Medsurg 1 Final

The PACU nurse caring for a client with a nasogastric (NG) tube notes 300 mL of bright red blood has collected. What is the appropriate nursing action? Select one: a. Call the client's surgeon to report the drainage. b. Immediately remove the NG tube. c. Place the client in Trendelenburg position. d. Document as a normal finding.

A. Call the client's surgeon to report the drainage.

The nurse suspects that a patient is deficient in thyroid-stimulating hormone. What assessment findings would correlate to this condition? (Select all that apply.) Select one or more: a. Decreased libido b. Weight gain c. Alopecia d. Hyperactivity

a. Decreased libido b. Weight gain c. Alopecia

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? a. Twitching b. Hypoactive bowel sounds c. Negative Trousseau's sign d. Hypoactive deep tendon reflexes

a. Twitching

You're assessing the patient's complete blood count (CBC). Which lab result below demonstrates leukopenia? a. WBC 3,000 b. Platelets 500,000 c. Platelets 90,000 d. WBC 7,000

a. WBC 3,000

A nurse cares for a patient with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? Select one: a. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." b. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "You need to start with multiple injections until you become more proficient at self-injection."

a. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."

A patient has peripheral arterial disease (PAD). What statement by the patient indicates misunderstanding about self-management activities? Select one: a. "I can use a heating pad on my legs if it's set on low." b. "It's going to be really hard but I will stop smoking." c. "I should not cross my legs when sitting or lying down." d. "I will go out and buy some warm, heavy socks to wear."

a. "I can use a heating pad on my legs if it's set on low."

After teaching a patient who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the patient's understanding. Which statement by the patient indicates a correct understanding of the teaching? Select one: a. "I will avoid sources of strong electromagnetic fields." b. "I should participate in a strenuous exercise program." c. "I should wear a snug-fitting shirt over the ICD." d. "Now I can discontinue my antidysrhythmic medication."

a. "I will avoid sources of strong electromagnetic fields."

The nurse is assisting in administering immunizations as well as providing education to the clients who receive them at a health care clinic. Which statement by a client indicates that teaching was successful? a. "Immunizations are a way to acquire immunity to a specific disease." b. "Immunizations can provide innate immunity." c. "Immunizations protect against all diseases." d. "Immunizations can provide natural immunity."

a. "Immunizations are a way to acquire immunity to a specific disease."

A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure? Select one: a. "My shoes fit really tight lately." b. "I wake up coughing every night." c. "I have trouble catching my breath." d. "I sleep with four pillows at night."

a. "My shoes fit really tight lately."

A nurse is caring for a patient who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The patient's symptoms have now resolved and the patient asks, "When can I stop taking these medications?" How would the nurse respond? Select one: a. "Once you start corticosteroids, you have to be weaned off them." b. "The drug suppresses your immune system, which must be built back up." c. "You must decrease the dose slowly so your hormones will work again." d. "It is possible for the inflammation to recur if you stop the medication."

a. "Once you start corticosteroids, you have to be weaned off them."

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? a. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." b. "Oxygen will prevent the development of any thrombus." c. "Oxygen has a calming effect." d. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."

a. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells."

The nurse provides education to the client about the primary purpose of neutrophils. Which statement by the client indicates successful teaching? a. "They engulf any potential foreign materials." b. "They increase fluids at the injury site." c. "They close up blood vessels." d. "They open up blood vessels."

a. "They engulf any potential foreign materials."

A client has fluid volume deficit and the provider has prescribed isotonic IV solution at a rate of 100 ml/hour. Which solution does the nurse choose? a. 0.9% sodium chloride (NS) b. 5% dextrose in water (D5W) c. 0.45% sodium chloride (1/2 NS) d. 10% dextrose in water (D10W)

a. 0.9% sodium chloride (NS)

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. a. 10% dextrose in water b. 0.45% sodium chloride c. 5% dextrose in 0.9% saline d. 5% dextrose in 0.45% saline e. 0.9% Normal Saline

a. 10% dextrose in water c. 5% dextrose in 0.9% saline d. 5% dextrose in 0.45% saline

The nurse is making morning rounds to assess assigned patients. Of the following patients with history of asthma, which patient is of highest priority to assess first? Select one: a. A 35-year-old patient who has a longer expiratory phase than inspiratory phase b. A 25-year-old patient with a heart rate of 110 beats/min c. A 66-year-old patient with a barrel chest and clubbed fingernails d. A 42-year-old patient with an oxygen saturation level of 91% at rest

a. A 35-year-old patient who has a longer expiratory phase than inspiratory phase

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? a. Daily weight b. Urinary output c. IV fluid intake d. NG tube intake

a. Daily weight

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? a. A client with an ileostomy b. A client with heart failure c. A client on long-term corticosteroid therapy d. A client receiving frequent wound irrigations

a. A client with an ileostomy

A patient with the diagnosis of chronic obstructive pulmonary disease (COPD) becomes increasingly short of breath. Which nursing intervention is most appropriate? Select one: a. Administer O2 using a Venturi mask at 24% b. Use nasal cannula to administer high flow oxygen c. Do not administer O2 due to history of COPD d. Begin oxygen therapy using a simple face mask at 8L

a. Administer O2 using a Venturi mask at 24%

A nurse assesses a patient who has diabetes mellitus and notes that the patient is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the patient's clinical manifestations have not changed. What action would the nurse take next? Select one: a. Administer another half-cup (120 mL) of orange juice b. Administer 1 mg of glucagon intramuscularly. c. Administer 10 units of regular insulin subcutaneously. d. Administer a half-ampule of dextrose 50% intravenously.

a. Administer another half-cup (120 mL) of orange juice

A patient who had a chest tube placed 8 hours ago and refuses to take deep breaths because of the pain. What action is of highest priority? Select one: a. Administer pain medication and encourage the patient to take deep breaths. b. Ambulate the patient in the hallway to promote deep breathing. c. Auscultate the patient's anterior and posterior lung fields. d. Contact the prescriber and request a STAT chest X-ray

a. Administer pain medication and encourage the patient to take deep breaths.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? a. Administer short-duration insulin intravenously. b. Apply a monitor for an electrocardiogram. c. Correct the acidosis d. Administer 5% dextrose intravenously.

a. Administer short-duration insulin intravenously.

The nurse assesses a patient who reports waking up feeling very tired, even after 9 hours of undisturbed sleep. What action would the nurse take first? Select one: a. Ask the patient if he or she has ever been evaluated for sleep apnea. b. Advise the patient to avoid beverages with caffeine before bed. c. Request a prescription for a sleep aid from the prescriber d. Educate the patient regarding benefits of sleeping upright in a reclining chair.

a. Ask the patient if he or she has ever been evaluated for sleep apnea.

A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take? a. Assess for anaphylaxis and prepare for emergency treatment. b. Teach the client about the relationship between asthma and allergies. c. Obtain an arterial blood gas and immunoglobulin E (IgE) blood level. d. Place the client on 100% oxygen and prepare for intubation.

a. Assess for anaphylaxis and prepare for emergency treatment.

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? a. Assess the client for signs of dizziness and hypotension. b. Assist the client to move quickly from the lying position to the sitting position. c. Allow the client to rise from the bed to a standing position unassisted. d. Elevate the head of the bed quickly to assist the client to a sitting position.

a. Assess the client for signs of dizziness and hypotension.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. a. Bananas b. potatoes c. peas d. cantaloupe e. cauliflower

a. Bananas b. potatoes d. cantaloupe

Which finding in a postoperative client would be of concern to the nurse? a. Blood pressure of 88/52 mm Hg b. Urinary output of 40 mL/hr c. Moderate drainage on the surgical dressing d. Temperature of 37.6°C (99.6°F)

a. Blood pressure of 88/52 mm Hg

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. a. Bounding pulse b. difficulty breathing c. increased during output d. presence of dependent edema e. Neck vein distention in the upright position

a. Bounding pulse b. difficulty breathing d. presence of dependent edema e. Neck vein distention in the upright position

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply. a. Check the drain for patency. b. Observe for bright red bloody drainage. c. Maintain aseptic technique when emptying the drain. d. Curl the drain tightly, and tape it firmly to the body. e. Clamp the drain for 15 minutes every hour.

a. Check the drain for patency. b. Observe for bright red bloody drainage. c. Maintain aseptic technique when emptying the drain.

A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: a. Clot formation in microcirculation b. Vasodilation c. A significantly decreased cardiac output d. Increased systemic vascular resistance e. Increased capillary permeability

a. Clot formation in microcirculation b. Vasodilation e. Increased capillary permeability

A nurse is assessing a patient with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.) Select one or more: a. Confusion, restlessness b. Pulmonary crackles c. Cough that worsens at night d. Pulmonary hypertension e. dependent edema

a. Confusion, restlessness b. Pulmonary crackles c. Cough that worsens at night

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? a. Crackles in the bases b. Rhonchi c. Crackles throughout the lung fields d. Wheezes

a. Crackles in the bases

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. a. Deep, rapid breathing b. Elevated blood glucose c. increased pH d. Decreased urine output

a. Deep, rapid breathing b. Elevated blood glucose

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client most likely has which condition? a. Dehydration b. Hypokalemia c. Fluid Overload d. Hypernatremia

a. Dehydration

A patient had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates that a priority outcome for this patient has been met? Select one: a. Distal pulse on affected extremity 2+/4+ b. Pain rated as 2/10 after medication c. Verbalizes understanding of procedure d. Remains on bedrest as directed

a. Distal pulse on affected extremity 2+/4+

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. a. Dyspnea at rest b. Decreased respiratory rate c. Increased body temperature d. Clubbed fingers e. Muscle retractions f. Prolonged expiratory breathing phase

a. Dyspnea at rest d. Clubbed fingers e. Muscle retractions f. Prolonged expiratory breathing phase

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. a. Encourage alternating activity with rest periods. b. Keep the client in a supine position as much as possible. c. Teach the client techniques of chest physiotherapy. d. Reduce fluid intake to less than 1500 mL/day. e. Teach diaphragmatic and pursed-lip breathing.

a. Encourage alternating activity with rest periods. c. Teach the client techniques of chest physiotherapy. e. Teach diaphragmatic and pursed-lip breathing.

The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. a. Encourage the client to consume a well-balanced diet. b. Instruct the client that episodes of chest pain are expected to occur. c. A thyroid-releasing inhibitor will be prescribed. d. Instruct the client to consume a low-fat diet. e. Instruct the client that thyroid replacement therapy will be needed. f. Provide a warm environment for the client.

a. Encourage the client to consume a well-balanced diet. c. A thyroid-releasing inhibitor will be prescribed.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? a. Glucose Intolerance b. Hyperlipidemia c. Hypertension d. Age

a. Glucose Intolerance

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? a. IV fluids containing dextrose b. NPH insulin subcutaneously c. An ampule of 50% dextrose d. Phenytoin for the prevention of seizures

a. IV fluids containing dextrose

A nurse teaches a patient with hyperthyroidism. Which dietary modifications should the nurse include in this patient's teaching? (Select all that apply.) Select one or more: a. Increased carbohydrates b. Increased calorie intake c. Decreased fats d. Increased proteins

a. Increased carbohydrates b. Increased calorie intake d. Increased proteins

The nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm. After calling for assistance and a defibrillator, what action would the nurse take next? Select one: a. Initiate cardiopulmonary resuscitation (CPR). b. Start an 18-gauge intravenous line. c. Ask the patient's family about code status. d. Perform a pericardial thump.

a. Initiate cardiopulmonary resuscitation (CPR).

A nurse evaluates the following laboratory results for a patient who has hypoparathyroidism: Calcium 7.2 mg/dL (1.8 mmol/L) Sodium 144 mEq/L (144 mmol/L) Magnesium 1.2 mEq/L (0.6 mmol/L) Potassium 5.7 mEq/L (5.7 mmol/L) Based on these results, which medications does the nurse anticipate administering? (Select all that apply.) Select one or more: a. Intravenous calcium chloride b. Oral potassium chloride c. Oral calcitriol (Rocaltrol) d. 50% magnesium sulfate e. 3% normal saline IV solution

a. Intravenous calcium chloride d. 50% magnesium sulfate

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? a. Maintain inflation of the alveoli. b. Enhance ciliary action in the tracheobronchial tree. c. Increase surfactant production d. Dilate the major bronchi.

a. Maintain inflation of the alveoli.

You're explaining to a group of outpatients about the signs and symptoms that may present with osteoarthritis. Select all the signs and symptoms that may present with this condition: a. Morning stiffness for less than 30 minutes b. Anemia c. Bouchard's Node d. Crepitus e. Fever f. Herberden's Node g. Hard and bony joints h. Soft, tender, warm joints

a. Morning stiffness for less than 30 minutes c. Bouchard's Node d. Crepitus f. Herberden's Node g. Hard and bony joints

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. a. Nervousness b. Hot, dry skin c. Anorexia d. Irritability e. Tremors

a. Nervousness d. Irritability e. Tremors

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. a. Persistant lethargy b. Feeling cold c. Loss of body hair d. Tremors e. Weight loss

a. Persistant lethargy b. Feeling cold c. Loss of body hair

A nurse assesses a patient with Cushing's disease. Which assessment findings would the nurse correlate with this disorder? (Select all that apply.) Select one or more: a. Petechiae b. Hypotension c. Muscle atrophy d. Weight loss e. Moon face

a. Petechiae c. Muscle atrophy e. Moon face

Your patient is started on an IV antibiotic to treat a severe infection. During infusion, the patient uses the call light to notify you that she feels a tight sensation in her throat and it's making it hard to breathe. You immediately arrive to the room and assess the patient. While auscultating the lungs you note wheezing. You also notice that the patient is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck and torso. The patient's vital signs are the following: blood pressure 89/62, heart rate 118 bpm, and oxygen saturation 88% on room air. You suspect anaphylactic shock. Select all the appropriate interventions for this patient: a. Place the patient on oxygen b. Prepare for the administration of Epinephrine c. Call a rapid response d. Slow down the antibiotic infusion

a. Place the patient on oxygen b. Prepare for the administration of Epinephrine c. Call a rapid response

A nurse evaluates laboratory results for a patient with heart failure. Which results would the nurse expect? (Select all that apply.) Select one or more: a. Proteinuria b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) d. Hematocrit: 32.8% e. Serum potassium: 4.0 mEq/L (4.0 mmol/L)

a. Proteinuria b. Serum sodium: 130 mEq/L (130 mmol/L) d. Hematocrit: 32.8%

A nurse assesses a patient with anterior pituitary hyperfunction. Which clinical manifestations would the nurse expect? (Select all that apply.) Select one or more: a. Protrusion of the lower jaw b. Barrel-shaped chest c. High-pitched voice d. Enlarged hands and feet

a. Protrusion of the lower jaw b. Barrel-shaped chest d. Enlarged hands and feet

A nurse cares for a patient who is recovering from a pituitary gland resection (hypophysectomy). What action would the nurse take first? Select one: a. Report clear or light yellow drainage from the nose. b. Instruct the patient to cough, turn, and deep breathe. c. Apply petroleum jelly to lips to avoid dryness d. Keep the head of the bed flat and the patient supine.

a. Report clear or light yellow drainage from the nose.

A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level is 114 mEq/L (114 mmol/L). What action would the nurse take first? Select one: a. Restrict the patient's fluid intake to 600 mL/day. b. Handle the patient gently by using turn sheets for repositioning. c. Consult with the dietitian about increased dietary sodium d. Instruct unlicensed assistive personnel to measure intake and output.

a. Restrict the patient's fluid intake to 600 mL/day.

The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy (gall bladder removal). Which intervention would be of highest priority in the preoperative teaching plan? a. Teaching coughing and deep breathing exercises b. Providing instructions regarding fluid restrictions c. Teaching leg exercises d. Assessing the client's understanding of the surgical procedure

a. Teaching coughing and deep breathing exercises

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control? a. The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing. b. The caregiver selects a previously opened gauze to cover the sternal wound. c. The caregiver covers her mouth with her hand when she sneezes and then continues with the dressing change. d. The caregiver dons gloves before removal of the old dressing and then applies the new dressing.

a. The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing.

A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? a. The client needs immediate education before discharge. b. The client's statement is inaccurate, and he or she should be scheduled for educational home health visits. c. The client requires follow-up teaching regarding the administration of oral antidiabetics. d. The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling.

a. The client needs immediate education before discharge.

Which assessment data finding for a client scheduled for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? Select all that apply. Select one or more: a. The client took a total of 1300 mg of aspirin yesterday. b. The client took a regularly scheduled antihypertensive drug with a sip of water 2 hours ago. c. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker. d. The serum potassium level is 3.0 mEq/L (3.0 mmol/L). e. The oxygen saturation is 97%.

a. The client took a total of 1300 mg of aspirin yesterday. c. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker. d. The serum potassium level is 3.0 mEq/L (3.0 mmol/L).

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? a. The client who is taking diuretics b. The client with hyperaldosteronism c. The client with Cushing's syndrome

a. The client who is taking diuretics

The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning? Select one: a. Triglycerides: 198 mg/dL b. Cholesterol: 126 mg/dL c. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL d. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL

a. Triglycerides: 198 mg/dL

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. a. Walk each day to increase circulation to the legs. b. Soak the feet in hot water daily. c. Cut down on the amount of fats consumed in the diet. d. Use a heating pad on the legs to aid vasodilation. e. Be careful not to injure the legs or feet.

a. Walk each day to increase circulation to the legs. c. Cut down on the amount of fats consumed in the diet. e. Be careful not to injure the legs or feet.

A nurse cares for a patient recovering from prosthetic valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse? Select one: a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

b. "Blood clots form more easily in artificial replacement valves."

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which questions would the nurse ask to determine the patient's activity tolerance? (Select all that apply) Select one: a. "Do you walk upstairs every day?" b. "How long does it take to perform your morning routine?" c. "Have you lost any weight lately?" d. "Do you have any difficulty sleeping?"

b. "How long does it take to perform your morning routine?"

A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism? Select one: a. "My sister has thyroid problems." b. "I am always tired, even with 12 hours of sleep." c. "Food just doesn't taste good without a lot of salt." d. "I seem to feel the heat more than other people."

b. "I am always tired, even with 12 hours of sleep."

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? Select one: a. "I am awakened by the need to urinate at night." b. "I must stop halfway up the stairs to catch my breath." c. "I have been drinking more water than usual." d. "I have experienced blurred vision on several occasions." Clear my choice

b. "I must stop halfway up the stairs to catch my breath."

The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. All of the following are characteristics of natural resistance EXCEPT? a. "It does not require previous exposure to the antigen." b. "It includes all antigen-specific immunities a person develops during a lifetime." c. "It also is called inherited immunity." d. "It is the immunity with which a person is born."

b. "It includes all antigen-specific immunities a person develops during a lifetime."

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? a. "Crackles in the lungs will be present." b. "Pulse rate will increase." c. "Edema will be present in the legs." d. "Blood pressure will decrease."

b. "Pulse rate will increase."

A nurse teaches a patient who is prescribed an unsealed radioactive isotope. Which statements will the nurse include in this patient's education? (Select all that apply.) Select one or more: a. "You can play with your grandchildren for 1 hour each day." b. "Wash your clothing separate from others in the household." c. "Do not share utensils, plates, and cups with anyone else." d. "Take a laxative 2 days after therapy to excrete the radiation."

b. "Wash your clothing separate from others in the household." c. "Do not share utensils, plates, and cups with anyone else." d. "Take a laxative 2 days after therapy to excrete the radiation."

A student nurse is giving hand-off report to the registered nurse on four clients who have fluid volume deficit. Which client should the registered nurse assess first? a. 66 kg client, urine output averages 36ml/hour for the last 4 hours b. 86-year-old client, IV fluids infusing at 100 ml/hour, rales bilaterally c. 76-year-old client, urine specific gravity 1.028 d. 100 kg client, lying BP 128/72 mmHg, standing BP 118/68 mmHg

b. 86-year-old client, IV fluids infusing at 100 ml/hour, rales bilaterally

The nurse is assessing four hospitalized clients for fluid volume deficit. Which client should the nurse assess further as the priority? a. 102 kg client; urine output 73 ml in 1 hour b. 98 kg client; urine specific gravity 1.042 (high) c. 106 kg client; pulse 108 beats per minute d. 79 kg client; cannot obtain fluids

b. 98 kg client; urine specific gravity 1.042 (high)

A nurse assesses patients for potential endocrine disorders. Which patient is at greatest risk for hyperparathyroidism? Select one: a. A 66-year-old female with moderate heart failure b. A 41-year-old male receiving dialysis for end-stage kidney disease c. A 29-year-old female with pregnancy-induced hypertension d. A 72-year-old male who is prescribed home oxygen therapy

b. A 41-year-old male receiving dialysis for end-stage kidney disease

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? a. A white blood cell (WBC) count of 6.0 b. A potassium (K+) level of 3.0 mEq/L c. A blood glucose level of 110 mg/d d. A platelet count of 200,000 mm3

b. A potassium (K+) level of 3.0 mEq/L

A client is scheduled for surgery at noon. The surgeon is delayed and the surgery is now scheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic antibiotic? Select one: a. Cancel orders; preoperative prophylactic antibiotics are given optionally. b. Adjust the administration time to be given within one hour prior to surgery. c. Give at noon as originally prescribed. d. Hold the preoperative antibiotic so it can be administered immediately following surgery.

b. Adjust the administration time to be given within one hour prior to surgery.

A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has capillary blood glucose of 33 mg/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first? Select one: a. Administer 25 mL dextrose 50% (D50) IV push. b. Administer 1 mg of intramuscular glucagon. c. Insert a new intravenous access line. d. Encourage the patient to drink orange juice.

b. Administer 1 mg of intramuscular glucagon.

A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) Select one or more: a. Administer a prophylactic antibiotic. b. Administer intravenous fluids. c. Assess for allergies to iodine. d. Assess blood urea nitrogen (BUN) and creatinine results. e. Insert a Foley catheter.

b. Administer intravenous fluids. c. Assess for allergies to iodine. d. Assess blood urea nitrogen (BUN) and creatinine results.

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider? a. An antibiotic b. An anticoagulant c. A calcium channel blocker d. A beta-blocker

b. An anticoagulant

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? a. A stage 1 pressure ulcer b. An arterial ulcer c. A vascular ulcer d. A venous stasis ulcer

b. An arterial ulcer

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP's prescriptions? a. A decreased-calorie diet b. An increased amount of NPH insulin daily insulin c. An increased-calorie diet d. A decreased amount of NPH insulin daily insulin

b. An increased amount of NPH insulin daily insulin

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. a. Hot air b. An upper respiratory infection (URI) c. Exercise d. Cold air e. Non-steroidal anti-inflammatories

b. An upper respiratory infection (URI) c. Exercise d. Cold air e. Non-steroidal anti-inflammatories

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's (HCP's) prescriptions? Select all that apply. a. Ambulation in around the nursing unit every hour b. Application of moist heat to the right leg c. Elevation of the right leg d. Monitoring for signs of pulmonary embolism e. Administration of acetaminophen

b. Application of moist heat to the right leg c. Elevation of the right leg d. Monitoring for signs of pulmonary embolism e. Administration of acetaminophen

When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound? a. Apply a sterile dressing soaked in povidone-iodine. b. Apply a sterile dressing soaked with normal saline. c. Irrigate the wound and apply a sterile dry dressing. d. Leave the incision open to the air to dry the area.

b. Apply a sterile dressing soaked with normal saline.

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. a. Maintain a high-sodium diet. b. Assess extremities for edema. c. Monitor daily weight. d. Monitor intake and output. e. Maintain a low-potassium diet.

b. Assess extremities for edema. c. Monitor daily weight. d. Monitor intake and output.

The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply. a. Administer all the daily medications 2 hours before the scheduled time of the surgery. b. Assist the client to void before transfer to the operating room. c. Check all surgeon's prescriptions to ensure they have been carried out. d. Teach postoperative breathing exercises before the client is premedicated. e. Review the client's record for a history and physical report and laboratory reports.

b. Assist the client to void before transfer to the operating room. c. Check all surgeon's prescriptions to ensure they have been carried out. e. Review the client's record for a history and physical report and laboratory reports.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? a. Just after each T wave b. Before each QRS complex c. During each P wave d. Just after each P wave

b. Before each QRS complex

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of kidney disease. What action should the nurse take first? a. Hang the solution. b. Contact the health care provider (HCP). c. Check the client's daily laboratory results. d. Ask the client if any labs have ever been done to examine renal function.

b. Contact the health care provider (HCP).

A nurse cares for a patient with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) Select one or more: a. Increase in urine output b. Decrease in urine output c. Increase in cardiac output d. Decrease in cardiac output

b. Decrease in urine output d. Decrease in cardiac output

The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? a. Administer all the daily medications. b. Ensure that the client has voided. c. Verify that the client has not eaten for the past 24 hours. d. Have the client practice postoperative breathing exercises.

b. Ensure that the client has voided.

True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. a. TRUE b. FALSE

b. FALSE

A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? a. Metformin b. Glucagon c. Glyburide d. Regular insulin

b. Glucagon

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Select one: a. Report immediately any slight increase in blood pressure or pulse. b. Have the client void immediately before going into surgery. c. Verify that the client has not eaten for the last 24 hours. d. Avoid oral hygiene and rinsing with mouthwash.

b. Have the client void immediately before going into surgery.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? a. A shortened expiratory phase of the respiratory cycle b. Hyperinflation of lungs documented by chest x-ray c. Increased oxygen saturation with ambulation d. A widened diaphragm documented by chest x-ray

b. Hyperinflation of lungs documented by chest x-ray

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? a. Altered breathing pattern secondary to increased work of breathing b. Inability to clear the airway related to inability to expectorate sputum c. Low cardiac output secondary to cor pulmonale (right-sided heart failure) d. Gas exchange alteration related to ventilation-perfusion mismatch

b. Inability to clear the airway related to inability to expectorate sputum

An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? Select one: a. Extremity tremors followed by seizure activity b. Increased rate and depth of respiration c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

b. Increased rate and depth of respiration

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. a. Instruct the client to consume a high-fat diet. b. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. c. Provide a cool environment for the client. d. Instruct the client about thyroid replacement therapy. e. Encourage the client to consume fluids and high-fiber foods in the diet. f. Inform the client that iodine preparations will be prescribed to treat the disorder.

b. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. d. Instruct the client about thyroid replacement therapy. e. Encourage the client to consume fluids and high-fiber foods in the diet.

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? a. Right ventricle b. Left ventricle c. Right atrium d. Left atrium

b. Left ventricle

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. a. Fruity Breath b. Lightheadedness c. Palpitations d. Polyuria e. Shakiness

b. Lightheadedness c. Palpitations e. Shakiness

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. Warm the client b. Maintain a patent airway c. Administer thyroid hormone d. Administer fluid replacement

b. Maintain a patent airway

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? a. Increases surfactant production b. Maintains inflation of the alveoli c. Dilates the major bronchi d. Enhances ciliary action in the tracheobronchial tree

b. Maintains inflation of the alveoli

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic alkalosis

Your patient has arthritis that affects the weight-bearing joints such as the hands, knees, hips, and spine. This type of arthritis is most likely: a. Rheumatoid arthritis b. Osteoarthritis

b. Osteoarthritis

A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicates that a priority outcome has been met? Select one: a. Verbalizing risk factors b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Ambulates with assistance

b. Oxygen saturation of 98%

Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: a. Central venous pressure (CVP) of 18 [HIGH] b. Patient needs Norepinephrine [vasopressor] to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement c. Serum lactate less than 2 mmol/L [LOW] d. Blood pressure of 70/34 after the fluid bolus

b. Patient needs Norepinephrine [vasopressor] to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement d. Blood pressure of 70/34 after the fluid bolus

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? a. Decreased respiratory rate b. Polyuria c. Pedal Edema d. Diaphoresis

b. Polyuria

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? a. Unresponsive pupils b. Positive Trousseau's sign c. Negative Chvostek's sign d. Hypoactive bowel sounds

b. Positive Trousseau's sign

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a. Encouraging discussion about lifestyle changes b. Protecting the client from infection c. Identifying factors that decreased the immune function d. Providing emotional support to decrease fear

b. Protecting the client from infection

The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? a. Shake the client gently to arouse. b. Recheck the vital signs in 15 minutes. c. Cover the client with a warm blanket. d. Call the surgeon immediately.

b. Recheck the vital signs in 15 minutes.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? a. Sustained tissue damage b. Requires nasogastric suction c. Has a history of Addison's disease d. Uric acid level of 9.4 mg/dL (high)

b. Requires nasogastric suction

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. a. Respirations that are shallow b. Respirations that are increased in rate c. Respirations that are abnormally slow d. Respirations that are abnormally deep

b. Respirations that are increased in rate d. Respirations that are abnormally deep

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? a. Metabolic acidosis, compensated b. Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated

b. Respiratory alkalosis, compensated

Which statement is FALSE concerning rheumatoid arthritis? a. Ankylosis can occur in severe cases of rheumatoid arthritis. b. Rheumatoid arthritis is different from osteoarthritis in that it doesn't affect other systems of the body. c. Rheumatoid arthritis most commonly affects the fingers and wrist. d. Rheumatoid arthritis can occur at any age (20-60 year old most commonly).

b. Rheumatoid arthritis is different from osteoarthritis in that it doesn't affect other systems of the body.

A nurse reviews the laboratory results of a patient who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? Select one: a. Serum chloride level of 98 mEq/L (98 mmol/L) b. Serum potassium level of 2.5 mEq/L (2.5 mmol/L) c. Serum sodium level of 132 mEq (132 mmol/L) d. Serum calcium level of 8.8 mg/dL (2.2 mmol/L)

b. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? a. Bundle of His b. Sinoatrial (SA) node c. Atriventricluar (AV) node d. Purkinje fibers

b. Sinoatrial (SA) node

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a. Sitting in a recliner chair b. Sitting up and leaning on an overbed table c. Sitting up in bed d. Side-lying in bed

b. Sitting up and leaning on an overbed table

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? a. The client breathes in through the mouth. b. The client breathes out slowly through the mouth. c. The client puffs out the cheeks when breathing out through the mouth. d. The client avoids using the abdominal muscles to breathe out.

b. The client breathes out slowly through the mouth.

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. a. Bradycardia b. Tremors c. Lethargy d. Nausea e. Confusion f. Fever

b. Tremors d. Nausea e. Confusion f. Fever

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? a. Aerosol mask b. Venturi mask c. Face tent d. Tracheostomy collar

b. Venturi mask

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? a. Take a double dose of the diuretic if peripheral edema is noted. b. Weigh self on a daily basis. c. Withhold prescribed digoxin if slight respiratory distress occurs. d. Sleep with the head of the bed flat.

b. Weigh self on a daily basis.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? a. The client has acidotic blood. b. The client is fluid volume overloaded. c. The client is probably hyperventilating. d. The client has COPD

c. The client is probably hyperventilating.

The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? a. "I won't be able to have a magnetic resonance imaging test (MRI)." b. "My wife knows how to call the emergency medical services (EMS) if I need it." c. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker." d. "If I feel an internal defibrillator shock, I should sit down."

c. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker."

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? a. "I need to avoid alcohol and sedative medications." b. "I have to cut down on the percentage of carbohydrates in my diet." c. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." d. "Besides smoking, I can't be around second- or thirdhand smoke."

c. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? a. "I need to increase my fluid intake." b. "I need to call the health care provider (HCP) because of these symptoms." c. "I need to stop my insulin." d. "I need to monitor my blood glucose every 3 to 4 hours."

c. "I need to stop my insulin."

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? a. "I'm going to weigh myself daily to be sure I don't gain too much fluid." b. "I can have most fresh fruits and vegetables." c. "I'm going to have a ham and cheese sandwich and potato chips for lunch." d. "I'm not supposed to eat cold cuts."

c. "I'm going to have a ham and cheese sandwich and potato chips for lunch."

A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? Select one: a. "Do you have trouble affording your medications?" b. "You are lucky; most people get severe morning headaches." c. "Most people with hypertension do not have symptoms." d. "You need to take your medicine or you will get kidney failure."

c. "Most people with hypertension do not have symptoms."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? Select one: a. "Administration of intravenous fluids will prevent or treat fluid imbalance." b. "Close monitoring of your oxygen saturation will detect hypoxemia." c. "Use of an incentive spirometer will help prevent pneumonia." d. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

c. "Use of an incentive spirometer will help prevent pneumonia."

A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond? Select one: a. "When blood tests indicate normal thyroid function, you can stop the medication." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "You will need to take the thyroid medication until the goiter is completely gone."

c. "You'll need thyroid pills for life because your thyroid won't start working again."

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? a. Tap Water b. Sterile Water c. 0.9% sodium chloride d. 0.45% sodium chloride

c. 0.9% sodium chloride

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. a. Pulmonary function tests that demonstrate increased vital capacity b. A low arterial PCo2 level c. A hyperinflated chest noted on the chest x-ray d. A widened diaphragm noted on the chest x-ray e. Decreased oxygen saturation with mild exercise

c. A hyperinflated chest noted on the chest x-ray e. Decreased oxygen saturation with mild exercise

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? Select one: a. High school sports camps b. Women's health clinics c. African-American churches d. Asian-American groceries

c. African-American churches

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? a. Peptic Ulcer Disease b. Pacemaker c. Alcohol Abuse d. Osteoporosis

c. Alcohol Abuse

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? a. A decreased pH and a compensatory increased PaCO2 b. An increased pH and a compensatory decreased PaCO2 c. An increased pH and compensatory decreased HCO3- d. An increased pH and compensatory increase in HCO3

c. An increased pH and compensatory decreased HCO3-

A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth (NPO) status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? a. Absence of nausea b. Presence of bowel sounds c. Appetite d. Presence of a swallow reflex

c. Appetite

When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? a. Check the rate of the intravenous infusion. b. Administer oxygen to the client. c. Obtain the client's vital signs. d. Assess the client's pain.

c. Obtain the client's vital signs.

A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? a. Advise the client to soak the site in hydrogen peroxide. b. Tell the client to call an ambulance for transport to the emergency department. c. Ask the client if he ever sustained a bee sting in the past. d. Tell the client not to worry about the sting unless difficulty with breathing occurs.

c. Ask the client if he ever sustained a bee sting in the past.

A patient is 4 hours postoperative after a femoral-popliteal bypass. The patient reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? Select one: a. Notify the surgeon immediately. b. Document the findings in the patient's chart. c. Assess distal pulses and skin color. d. Administer pain medication as ordered.

c. Assess distal pulses and skin color.

While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop (extra heart sound). What action would the nurse take next? Select one: a. Call the healthcare provider immediately. b. Document this as a normal finding. c. Assess for symptoms of left-sided heart failure. d. Transfer the patient to the intensive care unit.

c. Assess for symptoms of left-sided heart failure.

What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient? a. Administering Epinephrine b. Administering Corticosteroids c. Assessing, documenting, and avoiding all the patient allergies d. Establishing IV access

c. Assessing, documenting, and avoiding all the patient allergies

A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? a. Parasite b. Virus c. Bacteria d. Fungus

c. Bacteria

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? a. Bradycardia b. Elevated blood pressure c. Changes in mental status d. Bilateral crackles in the lungs

c. Changes in mental status

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? a. Urge to cough b. Pressure at insertion site c. Chest pain d. Warm, flushed feeling

c. Chest pain

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? a. Check for an air leak. b. Change the chest tube drainage system c. Document the findings. d. Notify the health care provider.

c. Document the findings.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? a. Placing a pillow under the knees b. Restricting fluids c. Encouraging active range-of-motion exercises d. Applying a heating pad to the lower extremities

c. Encouraging active range-of-motion exercises

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? a. Flat neck veins. b. Complaints of headache. c. Hypotension. d. Complaints of nausea.

c. Hypotension.

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse NOT include? Select one: a. Place the mouthpiece in your mouth and seal your lips tightly around it. b. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. c. Inhale as deeply and quickly as possible. d. Sit upright in the bed or in a chair.

c. Inhale as deeply and quickly as possible.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? a. Urinary output b. Wound drainage c. Integumentary output d. The gastrointestinal tract

c. Integumentary output

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? a. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. b. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. c. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. d. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream.

c. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? Select one: a. Atropine sulfate b. Epinephrine (Adrenalin) c. Levothyroxine sodium (Synthroid) d. Propranolol (Inderal)

c. Levothyroxine sodium (Synthroid)

A nurse assesses a patient with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? Select one: a. P wave touching the T wave b. Increased urine output c. Midsternal chest pain d. Mild orthostatic hypotension

c. Midsternal chest pain

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? a. Obtain fingernail polish remover, remove the polish, and then obtain the pulse oximetry reading from a finger. b. Remove one of the artificial nails and then obtain the reading from the finger. c. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. d. Check labs, Hgb and Hct. e. Take the pulse oximetry reading from any finger.

c. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. Excessive bubbling in the water seal chamber b. Vigorous bubbling in the suction control chamber c. Occlusive dressing in place over the chest tube insertion site d. 50 mL of drainage in the drainage collection chamber e. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation f. Drainage system maintained below the client's chest

c. Occlusive dressing in place over the chest tube insertion site d. 50 mL of drainage in the drainage collection chamber e. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation f. Drainage system maintained below the client's chest

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? a. Cyanosis b. Dyspnea, especially on exhalation c. Paradoxical chest movement d. Hypotension

c. Paradoxical chest movement

The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention? a. Mask or respiratory protection device and gown b. Room with positive-pressure airflow c. Private room, gown, gloves, and face shield d. Private room with negative-pressure airflow

c. Private room, gown, gloves, and face shield

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? a. Promote oxygen intake. b. Strengthen the diaphragm. c. Promote carbon dioxide elimination. d. Strengthen the intercostal muscles.

c. Promote carbon dioxide elimination.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? a. Monitor oxygenation (the oxygen saturation [SaO2]) during activity. b. Plan activities with rest periods to conserve oxygen needs. c. Provide nasotracheal suctioning as needed to remove secretions. d. Initiate and maintain supplemental oxygen as prescribed.

c. Provide nasotracheal suctioning as needed to remove secretions.

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? a. Pulse rate increased from 80 to 104 beats per minute. b. Blood pressure decreased from 140/86 to 112/72 mm Hg. c. Respiratory rate increased from 16 to 19 breaths per minute. d. Oxygen saturation decreased from 96% to 91%.

c. Respiratory rate increased from 16 to 19 breaths per minute.

A nurse assesses a patient with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? Select one: a. Dyspnea with activity b. Sinus tachycardia c. Speech alterations d. Fatigue

c. Speech alterations

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator (TPA). What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? a. orange-colored urine b. decreased urine output c. Tar-like stools d. Nausea and vomiting

c. Tar-like stools

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? a. The client will complain of facial numbness and tingling. b. The client will lose consciousness. c. The client's arterial blood gas results will reflect acidosis. d. The client's sodium and chloride levels will rise.

c. The client's arterial blood gas results will reflect acidosis.

The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? a. Patient's skin is warm and flushed. b. Patient's urinary output is 20 mL/hr. c. The patient's blood pressure changes from 75/48 to 110/82. d. Patient's CVP 2 mmHg

c. The patient's blood pressure changes from 75/48 to 110/82.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? Select one: a. Serous drainage on the surgical dressing b. Temperature of 37.6°C (99.6°F) c. Urinary output of 20 mL/hour d. Blood pressure of 100/70 mm Hg

c. Urinary output of 20 mL/hour

A nurse cares for a patient who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.) Select one or more: a. Urine osmolality is decreased. b. Specific gravity is decreased. c. Urine osmolality is increased. d. Urine output is increased. e. Specific gravity is increased. f. Urine output is decreased.

c. Urine osmolality is increased. e. Specific gravity is increased. f. Urine output is decreased.

A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient's medication administration record to prevent a common complication of this condition? Select one: a. Atropine (Sal-Tropine) b. Lidocaine (Xylocaine) c. Warfarin (Coumadin) d. Sotalol (Betapace)

c. Warfarin (Coumadin)

The nursing student conducting a clinical conference on immunity places an emphasis on active immunity. Which statement by fellow nursing students indicates successful teaching? a. "Active immunity only lasts from days to months." b. "Passive immunity can last for years." c. "Active immunity provides protection immediately and forever." d. "Active immunity lasts for years and can be easily reactivated by a booster dose of antigen."

d. "Active immunity lasts for years and can be easily reactivated by a booster dose of antigen."

After teaching a patient who is recovering from a complete thyroidectomy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional instruction? Select one: a. "I can receive pain medication if I feel that I need it." b. "I may need calcium replacement after surgery." c. "I'll need to take thyroid hormones for the rest of my life." d. "After surgery, I won't need to take thyroid medication."

d. "After surgery, I won't need to take thyroid medication."

A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? Select one: a. "Make certain that your bath water is warm." b. "Avoid strenuous exercise such as running." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid straining while having a bowel movement."

d. "Avoid straining while having a bowel movement."

The nurse educator is teaching the new registered nurse (RN) how to care for clients with a decrease in blood pressure. Which statement by the new RN indicates the need for further instruction? a. "Increased resistance to electrical stimulation often occurs." b. "Decreased contractility occurs." c. "Decreased heart rate is not a side effect." d. "Decreased myocardial blood flow is not a concern."

d. "Decreased myocardial blood flow is not a concern."

The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? a. "I will check my blood glucose level 1 hour after each meal." b. "I will check my blood glucose level every day at 5:00 p.m." c. "I will check my blood glucose level 2 hours after each meal." d. "I will check my blood glucose level before each meal and at bedtime."

d. "I will check my blood glucose level before each meal and at bedtime."

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? a. "I will decrease my insulin dose during times of illness." b. "I will adjust my insulin dose according to the level of glucose in my urine." c. "I will stop taking my insulin if I'm too sick to eat." d. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."

d. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."

The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective? a. "Calcium has no effect on urinary stone formation." b. "Low calcium levels cause high blood pressure." c. "Calcium has no effect on the risk for stroke." d. "Low calcium levels can lead to cardiac arrest."

d. "Low calcium levels can lead to cardiac arrest."

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? a. "I should not exercise since I am taking insulin." b. "The best time for me to exercise is mid- to late afternoon." c. "NPH is a basal insulin, so I should exercise in the evening." d. "The best time for me to exercise is after breakfast."

d. "The best time for me to exercise is after breakfast."

The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? a. "They initiate phagocytosis." b. "They attack and kill the target cell directly." c. "They activate T cells." d. "They produce antibodies."

d. "They produce antibodies."

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? a. "Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves." b. "Ventricular fibrillation appears as irregular beats within a rhythm." c. "Ventricular fibrillation is a regular pattern of wide QRS complexes." d. "Ventricular fibrillation does not have P waves or QRS complexes."

d. "Ventricular fibrillation does not have P waves or QRS complexes."

The nurse is caring for four clients who will undergo surgery today. Which client does the nurse recognize as at highest risk for surgical complication? Select one: a. 69-year-old who will be discharged after surgery to an extended care facility b. 58-year-old who has well-controlled Type II diabetes c. 64-year-old who has just received pre-surgical prophylactic antibiotics d. 52-year-old who takes aspirin daily

d. 52-year-old who takes aspirin daily

A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath? a. Gloves and shoe protectors b. Gloves and goggles c. A gown and goggles d. A gown and gloves

d. A gown and gloves

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? a. Do not exceed 2 L/min. b. Do not exceed 1 L/min. c. Adjust the oxygen depending on respiratory rate. d. Adjust the oxygen depending on SpO2.

d. Adjust the oxygen depending on SpO2.

At 4:45 PM, a nurse assesses a patient with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the patient is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) At 06:30—95 //At 11:30—70 //At 16:30—47 Dietary Intake Breakfast: 10% eaten—patient states that she is not hungry Lunch: 5% eaten—patient is nauseous; vomits once After reviewing the patient's assessment data, which action is appropriate at this time? Select one: a. Provide a glass of orange juice and encourage the patient to eat dinner. b. Assess the patient's oxygen saturation level and administer oxygen. c. Reorient the patient and apply a cool washcloth to the patient's forehead. d. Administer dextrose 50% intravenously and reassess the patient.

d. Administer dextrose 50% intravenously and reassess the patient.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? a. Instruct the client to limit fluid intake. b. Place the client in low Fowler's position. c. Place a continuous pulse oximeter on the client. d. Administer the prescribed bronchodilator.

d. Administer the prescribed bronchodilator.

A nurse assesses a patient who is scheduled for a cardiac catheterization. Which assessment would the nurse complete prior to this procedure? Select one: a. Ability to turn self in bed b. Cardiac rhythm and heart rate c. Patient's level of anxiety d. Allergies to iodine-based agents

d. Allergies to iodine-based agents

The nurse must be alert for signs of respiratory acidosis in the client with emphysema, because this individual has a long-term problem with oxygen maintenance and: Select one: a. There is a loss of carbon dioxide from the body's buffer pool b. Localized tissue necrosis occurs as a result of poor oxygen supply c. Hyperventilation occurs, even if the cause is not physiologic d. An inability to fully exhale retained CO2

d. An inability to fully exhale retained CO2

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? a. Bloody, with frequent small clots b. Serous c. Serosanguineous d. Bloody

d. Bloody

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? a. Identifies which additional tests need to be performed b. Confirms the diagnosis of a connective tissue disorder c. Determines the presence of antigens d. Confirms the presence of inflammation or infection in the body

d. Confirms the presence of inflammation or infection in the body

A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? Select one: a. Document the finding and assess the patient hourly. b. Place the patient in high-Fowler's position and apply oxygen c. Reassure the patient that the voice change is temporary. d. Contact the provider and prepare for intubation.

d. Contact the provider and prepare for intubation.

You are providing discharge teaching to a patient with newly diagnosed asthma. What would be the priority goal to established as part of the teaching plan prior to being discharged from the hospital? The patient will: Select one: a. Is able to obtain pulse oximeter readings b. Knows the primary care provider's office hours c. Has identified a pharmacy for prescription medications d. Demonstrates correct use of prescribed inhalers

d. Demonstrates correct use of prescribed inhalers

A nurse assesses a patient with pericarditis. Which assessment finding would the nurse expect to find? Select one: a. Heart rate that speeds up and slows down b. Presence of a regular gallop rhythm c. Coarse crackles in bilateral lung bases d. Friction rub at the left lower sternal border

d. Friction rub at the left lower sternal border

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? a. Compromised family coping b. Inadequate consumption of nutrients c. Lack of Knowledge d. Inadequate fluid volume

d. Inadequate fluid volume

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? a. Increase to 3 L/min and titrate until the SpO2 is 95%. b. Maintain at 2 L/min and call respiratory therapy for a breathing treatment. c. Place the client on a nonrebreather mask on 100% FiO2. d. Increase to 3 L/min and titrate until the SpO2 is 92%.

d. Increase to 3 L/min and titrate until the SpO2 is 92%.

A patient is in anaphylactic shock. The patient has a severe allergy to peanuts and mistakenly consumed an eggroll containing peanut ingredients during his lunch break. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have what effect on the body? a. It will prevent a recurrent attack. b. It will help block the effects of histamine in the body. c. It will cause vasoconstriction and decrease the blood pressure. d. It will help dilate the airways.

d. It will help dilate the airways.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. Assessing for jugular vein distention b. Palpating for organomegaly (organ enlargement) c. Assessing for peripheral and sacral edema d. Listening to lung sounds

d. Listening to lung sounds

The nurse has delegated taking orthostatic vital signs to the unlicensed assistive personnel (UAP). The UAP reports the following vital signs. Which client should the nurse assess as the priority? a. Lying BP: 118/76 mmHg; standing BP 128/88 mmHg b. Lying BP: 144/94 mm Hg; standing BP 136/88 mmHg c. Lying BP: 122/86 mmHg; standing BP 116/78 mmHg d. a) Lying BP: 136/96 mmHg; standing BP 134/76 mmHg

d. Lying BP: 136/96 mmHg; standing BP 134/76 mmHg

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? a. Heart failure. b. Atrial fibrillation. c. Ventricular tachycardia. d. Myocardial infarction.

d. Myocardial infarction.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? Select one: a. Have the charge nurse sign the informed consent immediately. b. Obtain a court order for the surgery. c. Send the client to surgery without the consent form being signed. d. Obtain a telephone consent from a family member, following agency policy.

d. Obtain a telephone consent from a family member, following agency policy.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action to lessen chance of repeat pneumothorax? a. Exhale very quickly. b. Stay very still. c. Inhale and exhale quickly. d. Perform the Valsalva maneuver.

d. Perform the Valsalva maneuver.

What client teaching will the nurse provide regarding postoperative leg exercises, to minimize the risk for development of deep vein thrombosis after surgery? Select one: a. Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract. Repeat several times, then switch legs. b. Only perform each exercise one time to prevent overuse. c. Begin exercises by sitting at a 90-degree angle on the side of the bed. d. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs.

d. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs.

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? a. Removing the gloves and then removing the gown using the neck ties b. Washing the hands after the entire procedure has been completed c. Taking off the gloves first before removing the gown d. Removing the gown without rolling it from inside out

d. Removing the gown without rolling it from inside out

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? a. Metabolic acidosis with compensation b. Respiratory acidosis with compensation c. Metabolic acidosis without compensation d. Respiratory acidosis without compensation

d. Respiratory acidosis without compensation

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? a. Level of hoarseness b. Edema at the surgical site c. Hypoglycemia d. Respiratory distress

d. Respiratory distress

A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action? a. Check the heart rate. b. Check the blood pressure. c. Ask the client about sensation of moistness on her perineal pad. d. Roll the client to one side and check her perineal pad.

d. Roll the client to one side and check her perineal pad.

A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client? Select one: a. Knee chest, with the foot of the bed elevated b. Semi Fowler's, with the knees placed on top of 1 pillow c. Supine, with the head of the bed elevated 45 to 90 degrees d. Supine, with the head of the bed elevated about 15 degrees

d. Supine, with the head of the bed elevated about 15 degrees (Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 6 to 12 hours. The client may turn from side to side. The head of the bed is not elevated more than 15 degrees (unless otherwise prescribed) to prevent kinking of the blood vessel at the groin and possible arterial occlusion.)

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? a. Blood Pressure b. Pulse c. Respiration d. Temperature

d. Temperature

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? a. Keep a loose seal between the lips and the mouthpiece. b. Inhale as rapidly as possible. c. After maximum inspiration, hold the breath for 15 seconds and exhale. d. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

d. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? a. The client taking diuretics and has tenting of the skin b. The client with an ileostomy from a recent abdominal surgery c. The client who requires intermittent gastrointestinal suctioning d. The client with kidney disease and a 12-year history of diabetes mellitus

d. The client with kidney disease and a 12-year history of diabetes mellitus

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? a. The client is not experiencing nausea or vomiting. b. The client is not experiencing dyspnea. c. The client says the pain began while she was trying to open a stuck dresser drawer. d. The pain has not been relieved by rest and nitroglycerin tablets.

d. The pain has not been relieved by rest and nitroglycerin tablets.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? a. The respiratory muscles contract. b. Air is flowing against a pressure gradient. c. Air flows by gravity. d. The respiratory muscles relax.

d. The respiratory muscles relax.

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? a. To prevent cardiac irritability b. To stimulate release of parathyroid hormone c. To treat thyroid storm d. To treat hypocalcemic tetany

d. To treat hypocalcemic tetany

While assessing a patient with Graves' disease, the nurse notes that the patient's temperature has risen 1° F (1° C). What does the nurse do first? Select one: a. Administer a dose of acetaminophen (Tylenol). b. Call for an immediate electrocardiogram (ECG). c. Calculate the patient's apical-radial pulse deficit. d. Turn the lights down and shut the patient's door.

d. Turn the lights down and shut the patient's door.

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept? a. Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. b. Vagus nerve stimulation causes an increase in heart rate and cardiac contractility. c. Sympathetic nerve stimulation causes an increase in heart rate and cardiac contractility. d. Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility.

d. Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility.

A nurse assesses a patient's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How would the nurse interpret this observation? Select one: a. The patient has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The patient's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

d. Ventricular and atrial depolarizations are initiated from different sites.

An arterial blood gas report indicates the client's pH is 7.30, PCO2 is 55 mm Hg and HCO3 is 20 mEq/L. These results are consistent with: Select one: a. metabolic acidosis b. respiratory alkalosis c. metabolic alkalosis d. respiratory acidosis

d. respiratory acidosis