MED SURG FINAL!!
Parkinson Bromocriptine AE
hallucinations, and abnormal involuntary movements- similar to the nature to those of levodopa.
The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed?
"I eat small meals throughout the day and have a bedtime snack"
Diagnosis of AIDS
-CD4+ T-cell count <200 cells/mm3 OR -HIV w/ an opportunistic infection present
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) Antidiarrheal 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
A) Antidiarrheal medications 30 minutes before a meal
A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patients care plan? A) Protective isolation and vigilant use of standard precautions B) Provision of a high-calorie, low-texture diet and appropriate oral hygiene C) Including the family in planning the patients activities of daily living D) Monitoring and treating the patients pain
A) Protective isolation and vigilant use of standard precautions
A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? A. "I have this ringing in my ears that just won't 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 that's high in fat, I get really nauseous." D. "I seem to have lost my appetite, which is unusual for me.
A. "I have this ringing in my ears that just won't go away."
Peritonitis s/s:
pain, tenderness, rigid abdominal muscles, fever, nausea, vomit, bloating, chills, fever, loss of appetite
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? A. Instill the medication in the conjunctival sac. B. Maintain a supine position for 10 minutes after administration. C. Keep the eyes closed for 1 to 2 minutes after administration. D. Apply the medication evenly to the sclera
A. Instill the medication in the conjunctival sac.
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
B) Tofu
The nurse is assessing the client for the presence of a Chvostek sign. Which electrolyte imbalance would a positive Chvostek sign indicate? A. Hypermagnesemia B. Hyponatremia C. Hypocalcemia D. Hyperkalemia
C. Hypocalcemia
The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care? A. Risk for disturbed sensory perception B. Risk for unilateral neglect C. Risk for falls D. Risk for ineffective health maintenance
C. Risk for falls
The nurse is caring for a 78-year old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? A. Sit in a chair for 10 minutes prior to ambulating. B. Drink plenty of fluids to increase circulating blood volume. C. Stand upright for 2 to 3 minutes prior to ambulating. D. Perform range-of-motion exercises for each joint
C. Stand upright for 2 to 3 minutes prior to ambulating.
Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the nurses teaching about the purpose of the biopsy has been effective? A. The biopsy will remove the cancer in my prostate gland. B. The biopsy will determine how much longer I have to live. C. The biopsy will help decide the treatment for my enlarged prostate. D. The biopsy will indicate whether the cancer has spread to other organs.
C. The biopsy will help decide the treatment for my enlarged prostate.
T-tube monitoring
Monitor tube patency
The nurse explains to a patient undergoing brachytherapy of the cervix that she A. must undergo simulation to locate the treatment area B. requires the use of radioactive precautions during nursing care C . may experience desquamation of the skin on the abdomen and upper legs D. requires shielding of the ovaries during treatment to prevent ovarian damage.
B. requires the use of radioactive precautions during nursing care
While on spring break, a 22-year-old client was taken to the hospital for heat strokeand alcohol poisoning. The client is worried and states that a biopsy was taken and showed "some kind of benign condition." Which response by the nurse would be best? A. "I understand that you are worried. Benign conditions are noncancerous, but let's look at your chart to see your results." B. "You have every right to be upset; a benign condition means you may have cancerous cells. Let me call your health care provider to talk to you." C. "Are you sure a biopsy was done? Your admitting diagnosis would not prompt that kind of procedure." D. "Do not worry; if something was wrong, your primary health care provider would have told you and started treatment."
A. "I understand that you are worried. Benign conditions are noncancerous, but let's look at your chart to see your results."
A client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address which potential adverse effect? A. Bone marrow suppression B. Acute confusion C. Sedation D. Malignant hyperthermia
A. Bone marrow suppression
The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration, the nurse explains to a newly licensed nurse how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing which process? A. Diffusion B. Osmosis C. Active transport
A. Diffusion
The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration? A. Extravasation of the medication B. Discomfort to the client C. Blanching at the site D. Hypersensitivity reaction to the medication
A. Extravasation of the medication
A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) B. Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) C. Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions D. Random plasma glucose greater than 126 mg/dL (7.0 mmol/L)
A. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L)
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding
A. Fried chicken
A nurse is teaching a 53-year-old man about prostate cancer, given the fact that the client has a family history of the disease. What information should the nurse provide to best facilitate the early identification of prostate cancer? A. Have a digital rectal examination and prostate- specific antigen (PSA) test done as recommended. B. Have a transrectal ultrasound every 5 years. C. Perform monthly testicular self- examinations, especially after age 60. D. Have a complete blood count (CBC), blood urea nitrogen (BUN), and creatinine assessment performed annually
A. Have a digital rectal examination and prostate- specific antigen (PSA) test done as recommended.
A client has been brought to the emergency department by paramedics after being found unconscious. The client's MedicAlert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A. IV administration of 50% dextrose in water B. Subcutaneous administration of 10 units of Humalog C. Subcutaneous administration of 12 to 15 units of regular insulin D. IV bolus of 5% dextrose in 0.45% NaC
A. IV administration of 50% dextrose in water
The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? A. Increased serum sodium B. Decreased serum potassium C. Decreased hemoglobin D. Increased platelets
A. Increased serum sodium
The nurse is caring for a 63-year- old client with ovarian cancer. The client is to receive chemotherapy consisting of paclitaxel and carboplatin. For what adverse effect of this treatment should the nurse monitor the client? A. Leukopenia B. Metabolic acidosis C. Hyperphosphatemia D. Respiratory alkalosis
A. Leukopenia
A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high- dose radiation (HDR). What safety measure should the nurse include in this client's plan of care? A. Limit the time that visitors spend at the client's bedside. B. Teach the client to perform all aspects of basic care independently. C. Assign male nurses to the client's care whenever possible. D. Situate the client in a shared room with other clients receiving brachytherapy
A. Limit the time that visitors spend at the client's bedside.
A nurse who works in an oncology clinic is assessing a client who has arrived for a 2 month follow- up appointment following chemotherapy. The nurse notes that the client's 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
A. Liver function tests (LFTs)
A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate
A. Metoclopramide
A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, "Wouldn't sterile water be a more appropriate choice than salt water?" Under what circumstances would the nurse administer electrolyte- free water intravenously? A. Never, because it rapidly enters red blood cells, causing them to rupture. B. When the client is severely dehydrated, resulting in neurologic signs and symptoms C. When the client is in excess of calcium and/or magnesium ions D. When a client's fluid volume deficit is due to acute or chronic kidney disease
A. Never, because it rapidly enters red blood cells, causing them to rupture.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis
A. Respiratory acidosis
A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis
A. Rheumatoid arthritis (RA)
When caring for a patient who is pancytopenic, which action by nursing assistive personnel (NAP) indicates a need for the RN to intervene? A. The NAP assists the patient to use dental floss after eating. B. The NAP adds baking soda to the patients saline oral rinses. C. The NAP puts fluoride toothpaste on the patients toothbrush. D. The NAP has the patient rinse after meals with a saline solution.
A. The NAP assists the patient to use dental floss after eating.
A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely to detect malignant changes. B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C. Small amounts of blood are likely to be present in the stools and are not cause for concern. D. Antacids may be discontinued when symptoms of heartburn subside.
A. The client will be monitored closely to detect malignant changes.
A client is postoperative day 6 following tympanoplasty and mastoidectomy. The client has phoned the surgical unit and states experiencing occasional sharp, shooting pains in the affected ear. How should the nurse best interpret this client's report? A. These pains are an expected finding during the first few weeks of recovery. B. The client's report is suggestive of a postoperative infection. C. The client may have experienced a spontaneous rupture of the tympanic membrane. D. The client's surgery may have been unsuccessful.
A. These pains are an expected finding during the first few weeks of recovery.
A teenage client is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? A. Type 1 diabetes B. Type 2 diabetes C. Non-insulin-dependent diabetes D. Prediabetes
A. Type 1 diabetes
During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: A. acquired immunity. B. natural immunity. C. phagocytic immunity. D. humoral immunity
A. acquired immunity.
A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of: A. lymphocytes. B. cytoblasts. C. antibodies. D. capillaries
A. lymphocytes.
When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is staged as Tis, N0, M0. The nurse will teach the patient that A. the cancer is localized to the cervix. B. the cancer cells are well-differentiated. C. further testing is needed to determine the spread of the cancer. D. it is difficult to determine the original site of the cervical cancer.
A. the cancer is localized to the cervix.
A client who had a cholecystectomy has a T-tube for drainage. The nurse measures the amount of bile drainage from the T-tube at the end of each shift. How should the nurse record the drainage? A. adding it to the client's urine output B. charting it separately on the output record C. adding it to the amount of wound drainage D. subtracting it from the total intake for each day
B. charting it separately on the output record
A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse? A) A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. B) A person whose vision is 20/40 can see an object from 20 feet away that person with 20/20 vision can see from 40 feet away. C) A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away. D) A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.
B) A person whose vision is 20/40 can see an object from 20 feet away that person with 20/20 vision can see from 40 feet away.
A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A. "Abdominal ultrasound is very safe, but it can't be performed if you're pregnant." B. "Abdominal ultrasound poses no known safety risks of any kind." C. "Current guidelines state that a person can have up to 3ultrasounds per year." D. "Current guidelines state that a person can have up to 6 ultrasounds per year."
B. "Abdominal ultrasound poses no known safety risks of any kind."
A client at high risk for breast cancer is scheduled for an incisional biopsy in theoutpatient surgery department. When the nurse is providing preoperative education, the client asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurse'sbest response? A. "An incisional biopsy is performed because it's known to be less painful and more accurate than other forms of testing." B. "An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment." C. "An incisional biopsy is performed to assess the potential for recovery from a mastectomy." D. "An incisional biopsy is performed on clients who are younger than the age of 40and who are otherwise healthy.
B. "An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment."
An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being suggestive of diabetes? A. "I've always been a fan of sweet foods, but lately I'm turned off by them." B. "Lately, I drink and drink and can't seem to quench my thirst." C. "No matter how much sleep I get, it seems to take me hours to wake up." D. "When I went to the washroom the last few days, my urine smelled odd."
B. "Lately, I drink and drink and can't seem to quench my thirst."
A client has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the health care provider prescribe for this client? A. A sulfonylurea B. A biguanide C. A thiazolidinedione D. An alpha-glucosidase inhibitor
B. A biguanide {Sulfonylureas} exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective {Thiazolidinediones} enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. {Alpha-glucosidase inhibitors} work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level
A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribed B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area
B. Application of heat 15 to 20 minutes each hour Rationale: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed.
The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? A. Pain and peritonitis B. Bleeding and perforation C. Acidosis and hypoglycemia D. Gangrene of the gallbladder and hyperglycemia
B. Bleeding and perforation
When discussing with a client factors that distinguish malignant cells from benign cells of the same tissue type, which characteristic should the nurse mention? A. Slow rate of mitosis of cancer cells B. Different proteins in the cell membrane C. Differing size of the cells D. Different molecular structure in the cells
B. Different proteins in the cell membrane
A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? A. Petechiae B. Erythematous rash C. Jaundice D. Skin sloughing
B. Erythematous rash
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? A. Hearing will not be affected by a decibel level in this range. B. Hearing loss may occur with a decibel level in this range. C. Sounds in this decibel level are not perceived to be harsh to the ear. D. Ear plugs will have no effect on these decibel levels
B. Hearing loss may occur with a decibel level in this range.
The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first suspect? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia
B. Hypocalcemia
A nurse is providing care for a client who has just been diagnosed with early-stage rheumatoid arthritis (RA). The nurse should anticipate the administration of which medication? A. Hydromorphone B. Methotrexate C. Allopurinol D. Prednisone
B. Methotrexate
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities
B. Neck flexion produces flexion of knees and hips
A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described with which of the following terms? A. Hydrostatic pressure B. Osmosis and osmolality C. Diffusion D. Active transport
B. Osmosis and osmolality
A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well recognized sign of this infection? A. Negative Brudzinski sign B. Positive Kernig sign C. Hyperpatellar reflex D. Sluggish pupil reaction
B. Positive Kernig sign
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO 2 D. Metabolic acidosis
B. Respiratory alkalosis
While performing an assessment, the nurse notes that a client has soft subcutaneous nodules along the extensor tendons of the fingers. Which disorder does this client most likely have? A. Osteoarthritis B. Rheumatoid arthritis C. Gout D. Paget disease
B. Rheumatoid arthritis
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit? A. Recent completion of radiation therapy for treatment of thyroid cancer B. Routine use of quinine for management of leg cramps C. Allergy to hair coloring and hair spray D. Previous perforation of the eardrum
B. Routine use of quinine for management of leg cramps
A client is receiving ongoing nursing care for the treatment of Parkinson disease. When assessing this client's gait, which finding is most closely associated with this health problem? A. Spastic hemiparesis gait B. Shuffling gait C. Rapid gait D. Steppagegai
B. Shuffling gait
A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? A. Tzanck smear B. Skin biopsy C. Patch testing D. Skin scrapings
B. Skin biopsy
A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A. Surgery is delayed until the client can eat a regular diet without vomiting. B. Surgery is delayed until the acute symptoms subside. C. The client requires aggressive nutritional support prior to surgery. D. Time is needed to determine whether a laparoscopic procedure can be used.
B. Surgery is delayed until the acute symptoms subside.
A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C. The kidneys react rapidly to compensate for imbalances in the body. D. The kidneys regulate the bicarbonate level in the intracellular fluid
B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action? A. The patient ambulates several times a day in the room. B. The patients visitors bring in some fresh peaches from home. C. The patient cleans with a warm washcloth after having a stool. D. The patient uses soap and shampoo to shower every other day.
B. The patients visitors bring in some fresh peaches from home.
When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to A. infuse the medication over a short period of time. B. stop the infusion if swelling is observed at the site. C. administer the chemotherapy through small-bore catheter. D. hold the medication unless a central venous line is available
B. stop the infusion if swelling is observed at the site.
A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion
C. Meningitis
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered
C) Administration of thorough oral hygiene
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig
C) Sumatriptan succinate (Imitrex)
While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? A. Benign tumors do not cause damage to other tissues. B. Benign tumors are likely to recur in the same location. C. Malignant tumors may spread to other tissues or organs. D. Malignant cells reproduce more rapidly than normal cells
C. Malignant tumors may spread to other tissues or organs.
The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed nursing assistant? A. Check the abdominal dressings for bleeding. B. Increase the IV fluid if the blood pressure is low. C. Document the amount of output on the I & O sheet. D. Listen to the breath sounds in all lobes.
C. Document the amount of output on the I & O sheet.
The client is six hours postoperative open cholecystectomy and the nurse finds a large amount of red drainage on the dressing. Which intervention should the nurse implement? A. Measure the abdominal girth. B. Palpate the lower abdomen for a mass. C. Turn client onto side to assess for further drainage. D. Remove the dressing to determine the source.
C. Turn client onto side to assess for further drainage.
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's 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
C. An absence of blood in stool
A 45-year- old client has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the health care provider explained to the client that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called? A. Internal beam radiation B. Trachelectomy C. Brachytherapy D. External radiation
C. Brachytherapy
A client with hypertension has been prescribed hydrochlorothiazide. What nursin gaction will best reduce the client's risk for electrolyte disturbances? A. Maintain a low-sodium diet. B. Encourage the use of over-the-counter calcium supplements. C. Ensure the client has sufficient potassium intake. D. Encourage fluid intake
C. Ensure the client has sufficient potassium intake.
The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation? A. Endocarditis B. Multiple myeloma C. Guillain-Barré syndrome D. Overdose of amphetamine
C. Guillain-Barré syndrome
A nurse is performing the health history and physical assessment of a client 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 lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints
C. Joint stiffness lasting longer than 1 hour, especially in the morning
An intravenous solution of lactated Ringers is prescribed to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. The nurse recalls that the condition that will improve if the administration of lactated Ringers solution is effective is: A. Urinary stasis B. Paralytic ileus C. Metabolic acidosis D. Increased potassium level
C. Metabolic acidosis
The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission, and since that time the client has been on low intermittent suction. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? A. Hypercalcemia B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis
C. Metabolic alkalosis
When administering a client's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A. Ensure that the client is well hydrated at all times. B. Encourage self-administration of eye drops. C. Occlude the puncta after applying the medication. D. Position the client supine before administering eye drops
C. Occlude the puncta after applying the medication.
The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma? A. The client uses over-the-counter NSAIDs. B. The client has a history of stroke. C. The client has diabetes. D. The client has Asian ancestry.
C. The client has diabetes.
In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? A. The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediate postoperative period. B. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.
C. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.
A client has an open cholecystectomy w/ bile duct exploration. Following surgery, the client has a T tube. What should the nurse do to determine the effectiveness of the T tube? A. Irrigate the tube w/ 20 mL normal saline q4h B. unclamp the T tube & empty the contents everyday C. assess the color & amount of drainage every shift D. monitor the incision sites for bile drainage
C. assess the color & amount of drainage every shift
External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient that an important measure to prevent complications from the effects of the radiation is to A. test all stools for the presence of blood. B. maintain a high-residue, high-fiber diet. C. clean the perianal area carefully after every bowel movement. D. inspect the mouth and throat daily for the appearance of thrush.
C. clean the perianal area carefully after every bowel movement.
A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. The nurse explains that the expected outcome of this surgery is A. relief of pain by cutting sensory nerves in the stomach. B. control of the tumor growth by removal of malignant tissue. C. decrease in tumor size to improve the effects of other therapy. D. promotion of better nutrition by relieving the pressure in the stomach.
C. decrease in tumor size to improve the effects of other therapy
At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), what should the nurse do next? Chart: Output record:1200 - 50 mL1600 - 60 mL2000 - 60 mL0000 - 70 mL0400 - 70 mL0800 - 10 mL A. report the 24 hr drainage amount at 1200 B. clamp the T-tube C. evaluate tube for patency D. irrigate the T-tube
C. evaluate tube for patency
The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye? A. 30 seconds B. 1 minute C. 3 minutes D. 5 minutes
D. 5 minutes
A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. G astrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Administration of injections of vitamin B12
D. Administration of injections of vitamin B12
A client's most recent laboratory results show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? A. Apples B. Fish C. Rice D. Bananas
D. Bananas
When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A. Active transport of hydrogen ions across the capillary walls B. Pressure of the blood in the renal capillaries C. Action of the dissolved particles contained in a unit of blood D. Hydrostatic pressure resulting from the pumping action of the heart
D. Hydrostatic pressure resulting from the pumping action of the heart
The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia
D. Hypovolemia
The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? A. Respiratory acidosis with no compensation B. Me tabolic alkalosis with compensatory alkalosis C. Metabolic acidosis with no compensation D. Metabolic acidosis with compensatory respiratory alkalosis
D. Metabolic acidosis with compensatory respiratory alkalosis
A neonate exhibited some preliminary signs of infection, but the infant's condition resolved spontaneously prior to discharge home from the hospital. This infant's recovery was most likely due to which type of immunity? A. Cytokine immunity B. Specific immunity C. Active acquired immunity D. Nonspecific immunity
D. Nonspecific immunity (natural immunity)
The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An arterial blood gas test reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3-20 mEq/L. The nurse should recognize the likelihood of which acid-base disorder(s)? A. Respiratory acidosis only B. Respiratory acidosis and metabolic alkalosis C. Respiratory alkalosis and metabolic acidosis D. Respiratory acidosis and metabolic acidosis
D. Respiratory acidosis and metabolic acidosis
A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? A. Monitoring the client's neutrophil levels B. Assessing the client for signs of impaired liver function C. Monitoring the client's level of consciousness and behavior D. Reviewing the client's creatinine and BUN levels
D. Reviewing the client's creatinine and BUN levels
A client with rheumatic disease has developed a gastrointestinal (GI) bleed. The nurse caring for the client should further assess for medications that typically exacerbate this condition. Which medication applies? A. Corticosteroids B. Immunomodulators C. Antimalarials D. Salicylate therapy
D. Salicylate therapy
A 70-yr-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? A. Weight gain of 6 lb B. Nausea and vomiting C. Urine specific gravity of 1.004 D. Serum sodium level of 118 mEq/L
D. Serum sodium level of 118 mEq/L
The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A. Hypertension B. Kussmaul respirations C. Increased DTRs D. Shallow respirations
D. Shallow respirations
Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider? A. Hematocrit of 30% B. Platelets of 95,000/l C. Hemoglobin of 10 g/L D. WBC count of 1700/l
D. WBC count of 1700/l
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to A. teach about the importance of nutrition during treatment. B. have the patient eat large meals when nausea is not present. C. offer dry crackers and carbonated fluids during chemotherapy. D. administer prescribed antiemetics 1 hour before the treatments.
D. administer prescribed antiemetics 1 hour before the treatments.
Which nursing diagnosis would be highest priority for the client who had an open cholecystectomy surgery? A. Alteration in nutrition. B. Alteration in skin integrity. C. Alteration in urinary pattern. D. Alteration in comfort.
D. Alteration in comfort
