proteinuria, positive phenylketonuria, and malignancy are not diagnostic for CF.

2. A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? A) HIV encephalopathy B) B-cell lymphoma C) Kaposis sarcoma D) Wasting syndrome

Ans: A Feedback: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.

30. An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the patients increased risk for Mycobacterium aviumcomplex (MAC disease). The nurse should anticipate the administration of what drug? A) Azithromycin B) Vancomycin C) Levofloxacin D) Fluconazole

Ans: A Feedback: HIV-infected adults and adolescents should receive chemoprophylaxis against disseminatedMycobacterium avium complex (MAC disease) if they have a CD4+ count less than 50 cells/L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the preferred prophylactic agents. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.

29. A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities? A) Ensure that the patients heels are protected and supported. B) Closely monitor the patients serum albumin and prealbumin levels. C) Perform gentle massage of the patients lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.

Ans: A Feedback: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.

13. The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

Ans: A Feedback: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.

23. The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the-knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate

Ans: A Feedback: Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patients bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not administered to treat active postsurgical bleeding.

6. A patients decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem? A) Rheumatoid arthritis (RA) B) Systemic lupus erythematosus C) Osteoporosis D) Polymyositis

Ans: A Feedback: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.

40. The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient? A) Insertion of an implantable cardioverter defibrillator B) Insertion of an implantable pacemaker C) Administration of a calcium channel blocker D) Administration of a beta-blocker

Ans: A Feedback: In patients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the patient with left ventricular dysfunction.

7. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

Ans: A Feedback: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

22. A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions? A) Many older adults do not see themselves as being at risk for HIV infection. B) Many older adults are not aware of the difference between HIV and AIDS. C) Older adults tend to have more sex partners than younger adults. D) Older adults have the highest incidence of intravenous drug use.

Ans: A Feedback: It is known that many older adults do not see themselves as being at risk for HIV infection. Knowledge of the relationship between HIV infection and AIDS is not known to affect the incidence of new cases. The statements about sex partners and IV drug use are untrue.

32. A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status? A) Ensure that none of the patients visitors has an infection. B) Arrange for a diet that is high in protein and low in fat. C) Administer colony stimulating factors (CSFs) as ordered. D) Prepare to administer chemotherapeutics as ordered.

Ans: A Feedback: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the patients immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.

7. The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurses plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema

Ans: A Feedback: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patients body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patients physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.

21. A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? A) Maintaining a patent airway B) Preventing the need for suctioning C) Maintaining the sterility of the patients airway D) Increasing the patients lung compliance

Ans: A Feedback: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube. The other answers are incorrect.

38. A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention? A) Teach the patient guided imagery. B) Give the patient more control of her antiretroviral regimen. C) Increase the patients activity level. D) Collaborate with the patients physician to obtain an order for hydromorphone.

Ans: A Feedback: Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Increased activity may be of benefit, but for other patients this may exacerbate feelings of anxiety or loss. Granting the patient control has the potential to reduce anxiety, but the patient is not normally given unilateral control of the ART regimen. Hydromorphone is not used to treat anxiety.

5. A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.

Ans: A Feedback: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

30. A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize? A) The patient will successfully mobilize pulmonary secretions. B) The patient will maintain an oxygen saturation level of 98%. C) The patients pulmonary blood pressure will decrease to within reference ranges. D) The patient will resume prediagnosis level of function within 72 hours.

Ans: A Feedback: Nursing management focuses on alleviating symptoms and helping patients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of the patient with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals.

11. A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A) OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. B) OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees. C) OA originates with an infection. RA is a result of your bodys cells attacking one another. D) OA is associated with impaired immune function; RA is a consequence of physical damage.

Ans: A Feedback: OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infectious etiology.

4. The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurses postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patients extremities when at rest

Ans: A Feedback: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

14. A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patients care, what goal should the nurse include? A) The patient will express satisfaction with her ability to perform ADLs. B) The patient will recover from OA within 6 months. C) The patient will adhere to the prescribed plan of care. D) The patient will deny signs or symptoms of OA.

Ans: A Feedback: Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care.

35. A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action? A) Rapidly assess the patients cardiopulmonary status. B) Arrange for an ECG. C) Increase the height of the patients bed. D) Manage the patients anxiety.

Ans: A Feedback: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.

22. A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? A) Blood pressure B) Level of consciousness (LOC) C) Assessment for nausea D) Oxygen saturation

Ans: A Feedback: Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.

30. The nurse is providing patient education prior to a patients discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist? A) Know how to recognize and prevent orthostatic hypotension. B) Weigh yourself weekly at a consistent time of day. C) Measure everything you eat and drink until otherwise instructed. D) Limit physical activity to only those tasks that are absolutely necessary.

Ans: A Feedback: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.

15. A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of care? A) Fatigue Related to Anemia B) Risk for Ineffective Tissue Perfusion Related to Venous Thromboembolism C) Acute Confusion Related to Increased Serum Ammonia Levels D) Risk for Ineffective Tissue Perfusion Related to Increased Hematocrit

Ans: A Feedback: Patients with SLE nearly always experience fatigue, which is partly attributable to anemia. Ammonia levels are not affected and hematocrit is typically low, not high. VTE is not one of the central complications of SLE.

17. The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? A) Pulmonary function studies B) Exercise tolerance tests C) Arterial blood gas values D) Chest x-ray

Ans: A Feedback: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.

18. A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem? A) The patient requests that her family bring her makeup and wig. B) The patient begins to discuss the future with her family. C) The patient reports less disruption from pain and discomfort. D) The patient cries openly when discussing her disease.

Ans: A Feedback: Requesting her wig and makeup indicates that the patient with alopecia is becoming interested in looking her best and that her body image and self-esteem may be improving. The other options may indicate that other nursing goals are being met, but they do not necessarily indicate improved body image and self-esteem.

19. The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? A) The younger you are when you start smoking, the higher your risk of lung cancer. B) The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays. C) The risk for lung cancer is determined mostly by what type of cigarettes you smoke. D) The risk for lung cancer depends primarily on the other risk factors for cancer that you have.

Ans: A Feedback: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor.

20. A patient presents to a clinic complaining of a leg ulcer that isnt healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what? A) Staphylococcus aureus B) Proteus C) Pseudomonas D) Escherichia coli

Ans: A Feedback: S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.

23. The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient? A) A beta-adrenergic blocker B) An antiplatelet aggregator C) A calcium channel blocker D) A nonsteroidal anti-inflammatory drug (NSAID)

Ans: A Feedback: Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

17. A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? A) Increases the amount of mucus production B) Destabilizes hemoglobin C) Shrinks the alveoli in the lungs D) Collapses the alveoli in the lungs

Ans: A Feedback: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.

16. The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy

Ans: A Feedback: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

12. An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? A) The importance of adhering closely to the prescribed medication regimen B) The fact that the disease is a lifelong, chronic condition that will affect ADLs C) The fact that TB is self-limiting, but can take up to 2 years to resolve D) The need to work closely with the occupational and physical therapists

Ans: A Feedback: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

24. The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5 cm H2O

Ans: A Feedback: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

40. A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation? A) Teach the patient strategies for promoting diaphragmatic breathing. B) Administer supplementary oxygen by simple face mask. C) Teach the patient to perform airway suctioning. D) Assist the patient in developing an appropriate exercise program.

Ans: A Feedback: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in patients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate.

13. A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isnt answered immediately. What would be the most appropriate response? A) You seem like youre feeling angry. Is that something that we could talk about? B) Try to remember that stress can make your symptoms worse. C) Would you like to talk about the problem with the nursing supervisor? D) I can see youre angry. Ill come back when youve calmed down.

Ans: A Feedback: The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care, as well as sensitivity to the psychological reactions of the patient. Offering to listen to the patient express anger can help the nurse and the patient understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the patient to calm down doesnt acknowledge her feelings. Ignoring the patients feelings suggests that the nurse has no interest in what the patient has said. Offering to get the nursing supervisor also does not acknowledge the patients feelings.

36. The hospice nurse has just admitted a new patient to the program. What principle guides hospice care? A) Care addresses the needs of the patient as well as the needs of the family. B) Care is focused on the patient centrally and the family peripherally. C) The focus of all aspects of care is solely on the patient. D) The care team prioritizes the patients physical needs and the family is responsible for the patients emotional needs.

Ans: A Feedback: The focus of hospice care is on the family as well as the patient. The family is not solely responsible for the patients emotional well-being

26. The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? A) An S3 heart sound B) Pleural friction rub C) Faint breath sounds D) A heart murmur

Ans: A Feedback: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.

30. A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A) Post thoracotomy B) Spontaneous pneumothorax C) Need for postural drainage D) Chest trauma resulting in pneumothorax E) Pleurisy

Ans: A, B, D Feedback: Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

17. While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care? A) Avoid actions that will cause the patient to breathe deeply. B) Ambulate the patient at least three times daily. C) Arrange for a soft-textured diet and increased fluid intake. D) Encourage the patient to speak as little as possible

Ans: A Feedback: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. A soft diet is not necessarily indicated and there is no need for the patient to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.

20. The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment? A) Lately, I have this cough that just never seems to go away. B) I find that I dont have nearly the stamina that I used to. C) I seem to get nearly every cold and flu that goes around my workplace. D) I never used to have any allergies, but now I think Im developing allergies to dust and pet hair.

Ans: A Feedback: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections and fatigue are not characteristic early signs of lung cancer.

2. A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? A) Increase oral fluids unless contraindicated. B) Call the nurse for oral suctioning, as needed. C) Lie in a low Fowlers or supine position. D) Increase activity.

Ans: A Feedback: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

34. A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A) Perianal region and oral mucosa B) Sacral region and lower abdomen C) Scalp and skin over the scapulae D) Axillae and upper thorax

Ans: A Feedback: The nurse should inspect all the patients skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection.

18. The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) Be sure to practice meticulous foot care. B) Consider cutting down on your smoking. C) Reduce your activity level to accommodate your limitations. D) Try to make sure you eat enough protein.

Ans: A Feedback: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smokingnot just cut downbecause nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patients symptoms.

19. A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.

Ans: A Feedback: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patients status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.

16. The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator

Ans: A Feedback: The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

3. The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? A) Administer intradermal injections into the childrens inner forearms. B) Administer intramuscular injections into each childs vastus lateralis. C) Administer a subcutaneous injection into each childs umbilical area. D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid.

Ans: A Feedback: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.

32. A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really thought I would be better by now. What nursing action should the nurse prioritize? A) Provide emotional support to the patient and family. B) Schedule a visit to the patients primary physician within 24 hours. C) Notify the physician that the patient needs a referral to a psychiatrist. D) Place a referral for a social worker to visit the patient.

Ans: A Feedback: The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse. It is not necessary, based on this scenario, to schedule a visit with the physician within 24 hours, or to get a referral to a psychiatrist or a social worker.

5. A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position? A) Sitting upright, leaning forward slightly B) Low Fowlers, with the neck slightly hyperextended C) Prone D) Trendelenburg

Ans: A Feedback: The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe. Low Fowlers positioning would be less likely to aid oxygenation. Prone or Trendelenburg positioning would exacerbate shortness of breath.

16. The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk? A) Providing thorough oral care before and after meals B) Administering prophylactic antibiotics C) Promoting nutrition and adequate fluid intake D) Applying skin emollients as needed

Ans: A Feedback: Thorough mouth care has the potential to prevent or limit the severity of this infection. Antibiotics are irrelevant because of the fungal etiology. The patient requires adequate food and fluids, but these do not necessarily prevent candidiasis. Skin emollients are not appropriate because candidiasis is usually oral.

20. A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? A) I have this ringing in my ears that just wont go away. B) I feel so foggy in the mornings and it takes me so long to wake up. C) When I eat a meal thats high in fat, I get really nauseous. D) I seem to have lost my appetite, which is unusual for me.

Ans: A Feedback: Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia.

5. A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this womans care needs? A) Ineffective Role Performance Related to Pain B) Risk for Impaired Skin Integrity Related to Myalgia C) Risk for Infection Related to Tissue Alterations D) Unilateral Neglect Related to Neuropathic Pain

Ans: A Feedback: Typically, patients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying FM can often impair a patients ability to perform normal roles and functions. Skin integrity is unaffected and the disease has no associated infection risk. Activity limitations may result in neglect, but not of a unilateral nature.

8. A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse effect? A) Infection B) Acute confusion C) Sedation D) Malignant hyperthermia

Ans: A Feedback: When administering immunosuppressives such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects. Malignant hyperthermia is a surgical complication and not a possible adverse effect.

30. You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? A) Palliative B) Reconstructive C) Salvage D) Prophylactic

Ans: A Feedback: When cure is not possible, the goals of treatment are to make the patient as comfortable as possible and to promote quality of life as defined by the patient and his or her family. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusion. Reconstructive surgery may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach. Prophylactic surgery involves removing nonvital tissues or organs that are at increased risk to develop cancer.

15. An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem? A) Osteomyelitis B) Osteoporosis C) Osteomalacia D) Septic arthritis

Ans: A Feedback: When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is the most prevalent bone disease in the world. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septicarthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation.

37. A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result? A) Acute pulmonary edema B) Right-sided HF C) Right ventricular hypertrophy D) Left-sided HF

Ans: A Feedback: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.

6. The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.

Ans: A Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.

2. A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patients skin appears yellow. Which blood tests should be done to further explore this clinical sign? A) Liver function tests (LFTs) B) Complete blood count (CBC) C) Platelet count D) Blood urea nitrogen and creatinine

Ans: A Feedback: Yellow skin is a sign of jaundice and the liver is a common organ affected by metastatic disease. An LFT should be done to determine if the liver is functioning. A CBC, platelet count and tests of renal function would not directly assess for liver disease.

40. A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A) Current medication regimen B) Identification of patients support system C) Immune system function D) Genetic risk factors for HIV E) History of sexual practices

Ans: A, B, C, E Feedback: Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function and sexual history. HIV does not have a genetic component.

31. The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? Select all that apply. A) Time frame of exposure B) Type of respiratory protection used C) Immunization status D) Breath sounds E) Intensity of exposure

Ans: A, B, D, E Feedback: Key aspects of any assessment of patients with a potential occupational respiratory history include job and job activities, exposure levels, general hygiene, time frame of exposure, effectiveness of respiratory protection used, and direct versus indirect exposures. The patients current respiratory status would also be a priority. Occupational lung hazards are not normally influenced by immunizations.

33. A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A) Serum albumin level B) Weight history C) White blood cell count D) Body mass index E) Blood urea nitrogen (BUN) level

Ans: A, B, D, E Feedback: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patients ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment.

35. The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels

Ans: A, B, E Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.

21. A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR? Select all that apply. A) PMR has an association with the genetic marker HLA-DR4. B) Immunoglobulin deposits occur in PMR. C) PMR is considered to be a wear-and-tear disease. D) Foods high in purines exacerbate the biochemical processes that occur in PMR. E) PMR occurs predominately in Caucasians.

Ans: A, B, E Feedback: The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in first-degree relatives. An association with the genetic marker HLA-DR4 suggests a familial predisposition. Immunoglobulin deposits in the walls of inflamed temporal arteries also suggest an autoimmune process. Purines are unrelated and it is not a result of physical degeneration.

33. The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A) Facilitate the presence of friends and family whenever possible. B) Teach the patient about the harmful effects of anxiety on cardiac function. C) Provide supplemental oxygen, as needed. D) Provide validation of the patients expressions of anxiety. E) Administer benzodiazepines two to three times daily.

Ans: A, C, D Feedback: The nurse should empathically validate the patients sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.

30. The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patients legs E) Identification of mobility limitations

Ans: A, C, D, E Feedback: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.

3. What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy? A) A patient has a respiratory rate of 10 breaths per minute. B) A patient requires permanent ventilation. C) A patient exhibits symptoms of dyspnea. D) A patient has respiratory acidosis.

Ans: B Feedback: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

21. The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care? A) Improve functional status B) Prevent endocarditis. C) Extend survival. D) Limit physical activity. E) Relieve patient symptoms.

Ans: A, C, E Feedback: The overall goals of management of HF are to relieve the patients symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.

34. A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply. A) Chest tightness B) Crackles C) Bradypnea D) Wheezing E) Cough

Ans: A, D, E Feedback: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.

3. A nurse is caring for a young adult patient whose medical history includes an alpha1-antitrypsin deficiency. This deficiency predisposes the patient to what health problem? A) Pulmonary edema B) Lobular emphysema C) Cystic fibrosis (CF) D) Empyema

Ans: B Feedback: A host risk factor for COPD is a deficiency of alpha1-antitrypsin, an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency predisposes young patients to rapid development of lobular emphysema even in the absence of smoking. This deficiency does not influence the patients risk of pulmonary edema, CF, or empyema.

28. A nurse is developing a teaching plan for a patient with COPD. What should the nurse include as the most important area of teaching? A) Avoiding extremes of heat and cold B) Setting and accepting realistic short- and long-range goals C) Adopting a lifestyle of moderate activity D) Avoiding emotional disturbances and stressful situations

Ans: B Feedback: A major area of teaching involves setting and accepting realistic short-term and long-range goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals.

1. The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patients subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynauds disease

Ans: B Feedback: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynauds disease; none of these health problems produce this cluster of signs and symptoms.

20. The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patients needs? A) Non-rebreathing mask B) Nasal cannula C) Simple mask D) Partial-rebreathing mask

Ans: B Feedback: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patients respiratory status does not require a partial- or non-rebreathing mask.

8. An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? A) Sit with crossed legs for a few minutes each hour to promote relaxation. B) Walk for several minutes every hour to promote circulation. C) Elevate the legs when tired. D) Wear snug-fitting ankle socks to decrease edema.

Ans: B Feedback: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.

1. A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication? A) Acute respiratory distress syndrome (ARDS) B) Atelectasis C) Aspiration D) Pulmonary embolism

Ans: B Feedback: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

37. A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that priority systems to be assessed include what? A) Hepatic B) Gastrointestinal C) Genitourinary D) Neurologic

Ans: B Feedback: Assessment of systemic involvement with scleroderma requires a systems review with special attention to gastrointestinal, pulmonary, renal, and cardiac systems. Liver, GU, and neurologic functions are not central priorities.

2. While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patients use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patients activity level to accommodate decreased coronary output.

Ans: B Feedback: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.

27. A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? A) Promoting appropriate use of complementary therapies B) Addressing possible barriers to adherence C) Educating the patient about the pathophysiology of HIV D) Teaching the patient about the need for follow-up blood work

Ans: B Feedback: ART is highly dependent on adherence to treatment, and the nurse should proactively address this. Blood work is necessary, but this will not have a direct bearing on the success or failure of treatment. Complementary therapies are appropriate, but are not the main factor in successful treatment. The patient may or may not benefit from teaching about HIV pathophysiology.

35. A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next? A) Flush the wound site with chlorhexidine. B) Report to the emergency department or employee health department. C) Apply a hydrocolloid dressing to the wound site. D) Follow up with the nurses primary care provider.

Ans: B Feedback: After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurses own primary care provider would require an unacceptable delay.

24. A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention? A) Application of a walking boot B) Application of a cast C) Education on how to use crutches D) Passive range of motion exercises

Ans: B Feedback: After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.

38. A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS? A) Psychological counseling B) Nutritional support C) High-protein oral diet D) Occupational therapy

Ans: B Feedback: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS.

11. A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynauds disease

Ans: B Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchows triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this womans case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynauds disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

3. A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? A) Petechiae B) Butterfly rash C) Jaundice D) Skin sloughing

Ans: B Feedback: An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Patients with SLE do not typically experience jaundice or skin sloughing.

19. A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism

Ans: B Feedback: Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary.Tinnitus is associated with salicylate therapy, stomatitis is associated with gold therapy, and hirsutism is associated with corticosteroid therapy.

23. When assessing for substances that are known to harm workers lungs, the occupational health nurse should assess their potential exposure to which of the following? A) Organic acids B) Propane C) Asbestos D) Gypsum

Ans: C Feedback: Asbestos is among the more common causes of pneumoconiosis. Organic acids, propane, and gypsum do not have this effect.

38. An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? A) Encouraging patients to carry a corticosteroid rescue inhaler at all times B) Educating patients about recognizing and avoiding asthma triggers C) Teaching patients to utilize alternative therapies in asthma management D) Ensuring that patients keep their immunizations up to date

Ans: B Feedback: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.

35. A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A) Rescue inhalers B) Anti-inflammatory drugs C) Antibiotics D) Antitussives

Ans: B Feedback: Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the first-line control of persistent asthma.

10. The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results

Ans: B Feedback: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins.

17. The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke

Ans: B Feedback: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.

6. A patient has a concentration of S. aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A) Infection B) Colonization C) Disease D) Bacteremia

Ans: B Feedback: Colonization refers to the presence of microorganisms without host interference or interaction. Infection is a condition in which the host interacts physiologically and immunologically with a microorganism. Disease is the decline in wellness of a host due to infection. Bacteremia is a condition of bacteria in the blood.

34. The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem? A) Cognitive deficits B) Impaired wound healing C) Cardiac tamponade D) Tumor lysis syndrome

Ans: B Feedback: Combining other treatment methods, such as radiation and chemotherapy, with surgery contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of deep vein thrombosis.

15. The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology? A) Carboxyhemoglobin level B) Brain natriuretic peptide (BNP) level C) C-reactive protein (CRP) level D) Complete blood count

Ans: B Feedback: Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

16. A patient has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A) Deficient fluid volume B) Delayed wound healing C) Hypocalcemia D) Pathologic fractures

Ans: B Feedback: Delayed wound healing is a complication of surgery due to tissue trauma from the surgery. Nutritional deficiency is usually due to the effects of chemotherapy and radiation therapy, which may cause weight loss. Pathologic fractures are not a complication of surgery.

13. A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? A) Acute Abdominal Pain B) Diarrhea C) Bowel Incontinence D) Constipation

Ans: B Feedback: Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.

29. A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patients CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? A) Integration B) Attachment C) Cleavage D) Budding

Ans: B Feedback: During the process of attachment, glycoproteins of HIV bind with the hosts uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle.

13. A nurse is developing the teaching portion of a care plan for a patient with COPD. What would be the most important component for the nurse to emphasize? A) Smoking up to one-half of a pack of cigarettes weekly is allowable. B) Chronic inhalation of indoor toxins can cause lung damage. C) Minor respiratory infections are considered to be self-limited and are not treated. D) Activities of daily living (ADLs) should be clustered in the early morning hours.

Ans: B Feedback: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all patients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit patients to perform these without excessive distress.

32. The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise? A) Do not exercise unsupervised. B) Eventually aim to work up to 30 minutes of exercise each day. C) Slow down if you get dizzy or short of breath. D) Start your exercise program with high-impact activities.

Ans: B Feedback: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms should prompt the patient to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized.

16. The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment? A) Elevate the patients head to 90 degrees. B) Press the right upper abdomen. C) Press above the patients symphysis pubis. D) Lay the patient flat in bed.

Ans: B Feedback: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.

3. A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? A) Oral temperature of 100F B) Tachypnea and restlessness C) Frequent loose stools D) Weight loss of 1 pound since yesterday

Ans: B Feedback: In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 pound is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 100F is not considered a fever and would not be the first issue addressed.

28. A patient with thoracic trauma is admitted to the ICU. The nurse notes the patients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A) A chest tube B) A tracheostomy C) An endotracheal tube D) A feeding tube

Ans: B Feedback: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.

26. A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A) Appropriate use of prophylactic antibiotics B) Importance of personal hygiene C) Signs and symptoms of wasting syndrome D) Strategies for adjusting antiretroviral dosages

Ans: B Feedback: Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the patients CD4 count is below 50.

33. A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? A) Correct use of a ventilator B) Correct use of incentive spirometry C) Correct use of a mini-nebulizer D) Correct technique for rhythmic breathing

Ans: B Feedback: Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

14. The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets better when I rest. The patients care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis

Ans: B Feedback: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.

15. While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? A) Every 2 hours when the patient is awake B) When adventitious breath sounds are auscultated C) When there is a need to prevent the patient from coughing D) When the nurse needs to stimulate the cough reflex

Ans: B Feedback: It is usually necessary to suction the patients secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.

39. A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS? A) Risk for Disuse Syndrome Related to Kaposis Sarcoma B) Impaired Skin Integrity Related to Kaposis Sarcoma C) Diarrhea Related to Kaposis Sarcoma D) Impaired Swallowing Related to Kaposis Sarcoma

Ans: B Feedback: Kaposis sarcoma (KS) is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome.

35. The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis? A) Asthma B) Pneumonia C) Lung cancer D) COPD

Ans: D Feedback: Breathing retraining is especially indicated in patients with COPD and dyspnea. Breathing retraining may be indicated in patients with other lung pathologies, but not to the extent indicated in patients with COPD.

28. A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient? A) Referral for assistive devices B) Teaching about symptom management C) Referral to classes to stop smoking D) Setting up an exercise program

Ans: B Feedback: Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. This is a priority over the use of assistive devices, smoking cessation, and exercise programs, though these topics may be of importance for some patients.

12. A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients? A) Encourage several small meals daily. B) Provide skin care to maintain skin integrity. C) Assist the patient with hygiene, as needed. D) Assess the integrity of the patients oral mucosa regularly.

Ans: B Feedback: Nursing care for patients with skin reactions includes maintaining skin integrity, cleansing the skin, promoting comfort, reducing pain, preventing additional trauma, and preventing and managing infection. Malnutrition in oncology patients may be present, but it is not the leading cause of infection-related death. Poor hygiene does not normally cause events that result in death. Broken oral mucosa may be an avenue for infection, but it is not the leading cause of death in an oncology patient.

31. The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics? A) Avoid drinking fluids for 2 hours after taking the diuretic. B) Take the diuretic in the morning to avoid interfering with sleep. C) Avoid taking the medication within 2 hours consuming dairy products. D) Take the diuretic only on days when experiencing shortness of breath.

Ans: B Feedback: Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patients nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.

1. The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? A) Bradycardia and frontal headache B) Dyspnea and substernal pain C) Peripheral cyanosis and restlessness D) Hypotension and tachycardia

Ans: B Feedback: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.

3. The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy

Ans: B Feedback: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.

8. Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A) A middle-age adult who takes ibuprofen daily for rheumatoid arthritis B) An elderly patient with an infected pressure ulcer in the sacral area C) A 17-year-old football player who had orthopedic surgery 6 weeks prior D) An infant diagnosed with jaundice

Ans: B Feedback: Patients who are at high risk of osteomyelitis include those who are poorly nourished, elderly, and obese. The elderly patient with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this patient has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The patient with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The patient 6 weeks postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection.

7. A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure

Ans: B Feedback: Patients with an unstable fracture must have their spine in alignment at all times in order to prevent neurologic damage. This is a greater threat, and higher priority, than promoting function and preventing infection, even though these are both valid considerations. Increased ICP is not a high risk.

31. A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action? A) Initiate a program of passive range of motion exercises B) Facilitate referrals to occupational and physical therapy C) Administer skeletal muscle relaxants as ordered D) Encourage a progressive program of weight-bearing exercise

Ans: B Feedback: Patients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as hair combing, reaching overhead, and using stairs difficult. Therefore, use of assistive devices may be recommended, and referral to occupational or physical therapy may be warranted. The muscle weakness is a product of the disease process, not lack of exercise. Skeletal muscle relaxants are not used in the treatment of polymyositis.

39. An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? A) Highest airflow during a forced inspiration B) Highest airflow during a forced expiration C) Airflow during a normal inspiration D) Airflow during a normal expiration

Ans: B Feedback: Peak flow meters measure the highest airflow during a forced expiration.

22. A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A) Administration of prophylactic antibiotics B) Administration of pneumococcal vaccine to vulnerable individuals C) Obtaining culture and sensitivity swabs from all newly admitted patients D) Administration of antiretroviral medications to patients over age 65

Ans: B Feedback: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all patients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.

13. The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response? A) CPAP allows a higher percentage of oxygen to be safely used. B) CPAP allows a lower percentage of oxygen to be used with a similar effect. C) CPAP allows for greater humidification of the oxygen that is administered. D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems.

Ans: B Feedback: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for controlling bacterial growth.

5. The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C) How to take prophylactic antibiotics correctly D) How to manage the need for fluid restriction

Ans: B Feedback: Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.

10. A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? A) The patient has a 30 pack-year smoking history. B) The patients body mass index is 34 (obese). C) The patient has primary hypertension. D) The patient is 58 years old.

Ans: B Feedback: Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a patient who is 58 would not yet face a significantly heightened risk.

38. A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis? A) Osteoarthritis (OA) B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis (RA) D) Gout

Ans: B Feedback: SLE has a high degree of neurologic involvement, and can result in central nervous system changes. The patient and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.

22. An older adult patient has been diagnosed with COPD. What characteristic of the patients current health status would preclude the safe and effective use of a metered-dose inhaler (MDI)? A) The patient has not yet quit smoking. B) The patient has severe arthritis in her hands. C) The patient requires both corticosteroids and beta2-agonists. D) The patient has cataracts.

Ans: B Feedback: Safe and effective MDI use requires the patient to be able to manipulate the device independently, which may be difficult if the patient has arthritis. Smoking does not preclude MDI use. A modest loss of vision does not preclude the use of an MDI and a patient can safely use more than one MDI.

18. A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications? A) Corticosteroids B) Gold-containing compounds C) Antimalarials D) Salicylate therapy

Ans: B Feedback: Stomatitis is an adverse effect that is associated with gold therapy. Steroids, antimalarials, and salicylates do not normally have this adverse effect.

17. A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patients ability to swallow? A) Temporal lobe B) Medulla oblongata C) Cerebellum D) Pons

Ans: B Feedback: Swallowing is a voluntary act that is regulated by a swallowing center in the medulla oblongata of the central nervous system. Swallowing is not regulated by the temporal lobe, cerebellum, or pons.

21. A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF? A) Alveolar mucus plugging, infection, and eventual bronchiectasis B) Bronchial mucus plugging, inflammation, and eventual bronchiectasis C) Atelectasis, infection, and eventual COPD D) Bronchial mucus plugging, infection, and eventual COPD

Ans: B Feedback: The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and progresses to involve all lobes. Infection, atelectasis, and COPD are not hallmark pathologies of CF.

17. A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patients cast care? A) Cover the cast with a blanket until the cast dries. B) Keep your right leg elevated above heart level. C) Use a clean object to scratch itches inside the cast. D) A foul smell from the cast is normal after the first few days.

Ans: B Feedback: The leg should be elevated to promote venous return and prevent edema. The cast shouldnt be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

26. A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patients oxygenation status at the bedside? A) Obtain serial ABG samples. B) Monitor pulse oximetry readings. C) Test pulmonary function. D) Monitor incentive spirometry volumes.

Ans: B Feedback: The nurse assesses the patient with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status.

13. A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.

Ans: B Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

33. A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care? A) Facilitation of long-term intubation B) Restoration of adequate gas exchange C) Attainment of effective coping D) Self-management of oxygen therapy

Ans: B Feedback: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.

15. A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective? A) I will have a ham and cheese sandwich for lunch. B) I will have a baked potato with broiled chicken for dinner. C) I will have a tossed salad with cheese and croutons for lunch. D) I will have chicken noodle soup with crackers and an apple for lunch.

Ans: B Feedback: The patients choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.

24. A patient is in the primary infection stage of HIV. What is true of this patients current health status? A) The patients HIV antibodies are successfully, but temporarily, killing the virus. B) The patient is infected with HIV but lacks HIV-specific antibodies. C) The patients risk for opportunistic infections is at its peak. D) The patient may or may not develop long-standing HIV infection.

Ans: B Feedback: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease.

28. How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patients legs flat and straight. B) Keep the patients knees bent to 45-degree angle and supported with pillows. C) Elevate the patients lower extremities. D) Dangle the patients legs over the side of the bed.

Ans: C Feedback: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patients legs and applying pillows may further compromise venous return.

29. The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? A) Teach him postural drainage. B) Teach him how to perform huffing. C) Teach him to use a mini-nebulizer. D) Teach him how to use a metered dose inhaler.

Ans: B Feedback: The technique of huffing may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

31. A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea? A) Zithromax B) Sandostatin C) Levaquin D) Biaxin

Ans: B Feedback: Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat chronic severe diarrhea.

24. An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? A) Kyphosis and clubbing of the fingers B) Dyspnea and hypoxemia C) Sepsis and pneumothorax D) Bradypnea and pursed lip breathing

Ans: B Feedback: These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.

14. A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation

Ans: B Feedback: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.

9. A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions? A) Lifestyle actions that improve immune function B) Educational programs that focus on control and prevention C) Appropriate use of standard precautions D) Screening programs for youth and young adults

Ans: B Feedback: Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions apply to very few cases of HIV infection.

32. A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patients lower leg. D) Massage the patients lower leg to temporarily restore venous return.

Ans: B Feedback: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patients leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.

16. The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patients wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed

Ans: B Feedback: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.

26. A nurses assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm? A) Fine or coarse crackles on auscultation B) Wheezes or diminished breath sounds on auscultation C) Reduced respiratory rate or lethargy D) Slow, deliberate respirations

Ans: B Feedback: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, inefficient breathing and agitation.

10. A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? A) 75 cells/mm3 of blood B) 200 cells/mm3 of blood C) 325 cells/mm3 of blood D) 450 cells/mm3 of blood

Ans: B Feedback: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.

9. A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patients exposure risk to toxic substances? A) Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air. B) Wear protective attire and devices when working with a toxic substance. C) Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins. D) Always wear a disposable paper face mask when you are working with inhalable toxins.

Ans: B Feedback: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.

29. A nurse is assessing a patient who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply. A) Pulmonary hypertension B) Airway obstruction C) Pulmonary infections D) Genetic disorders E) Atelectasis

Ans: B, C, D Feedback: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis.

23. The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

Ans: B, C, D Feedback: Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

34. The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply. A) Platelet level B) Fluid status C) Cardiac rhythm D) Action of medications E) Sputum volume

Ans: B, C, D Feedback: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.

25. A nurse is caring for a patient who is suspected of having giant cell arteritis (GCA). What laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply. A) Erythrocyte count B) Erythrocyte sedimentation rate C) Creatinine clearance D) C-reactive protein E) D-dimer

Ans: B, D Feedback: Simultaneous elevation in the ESR and CRP have a sensitivity of 88% and a specificity of 98% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful.

31. An interdisciplinary team is planning the care of a patient with bronchiectasis. What aspects of care should the nurse anticipate? Select all that apply. A) Occupational therapy B) Antimicrobial therapy C) Positive pressure isolation D) Chest physiotherapy E) Smoking cessation

Ans: B, D, E Feedback: Chest physiotherapy, antibiotics, and smoking cessation are cornerstones of the care of patients with bronchiectasis. Occupational therapy and isolation are not normally indicated.

34. A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs

Ans: B, D, E Feedback: Patients are usually treated in the ICU. The nurse assesses the patients respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.

24. The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? A) Loop diuretic and antiplatelet aggregator B) Loop diuretic and calcium channel blocker C) Combination of hydralazine and isosorbide dinitrate D) Combination of digoxin and normal saline

Ans: C Feedback: A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.

14. The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient? A) Fatigue related to altered metabolic processes B) Altered nutrition: less than body requirements related to anorexia C) Risk for infection related to altered immunologic response D) Body image disturbance related to weight loss and anorexia

Ans: C Feedback: A priority nursing diagnosis for this patient is risk for infection related to altered immunologic response. Because the patients immunity is suppressed, he or she will be at a high risk for infection. The other listed nursing diagnoses are valid, but they are not as high a priority as is risk for infection.

18. A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response? A) Do you think that you might already have HIV? B) Dont worry. Your immune system is likely very healthy. C) AIDS isnt transmitted by casual contact. D) You cant contract AIDS in a hospital setting.

Ans: C Feedback: AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection.

22. A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient? A) Placing the patient in a left lateral position B) Administering opioids as ordered C) Placing the patient in Fowlers position D) Teaching the patient to use the patient-controlled analgesia (PCA) system

Ans: C Feedback: After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in Fowlers position to facilitate breathing and promote comfort. Lateral positioning does not facilitate oxygenation or comfort. Medications do not facilitate spontaneous breathing.

8. A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? A) Gradually increase levels of physical exertion. B) Change filters on heaters and air conditioners frequently. C) Take prescribed medications as scheduled. D) Avoid goose-down pillows.

Ans: C Feedback: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.

28. A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patients postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? A) Ineffective Thermoregulation B) Risk-Prone Health Behavior C) Disturbed Body Image D) Deficient Diversion Activity

Ans: C Feedback: Amputations present a serious threat to any patients body image. None of the other listed diagnoses is specifically associated with amputation.

8. The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? A) Coumadin will continue to break up the clot over a period of weeks B) Coumadin must be taken concurrent with ASA to achieve anticoagulation. C) Anticoagulant therapy usually lasts between 3 and 6 months. D) He should take a vitamin supplement containing vitamin K

Ans: C Feedback: Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

39. A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynauds phenomenon B) CAD C) Arterial insufficiency D) Varicose veins

Ans: C Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynauds, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.

22. The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process? A) Explain the suctioning procedure to the patient and reposition the patient. B) Turn on suction source at a pressure not exceeding 120 mm Hg. C) Assess the patients lung sounds and SAO2 via pulse oximeter. D) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.

Ans: C Feedback: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patients level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.

39. A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action? A) Arrange a family meeting in order to explore assisted living options. B) Refer the patient to a support group. C) Arrange for the patient to be assessed in her home environment. D) Refer the patient to social work.

Ans: C Feedback: Assessment in the patients home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the patient would benefit from social work or a support group.

7. A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this clients airflow obstruction? A) Administer corticosteroids by metered dose inhaler B) Administer inhaled anticholinergics C) Administer an inhaled beta-adrenergic agonist D) Utilize a peak flow monitoring device

Ans: C Feedback: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.

36. A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? A) Dyspnea and increased respiratory secretions B) Nausea and vomiting C) Cough and oral thrush D) Fatigue and decreased level of consciousness

Ans: C Feedback: Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). The other listed adverse effects are not associated with this drug.

18. An elderly patients hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurses priority assessment? A) The presence of leg shortening B) The patients complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation

Ans: C Feedback: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

36. The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? A) Lay the patient flat. B) Notify the family of the patients critical state. C) Stay with the patient. D) Update the physician.

Ans: C Feedback: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.

14. The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure? A) Jugular vein distention B) Right upper quadrant pain C) Bibasilar fine crackles D) Dependent edema

Ans: C Feedback: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

9. A student nurse is preparing to care for a patient with bronchiectasis. The student nurse should recognize that this patient is likely to experience respiratory difficulties related to what pathophysiologic process? A) Intermittent episodes of acute bronchospasm B) Alveolar distention and impaired diffusion C) Dilation of bronchi and bronchioles D) Excessive gas exchange in the bronchioles

Ans: C Feedback: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles that results from destruction of muscles and elastic connective tissue. It is not characterized by acute bronchospasm, alveolar distention, or excessive gas exchange.

0. The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patients pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, I hit my leg on the car door 4 or 5 days ago and it has been sore ever since. The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE

Ans: C Feedback: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a patients risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain related to activity. This patient does not have signs and symptoms of VTE.

10. The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patients pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, I hit my leg on the car door 4 or 5 days ago and it has been sore ever since. The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE

12. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome

Ans: C Feedback: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.

2. A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? A) Lung cancer B) Cystic fibrosis C) Respiratory failure D) Hemothorax

Ans: C Feedback: Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (corpulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.

11. While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.

Ans: C Feedback: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

9. The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? A) Deflate the cuff overnight to prevent tracheal tissue trauma. B) Inflate the cuff to the highest possible pressure in order to prevent aspiration. C) Monitor the pressure in the cuff at least every 8 hours D) Keep the tracheostomy tube plugged at all times.

Ans: C Feedback: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

25. A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following? A) Static stage B) Latent stage C) Viral set point D) Window period

Ans: C Feedback: The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though he or she is infected.

24. A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he just cant breathe enough. The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? A) Pneumoconiosis B) Pleural effusion C) Acute respiratory failure D) Pneumonia

Ans: C Feedback: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

1. An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurses health education should include which of the following? A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C) Use of strategies to prevent falls stemming from postural hypotension D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Ans: C Feedback: Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.

28. A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis? A) A patient who is receiving intravenous antibiotic therapy in the home setting B) A patient who has a chronic venous ulcer C) An older adult whose medication regimen includes an anticholinergic D) A patient with poorly controlled diabetes who receives weekly wound care

Ans: C Feedback: Elderly, acutely ill, or debilitated people with decreased salivary flow from general dehydration or medications are at high risk for parotitis. Anticholinergic medications inhibit saliva production. Antibiotics, diabetes, and wounds are not risk factors for parotitis.

34. A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response? A) The physician may feel that mechanical ventilation will have to be used long-term. B) Long-term use of an endotracheal tube diminishes the normal breathing reflex. C) When an endotracheal tube is left in too long it can damage the lining of the windpipe. D) It is much harder to breathe through an endotracheal tube than a tracheostomy.

Ans: C Feedback: Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.

12. A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement? A) Ill make sure I get enough exposure to sunlight to keep up my vitamin D levels. B) Ill try to be as physically active as possible between flare-ups. C) Ill make sure to monitor my body temperature on a regular basis. D) Ill stop taking my steroids when I get relief from my symptoms.

Ans: C Feedback: Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Patients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. As well, these drugs should not be independently adjusted by the patient.

35. A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response? A) It eliminates the risk for infection. B) Feeds can be infused at a faster rate. C) Regurgitation and aspiration are less likely. D) It allows caregivers to provide personal hygiene more easily.

Ans: C Feedback: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.

20. A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors? A) The nurse wears face protection, gloves, and a gown when irrigating a wound. B) The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves. C) The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. D) The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.

Ans: C Feedback: Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient. Each of the other listed actions adheres to standard precautions.

36. The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A) Continue suctioning the patient until no more secretions are obtained. B) Perform chest physiotherapy rather than nasotracheal suctioning. C) Wait several minutes and then repeat suctioning. D) Perform postural drainage and then repeat suctioning.

Ans: C Feedback: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.

24. The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patients renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.

Ans: C Feedback: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

4. The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient? A) Signs of oxygen toxicity B) Chronic chest pain C) A barrel chest D) Long, thin fingers

Ans: C Feedback: In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The patient would not show signs of oxygen toxicity unless he or she received excess supplementary oxygen.

7. A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A) Cool joints with decreased range of motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints

Ans: C Feedback: In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.

21. A client presents to the walk-in clinic complaining of a dry, irritating cough and production of a minute amount of mucus-like sputum. The patient complains of soreness in her chest in the sternal area. The nurse should suspect that the primary care provider will assess the patient for what health problem? A) Pleural effusion B) Pulmonary embolism C) Tracheobronchitis D) Tuberculosis

Ans: C Feedback: Initially, the patient with tracheobronchitis has a dry, irritating cough and expectorates a scant amount of mucoid sputum. The patient may report sternal soreness from coughing and have fever or chills, night sweats, headache, and general malaise. Pleural effusion and pulmonary embolism do not normally cause sputum production and would likely cause acute shortness of breath. Hemoptysis is characteristic of TB.

19. A nurse is providing discharge teaching for a client with COPD. When teaching the client about breathing exercises, what should the nurse include in the teaching? A) Lie supine to facilitate air entry B) Avoid pursed lip breathing C) Use diaphragmatic breathing D) Use chest breathing

Ans: C Feedback: Inspiratory muscle training and breathing retraining may help improve breathing patterns in patients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.

32. A patients severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patients statements suggests a need for further education? A) I know that these drugs can sometimes make my heart beat faster. B) Ive heard that this drug is particularly good at preventing asthma attacks during exercise. C) Ill make sure to use this each time I feel an asthma attack coming on. D) Ive heard that this drug sometimes gets less effective over time.

Ans: C Feedback: LABAs are not used for management of acute asthma symptoms. Tachycardia is a potential adverse effect and decreased protection against exercise-induced bronchospasm may occur with regular use.

24. The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following? A) Reduced intake of protein and carbohydrates B) Increased intake of calcium and vitamin D C) Reduced intake of fat and sodium D) Increased intake of potassium, vitamin B12 and vitamin D

Ans: C Feedback: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some patients, but a specific reduction in protein and carbohydrates is not normally indicated.

31. A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patients medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator

Ans: C Feedback: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.

32. A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores? A) Advera B) Momordicacharantia C) Megestrol D) Ranitidine

Ans: C Feedback: Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain. In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Advera is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS. Momordicacharantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine prevents ulcers.

39. The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patients history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer

Ans: C Feedback: Most empyemas occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.

37. A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD

Ans: C Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.

26. A patient with SLE has come to the clinic for a routine check-up. When auscultating the patients apical heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurses most appropriate action? A) Reposition the patient and auscultate posteriorly. B) Document the presence of S3 and monitor the patient closely. C) Inform the primary care provider that a friction rub may be present. D) Inform the primary care provider that the patient may have pneumonia.

Ans: C Feedback: Patients with SLE are susceptible to developing a pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions; this warrants prompt medical follow-up. This finding is not characteristic of pneumonia and does not constitute S3. Posterior auscultation is unlikely to yield additional meaningful data.

35. An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following? A) Assess the patient hourly for signs of compartment syndrome. B) Assess the patients fine motor skills once per shift. C) Assess the patients wound for dehiscence every 4 hours. D) Maintain the patients head of bed at 45 degrees or more at all times.

Ans: C Feedback: Postoperatively, the nurse assesses the patients responses to the surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. Fine motor skills are unlikely to be affected by surgery and compartment syndrome is a complication of fracture casting, not abdominal surgery. There is no need to maintain a high head of bed.

11. A patient arrives in the emergency department with an attack of acute bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this patients care? A) Oral administration of diuretics B) Intravenous fluids to reduce the viscosity of secretions C) Postural chest drainage D) Pulmonary function testing

Ans: C Feedback: Postural drainage is part of all treatment plans for bronchiectasis, because draining of the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Diuretics and IV fluids will not aid in the mobilization of secretions. Lung function testing may be indicated, but this assessment will not relieve the patients symptoms.

25. The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient? A) Safe technique for self-suctioning of secretions B) Technique for performing postural drainage C) Correct and safe use of oxygen therapy equipment D) How to provide safe and effective tracheostomy care

Ans: C Feedback: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy (CPT), and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.

10. A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.

Ans: C Feedback: Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.

25. The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with nonsmall cell tumors is what? A) Chemotherapy B) Radiation C) Surgical resection D) Bronchoscopic opening of the airway

Ans: C Feedback: Surgical resection is the preferred method of treating patients with localized nonsmall cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

29. The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment? A) Pulmonary hypotension due to decreased cardiac output B) Severe and progressive pulmonary hypertension C) Hypovolemia secondary to leakage of fluid into the interstitial spaces D) Increased cardiac output from high levels of PEEP therapy

Ans: C Feedback: Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.

17. The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patients warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%

Ans: C Feedback: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the clients PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.

19. A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? A) Non-rebreather air mask B) Tracheostomy collar C) Venturi mask D) Face tent

Ans: C Feedback: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.

15. A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results? A) Another EIA test B) Viral load test C) Western blot test D) CD4/CD8 ratio

Ans: C Feedback: The Western blot test detects antibodies to HIV and is used to confirm the EIA test results. The viral load test measures HIV RNA in the plasma and is not used to confirm EIA test results, but instead to track the progression of the disease process. The CD4/CD8 ratio test evaluates the ratio of CD4 and CD8 cells but is not used to confirm results of EIA testing.

35. A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A) Older adults have less compliant lung tissue than younger adults. B) Older adults are not normally candidates for pneumococcal vaccination. C) Older adults often lack the classic signs and symptoms of pneumonia. D) Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.

Ans: C Feedback: The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients. Mortality from pneumonia in the elderly is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults.

11. The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patients level of consciousness (LOC). B) Assess the patients extremities for signs of cyanosis. C) Assess the patients oxygen saturation level. D) Review the patients hemoglobin, hematocrit, and red blood cell levels.

Ans: C Feedback: The effectiveness of the patients oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patients LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

29. A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response? A) Taking care of you in the best way involves seeing you face to face. B) Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. D) Taking care of you in the best way involves drawing blood work every month.

Ans: C Feedback: The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Management of SLE involves regular monitoring to assess disease activity and therapeutic effectiveness. Stating the benefit of face-to-face interaction does not answer the patients question. Blood work is not necessarily drawn monthly and assessing medication adherence is not the sole purpose of visits.

27. The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing? A) Traumatic pneumothorax B) Empyema C) Pleuritic pain D) Myocardial infarction

Ans: C Feedback: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patients vital signs profoundly.

25. The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A) Warfarin (Coumadin) B) Furosemide (Lasix) C) Sodium nitroprusside (Nitropress) D) Ramipril (Altace)

Ans: C Feedback: The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex), fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patients immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication for anticoagulants such as Coumadin.

6. The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient? A) Would you like me to have the chaplain come speak with you? B) Youll learn much about the promise of a cure for HIV. C) Can you tell me what concerns you most about dying? D) You need to maintain hope because you may live for several years.

Ans: C Feedback: The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the patient to identify fears about being diagnosed with a life-threatening chronic illness. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the patients expressed fears.

14. A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A) Complementary therapies generally have not been approved, so patients are usually discouraged from using them. B) Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we suggest that you stay away from these therapies until there is solid research data available. C) Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks. D) Youll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach.

Ans: C Feedback: The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment.

32. The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia? A) Stool softeners are contraindicated. B) Laxatives should be taken daily. C) Consume 2 to 4 L of fluid daily. D) Restrict calcium intake.

Ans: C Feedback: The nurse should identify patients at risk for hypercalcemia, assess for signs and symptoms of hypercalcemia, and educate the patient and family. The nurse should teach at-risk patients to recognize and report signs and symptoms of hypercalcemia and encourage patients to consume 2 to 4 L of fluid daily unless contraindicated by existing renal or cardiac disease. Also, the nurse should explain the use of dietary and pharmacologic interventions, such as stool softeners and laxatives for constipation, and advise patients to maintain nutritional intake without restricting normal calcium intake.

21. A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patients right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynauds phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE

Ans: C Feedback: The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynauds or lymphedema. The upper extremities are rare sites for VTE.

35. A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patients adherence to her medication regimen? A) Encourage the patient to store the bottles with their tops removed. B) Have a trusted family member take over the management of the patients medication regimen. C) Encourage her to have her pharmacy replace the tops with alternatives that are easier to open. D) Have the patient approach her primary care provider to explore medication alternatives.

Ans: C Feedback: The patients pharmacy will likely be able to facilitate a practical solution that preserves the patients independence while still fostering adherence to treatment. There should be no need to change medications, and storing open medication containers is unsafe. Delegating medications to a family member is likely unnecessary at this point and promotes dependence.

37. A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? A) Determine whether the patient can now perform forced expiratory technique (FET). B) Percuss the patients lungs and thorax. C) Measure the patients oxygen saturation. D) Have the patient perform incentive spirometry.

Ans: C Feedback: The patients response to suctioning is usually determined by performing chest auscultation and by measuring the patients oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

12. A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A) Shallow respirations B) Increased anterior-posterior (A-P) diameter C) Bilateral wheezes D) Bradypnea

Ans: C Feedback: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the childs A-P diameter does not normally change.

14. The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment? A) The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. B) The patient requires a high-flow system for use with a tracheostomy collar. C) The patient desires a portable oxygen delivery system that can deliver 2 L/min. D) The patients respiratory status requires a system that provides an FiO2 of 65%.

Ans: C Feedback: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The patient desiring a portable oxygen delivery system of 2L/min will benefit from the use of an oxygen concentrator.

28. The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action? A) Assess the patient for additional signs and symptoms of Kaposis sarcoma. B) Review the patients most recent viral load and CD4+ count. C) Place the patient on respiratory isolation and inform the physician. D) Perform oral suctioning to reduce the patients risk for aspiration.

Ans: C Feedback: These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the patients blood work will not reflect the onset of this opportunistic infection.

13. The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A) Monitor her blood pressure daily B) Assess her radial pulses daily C) Monitor her weight daily D) Monitor her bowel movements

Ans: C Feedback: To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.

12. A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

Ans: C Feedback: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.

36. A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurses best response? A) The type of treatment depends on the patients age and health status. B) The type of treatment depends on what the patient wants when given the options. C) The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patients health status. D) The type of treatment depends on the discussion between the patient and the physician of which treatment is best.

Ans: C Feedback: Treatment of lung cancer depends on the cell type, the stage of the disease, and the patients physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the patients age or the patients preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the patient and the physician of which treatment is best, though this discussion will take place.

9. An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family? A) Family members should avoid receiving vaccinations until the patient has recovered from his or her illness. B) Wipe down hard surfaces with a dilute bleach solution once per day. C) Maintain cleanliness in the home, but recognize that the home does not need to be sterile. D) Avoid physical contact with the patient unless absolutely necessary.

Ans: C Feedback: When assessing the risk of the immunosuppressed patient in the home environment for infection, it is important to realize that intrinsic colonizing bacteria and latent viral infections present a greater risk than do extrinsic environmental contaminants. The nurse should reassure the patient and family that their home needs to be clean but not sterile. Common-sense approaches to cleanliness and risk reduction are helpful. The family need not avoid vaccinations and it is unnecessary to avoid all contact or to wipe down surfaces daily.

1. A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the patient gets home. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.

Ans: D Feedback: A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The cast will exude heat while it dries and should not be wrapped.

38. An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

Ans: D Feedback: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.

33. A nurse is providing health education to the family of a patient with bronchiectasis. What should the nurse teach the patients family members? A) The correct technique for chest palpation and auscultation B) Techniques for assessing the patients fluid balance C) The technique for providing deep nasotracheal suctioning D) The correct technique for providing postural drainage

Ans: D Feedback: A focus of the care of bronchiectasis is helping patients clear pulmonary secretions; consequently, patients and families are taught to perform postural drainage. Chest palpation and auscultation and assessment of fluid balance are not prioritized over postural drainage. Nasotracheal suctioning is not normally necessary.

14. A nursing is planning the care of a patient with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? A) Taking prophylactic antibiotics as ordered B) Adhering to the treatment regimen in order to cure the disease C) Avoiding airplanes, buses, and other crowded public places D) Setting realistic short-term and long-range goals

Ans: D Feedback: A major area of teaching involves setting and accepting realistic short-term and long-range goals. Emphysema is not considered curable and antibiotics are not used on a preventative basis. The patient does not normally need to avoid public places.

40. A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurses response to the patient? A) New evidence shows CAM to be as effective as medical treatment. B) CAM therapies negate many of the benefits of medications. C) CAM therapies typically do more harm than good. D) Evidence shows minimal benefits from most CAM therapies.

Ans: D Feedback: A recent systematic review of complementary and alternative medicine (CAM) examined the efficacy of herbal medicine, acupuncture, Tai chi and biofeedback for the treatment of rheumatoid arthritis and osteoarthritis. Although acupuncture treatment for pain management showed some promise, in all modalities the evidence was ambiguous. There is not enough evidence of the effectiveness of CAM and more rigorous research is needed.

37. A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient? A) Position the patient in the high Fowlers position whenever possible. B) Temporarily eliminate animal protein from the patients diet. C) Make sure the patient eats at least two servings of raw fruit each day. D) Obtain a stool culture to identify possible pathogens.

Ans: D Feedback: A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Patients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the patients bed.

26. Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a one day on, one day off schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points

Ans: D Feedback: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.

1. A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved? A) Angiography B) Myelography C) Paracentesis D) Arthocentesis

Ans: D Feedback: Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.

22. A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis (GCA). What aspect of physical assessment should the nurse prioritize? A) Assessment for subtle signs of bleeding disorders B) Assessment of the metatarsal joints and phalangeal joints C) Assessment for thoracic pain that is exacerbated by activity D) Assessment for headaches and jaw pain

Ans: D Feedback: Assessment of the patient with GCA focuses on musculoskeletal tenderness, weakness, and decreased function. Careful attention should be directed toward assessing the head (for changes in vision, headaches, and jaw claudication). There is not a particular clinical focus on the potential for bleeding, hand and foot pain, or thoracic pain.

40. An oncology nurse is contributing to the care of a patient who has failed to respond appreciably to conventional cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRFs). The nurse should know that these achieve a therapeutic effect by what means? A) Promoting the synthesis and release of leukocytes B) Focusing the patients immune system exclusively on the tumor C) Potentiating the effects of chemotherapeutic agents and radiation therapy D) Altering the immunologic relationship between the tumor and the patient

Ans: D Feedback: BRFs alter the immunologic relationship between the tumor and the cancer patient (host) to provide a therapeutic benefit. They do not necessarily increase white cell production or focus the immune system solely on the tumor. BRFs do not potentiate radiotherapy and chemotherapy.

19. The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurses rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) Asystole

Ans: D Feedback: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.

15. A nurse is documenting the results of assessment of a patient with bronchiectasis. What would the nurse most likely include in documentation? A) Sudden onset of pleuritic chest pain B) Wheezes on auscultation C) Increased anterior-posterior (A-P) diameter D) Clubbing of the fingers

Ans: D Feedback: Characteristic symptoms of bronchiectasis include chronic cough and production of purulent sputum in copious amounts. Clubbing of the fingers also is common because of respiratory insufficiency. Sudden pleuritic chest pain is a common manifestation of a pulmonary embolism. Wheezes on auscultation are common in patients with asthma. An increased A-P diameter is noted in patients with COPD.

6. A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid

Ans: D Feedback: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.

24. A patients rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patients drug regimen. What principle will guide this aspect of the patients treatment? A) The patient will need daily blood testing for the duration of treatment. B) The patient must stop all other drugs 72 hours before starting prednisone. C) The drug should be used at the highest dose the patient can tolerate. D) The drug should be used for as short a time as possible.

Ans: D Feedback: Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the patient does not need to stop other drugs prior to using corticosteroids.

26. The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patients discharge teaching? A) How to count her respirations accurately B) How to collect serial sputum samples C) How to independently wean herself from treatment D) How to perform diaphragmatic breathing

Ans: D Feedback: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer. Patient teaching would not include counting respirations and the patient should not wean herself from treatment without the involvement of her primary care provider. Serial sputum samples are not normally necessary.

36. A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? A) Maximize range of motion while minimizing exertion B) Increase joint size and strength C) Limit energy output in order to preserve strength for healing D) Preserve and increase range of motion while limiting joint stress

Ans: D Feedback: Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular exertion should remain within age-based limits and individual ability, but it is not a goal to minimize exertion. Increasing joint size is not a valid goal.

9. A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? A) Impaired Urinary Elimination Related to Neuropathy B) Altered Nutrition Related to Impaired Absorption C) Disturbed Sleep Pattern Related to CNS Stimulation D) Fatigue Related to Pain

Ans: D Feedback: Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness. Impaired urinary elimination is not a common manifestation of the disease. Altered nutrition and disturbed sleep pattern are potential nursing diagnoses, but are not the priority.

23. A nurse is preparing to perform an admission assessment on a patient with COPD. It is most important for the nurse to review which of the following? A) Social work assessment B) Insurance coverage C) Chloride levels D) Available diagnostic tests

Ans: D Feedback: In addition to the patients history, the nurse reviews the results of available diagnostic tests. Social work assessment is not a priority for the majority of patients. Chloride levels are relevant to CF, not COPD. Insurance coverage is not normally the domain of the nurse.

40. The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? A) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B) Inform the physician promptly that there is in imminent leak in the drainage system. C) Encourage the patient to do deep breathing and coughing exercises. D) Document that the chest drainage system is operating as it is intended.

Ans: D Feedback: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

16. The nurse is caring for a patient has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the patients care needs are unable to be met in a home environment. What might you suggest as an alternative? A) Discuss a referral for rehabilitation hospital. B) Panel the patient for a personal care home. C) Discuss a referral for acute care. D) Discuss a referral for hospice care.

Ans: D Feedback: Hospice care can be provided in several settings. Because of the high cost associated with free-standing hospices, care is often delivered by coordinating services provided by both hospitals and the community. The primary goal of hospice care is to provide support to the patient and family. Patients who are referred to hospice care generally have fewer than 6 months to live. Each of the other listed options would be less appropriate for the patients physical and psychosocial needs.

35. A 55-year-old patient comes to the clinic for a routine check-up. The patients BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurses best response? A) Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs. B) Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group. C) Hypertension is the leading cause of death in people your age. D) Hypertension greatly increases your risk of stroke and heart disease.

Ans: D Feedback: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.

37. A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy? A) Pupillary response B) Pressure in the vena cava C) White blood cell differential D) Pulmonary arterial pressure

Ans: D Feedback: If the patient has undergone surgical embolectomy, the nurse measures the patients pulmonary arterial pressure and urinary output. Pressure is not monitored in a patients vena cava. White cell levels and pupillary responses would be monitored, but not to the extent of the patients pulmonary arterial pressure.

12. A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A) Assure the patient that everything will be all right and that remaining calm is the best strategy. B) Ask a family member to interpret what the patient is trying to communicate. C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D) Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.

Ans: D Feedback: If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the patients wishes. Making them responsible for interpreting the patients gestures may frustrate the family. The patient may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

5. The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action? A) Smoking decreases the amount of mucus production. B) Smoke particles compete for binding sites on hemoglobin. C) Smoking causes atrophy of the alveoli. D) Smoking damages the ciliary cleansing mechanism.

Ans: D Feedback: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.

22. A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the residents feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynauds phenomenon C) VTE D) PAD

Ans: D Feedback: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynauds phenomenon do not cause the ischemia that underlies gangrene.

27. The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements

Ans: D Feedback: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.

12. A patients current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patients medication regimen? A) Avoid high-fat meals while taking this medication. B) Limit fluid intake to 2 liters a day. C) Limit sodium intake to 2 grams per day. D) Take this medication without regard to meals.

Ans: D Feedback: Many NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play no role in relation to these drugs.

21. An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurses best response? A) There is no way to know that for certain, but we do know that your baby has a one in four chance of being born with HIV. B) Your physician is likely the best one to ask that question. C) If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now. D) Its possible that your baby could contract HIV, either before, during, or after delivery.

Ans: D Feedback: Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breast-feeding. There is no evidence that the infants risk is 25%. Deferral to the physician is not a substitute for responding appropriately to the patients concern. Downplaying the patients concerns is inappropriate.

20. The nurse is reviewing a newly admitted patients electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated? A) Teach the patient deep breathing and coughing exercises. B) Administer supplemental oxygen at all times. C) Limit the patients activity level. D) Avoid positioning the patient supine.

Ans: D Feedback: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.

23. A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response? A) Theres no way to be sure you wont get HIV except to use condoms correctly. B) Only the correct use of a female condom protects against the transmission of HIV. C) There are new ways of protecting yourself from HIV that are being discovered every day. D) Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.

Ans: D Feedback: Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection. Both female and male condoms confer significant protection. New prevention techniques are not commonly discovered, though advances in treatment are constant.

4. A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? A) The patient is immune to HIV. B) The patients immune system is intact. C) The patient has AIDS-related complications. D) The patient has been infected with HIV.

Ans: D Feedback: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.

8. A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position. B) Perform the procedure immediately following the patients meals. C) Apply percussion firmly to bare skin to facilitate drainage. D) Assist the patient into a position that will allow gravity to move secretions.

Ans: D Feedback: Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.

37. A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? A) To ensure long-term prevention of asthma exacerbations B) To cure any systemic infection underlying asthma attacks C) To prevent recurrent pulmonary infections D) To gain prompt control of inadequately controlled, persistent asthma

Ans: D Feedback: Prednisone is used for a short-term (310 days) burst to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term.

16. A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session? A) Using crutches efficiently B) Exercising joints above and below the cast, as ordered C) Removing the cast correctly at the end of the treatment period D) Reporting signs of impaired circulation

Ans: D Feedback: Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.

38. An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis? A) Apply an ice pack or heating pad PRN to relieve pain and pruritis B) Avoid skin contact with water whenever possible C) Apply phototherapy PRN D) Avoid rubbing or scratching the affected area

Ans: D Feedback: Rubbing and or scratching will lead to additional skin irritation, damage, and increased risk of infection. Extremes of hot, cold, and light should be avoided. No need to avoid contact with water.

23. A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patients dorsalis pedis or posterior tibial pulse and the patients foot is pale. What is the nurses most appropriate action? A) Warm the patients foot and determine whether circulation improves. B) Reposition the patient with the affected foot dependent. C) Reassess the patients neurovascular status in 15 minutes. D) Promptly inform the primary care provider.

Ans: D Feedback: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.

16. A patient is having pulmonary-function studies performed. The patient performs a spirometry test, revealing an FEV1/FVC ratio of 60%. How should the nurse interpret this assessment finding? A) Strong exercise tolerance B) Exhalation volume is normal C) Respiratory infection D) Obstructive lung disease

Ans: D Feedback: Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of forced expiration volume in 1 second to forced vital capacity. Obstructive lung disease is apparent when an FEV1/FVC ratio is less than 70%.

40. An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care? A) Nasogastric intubation B) Administration of probiotic supplements C) Bedrest D) Cautious hydration

Ans: D Feedback: Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the patient.

32. A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurses response? A) The cells in small cell cancer of the lung are not large enough to visualize in surgery. B) Small cell lung cancer is self-limiting in many patients and surgery should be delayed. C) Patients with small cell lung cancer are not normally stable enough to survive surgery. D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

Ans: D Feedback: Surgery is primarily used for NSCLCs, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a patients medical instability are not the limiting factors. Lung cancer is not a self-limiting disease.

18. The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? A) Walk 1 mile 3 to 4 times a week. B) Use weights daily to increase arm strength. C) Walk on a treadmill 30 minutes daily. D) Perform shoulder exercises five times daily.

Ans: D Feedback: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

27. An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patients most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patients subsequent care, what nursing diagnosis should be identified? A) Risk for ineffective tissue perfusion related to dysrhythmia B) Risk for fluid volume excess related to medication regimen C) Risk for ineffective breathing pattern related to hypoxia D) Risk for falls related to hypotension

Ans: D Feedback: The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patients medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.

7. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? A) Attach the condom prior to erection. B) A condom may be reused with the same partner if ejaculation has not occurred. C) Use skin lotion as a lubricant if alternatives are unavailable. D) Hold the condom by the cuff upon withdrawal.

Ans: D Feedback: The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.

4. The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.

Ans: D Feedback: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.

30. The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient? A) Signs and symptoms of pulmonary infection B) Swallowing ability and signs of aspiration C) Activity level and role performance D) Residual effects of compromised oxygenation

Ans: D Feedback: The home care nurse should monitor the patient for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.

4. The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis? A) The patient is experiencing painless hemoptysis. B) The patients arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing. C) The patients oxygen saturation level is below 88%, but he denies shortness of breath. D) The patients pain intensifies when he coughs or takes a deep breath.

Ans: D Feedback: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The patients ABGs would most likely be abnormal and shortness of breath would be expected.

1. A clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what he could have done to minimize the risk of contracting this disease. What would be the nurses best answer? A) The most important risk factor for COPD is exposure to occupational toxins. B) The most important risk factor for COPD is inadequate exercise. C) The most important risk factor for COPD is exposure to dust and pollen. D) The most important risk factor for COPD is cigarette smoking.

Ans: D Feedback: The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.

31. The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? A) Resumption of the patients ADLs B) The familys willingness to care for the patient C) Nutritional status and fluid balance D) Signs and symptoms of respiratory complications

Ans: D Feedback: The nurse assesses the patients adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patients airway and breathing.

30. A patient is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better. Why must the nurse emphasize the need for continued adherence to the prescribed medication? A) To avoid complications such as venous thromboembolism B) To avoid the progression to osteoporosis C) To avoid the progression of GCA to degenerative joint disease D) To avoid complications such as blindness

Ans: D Feedback: The nurse must emphasize to the patient the need for continued adherence to the prescribed medication regimen to avoid complications of giant cell arteritis, such as blindness. VTE, OP, and degenerative joint disease are not among the most common complications for GCA.

28. The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? A) Administration of inhaled corticosteroids B) Assessment of neurologic status C) Turning and coughing D) Signs of pulmonary infection

Ans: D Feedback: The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs. Neurologic assessment and turning and coughing are less important than signs and symptoms of infection. Inhaled corticosteroids may or may not be prescribed.

39. A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient? A) Hold the spirometer at your lips and breathe in and out like you normally would. B) When youre ready, blow hard into the spirometer for as long as you can. C) Take a deep breath and then blow short, forceful breaths into the spirometer. D) Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.

Ans: D Feedback: The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece.

27. A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patients health should the nurse focus most closely during the visit? A) The patients understanding of rheumatoid arthritis B) The patients risk for cardiopulmonary complications C) The patients social support system D) The patients functional status

Ans: D Feedback: The patients functional status is a central focus of home assessment of the patient with RA. The nurse may also address the patients understanding of the disease, complications, and social support, but the patients level of function and quality of life is a primary concern.

11. During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection? A) Salmonella infection B) Mycobacterium tuberculosis C) Clostridium difficile D) Pneumocystis pneumonia

Ans: D Feedback: There are a number of opportunistic infections that can infect individuals with AIDS. The most common life-threatening infection in those living with AIDS is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly carinii). Other opportunistic infections may involveSalmonella,Mycobacterium tuberculosis, and Clostridium difficile.

2. The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A) Cognition is decreased. B) Daily arterial blood gases (ABGs) are necessary. C) Slight tracheal bleeding is anticipated. D) The cough reflex is depressed.

Ans: D Feedback: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

15. A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurses plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue. B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress. C) Walking helps your heart adjust to your new arteries and helps build your self-esteem. D) When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart.

Ans: D Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MIthere are no new arteries.

27. The case manager for a group of patients with COPD is providing health education. What is most important for the nurse to assess when providing instructions on self-management to these patients? A) Knowledge of alternative treatment modalities B) Family awareness of functional ability and activities of daily living (ADLs) C) Knowledge of the pathophysiology of the disease process D) Knowledge about self-care and their therapeutic regimen

Ans: D Feedback: When providing instructions about self-management, it is important for the nurse to assess the knowledge of patients and family members about self-care and the therapeutic regimen. This supersedes knowledge of alternative treatments or the pathophysiology of the disease, neither of which is absolutely necessary for patients to know. The patients own knowledge is more important than that of the family.

36. A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

Ans: D Feedback: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.

25. A nurse is caring for a patient with COPD. The patients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? Select all that apply. A) Negative sputum culture B) Increased viscosity of lung secretions C) Increased respiratory rate D) Increased expiratory flow rate E) Relief of dyspnea

Ans: D, E Feedback: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the patients respiratory status. Bronchodilators would not have a direct result on the patients infectious process.

5. When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor? A) Late childbearing B) Human papillomavirus (HPV) C) Postmenopausal bleeding D) Tobacco use

Ans: B Feedback: HPV is the most salient risk factor for cervical cancer, exceeding the risks posed by smoking, late childbearing, and postmenopausal bleeding.

28. The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A) Oxycodone B) Warfarin C) Morphine D) Acetaminophen

Ans: C Feedback: The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.

6. An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what? A) Brachial artery B) Brachial vein C) Femoral artery D) Greater saphenous vein

Ans: D Feedback: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.

17. Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings? A) Hyperuricemia B) Increased erythrocyte sedimentation rate C) Elevated serum creatinine D) Decreased platelets

Ans: D Feedback: Thrombocytopenia occurs in bone marrow suppression. Hyperuricemia occurs in gout, but is not caused by bone marrow suppression. Increased erythrocyte sedimentation rate may occur from inflammation associated with gout, but is not related to bone marrow suppression. An elevated serum creatinine level may indicate renal damage, but this is not associated with the use of allopurinol.

26. The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurses most appropriate initial action? A) Have the patient sit down and put his head between his knees. B) Have the patient perform pursed-lip breathing. C) Have the patient stand still and bend over at the waist. D) Place the patient on bed rest in a semi-Fowlers position.

Ans: D Feedback: When a patient experiences angina, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowlers position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. No need to have the patient put his head between his legs because cerebral perfusion is not lacking.

5. A nurse is providing a class on osteoporosis at the local seniors center. Which of the following statements related to osteoporosis is most accurate? A) Osteoporosis is categorized as a disease of the elderly. B) A nonmodifiable risk factor for osteoporosis is a persons level of activity. C) Secondary osteoporosis occurs in women after menopause. D) Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis.

Ans: D Feedback: When corticosteroid therapy is discontinued, the progression of osteoporosis is halted, but restoration of lost bone mass does not occur. Osteoporosis is not a disease of the elderly because its onset occurs earlier in life, when bone mass peaks and then begins to decline. A persons level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

6. A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? A) Spinach B) Tofu C) Multigrain bagel D) Blueberries

Ans: B Feedback: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, low-residue, high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, and blueberries are not low-residue.

38. The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. A) Abrupt closure of the coronary artery B) Venous insufficiency C) Bleeding at the insertion site D) Retroperitoneal bleeding E) Arterial occlusion

Ans: A, C, D, E Feedback: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.

6. The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A) Confusion and bradycardia B) Uncontrolled diuresis and tachycardia C) Numbness and tingling in the extremities D) Chest pain and shortness of breath

Ans: A Feedback: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.

12. A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient? A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B) Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C) Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D) Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

Ans: A Feedback: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is administered for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.

8. A nurse is collecting assessment data from a premenopausal patient who states that she does not have menses. What term should the nurse use to document the absence of menstrual flow? A) Amenorrhea B) Dysmenorrhea C) Menorrhagia D) Metrorrhagia

Ans: A Feedback: Amenorrhea refers to absence of menstrual flow, whereas dysmenorrhea is painful menstruation. Menorrhagia, also called hypermenorrhea, is defined as prolonged or excessive bleeding at the time of the regular menstrual flow. Metrorrhagia refers to vaginal bleeding between regular menstrual periods.

10. The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response? A) Explore the factors underlying the patients anxiety. B) Teach the patient guided imagery techniques. C) Obtain an order for a PRN benzodiazepine. D) Describe the procedure in greater detail.

Ans: A Feedback: An assessment of anxiety levels is required in the patient to assist the patient in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the patients anxiety before providing interventions such as education or medications.

15. The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs? A) The patient experiences chest pain, palpitations, or dyspnea. B) The patient experiences a noticeable increase in heart rate during activity. C) The patients oxygen saturation level drops below 96%. D) The patients respiratory rate exceeds 30 breaths/min.

Ans: A Feedback: Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

1. The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? A) Lipids and fibrous tissue B) White blood cells C) Lipoproteins D) High-density cholesterol

Ans: A Feedback: As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.

14. A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication? A) Chemical phlebitis B) Hyperglycemia C) Dumping syndrome D) Line sepsis

Ans: A Feedback: Formulations with dextrose concentrations of more than 10% should not be administered through peripheral veins because they irritate the intima (innermost walls) of small veins, causing chemical phlebitis. Hyperglycemia and line sepsis are risks with both peripheral and central administration of PN. PN is not associated with dumping syndrome.

7. A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela? A) Stroke B) Myocardial infarction (MI) C) Hemorrhage D) Peripheral edema

Ans: A Feedback: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.

8. A nurse is preparing to administer a patients intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurses action? A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B) The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D) The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

Ans: A Feedback: Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The patient does not need another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing.

10. A nurse is caring for a 6-year-old patient with cystic fibrosis. In order to enhance the childs nutritional status, what intervention should most likely be included in the plan of care? A) Pancreatic enzyme supplementation with meals B) Provision of five to six small meals per day rather than three larger meals C) Total parenteral nutrition (TPN) D) Magnesium, thiamine, and iron supplementation

Ans: A Feedback: Nearly 90% of patients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical.

33. The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A) Increase in the size of the arterys lumen B) Decrease in arterial blood flow in relation to venous flow C) Increase in the patients resting heart rate D) Increase in the patients level of consciousness (LOC)

Ans: A Feedback: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patients LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.

18. When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena? A) Exercise increases the hearts oxygen demands. B) Exercise causes vasoconstriction of the coronary arteries. C) Exercise shunts blood flow from the heart to the mesenteric area. D) Exercise increases the metabolism of cardiac medications.

Ans: A Feedback: Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.

8. The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care? A) With the patient, clarify the surgical procedure that will be performed. B) Withhold the patients scheduled medications for at least 12 hours preoperatively. C) Inform the patient that health teaching will begin as soon as possible after surgery. D) Avoid discussing the patients fears as not to exacerbate them.

Ans: A Feedback: Preoperatively, it is necessary to evaluate the patients understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the patients medication regimen if necessary; this will vary from patient to patient. Fears should be addressed directly and empathically.

11. A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? A) In a high Fowlers position B) On the left side-lying position C) In a flat, supine position D) In the Trendelenburg position

Ans: A Feedback: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.

13. A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A) Begin ECG monitoring. B) Obtain information about family history of heart disease. C) Auscultate lung fields. D) Determine if the patient smokes.

Ans: A Feedback: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.

27. A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment? A) Prompt initiation of an ECG B) Auscultation of the patients point of maximal impulse (PMI) C) Rapid assessment of the patients peripheral pulses D) Palpation of the patients cardiac apex

16. The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome? A) Raynauds phenomenon B) Thyroid dysfunction C) Esophageal varices D) Osteopenia

Ans: A Feedback: The R in CREST stands for Raynauds phenomenon. Thyroid dysfunction, esophageal varices, and osteopenia are not associated with scleroderma.

38. The nurse is working with a patient who expects to begin menopause in the next few years. What educational topic should the nurse prioritize when caring for a healthy woman approaching menopause? A) Patient teaching and counseling regarding healthy lifestyles B) Referrals to local support groups C) Nutritional counseling regarding osteoporosis prevention D) Drug therapy options

Ans: A Feedback: The individual womans evaluation of herself and her worth, now and in the future, is likely to affect her emotional reaction to menopause. Patient teaching and counseling regarding healthy lifestyles, health promotion, and health screening are of paramount importance. This broad goal of fostering healthy lifestyles transcends individual topics such as drug treatment, support groups, and osteoporosis prevention.

30. The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patients medication regimen? A) Anticholinergic medications 30 minutes before a meal B) Antiemetics on a PRN basis C) Vitamin B12 injections to prevent pernicious anemia D) Beta adrenergic blockers to reduce bowel motility

Ans: A Feedback: The nurse administers anticholinergic medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injections and beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease.

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A) Watery with blood and mucus B) Hard and black or tarry C) Dry and streaked with blood D) Loose with visible fatty streaks

Ans: A Feedback: The predominant symptoms of ulcerative colitis are diarrhea and abdominal pain. Stools may be bloody and contain mucus. Stools are not hard, dry, tarry, black or fatty in patients who have ulcerative colitis.

6. The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN? A) Checking the patients capillary blood glucose levels regularly B) Having the patient frequently rate his or her hunger on a 10-point scale C) Measuring the patients heart rhythm at least every 6 hours D) Monitoring the patients level of consciousness each shift

Ans: A Feedback: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.

1. A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A) Inflammatory bowel disease B) Intestinal polyps C) Diverticulitis D) Colon cancer

Ans: A Feedback: The use of a lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. It can safely be used with patients who have polyps, colon cancer, or diverticulitis.

9. A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment? A) Lumpectomy and radiation B) Partial mastectomy and radiation C) Partial mastectomy and chemotherapy D) Total mastectomy and chemotherapy

Ans: A Feedback: Treatment for breast cancer depends on the disease stage and type, the patients age and menopausal status, and the disfiguring effects of the surgery. For this patient, lumpectomy is the most likely option because the nodule is well-defined. The patient usually undergoes radiation therapy afterward. Because a lumpectomy is possible, mastectomy would not be the treatment of choice.

4. The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patients symptoms are due to an MI, what will have happened to the myocardium? A) It may have developed an increased area of infarction during the time without treatment. B) It will probably not have more damage than if he came in immediately. C) It may be responsive to restoration of the area of dead cells with proper treatment. D) It has been irreparably damaged, so immediate treatment is no longer necessary.

Ans: A Feedback: When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

38. A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A) Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion D) Teaching the patient to flush the line with sterile water E) Teaching the patient when it is safe to leave the access site open to air

Ans: A, B, C Feedback: An effective home care teaching program prepares the patient to store solutions, set up the infusion, flush the line with heparin, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Sterile water is never used for flushes and the access site must never be left open to air.

36. A patient has been discharged home on parenteral nutrition (PN). Much of the nurses discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply. A) Changes in lifestyle B) Loss of eating as a social behavior C) Chronic bowel incontinence from GI changes D) Sleep disturbances related to frequent urination during nighttime infusions E) Stress of choosing the correct PN formulation

Ans: A, B, D Feedback: Patients must cope with the loss of eating as a social behavior and with changes in lifestyle brought on by sleep disturbances related to frequent urination during night time infusions. PN is not associated with bowel incontinence and the patient does not select or adjust the formulation of PN.

29. The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A) Dyspnea B) Unusual fatigue C) Hypotension D) Syncope E) Peripheral cyanosis

Ans: A, B, D Feedback: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.

34. A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize? A) Take OTC calcium supplements consistently. B) Restrict consumption of foods high in purines. C) Ensure fluid intake of at least 4 liters per day. D) Restrict weight-bearing on right foot.

Ans: B Feedback: Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary and activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary for the patient to consume more than 4 liters daily.

10. A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A) Right-sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock

Ans: B Feedback: Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.

4. A premenopausal patient is complaining of vaginal spotting and sharp, colicky lower abdominal pain. She informs the nurse that her period is 2 weeks late. The nurse should recognize a need for this patient to be investigated for what health problem? A) Trichomonas vaginalis B) Ectopic pregnancy C) Cervical cancer D) Fibromyalgia

Ans: B Feedback: Clinical symptoms of an ectopic pregnancy include delay in menstruation of 1 to 2 weeks, vaginal spotting, and sharp, colicky pain. Trichomonas vaginalis causes a vaginal infection. Cervical cancer and fibromyalgia do not affect menstruation.

7. A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient? A) Hyperlipidemia B) Bleeding at insertion site C) Left ventricular hypertrophy D) Congestive heart failure

Ans: B Feedback: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.

4. Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? A) Monitor liver function studies B) Monitor for hypotension C) Assess the patients vitamin D intake D) Assess the patient for hyperkalemia

Ans: B Feedback: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.

11. A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A) Nervousness or paresthesia B) Throbbing headache or dizziness C) Drowsiness or blurred vision D) Tinnitus or diplopia

Ans: B Feedback: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

10. A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids? A) A 45-year-old teacher who stands for 6 hours per day B) A pregnant woman at 28 weeks gestation C) A 37-year-old construction worker who does heavy lifting D) A 60-year-old professional who is under stress

Ans: B Feedback: Hemorrhoids commonly affect 50% of patients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.

39. A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patients nutritional needs? A) Administration of parenteral feeds via a peripheral IV B) TPN administered via a peripherally inserted central catheter C) Insertion of an NG tube for administration of feeds D) Maintaining NPO status and IV hydration until treatment completion

Ans: B Feedback: If malabsorption is severe, or the cancer involves the upper GI tract, parenteral nutrition may be necessary. TPN is administered by way of a central line, not a peripheral IV. An NG would be contraindicated for this patient. Long-term NPO status would result in malnutrition.

17. The nurse is performing a comprehensive health history of a patient who is in her 50s. The nurse should identify what risk factor that may increase this patients risk for breast cancer? A) The patient breastfed each of her children. B) The patient gave birth to her first child at age 38. C) The patient experienced perimenopausal symptoms starting at age 46. D) The patient experienced menarche at age 13.

Ans: B Feedback: Late age at first pregnancy is a risk factor for breast cancer. None of the other listed aspects of the patients health history is considered to be a risk factor for breast cancer.

11. A patients physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device? A) Peripheral catheter B) Nontunneled central catheter C) Implantable port D) Tunneled central catheter

Ans: B Feedback: Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy. A peripheral catheter can be used for the administration of peripheral parenteral nutrition for 5 to 7 days. Implantable ports and tunneled central catheters are for long-term use and may remain in place for many years. Peripherally inserted central catheters (PICCs) are another potential option.

30. The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patients care plan? A) Facilitate daily arterial blood gas (ABG) sampling. B) Administer supplementary oxygen, as needed. C) Have patient maintain supine positioning when in bed. D) Perform chest physiotherapy, as indicated.

Ans: B Feedback: Oxygen should be administered along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.

10. A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions? A) Starting with a rapid infusion rate to meet the patients nutritional needs as quickly as possible B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance C) Changing the rate of administration every 2 hours based on serum electrolyte values D) Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

Ans: B Feedback: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the patients fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual patient based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.

20. You are caring for a patient who is diagnosed with Raynauds phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

Ans: B Feedback: Raynauds phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.

5. The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea

Ans: B Feedback: Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.

31. The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breath and the nurses rapid assessment reveals that the patients jugular veins are distended. The nurse should suspect the development of what oncologic emergency? A) Increased intracranial pressure B) Superior vena cava syndrome (SVCS) C) Spinal cord compression D) Metastatic tumor of the neck

Ans: B Feedback: SVCS occurs when there is gradual or sudden impaired venous drainage giving rise to progressive shortness of breath (dyspnea), cough, hoarseness, chest pain, and facial swelling; edema of the neck, arms, hands, and thorax and reported sensation of skin tightness and difficulty swallowing; as well as possibly engorged and distended jugular, temporal, and arm veins. Increased intracranial pressure may be a part of SVCS, but it is not what is causing the patients symptoms. The scenario does not mention a problem with the patients spinal cord. The scenario says that the cancer has metastasized, but not that it has metastasized to the neck.

19. The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A) P wave inversion B) T wave inversion C) Q wave changes with no change in ST or T wave D) P wave enlargement

Ans: B Feedback: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

34. A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A) Use clean technique and wear a mask during dressing changes. B) Change the dressing no more than weekly. C) Apply antibiotic ointment around the site with each dressing change. D) Irrigate the insertion site with sterile water during each dressing change.

Ans: B Feedback: The CDC (2011) recommends changing CVAD dressings not more than every 7 days unless the dressing is damp, bloody, loose, or soiled. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not used.

13. A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize? A) Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter B) Risk for Infection Related to the Presence of a Subclavian Catheter C) Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter D) Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter

Ans: B Feedback: The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The patient will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these.

33. A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patients plan of care, which of the following nursing diagnoses should be included? A) Risk for Peripheral Neurovascular Dysfunction Related to Catheter Placement B) Ineffective Role Performance Related to Parenteral Nutrition C) Bowel Incontinence Related to Parenteral Nutrition D) Chronic Pain Related to Catheter Placement

Ans: B Feedback: The limitations associated with PN can make it difficult for patients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction.

24. When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information? A) The patients activities limitations and level of consciousness after the attacks B) The patients symptoms and the activities that precipitate attacks C) The patients understanding of the pathology of angina D) The patients coping strategies surrounding the attacks

Ans: B Feedback: The nurse must gather information about the patients symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The patients coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

20. An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories B) Morphine sulphate, oxygen, and bed rest C) Oxygen and beta-adrenergic blockers D) Bed rest, albuterol nebulizer treatments, and oxygen

Ans: B Feedback: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

8. The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? A) Skin turgor B) Potassium level C) White blood cell count D) Peripheral pulses

Ans: B Feedback: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.

22. In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education? A) Ill try to stay in bed for the first few days to allow myself to heal. B) Ill make sure that I dont cross my legs when Im resting in bed. C) Ill keep pillows under my knees to help my blood circulate better. D) Ill put on those compression stockings if I get pain in my calves.

Ans: B Feedback: To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

26. A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patients care plan should include nursing actions relevant to what potential complications? Select all that apply. A) Dumping syndrome B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis

Ans: B, C, D, E Feedback: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

23. A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A) Ensuring adequate rest B) Limiting exposure to sunlight C) Limiting intake of alcohol D) Smoking cessation

Ans: C Feedback: Alcohol and red meat can precipitate an acute exacerbation of gout. Each of the other listed actions is consistent with good health, but none directly addresses the factors that exacerbate gout.

25. You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the womans statement? A) Spiritual distress related to change in health status B) Acute confusion related to prognosis for recovery C) Anxiety related to cardiac symptoms D) Deficient knowledge related to treatment of angina pectoris

Ans: C Feedback: Although further assessment is warranted, it is not unlikely that the patient is experiencing anxiety. In patients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it is not clear that a lack of knowledge or information is the root of her anxiety.

5. Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A) The symptoms indicate angina and should be treated as such. B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C) The symptoms indicate an acute coronary episode and should be treated as such. D) Treatment should be determined pending the results of an exercise stress test.

Ans: C Feedback: Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patients symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

1. The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy

Ans: C Feedback: As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patients hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

3. The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patients medical history, what is a potential primary cause of the patients heart failure? A) Endocarditis B) Pleural effusion C) Atherosclerosis D) Atrial-septal defect

Ans: C Feedback: Atherosclerosis of the coronary arteries is the primary cause of HF. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of HF.

31. The nurse is participating in the care conference for a patient with ACS. What goal should guide the care teams selection of assessments, interventions, and treatments? A) Maximizing cardiac output while minimizing heart rate B) Decreasing energy expenditure of the myocardium C) Balancing myocardial oxygen supply with demand D) Increasing the size of the myocardial muscle

Ans: C Feedback: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate because some patients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardiums energy expenditure is often beneficial, but this must be balanced with productivity.

26. A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms? A) A pattern of distinct exacerbations and remissions B) Severe diarrhea C) An absence of blood in stool D) Involvement of the rectal mucosa

Ans: C Feedback: Bloody stool is far more common in cases of UC than in Crohns. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohns) and patients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohns often has a more prolonged and variable course.

40. A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? A) Administration of bronchodilators by nebulizer B) Administration of inhaled corticosteroids by metered dose inhaler (MDI) C) Patients consistent performance of deep breathing and coughing exercises D) Patients active participation in the cardiac rehabilitation program

Ans: C Feedback: Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning, and chest physical therapy, as well as educating and encouraging the patient to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.

11. A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge? A) The familys ability to take care of the patients special diet needs B) The familys ability to monitor the patients changing health status C) The familys ability to provide emotional support D) The familys ability to manage the patients medication regimen

Ans: C Feedback: Emotional support from the family is key to the patients coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the patients health status. It is highly beneficial if the family is willing and able to accommodate the patients dietary needs, but emotional support is paramount and cannot be solely provided by the patient alone.

4. A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following? A) Autoimmune processes in the joints B) Chronic metabolic acidosis C) Increased uric acid levels D) Unstable serum calcium levels

Ans: C Feedback: Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune disease and it does not result from metabolic acidosis or unstable serum calcium levels.

36. A 51-year-old woman is experiencing perimenopausal symptoms and expresses confusion around the possible use of hormone therapy (HT). She explains that her mother and aunts used HT and she is unsure why few of her peers have been prescribed this treatment. What should the nurse explain to the patient? A) Large, long-term health studies have revealed that HT is minimally effective. B) HT has been largely replaced by other nonpharmacologic interventions. C) Research has shown that significant health risks are associated with HT. D) HT has been shown to exacerbate symptoms of menopause in a minority of women.

Ans: C Feedback: HT is effective, but has been associated with serious adverse effects. However, it does not exacerbate the symptoms of menopause. Nonpharmacologic interventions that address perimenopausal symptoms have not yet been identified.

21. The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response? A) Document this expected assessment finding during the initial postoperative period. B) Reposition the patient with his left leg in a dependent position. C) Inform the patients physician of this assessment finding. D) Administer an ordered dose of subcutaneous heparin.

Ans: C Feedback: If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.

3. The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A) Ineffective breathing pattern related to decreased cardiac output B) Anxiety related to fear of death C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D) Impaired skin integrity related to CAD

Ans: C Feedback: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

39. A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action? A) Document the patients low urine output and monitor closely for the next several hours. B) Contact the dietitian and suggest the need for increased oral fluid intake. C) Contact the patients physician and suggest assessment of fluid balance and renal function. D) Increase the infusion rate of the patients IV fluid to prompt an increase in renal function.

Ans: C Feedback: Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

38. A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patients plan of care. What intervention is most justified in the care of this patient? A) Administration of prophylactic antibiotics B) Total parenteral nutrition (TPN) C) Use of a pressure-relieving mattress D) Use of a Foley catheter until discharge

Ans: C Feedback: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.

5. An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? A) Stool will be yellow for the first 24 hours postprocedure. B) The barium may cause diarrhea for the next 24 hours. C) Fluids must be increased to facilitate the evacuation of the stool. D) Slight anal bleeding may be noted as the barium is passed.

Ans: C Feedback: Postprocedural patient education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements, because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected.

36. The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care? A) Maximize the patients fluid intake. B) Provide total parenteral nutrition (TPN). C) Keep the patients bed linens free of wrinkles. D) Provide the patient with snug clothing at all times.

Ans: C Feedback: Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be adequate, and must be monitored, but maximizing fluid intake is not a goal. TPN is a nutritional intervention of last resort.

9. A nurse is participating in a patients care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN? A) TNA can be mixed by a certified registered nurse. B) TNA can be administered over 8 hours, while PN requires 24-hour administration. C) TNA is less costly than PN. D) TNA does not require the use of a micron filter.

Ans: C Feedback: TNA is mixed in one container and administered to the patient over a 24-hour period. A 1.5-micron filter is used with the TNA solution. Advantages of the TNA over PN include cost savings. Pharmacy staff must prepare both solutions.

7. A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what? A) 5% deficit in body weight compared to preillness weight and increased caloric need B) Calorie deficit and muscle wasting combined with low electrolyte levels C) Inability to take in adequate oral food or fluids within 7 days D) Significant risk of aspiration coupled with decreased level of consciousness

Ans: C Feedback: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parenteral.

12. The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified? A) Gender, obesity, family history, and smoking B) Inactivity, stress, gender, and smoking C) Obesity, inactivity, diet, and smoking D) Stress, family history, and obesity

Ans: C Feedback: The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.

11. A patient in her late fifties has expressed to the nurse her desire to explore hormone replacement therapy (HRT). Based on what aspect of the patients health history is HRT contraindicated? A) History of vaginal dryness B) History of hot flashes and night sweats C) History of vascular thrombosis D) Family history of osteoporosis

Ans: C Feedback: The use of HRT is contraindicated in women with a history of vascular thrombosis, active liver disease, some cases of uterine cancer, and undiagnosed vaginal bleeding. HRT is beneficial in women with a risk for osteoporosis. Vaginal dryness, hot flashes, and night sweats are symptoms of menopause that may be relieved with HRT.

35. The nurse is assessing a patient who believes that she has recently begun menopause. What principle should inform the nurses interactions with this patient? A) The nurse should express empathy for the patients difficult health situation. B) The nurse should begin by assuring the patient that her health will be much better in a few years. C) The nurse must carefully assess the patients feelings and beliefs surrounding menopause. D) The nurse should encourage the patient to celebrate this life milestone and its accompanying benefits.

Ans: C Feedback: Women have widely varying views on menopause and the nurse must ascertain these. It is wrong to presume either a positive or negative view of this transition without first performing assessment.

16. A 51-year-old woman has come to the OB/GYN clinic for her annual physical. She tells the nurse that she has been experiencing severe hot flashes, but that she is reluctant to begin hormone therapy (HT). What potential solution should the nurse discuss with the patient? A) Sodium restriction B) Adopting a vegan diet C) Massage therapy D) Vitamin supplements

Ans: D Feedback: For some women, vitamins B6 and E have proven beneficial for the treatment of hot flashes. Sodium restriction, vegan diet, and massage have not been noted to relieve this symptom of perimenopause.

28. A 48-year-old woman presenting for care is seeking information about hormone therapy (HT) for the treatment of her perimenopausal symptoms. The patients need for relief from hot flashes and other symptoms will be weighed carefully against the increased risks of what complications of HT? Select all that apply. A) Anaphylaxis B) Osteoporosis C) Breast cancer D) Cardiovascular disease E) Venous thromboembolism

Ans: C, D, E Feedback: Although HT decreases hot flashes and reduces the risk of osteoporotic fractures as well as colorectal cancer, studies have shown that it increases the risk of breast cancer, heart attack, stroke, and blood clots. There is no significant risk of anaphylaxis.

32. A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply. A) Surgical treatment options B) The importance of weight loss C) Managing Raynauds-type symptoms D) Smoking cessation E) The importance of vigilant skin care

Ans: C, D, E Feedback: Patient teaching for the patient with scleroderma focuses on management of Raynauds phenomenon, smoking cessation, and meticulous skin care. Surgical treatment options do not exist and weight loss is not a central concern.

12. The nurse has entered a patients room and found the patient unresponsive and not breathing. What is the nurses next appropriate action? A) Palpate the patients carotid pulse. B) Illuminate the patients call light. C) Begin performing chest compressions. D) Activate the Emergency Response System (ERS).

Ans: D Feedback: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.

32. The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patients psychosocial needs? A) Reinforce the fact that treatment will be successful. B) Facilitate a referral to a chaplain or spiritual leader. C) Increase the patients participation in rehabilitation activities. D) Directly address the patients anxieties and fears.

Ans: D Feedback: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the patients psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some patients, but it may exacerbate it for others.

9. The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first? A) Check for a carotid pulse. B) Apply supplemental oxygen. C) Give two full breaths. D) Gently shake and shout, Are you OK?

Ans: D Feedback: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.

40. A nurse is preparing to administer a patients scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurses best action? A) Recognize this as an expected finding. B) Place the bag in a warm environment for 30 minutes. C) Shake the bag vigorously for 10 to 20 seconds. D) Contact the pharmacy to obtain a new bag of PN.

Ans: D Feedback: Before PN infusion is administered, the solution must be inspected for separation, oily appearance (also known as a cracked solution), or any precipitate (which appears as white crystals). If any of these are present, it is not used. Warming or shaking the bag is inappropriate and unsafe.

37. A community health nurse is leading a health education session addressing menopause and other aspects of womens health. What dietary supplements should the nurse recommend to prevent morbidity associated with osteoporotic fractures? A) Vitamin B12 and vitamin C B) Vitamin A and potassium C) Vitamin B6 and phosphorus D) Calcium and vitamin D

Ans: D Feedback: Calcium and vitamin D supplementation may be helpful in reducing bone loss and preventing the morbidity associated with osteoporotic fractures. Phosphorus, potassium, vitamin B12, vitamin C, and vitamin B6 do not address this risk.

9. The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A) Coronary artery bypass graft (CABG) B) Percutaneous transluminal coronary angioplasty (PTCA) C) Atherectomy D) Cardiopulmonary bypass

Ans: D Feedback: Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.

14. The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following? A) Drug therapy and smoking cessation B) Diet and drug therapy C) Diet therapy only D) Diet therapy and smoking cessation

Ans: D Feedback: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

2. The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)? A) The patient takes Lasix (furosemide) 20 mg/day. B) The patients potassium level is 4.7 mEq/L. C) The patient is an African American man. D) The patients age is greater than 65.

Ans: D Feedback: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physicians office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF.

2. A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause? A) Decreased cardiac output B) Decreased cardiac contractility C) Infarction of the myocardium D) Coronary arteriosclerosis

Ans: D Feedback: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

36. Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject? A) Symptoms of hypovolemia B) Symptoms of low blood pressure C) Complications requiring graft removal D) Intubation and mechanical ventilation

Ans: D Feedback: Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is important that patients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most patients. Teaching would also generally not include rare complications that would require graft removal.

33. A 40-year-old woman was diagnosed with Raynauds phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient also states that many of her skin surfaces are stiff, like the skin is being stretched from all directions. The nurse should recognize the need for medical referral for the assessment of what health problem? A) Giant cell arteritis (GCA) B) Fibromyalgia (FM) C) Rheumatoid arthritis (RA) D) Scleroderma

Ans: D Feedback: Scleroderma starts insidiously with Raynauds phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA.

17. The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? A) High HDL values and high triglyceride values B) Absence of detectable total cholesterol levels C) Elevated blood lipids, fasting glucose less than 100 D) Low LDL values and high HDL values

Ans: D Feedback: The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.

23. An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness

Ans: D, E Feedback: Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.

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