MedSurg Comprehensive Final Examination

Which diagnostic procedure does the nurse anticipate being ordered for the 27-year-old female client reporting irregular menses and lower left abdominal pain during menses? 1. Pelvic sonogram. 2. Complete blood count (CBC). 3. Kidney, ureter, bladder (KUB) x-ray. 4. Computed tomography (CT) of the abdomen.

Answer: 1 1. The pelvic sonogram, which visualizes the ovary using sound waves, is a diagnostic test for an ovarian cyst, which would be suspected with the client's clinical manifestations. 2. A CBC may be ordered to rule out appendicitis, but this client does not have right lower abdominal pain. 3. A KUB x-ray is ordered for a client diagnosed with possible kidney stones. 4. A CT of the abdomen would not visualize contents in the pelvis.

The client asks the nurse, "What are the risk factors for developing multiple sclerosis?" Which statement is a risk factor for MS? 1. A close relative with MS may indicate a risk for MS. 2. Living in the southern United States predisposes a person to MS. 3. Use of tobacco product is the number-one risk for developing MS. 4. A sedentary lifestyle can cause a person to develop MS.

Answer: 1 1. A close relation (parent or sibling) diagnosed with MS may indicate a risk for the client also to develop MS. Other common risk factors are age, race, gender, environment, immune factors, and smoking. 2. There is a higher incidence of MS in people living in the northeastern United States and Canada, but there is no known reason for this occurrence. 3. Tobacco use is a risk factor but not the primary risk factor for MS. 4. A sedentary lifestyle does not predispose a person to develop MS.

The client diagnosed with chronic renal failure is receiving peritoneal dialysis. Which assessment by the nurse warrants immediate intervention? 1. The dialysate return is cloudy. 2. There is a greater dialysate return than input. 3. The client reports abdominal fullness. 4. The client voided 50 mL during the day.

Answer: 1 1. A cloudy dialysate indicates an infection and must be reported immediately to prevent peritonitis. 2. The dialysate should be greater than the intake, so fluid is being removed from the body. 3. After infusing 1,000 mL of dialysate, abdominal fullness is not unexpected. 4. The client voiding any amount does not warrant immediate intervention.

The client is 8 hours postoperative for small bowel resection. Which data indicate the client has a complication from the surgery? 1. A hard, rigid, boardlike abdomen. 2. High-pitched tinkling bowel sounds. 3. Absent bowel sounds. 4. Reports of pain at "6" on the pain scale.

Answer: 1 1. A hard, rigid, boardlike abdomen is the hallmark clinical manifestation of peritonitis, which is a life-threatening complication of abdominal surgery. 2. This occurs when the client has a nasogastric tube connected to suction and has minimal peristalsis, and it is not a complication of the surgery. 3. The client has had general anesthesia for this surgery, and absent bowel sounds at 8 hours postoperative does not indicate a complication. 4. The client with this type of surgery is expected to have pain at a "6" or higher on a 1-to-10 scale; this is not considered a complication.

The client comes to the emergency department reporting pain in the right forearm. The nurse notes a large area of redness and edema over the forearm, and the client has an elevated temperature. Which condition should the nurse suspect? 1. Cellulitis. 2. Intravenous drug abuse. 3. Raynaud's phenomenon. 4. Thromboangiitis obliterans.

Answer: 1 1. Cellulitis is the most common infectious cause of limb edema as a result of bacterial invasion of the subcutaneous tissue. This assessment would make the nurse suspect this condition. 2. Intravenous drug use can cause cellulitis, but the assessment did not include track marks or needle insertion sites. 3. Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in coldness, pain, and pallor of fingertips or toes. The client should keep warm to prevent vasoconstriction of extremities. 4. Buerger's disease (thromboangiitis obliterans) is a relatively uncommon occlusive disease limited to medium and small arteries and veins. The cause is unknown, but there is a strong association with tobacco use.

The client comes to the clinic, reporting itching on the left wrist near a wristwatch. The nurse notes an erythematous area along with pruritic vesicles around the left wrist. Which condition should the nurse suspect? 1. Contact dermatitis. 2. Herpes simplex 1. 3. Impetigo. 4. Seborrheic dermatitis.

Answer: 1 1. Contact dermatitis is a type of dermatitis caused by a hypersensitivity response. In this case, it is a hypersensitivity reaction to metal salts in the watch the client is wearing. Any time the nurse assesses redness or irritation in areas where jewelry (such as rings, watches, necklaces) or clothing (such as socks, shoes, or gloves) are worn, the nurse should suspect contact dermatitis. 2. Herpes simplex 1 virus occurs in oral or nasal mucous membranes. 3. Impetigo is a superficial infection of the skin caused by a staph or strep infection and occurs on the body, face, hands, or neck. 4. Seborrheic dermatitis is a chronic inflammation of the skin involving the scalp, eyebrows, eyelids, ear canals, nasolabial folds, axillae, and trunk.

The nurse is assessing the client diagnosed with a pneumothorax who has a closed-chest drainage system. Which data indicate the client's condition is stable? 1. There is fluctuation in the water-seal compartment. 2. There is blood in the drainage compartment. 3. The trachea deviates slightly to the left. 4. There is bubbling in the suction compartment.

Answer: 1 1. Fluctuation in the water-seal compartment with respirations indicates the system is working properly, and the client is stable. 2. Blood in the drainage compartment indicates there is a problem because the client is diagnosed with a pneumothorax, and there should not be any bleeding. 3. Any deviation of the trachea indicates a tension pneumothorax, a potentially life-threatening complication. 4. Bubbling in the suction compartment does not indicate a stable or unstable client.

The client diagnosed with stomach cancer has developed disseminated intravascular coagulopathy (DIC). Which collaborative intervention should the nurse expect to implement? 1. Prepare to administer intravenous heparin. 2. Assess for frank hemorrhage from venipuncture sites. 3. Monitor for a decreased level of consciousness. 4. Prepare to administer total parenteral nutrition.

Answer: 1 1. Heparin interferes with the clotting cascade and may prevent further clotting factor consumption resulting from uncontrolled thromboses formation. 2. Assessment is an independent intervention; it is not collaborative and does not require an HCP's order. 3. Assessment is an independent intervention; it is not collaborative and does not require an HCP's order. 4. TPN is not a treatment for a client diagnosed with DIC.

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Paralytic ileus. 4. Atelectasis.

Answer: 1 1. Medical client problems indicate the nurse and the HCP must collaborate to care for the client; the client must have medications for heart failure. 2. Without an HCP's order, the nurse can instruct the client to pace activities and teach about rest versus activity. 3. Paralytic ileus is a medical problem but would not be expected in a client diagnosed with cardiomyopathy. 4. Atelectasis occurs when airways collapse, which would not occur in a client diagnosed with cardiomyopathy.

The nurse is assessing the client diagnosed with psoriasis. Which data support this diagnosis? 1. Appearance of red, elevated plaques with silvery-white scales. 2. A burning, prickling row of vesicles located along the torso. 3. Raised, flesh-colored papules with a rough surface area. 4. An overgrowth of tissue with an excessive amount of collagen.

Answer: 1 1. Most clients diagnosed with psoriasis have red, raised plaques with silvery-white scales. 2. A burning, prickling row of vesicles located along the torso is the description of herpes zoster. 3. A raised, flesh-colored papule with a rough surface area is a description of a wart. 4. An overgrowth of tissue with an excessive amount of collagen is the definition of keloids.

Which comment by the client, diagnosed with rule-out Guillain-Barré (GB) syndrome, is most significant when completing the admission interview? 1. "I had a bad case of gastroenteritis a few weeks ago." 2. "I never use sunblock, and I use a tanning bed often." 3. "I started smoking cigarettes about 20 years ago." 4. "I was out of the United States for the last 2 months."

Answer: 1 1. The cause of GB syndrome is unknown, but a precipitating event usually occurs 1 to 3 weeks before the onset. The precipitating event may be a respiratory or gastrointestinal viral or bacterial infection. 2. These are not precipitating events or risk factors for developing GB syndrome. 3. Smoking is not a risk factor for developing GB syndrome. 4. GB syndrome is not more prominent in foreign countries than in the United States.

The 85-year-old client diagnosed with severe, end-stage chronic obstructive pulmonary disease has a chest x-ray incidentally revealing an 8-cm abdominal aortic aneurysm (AAA). Which intervention should the nurse implement? 1. Discuss possible end-of-life care issues. 2. Prepare the client for abdominal surgery. 3. Teach the client how to do pursed-lip breathing. 4. Talk with the family about the client's condition.

Answer: 1 1. The client diagnosed with end-stage COPD would not be a candidate for an AAA repair, although the size of the aneurysm places the client at risk for rupture. Although many nurses do not like to address end-of-life issues, this would be an important and timely intervention. 2. The client is not a surgical candidate because of the comorbid condition and age. 3. The client should know how to pursed-lip breathe at this point in the disease process. 4. Although the client is 85 years old, the nurse should discuss all health-care issues with the client and not the family. This is a violation of HIPAA.

The client diagnosed with type 2 diabetes mellitus asks the nurse, "What does it matter if my glucose level is high? I don't feel bad." Which statement by the nurse is most appropriate? 1. "The high glucose level can damage your eyes and kidneys over time." 2. "The glucose level causes microvascular and macrovascular problems." 3. "As long as you don't feel bad, everything will probably be all right." 4. "A high blood glucose level will cause you to get metabolic acidosis."

Answer: 1 1. The long-term complications of increased blood glucose levels to organs are the primary reasons for keeping the blood glucose level controlled. 2. This is the medical explanation for keeping the glucose under control, but this answer is not appropriate for laypeople. 3. The client diagnosed with type 2 diabetes often doesn't feel bad, but the organs are still being damaged as a result of increased blood glucose levels. 4. Metabolic acidosis occurs in clients diagnosed with type 1 diabetes, not type 2. Clients diagnosed with type 2 diabetes have hyperosmolar hyperglycemic nonketotic syndrome (HHNS).

The client is admitted to the medical unit reporting severe abdominal pain. Which intervention should the nurse implement first? 1. Assess for complications. 2. Medicate for pain. 3. Turn the television on. 4. Teach relaxation techniques.

Answer: 1 1. The nurse must rule out any complication requiring immediate intervention before masking the pain with medication. Pain indicates a problem in some instances; pain is expected after surgery, but complications should always be ruled out. 2. The nurse should not medicate for pain until ruling out complications. 3. The television provides a distraction, but it is not the first intervention. Assessment is the first intervention. 4. Teaching relaxation techniques will help the client's pain, but the first intervention must be an assessment to rule out any complication.

The nurse is at home preparing for the 7 a.m. to 7 p.m. shift and has the flu with a temperature of 100.4°F. Which action should the nurse take? 1. Notify the hospital that the nurse will not be coming into work. 2. Go to work and wear an isolation mask when caring for the clients. 3. Request an alternative assignment, not involving direct client care. 4. Take over-the-counter cold medication and report to work on time.

Answer: 1 1. The nurse should stay at home because the nurse will expose all other personnel and clients to the illness. Flu, especially with a fever, places the nurse at risk for secondary pneumonia. 2. The nurse is ill, and many errors are made when the nurse is not functioning at 100%. 3. Even if the nurse doesn't have direct client care, the nurse will expose other employees to the virus. 4. OTC medications will not prevent the transmission of flu to others, nor will they prevent the nurse from developing secondary pneumonia.

The nurse is discussing funeral arrangements with the family of a deceased client having organs and tissues donated today. Which information should the nurse discuss with the family? 1. The family can request an open casket funeral. 2. Your loved one must wear a long-sleeved shirt. 3. You might want to have a private viewing only. 4. This will not delay the timing of the funeral.

Answer: 1 1. The procurement of organs and tissues from the client will not be noticeable if there is an open casket funeral. 2. There is no reason for the client to wear a long-sleeved shirt because the skin is not removed from the arms. 3. There is no reason for a private viewing as a result of the organ and tissue donation. 4. The funeral may or may not have to be delayed depending on when the procurement team can make arrangements; the nurse should not give false information to the family.

The client is admitted to the intensive care unit diagnosed with rule-out adult respiratory distress syndrome (ARDS). The client is receiving 10 L/min of oxygen via nasal cannula. Which arterial blood gases indicate the client does not have ARDS? 1. - pH: 7.38 - PCO2: 45 - HCO3: 26 - PaO2: 82 2. - pH: 7.35 - PCO2: 43 - HCO3: 24 - PaO2: 74 3. - pH: 7.45 - PCO2: 45 - HCO3: 28 - PaO2: 60 4. - pH: 7.32 - PCO2: 55 - HCO3: 28 - PaO2: 50

Answer: 1 1. These are normal ABGs, which would not be expected if the client has ARDS. 2. This client has an oxygen level below 80 to 100; therefore, this client may be developing early ARDS. 3. This is respiratory acidosis, which would be expected in a client diagnosed with ARDS. 4. These are the expected ABGs of a client diagnosed with ARDS. There is a low oxygen level despite high oxygen administration.

The nurse is teaching the client in a cardiac rehabilitation unit. Which dietary information should the nurse discuss with the client? 1. No more than 30% of daily food intake should be fats. 2. Eighty percent of calories should come from carbohydrates. 3. Red meat should comprise at least 50% of daily intake. 4. Monounsaturated fat in the daily diet should be increased.

Answer: 1 1. This is a correct statement. The recommended proportions of food are 50% carbohydrates, 30% or less from fat, and 20% protein. 2. Only 50% of the calories should come from carbohydrates. 3. Red meat is an excellent source of protein but should only comprise 20% of the diet, and red meat is very high in fat. 4. Polyunsaturated fats, not the monounsaturated fats, are the better fats.

Which assessment data would make the nurse suspect the client has cancer of the bladder? 1. Gross painless hematuria. 2. Burning on urination. 3. Terminal dribbling. 4. Difficulty initiating the stream.

Answer: 1 1. This is the most common presenting clinical manifestation of bladder cancer. 2. Burning on urination is a clinical manifestation of a urinary tract infection. 3. Terminal dribbling is a clinical manifestation of benign prostatic hypertrophy. 4. Difficulty initiating a urine stream is a clinical manifestation of benign prostatic hypertrophy or neurogenic bladder.

The client is newly diagnosed with epilepsy. Which statement indicates the client needs clarification of the discharge teaching? 1. "I can drive as soon as I see my HCP for my follow-up visit." 2. "I should get at least 8 hours of sleep at night." 3. "I should take my medication every day even if I am sick." 4. "I will take showers instead of taking tub baths."

Answer: 1 1. This statement indicates the client does not understand the discharge teaching. The client will not be able to drive until the client is seizure-free for a certain period of time. The laws in each state differ. 2. Lack of sleep is a risk factor for having seizures. 3. Noncompliance with medication is a risk factor for having a seizure. 4. If the client has a seizure in the bathtub, the client could drown.

The 28-year-old client diagnosed with testicular cancer is scheduled for a unilateral orchiectomy. Which intervention should have priority in the client's plan of care? 1. Encourage the client to bank his sperm. 2. Discuss completing an advance directive. 3. Explain follow-up chemotherapy and radiation. 4. Allow the client to express his feelings regarding having cancer.

Answer: 1 1. With a remaining testicle, the client will be able to maintain sexual potency, but radiation and chemotherapy may cause the client to become sterile. Therefore, banking his sperm will allow him to father a child later in life. 2. Testicular cancer has a 90% cure rate with standard therapy; therefore, completing an advance directive is not a priority. 3. The client will not be undergoing chemotherapy for at least 6 weeks to allow the client to heal; therefore, this is not a priority intervention. 4. This is important, but when preparing the client for surgery, the priority intervention is to accomplish presurgical interventions.

The nurse is initiating a blood transfusion. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. 4. Hang 250 mL of D5W at a keep-open rate. 5. Check the EHR for the HCP's order.

Answer: 1, 2, 5 1. The nurse must make a decision on the amount of blood to infuse per hour. If the client is showing any clinical manifestation of heart or lung compromise, the nurse will infuse the blood at the slowest possible rate. 2. Blood products require the client to give specific consent to receive blood. 3. The IV should be started with an 18-gauge catheter if possible; the smallest possible catheter is a 20-gauge. Smaller gauge catheters break down the blood cells. 4. Blood is not compatible with D5W; the nurse should hang 0.9% normal saline to keep open. 5. The nurse should verify the HCP's order before having the client sign the consent form.

Which information should the nurse discuss with the client to prevent an acute exacerbation of diverticulitis? Select all that apply. 1. Increase the fiber in the diet. 2. Drink at least 1,000 mL of water a day. 3. Encourage sedentary activities. 4. Take cathartic laxatives daily. 5. Avoid heavy lifting.

Answer: 1, 5 1. Increasing fiber will help prevent constipation, the best way to prevent an acute diverticulitis exacerbation. 2. The client should increase fluid intake to at least 2,000 to 2,500 mL/day to prevent constipation. 3. The client should exercise daily to prevent constipation. 4. The client should take bulk-forming laxatives, which help prevent constipation by adding bulk to the stool. Cathartic laxatives are harsh colonic stimulants and should not be taken on a daily basis. 5. The client should avoid activities that increase intra-abdominal pressure because it could cause an exacerbation.

The client reports a painful twisting motion injury of the knee during a basketball game. The client is scheduled for arthroscopic surgery to repair the injury. Which information should the nurse teach the client about postoperative care? Select all that apply. 1. The client should begin strengthening the postsurgical leg. 2. The client should take pain medication routinely. 3. The client should remain on bedrest for 2 weeks. 4. The client should return to the doctor in 6 months. 5. The client should keep the dressing on the knee dry.

Answer: 1, 5 1. The client should begin exercises that will strengthen the surgical leg as soon as the surgery is completed. 2. Pain medication should be taken as needed, not routinely. 3. The client may ambulate with the restrictions ordered by the surgeon. 4. The client will return to see the surgeon before 6 months. The surgeon will need to monitor for healing and complications. 5. The client will have a dressing on the surgical site that should remain dry. The dressing will stay on for 3 days after surgery and is then covered with adhesive bandages.

Which clinical manifestations should the nurse expect to assess in the client diagnosed with Addison's disease? Select all that apply. 1. Hypotension and bronze skin pigmentation. 2. Water retention and osteoporosis. 3. Hirsutism and abdominal striae. 4. Truncal obesity and thin, wasted extremities. 5. Hypotension and hypoglycemia.

Answer: 1, 5 1. These are clinical manifestations of Addison's disease, which is adrenal cortex insufficiency. 2. These are clinical manifestations of Cushing's syndrome, which is adrenal cortex hyperfunction. 3. These are clinical manifestations of Cushing's syndrome, which is adrenal cortex hyperfunction. 4. These are clinical manifestations of Cushing's syndrome, which is adrenal cortex hyperfunction. 5. These are clinical manifestations of Addison's disease.

The nurse is administering 250 mL of packed red blood cells with 50 mL of preservative. The client has no jugular vein distention and has clear breath sounds. After the first 15 minutes, at what rate should the nurse set the IV infusion pump?

Answer: 150 mL/hr The nurse should infuse the blood in 2 hours because the client does not have clinical manifestations of fluid volume overload.

The client diagnosed with gastroesophageal reflux disease (GERD) has undergone surgery for a hiatal hernia repair. The client has a nasogastric tube in place. Intravenous fluid replacement is to be at 125 mL/hr plus the amount of drainage. The drainage from 0800 to 0900 is 45 mL. At which rate should the IV pump be set for the next hour?

Answer: 170 mL/hr 125 mL + 45 mL = 170 mL The IV pump should be set at this rate.

Which diagnostic test should the nurse expect to be ordered for the client diagnosed with a nevus, which is purple and brown with irregular borders? 1. Bone scan. 2. Skin biopsy. 3. Carcinoembryonic antigen (CEA). 4. Sonogram.

Answer: 2 1. A bone scan would not be ordered unless a biopsy proves malignant melanoma. 2. This is an abnormal-appearing mole on the skin, and the HCP would order a biopsy to confirm skin cancer. 3. A CEA is a test used to mark the presence or prognosis of several cancers but not skin cancer. 4. A sonogram would not be ordered to diagnose skin cancer.

Which assessment data indicate the client has developed a deep vein thrombosis (DVT) in the left leg? 1. A negative Homans' sign of the left leg. 2. Increased left leg calf circumference. 3. Elephantiasis of the left lower leg. 4. Brownish pigmentation of the left lower leg.

Answer: 2 1. A positive Homans' sign would indicate a DVT. 2. The calf with DVT becomes edematous, so there is an increase in the size of the calf when compared to the other leg. 3. Elephantiasis is characterized by tremendous edema, usually of the external genitalia and legs and is not associated with DVT. Elephantiasis is a lymphatic problem, not a venous problem. 4. The brownish discoloration is a clinical manifestation of chronic venous insufficiency.

The client diagnosed with a transient ischemic attack (TIA) is being discharged from the hospital. Which medication should the nurse expect the HCP to prescribe? 1. Warfarin. 2. Low-dose acetylsalicylic acid. 3. Propranolol. 4. Valproic acid.

Answer: 2 1. An oral coagulant such as warfarin (Coumadin) is ordered if the TIA was caused by atrial fibrillation, and that information is not presented in the stem. 2. Atherosclerosis is the most common cause of a TIA or stroke, and taking a low-dose acetylsalicylic acid (aspirin) [ASA], antiplatelet medication, every day helps prevent clot formation around plaques. 3. If the client had hypertension, then the beta blocker propranolol (Inderal) may be prescribed, but this information is not in the stem. 4. Anticonvulsant medications, such as valproic acid (Depakote), are not prescribed to help prevent TIAs.

Which problem is a priority for the 24-year-old client admitted to the gynecological unit diagnosed with endometriosis? 1. Hemorrhage. 2. Pain. 3. Constipation. 4. Dyspareunia.

Answer: 2 1. Anemia caused by endometriosis occurs over time and is not an acute complication, such as hemorrhaging. 2. Pain is the primary concern of the client; the pain occurs as a result of ectopic tissue bleeding into the abdominal cavity during menses. 3. Endometriosis does not cause constipation, and this would not be a priority problem. The client may experience pain during a bowel movement. 4. Dyspareunia is pain during intercourse, and this client is in the hospital (and unlikely to be having sex there).

Which assessment information is the most critical indicator of a neurological deficit? 1. Changes in pupil size. 2. Level of consciousness. 3. A decrease in motor function. 4. Numbness of the extremities.

Answer: 2 1. Changes in pupil size are a late clinical manifestation of a neurological deficit. 2. A change in the level of consciousness is the first and most critical indicator of any neurological deficit. 3. A decrease in motor function occurs with a neurological deficit, but it is not the most critical indicator. 4. Numbness of the extremities occurs with a neurological deficit, but it is not the most critical indicator.

Which intervention will help prevent the nurse from being sued for malpractice throughout professional practice? 1. Keep accurate and legible documentation of client care. 2. A kind, caring, and compassionate bedside manner at all times. 3. Maintain knowledge of medications for disease processes. 4. Follow all health-care provider orders explicitly.

Answer: 2 1. Documentation can help the nurse defend nursing actions if a lawsuit occurs, but it will not help prevent a lawsuit. 2. Research indicates nurses forming a trusting nurse-client relationship are less likely to be sued; if the nurse were to make an error, the client and family are often more forgiving. 3. Knowledge of medications will prevent medication errors but will not keep the nurse from being sued. Nurses are human and can make mistakes with medications even if they are knowledgeable. 4. The nurse is a client advocate and is legally, morally, and ethically required to question the HCP's orders when caring for assigned clients.

Which question should the nurse ask the client being admitted to rule out infective endocarditis? 1. "Do you have a history of a heart attack?" 2. "Have you had a cardiac valve replacement?" 3. "Is there a family history of rheumatic heart disease?" 4. "Do you take nonsteroidal anti-inflammatory medications?"

Answer: 2 1. Having a history of myocardial infarction is not a risk factor for developing infective endocarditis. 2. This is why clients must receive prophylactic antibiotic treatment before dental work and invasive procedures. 3. A personal history of rheumatic fever, not a family history, increases the risk of developing infective endocarditis. 4. NSAIDs have no effect on the development of infective endocarditis.

The nurse has taught Kegel exercises to the client, who is para 5, gravida 5. Which information indicates the exercises have been effective? 1. The client reports no SOB when walking upstairs. 2. The client has no reports of stress incontinence. 3. The client denies being pregnant at this time. 4. The client has lost 10 lbs. in the last 2 months.

Answer: 2 1. Kegel exercises do not have anything to do with activity endurance. 2. Kegel exercises are exercises that strengthen the perineal muscles. Multiple pregnancies weaken the pelvic muscles, resulting in bladder incontinence; a report of no stress incontinence indicates the Kegel exercises are effective. 3. Kegel exercises do not affect pregnancy. 4. Kegel exercises do not have anything to do with weight loss.

Which psychosocial client problem should the nurse write for the client diagnosed with cancer of the lung and metastasis to the brain? 1. Altered role performance. 2. Grieving. 3. Body image disturbance. 4. Anger.

Answer: 2 1. Metastasis indicates advanced disease; therefore, altered role performance would not be an appropriate client problem. 2. Metastasis indicates advanced disease, and the client should be allowed to express feelings of loss and grieving; the client is dying. 3. Body image is a psychosocial problem but would not be applicable in this scenario. 4. Anger is part of the grieving process.

The nurse has just received the shift assessment. Which client should the nurse assess first? 1. The client diagnosed with encephalitis reporting myalgia. 2. The client reporting chest pain. 3. The client refusing to eat hospital food. 4. The client scheduled to go to the whirlpool.

Answer: 2 1. Myalgia is muscle pain, which is expected in a client diagnosed with encephalitis. 2. The client reporting chest pain is the priority. Remember Maslow's hierarchy of needs. 3. Refusing to eat hospital food is not a priority. 4. The client going to the whirlpool is stable and is not a priority over chest pain.

The client has gastroesophageal reflux disease. Which HCP order should the nurse question? 1. Elevate the head of the client's bed with blocks. 2. Administer pantoprazole four times a day. 3. A regular diet with no citrus or spicy foods. 4. Activity as tolerated and sit up in a chair for all meals.

Answer: 2 1. The HOB is elevated to prevent the reflux of stomach contents into the esophagus. 2. Proton pump inhibitors are only administered once or twice a day; they should not be given four times a day because the pantoprazole (Protonix) decreases gastric acidity, and the stomach needs some gastric acid to digest foods. The nurse would question this order. 3. The client is not prescribed any special diet; limiting spicy and citrus foods decrease acid in the stomach. 4. Sitting upright after all meals decreases the reflux of stomach contents into the esophagus.

The client diagnosed with end-stage heart failure is being cared for by the home health nurse. Which intervention should the nurse teach the caregiver? 1. Report any time the client starts having difficulty breathing. 2. Notify the HCP if the client gains more than 3 lbs. in a week. 3. Teach how to take the client's apical pulse for 1 full minute. 4. Encourage the client to participate in 30 minutes of exercise a day.

Answer: 2 1. The client diagnosed with heart failure will be short of breath on exertion and with activity. The significant other should report difficulty breathing not subsiding with rest or stopping the activity. 2. Weight gain of 2 to 3 pounds reflects fluid retention as a result of heart failure, which warrants notifying the HCP. 3. The caregiver must not administer the digoxin if the radial pulse is less than 60 bpm. The apical pulse is more difficult to assess in a client than the radial pulse. 4. The client diagnosed with end-stage heart failure is dying and should not exercise daily; activity intolerance as a result of decreased cardiac output is the number-one life-limiting problem.

The client diagnosed with peptic ulcer disease is being discharged. Which nursing task can be delegated to a trained UAP? 1. Complete the discharge instructions sheet. 2. Remove the client's saline lock. 3. Clean the client's room after discharge. 4. Check the client's hemoglobin and hematocrit.

Answer: 2 1. The discharge instruction sheet is teaching, which cannot be delegated to a UAP. 2. The trained UAP can remove a saline lock from a stable client. 3. The UAP does not clean hospital rooms; this is the housekeeping department's responsibility. 4. The RN cannot delegate evaluation, which is checking the client's laboratory data before discharge; this is out of the UAP's area of expertise.

The student nurse accidentally punctured her finger with a contaminated needle. Which action should the student nurse take first? 1. Notify the infection control nurse. 2. Allow the puncture site to bleed. 3. Report to the emergency department. 4. Cleanse the site with povidone-iodine.

Answer: 2 1. The infection control nurse must be notified, but it is not the first action. 2. Allowing the site to bleed allows any pathogen to bleed out; the student nurse should not apply pressure or attempt to stop the flow of blood. 3. This would be done to document the occurrence and start early prophylaxis if necessary, but it is not the first intervention. 4. Cleaning the site with povidone-iodine (Betadine) is an appropriate intervention once the wound is allowed to bleed; this is a needle stick, so the nursing student will not bleed to death.

The client is being admitted into the hospital with a diagnosis of pneumonia. Which HCP order should the nurse implement first? 1. Initiate intravenous antibiotics. 2. Collect a sputum specimen for culture. 3. Obtain a clean voided midstream urinalysis. 4. Request a chest x-ray to confirm the diagnosis.

Answer: 2 1. The nurse should not administer antibiotics until the culture specimen is obtained. 2. The sputum must be collected first to identify the infectious organism so appropriate antibiotics can be prescribed. Administering broad-spectrum antibiotics before collecting sputum could alter the culture and sensitivity (C&S) results. 3. This is not a priority over sputum culture, and getting the antibiotic started. 4. Always treat the client first.

The 33-year-old client had a traumatic amputation of the right forearm as a result of a work-related injury. Which referral by the RN rehabilitation nurse is most appropriate? 1. Physical therapist. 2. Occupational therapist. 3. Workers' compensation. 4. State rehabilitation commission.

Answer: 2 1. The physical therapist focuses on evaluating, diagnosing movement dysfunctions (injured tissues and structures), and treating these issues. The PT helps restore movement and mobility. 2. The occupational therapist focuses on evaluating and improving functional abilities to optimize independence and address activities of daily living, which would be an appropriate referral. 3. Workers' compensation is an insurance provider for the employer and employee to cover medical expenses and loss of wages. This is not an appropriate referral by the rehabilitation nurse. 4. The client may need this referral, but after the occupational therapist has worked with the client and determined the ability to perform skills.

The female client is admitted to the orthopedic floor diagnosed with a spiral fracture of the arm and multiple contusions and abrasions covering the trunk of the body. Her husband accompanies her. During the admission interview, which intervention is a priority? 1. Notify the local police department of the client's admission. 2. Provide privacy to discuss how the injuries occurred to the client. 3. Refer the client to the social worker for names of women's shelters. 4. Ask the client if she prefers the husband to stay in the room.

Answer: 2 1. The police can be notified if the woman requests this course of action; otherwise, this cannot be done. It is not a priority at this time. 2. The nurse must ensure the husband cannot hear the client discussing how she was injured. The client needs to feel safe when answering these questions because a spiral fracture indicates a twisting motion, and the bruises are on areas covered with clothing. The nurse should suspect abuse with these types of injuries. 3. The nurse should refer to the social worker if it is determined the client has been abused, but the nurse should not refer during the admission interview. 4. The nurse should make every attempt to interview the client without the possible abuser present; the client will probably be afraid to tell the nurse she wants the husband to leave the room if he is the abuser.

The client is admitted into the medical unit diagnosed with heart failure and is prescribed levothyroxine orally. Which intervention should the nurse implement? 1. Call the pharmacist to clarify the order. 2. Administer the medication as ordered. 3. Ask why the client takes levothyroxine. 4. Request serum thyroid function levels.

Answer: 2 1. There is no reason to question or clarify this order; the nurse is responsible for clarifying the order with the HCP, not the pharmacist. 2. The thyroid hormone levothyroxine (Synthroid) is prescribed for hypothyroidism. Many older clients have comorbid conditions requiring daily medications, which are not the primary reason for admission into the hospital. 3. The nurse should know why the client is taking this medication; the thyroid hormone levothyroxine (Synthroid) is prescribed for only one reason, hypothyroidism. 4. The serum thyroid function levels are monitored by the HCP, usually yearly after maintenance doses have been established.

Which priority problem should the clinic nurse identify for the client exceeding ideal body weight at 87 kg? 1. Risk for complications. 2. Altered nutrition. 3. Body image disturbance. 4. Activity intolerance.

Answer: 2 1. This client is overweight but not morbidly obese, which would place the client at risk for complications. 2. "Altered nutrition: more than body requirements" is an appropriate client problem for a client weighing 175 pounds. 3. This is a psychosocial problem, which is not a priority over a physiological problem. 4. The client may or may not be active, but altered nutrition is a priority.

The client diagnosed with type 1 diabetes asks the nurse, "What causes me to get dehydrated when my glucose level is elevated?" Which statement would be the nurse's best response? 1. "The kidneys are damaged and cannot filter out the urine." 2. "The glucose causes fluid to be pulled from the tissues." 3. "The sweating as a result of the high glucose level causes dehydration." 4. "You get dehydrated with high glucose because you are so thirsty."

Answer: 2 1. This is not the rationale as to why the client becomes dehydrated. 2. The glucose in the bloodstream is hyperosmolar, which causes water from the extracellular space to be pulled into the vessels, resulting in dehydration. 3. The client has diaphoresis in hypoglycemia, not hyperglycemia. 4. The dehydration causes the client to be thirsty; the thirst does not cause dehydration.

The client diagnosed with venous insufficiency tells the nurse, "The doctor just told me about my disease and walked out of the room. What am I supposed to do?" Which statement is the nurse's best response? 1. "I will have your HCP come back and discuss this with you." 2. "One thing you can do is elevate your legs above your heart while watching TV." 3. "You will probably need to have surgery within a few months." 4. "This will go away after you lose about 20 pounds and start walking."

Answer: 2 1. This might be what the nurse wants to do, but the nurse should teach the client about the disease process. 2. Elevating the legs above the heart as much as possible will help decrease edema. 3. There are no surgical procedures to correct venous insufficiency. 4. Losing weight and walking are excellent lifestyle modifications, but there is no guarantee the venous insufficiency will resolve.

The client diagnosed with neurogenic diabetes insipidus (DI) asks the nurse, "What is wrong with me? Why do I urinate so much?" Which statement by the nurse is most appropriate? 1. "The islet cells in your pancreas are not functioning properly." 2. "Your pituitary gland is not secreting a necessary hormone." 3. "Your kidneys are in failure and you are overproducing urine." 4. "The thyroid gland is speeding up all your metabolism."

Answer: 2 1. This would cause the client to have diabetes mellitus. 2. The pituitary gland secretes vasopressin, the antidiuretic hormone (ADH) causing the body to conserve water, and if the pituitary is not secreting ADH, the body will produce large volumes of dilute urine. 3. There are two types of diabetes insipidus: neurogenic DI and nephrogenic DI. In neurogenic DI, the pituitary gland fails to produce ADH; in nephrogenic DI, the kidneys fail to respond to ADH. 4. The thyroid gland has nothing to do with DI.

The client diagnosed with cancer of the larynx had a partial laryngectomy. Which client problem has the highest priority? 1. Impaired communication. 2. Ineffective coping. 3. Risk for aspiration. 4. Social isolation.

Answer: 3 1. The client has a partial laryngectomy, and the voice quality may change, but the client can still speak. 2. This is a psychosocial problem, but it is not a priority over a potential physiological problem. 3. As a result of the injury to the musculature of the throat area, this client is at high risk for aspirating. 4. This is a psychosocial problem, but it is not a priority over a potential physiological problem.

The RN observes the UAP taking vital signs on an unconscious client. Which action by the UAP warrants intervention by the nurse? 1. The UAP uses a vital sign machine to check the BP. 2. The UAP takes the client's temperature orally. 3. The UAP verifies the blood pressure manually. 4. The UAP counts the respirations for 30 seconds.

Answer: 2 1. Using the vital sign machine to take the client's BP is an appropriate intervention. 2. The body temperature of an unconscious client should never be taken by mouth because the client is unable to hold the thermometer safely. 3. Manually verifying the blood pressure is an appropriate intervention if the UAP questions the automatic blood pressure reading. This action should be praised. 4. Counting the respiration for 30 seconds and multiplying by 2 is appropriate.

The nurse is planning the care for the client diagnosed with multiple stage IV pressure injuries. Which complication results from these pressure injuries? 1. Wasting syndrome. 2. Osteomyelitis. 3. Renal calculi. 4. Cellulitis.

Answer: 2 1. Wasting syndrome occurs in clients diagnosed with protein-calorie malnutrition. This syndrome leads to pressure injuries not healing, but it is not a complication of the pressure injury. 2. Stage IV pressure injuries frequently extend to the bone tissue, predisposing the client to develop a bone infection—osteomyelitis—which can rarely be treated effectively. 3. Renal calculi may be a result of immobility, but they are not a complication of pressure injuries. 4. Cellulitis is an inflammation of the skin, which is not a complication of pressure injuries.

According to the nursing process, which interventions should the nurse implement when caring for the client diagnosed with a right-sided cerebrovascular accident (stroke) having difficulty swallowing? Rank in order of performance. 1. Write the client problem of "altered tissue perfusion." 2. Assess the client's level of consciousness and speech. 3. Request dietary send a full liquid tray with beverage thickener. 4. Instruct the UAP to elevate the head of the bed 30 degrees. 5. Note the amount of food consumed on the dinner tray.

Answer: 2, 1, 3, 4, 5 2. This is the assessment step, the first step of the nursing process. 1. Diagnosis is the second step in the nursing process. In this case, it is "altered tissue perfusion." 3. Planning is the third step of the nursing process. 4. Implementation is the fourth step in the nursing process. 5. Evaluation is the last step of the nursing process.

The client, after receiving a permanent pacemaker, is admitted to the telemetry floor. The nurse writes the problem "knowledge deficit." Which interventions should be included in the plan of care? Select all that apply. 1. Take tub baths instead of showers from now on. 2. Avoid holding electrical devices near the pacemaker. 3. Carry the pacemaker identification card at all times. 4. Count the radial pulse 1 full minute every morning. 5. Notify the HCP if the pulse is 12 beats slower than the preset rate.

Answer: 2, 3, 4 1. Once the chest incision heals, the client can shower or bathe, whichever the client prefers. 2. Electrical devices may interfere with the functioning of the pacemaker. 3. This alerts any HCP as to the presence of a pacemaker. 4. The client should be taught to take the radial pulse for 1 full minute before getting out of bed. If the count is more than 5 bpm less than the preset rate, the HCP should be notified immediately because this may indicate the pacemaker is malfunctioning. 5. The client should notify the HCP if the pulse is 5 bpm less than the preset rate. This may indicate a pacemaker malfunction.

The 54-year-old female client is diagnosed with osteoporosis. Which interventions should the nurse discuss with the client? Select all that apply. 1. Instruct the client to swim 30 minutes every day. 2. Encourage drinking milk with added vitamin D. 3. Determine if the client smokes cigarettes. 4. Recommend the client not go outside. 5. Teach about safety and fall precautions.

Answer: 2, 3, 5 1. The nurse should suggest a daily walk because bones need stress to maintain strength. 2. Vitamin D helps the body absorb calcium. 3. Smoking interferes with estrogen's protective effects on bones, promoting bone loss. 4. Lack of exposure to sunlight results in decreased vitamin D, which is necessary for calcium absorption and normal bone mineralization. The client should go outside. 5. The client is at risk for fractures; therefore, a fall could result in serious complications.

The public health nurse is discussing hepatitis with a client traveling to a developing country in 1 month. Which recommendations should the nurse discuss with the client? Select all that apply. 1. A gamma globulin injection. 2. A hepatitis A vaccination. 3. A PPD skin test on the left arm. 4. A hepatitis B vaccination. 5. No additional vaccinations are required.

Answer: 2, 4 1. A gamma globulin injection is administered to provide passive immunity to clients exposed to hepatitis. 2. Hepatitis A is contracted through the fecal-oral route of transmission; poor sanitary practices in developing countries place the client at risk for hepatitis A. 3. This is a test to determine exposure to tuberculosis and does not have anything to do with hepatitis. 4. The hepatitis B vaccination is administered for exposure to blood and body fluids and recommended for individuals traveling to a developing country. 5. The CDC recommends routine vaccinations for individuals traveling outside the United States. Additionally, the CDC provided travel health notices, updated frequently on their Web site, with recommendations for enhanced precautions and vaccinations.

Which interventions should the emergency department nurse implement for a client with an AP of 122 and a BP of 80/50? Select all that apply. 1. Put the client in reverse Trendelenburg position. 2. Start an intravenous line with an 18-gauge catheter. 3. Have the client complete the admission process. 4. Cover the client with blankets and keep warm. 5. Request the laboratory to draw a type and crossmatch.

Answer: 2, 4, 5 1. The client would be placed in the Trendelenburg position, which is with the head lower than the feet. 2. The client is in shock and may need blood transfusions; therefore, a large-bore catheter should be started to infuse fluids, plasma expanders, and possible blood. 3. The admission process cannot be completed by the client because the condition is life-threatening. 4. The client will be cold as a result of vasoconstriction of the periphery resulting from a low pulse and blood pressure. 5. The client will more than likely need blood transfusions that require a type and crossmatch.

Which assessment data indicate to the nurse the client diagnosed with diarrhea is experiencing a complication? 1. Moist buccal mucosa. 2. A 3.6-mEq/L potassium level. 3. Tented tissue turgor. 4. Hyperactive bowel sounds.

Answer: 3 1. A moist mouth indicates the client is not dehydrated. 2. This is within normal limits for potassium—3.5 to 5.5 mEq/L. 3. Tented tissue turgor indicates dehydration, which is a complication of diarrhea. 4. Hyperactive bowel sounds would be expected in a client with diarrhea.

The telemetry nurse is monitoring the following clients. Which client should the telemetry nurse instruct the primary nurse to assess first? 1. The client diagnosed with occasional premature ventricular contractions (PVCs). 2. The client post-cardiac surgery with three unifocal PVCs in a minute. 3. The client diagnosed with myocardial infarction has two multifocal PVCs. 4. The client diagnosed with atrial fibrillation has an AP of 116 and no P wave.

Answer: 3 1. An occasional PVC does not warrant intervention; it is normal for most clients. 2. Less than six unifocal PVCs in 1 minute is not life-threatening. 3. Multifocal PVCs indicate the ventricle is irritable, and this client is at risk for a cardiac event such as ventricular fibrillation. 4. Atrial fibrillation is not life-threatening, and the nurse would expect the client not to have a P wave when exhibiting this dysrhythmia.

The client is diagnosed with aortic stenosis. Which assessment data indicate a complication is occurring? 1. Barrel chest and clubbing of the fingers. 2. Intermittent claudication and rest pain. 3. Pink, frothy sputum and dyspnea on exertion. 4. Bilateral wheezing and friction rub.

Answer: 3 1. Barrel chest and clubbing of the fingers are clinical manifestations of chronic lung disease. 2. Intermittent claudication and rest pain are clinical manifestations of peripheral arterial disease. 3. Pink, frothy sputum and dyspnea on exertion are clinical manifestations of heart failure, which occurs when the heart can no longer compensate for the strain of an incompetent valve. 4. Friction rub occurs with pericarditis, and bilateral wheezing occurs with asthma.

The 44-year-old female client calls the clinic and tells the nurse she felt a lump while performing breast self-examination (BSE). Which question should the nurse ask the client? 1. "Are you taking birth control pills?" 2. "Do you eat a lot of chocolate?" 3. "When was your last period?" 4. "Are you sexually active?"

Answer: 3 1. Birth control pills regulate the hormones in the body but will not cause changes in the breast tissue. 2. There is a theory that chocolate increases breast discomfort in women with fibrocystic breast changes. 3. During the menstrual cycle, pregnancy, and menopause, variations in breast tissue occur and must be distinguished from the pathological disease. BSE is best performed on days 5 to 7 after menses, counting the first day of menses as day 1. Although BSE is no longer recommended by the American Cancer Society, some women might still be comfortable doing regular self-exams and the nurse should be prepared to provide information. 4. Sexual manipulation of the breast does not cause malignant changes in breast tissue.

The client is admitted with rule-out leukemia. Which assessment data support the diagnosis of leukemia? 1. Cervical lymph node enlargement. 2. An asymmetrical dark-purple nevus. 3. Petechiae covering the trunk and legs. 4. Brownish-purple nodules on the face.

Answer: 3 1. Cervical lymph node enlargement would indicate Hodgkin's lymphoma. 2. An asymmetrical dark-purple nevus would indicate malignant melanoma. 3. Petechiae covering the trunk and legs is one of the indicators of bone marrow problems, which could be leukemia. 4. Brownish-purple nodules on the face indicate Kaposi's sarcoma, a complication of AIDS.

The client diagnosed with stage IV prostate cancer is receiving chemotherapy. Which laboratory value should the nurse assess before administering the chemotherapy? 1. Prostate-specific antigen (PSA). 2. Serum calcium level. 3. Complete blood count (CBC). 4. Alpha-fetoprotein (AFP).

Answer: 3 1. PSA is a tumor marker monitored to determine the progress of the disease and treatment, but it is not monitored before chemotherapy. 2. Serum calcium levels may be monitored to determine metastasis to the bone, but it would not be done before chemotherapy. 3. The CBC is monitored to determine if the client is at risk for developing an infection or bleeding as a result of the side effects of the chemotherapy medications. The chemotherapy could be held or decreased based on these results. 4. AFP is a tumor marker monitored to determine the progress of the disease and treatment, but it is not monitored before chemotherapy.

Which assessment data indicate to the nurse the client has a conductive hearing loss? 1. The Rinne test results in air-conducted sound being louder than bone-conducted sound. 2. The client is unable to hear accurately when conducting the whisper test. 3. The Weber test results in the sound being heard better in the affected ear. 4. The tympanogram results in the ticking watch heard better in the unaffected ear.

Answer: 3 1. The Rinne test result indicates normal hearing; in conductive hearing loss, the bone-conducted sound is heard as long as or longer than air-conducted sound. 2. The whisper test is used to make a general estimation of hearing, but it is not used to diagnose for conductive hearing loss specifically. 3. The Weber test uses bone conduction to test lateralization of sound by placing a tuning fork in the middle of the skull or forehead. A normal test results in the client hearing the sound equally in both ears. 4. The tympanogram (impedance audiometry) measures middle-ear muscle reflex to sound stimulation and compliance of the tympanic membrane by changing air pressure in a sealed ear canal. It does not specifically support the diagnosis of conductive hearing loss.

The home health nurse must see the following clients. Which client should the nurse assess first? 1. The client postoperative from an open cholecystectomy with green drainage coming from the T-tube. 2. The client diagnosed with heart failure reporting shortness of breath while fixing meals. 3. The client diagnosed with AIDS dementia whose family called and reported that the client is vomiting "coffee grounds stuff." 4. The client diagnosed with end-stage liver disease gaining 3 pounds and unable to wear house shoes.

Answer: 3 1. The T-tube is inserted into the common bile duct to drain bile until healing occurs, and bile is green, so this is expected. 2. The client diagnosed with congestive heart failure would be expected to experience dyspnea on exertion. 3. Coffee-ground emesis indicates gastrointestinal bleeding, and this client should be seen first. 4. The client diagnosed with end-stage liver disease is unable to assimilate protein from the diet, which leads to fluid volume retention and resulting weight gain. This is expected for this client.

Which client should the nurse consider at risk for developing acute renal failure? 1. The client diagnosed with essential hypertension. 2. The client diagnosed with type 2 diabetes. 3. The client diagnosed with an anaphylactic reaction. 4. The client after having an autologous blood transfusion.

Answer: 3 1. The client diagnosed with essential hypertension is at risk for chronic renal failure. 2. The client diagnosed with diabetes type 2 is at risk for chronic renal failure. 3. Anaphylaxis leads to circulatory collapse, which decreases perfusion of the kidneys and can lead to acute renal failure. 4. This is a transfusion of the client's own blood, which should not cause a reaction.

The client diagnosed with chronic pancreatitis is admitted with an acute exacerbation of the disease. Which laboratory result warrants immediate intervention by the nurse? 1. The client's amylase is elevated. 2. The client's WBC count is WNL. 3. The client's blood glucose is elevated. 4. The client's lipase is within normal limits.

Answer: 3 1. The client's amylase would be elevated in acute exacerbation of pancreatitis. 2. The WBC count is not elevated in this disease process. 3. In clients diagnosed with chronic pancreatitis, the beta cells of the pancreas are affected, and therefore, insulin production is affected. An elevated glucose level would warrant the nurse assessing the client. 4. Lipase is an enzyme that is excreted by the pancreas. Normal lipase levels indicate a normally functioning pancreas.

The client diagnosed with peripheral arterial disease is prescribed clopidogrel. Which assessment data indicate the medication is effective? 1. The client's pedal pulse is bounding. 2. The client's blood pressure has decreased. 3. The client does not exhibit clinical manifestations of a stroke. 4. The client has decreased pain when ambulating.

Answer: 3 1. The client's pedal pulse does not evaluate the effectiveness of this medication. 2. Clopidogrel (Plavix), an antiplatelet medication, is not administered to help decrease blood pressure. 3. Clopidogrel (Plavix), an antiplatelet medication, inhibits platelet aggregation and is considered effective when there is a decrease in atherosclerotic events, an example of which is a stroke. 4. This medication will not help the pain associated with peripheral arterial disease.

The client has a fractured right tibia. Which assessment data warrant immediate intervention? 1. The client reports right calf pain. 2. The nurse cannot palpate the radial pulse. 3. The client's right foot is cold to touch. 4. The nurse notes ecchymosis on the right leg.

Answer: 3 1. The nurse would expect the client diagnosed with a fractured right leg to have pain, but it would not warrant immediate intervention. 2. The nurse would assess the client's pedal or posterior tibial pulse for a client diagnosed with a fractured right tibia. 3. Any abnormal neurovascular assessment data, such as coldness, paralysis, or paresthesia, warrant immediate intervention by the nurse. 4. Ecchymosis is bruising and would be expected in the client diagnosed with a fractured tibia.

The client diagnosed with a closed head injury is admitted to the neuro-intensive care department following a motor vehicle accident. Which goal is an appropriate short-term goal for the client? 1. The client will maintain an optimal level of functioning. 2. The client will not develop extremity contractures. 3. The client's intracranial pressure will not be greater than 15 mmHg. 4. The client will be able to verbalize feelings of anger.

Answer: 3 1. This could be an appropriate long-term goal for the client based on the extent of the injury, but it is not an appropriate short-term goal. 2. This is an appropriate long-term goal to prevent immobility complications, but it is not an appropriate short-term goal. 3. The worst-case scenario with a closed head injury is increased intracranial pressure resulting in death. An appropriate short-term goal would be the intracranial pressure remaining within normal limits, which is 7 to 15 mmHg. 4. This is a psychosocial goal, which would not be a short-term goal, and the client may not be angry. The stem did not indicate the client is angry.

The 24-year-old African American female client tells the nurse she has a brother with sickle cell disease. She is engaged to be married and is concerned about passing this disease to her future children. Which information is most important to provide to the client? 1. Tell the client that she won't pass this on if she has never had symptoms. 2. Encourage the client to discuss this concern with her fiancé. 3. Recommend that she and her fiancé see a genetic counselor. 4. Discuss the possibility of adopting children after she gets married.

Answer: 3 1. This is a false statement. The client could have the sickle cell trait. 2. This should be discussed with her fiancé, but it is not the most important information. 3. Referral to a genetic counselor is the most important information to give the client. If she and her fiancé both have the sickle cell trait, there is a 25% chance of a child having sickle cell disease with each pregnancy. 4. Adoption may be a choice, but at this time, the most important information is to refer the couple to a genetic counselor.

The UAP empties the indwelling urinary catheter for a client 4 hours postoperative transurethral resection of the prostate then informs the RN the urine is red with some clots. Which intervention should the nurse implement first? 1. Assess the client's urine output immediately. 2. Notify the HCP that the client has gross hematuria. 3. Explain this is expected with this surgery. 4. Medicate for bladder spasms to decrease bleeding.

Answer: 3 1. This is a normal postoperative expectation with this procedure. 2. This is gross hematuria, but it is expected with this type of surgery, and the nurse should not call the surgeon. 3. The client has a three-way indwelling 30-mL catheter inserted in surgery. This type of catheter instills an irrigant into the bladder to flush the clots and blood from the bladder; bloody urine is expected after this surgery. 4. The stem does not indicate the client is having bladder spasms and bladder spasms are not causing the bleeding. Clots left in the bladder and not flushed out can cause bladder spasms.

The client diagnosed with a brain tumor having radiation treatment is developing alopecia. The client and asks, "When will my hair grow back?" Which statement is the nurse's best response? 1. "Your hair should start growing back within 3 weeks." 2. "Are you concerned your hair will not grow back?" 3. "It may take months if your hair grows back at all." 4. "It may take a couple of years for the hair to grow back."

Answer: 3 1. This is incorrect information for radiation therapy. It is correct for chemotherapy. 2. This is a therapeutic response, which does not answer the client's question. 3. Radiation therapy can cause permanent damage to the hair follicles, and the hair may not grow back at all; the nurse should answer the client's question honestly. 4. This is not a true statement.

The client is diagnosed with an acute exacerbation of Crohn's disease. Which laboratory assessment data warrant immediate attention? - Glucose: 148 - Serum amylase: 100 - WBCs: 10 - Potassium: 3.3 1. The client's WBC count. 2. The client's serum amylase. 3. The client's potassium level. 4. The client's blood glucose.

Answer: 3 1. This white blood cell (WBC) level is WNL and would not warrant immediate intervention. 2. This amylase level is within normal limits (100 to 300 units/L). 3. This potassium level is low as a result of excessive diarrhea and puts the client at risk for cardiac dysrhythmias. Therefore, these assessment data warrant immediate intervention. 4. The client's blood glucose level is elevated, but it would not warrant immediate intervention for a client diagnosed with Crohn's disease and hypokalemia.

The primary nurse is applying antiembolism hose to the client postoperative total hip replacement. Which situation warrants immediate intervention by the charge nurse? 1. Two fingers can be placed under the top of the band. 2. The peripheral capillary refill time is less than 3 seconds. 3. There are wrinkles in the hose behind the knees. 4. The nurse does not place a hose on the foot with a venous pressure injury.

Answer: 3 1. This would not warrant intervention because this indicates the hose are not too tight. 2. This indicates the hose are not too tight. 3. There should be no wrinkles in the hose after application. Wrinkles could cause constriction in the area, resulting in clot formation or skin breakdown; therefore, this would warrant immediate intervention by the charge nurse. 4. Antiembolism hose should not be put over a wound; they would restrict the circulation to the wound and cause a decrease in wound healing.

The RN and the UAP are caring for clients on a medical floor. Which nursing task could be delegated to the UAP? Select all that apply. 1. Retake the BP on a client having received a STAT nitroglycerin sublingual. 2. Notify the health-care provider of the client's elevated blood pressure. 3. Obtain and document the routine vital signs on all the clients on the floor. 4. Call the laboratory technician and discuss a hemolyzed blood specimen. 5. Pass breakfast trays to the clients on the medical floor with diets ordered.

Answer: 3, 5 1. This client is unstable and received medication for chest pain. The RN cannot delegate any task for an unstable client. 2. The UAP cannot notify the HCP because UAPs are not allowed to take verbal or telephone orders. 3. The UAP can take routine vital signs. The RN must evaluate the vital signs and take action if needed. The nurse should not delegate teaching, assessing, evaluating, or any unstable client. 4. This is outside the level of a UAP's expertise. 5. The UAP can pass food trays on the floor to the clients who have diets ordered.

The client has sustained severe burns on both the anterior right and left leg and the anterior chest and abdomen. According to the rule of nines, what percentage of the body has been burned?

Answer: 36% Each leg is 18%, with the anterior surface (front) being 9%. Because the anterior of both legs are burned (9% each), that would be 18%. That 18% plus the anterior surface of the trunk, which is 18%, totals 36% of the total body surface burned.

Which laboratory result warrants immediate intervention by the nurse for the female client diagnosed with systemic lupus erythematosus (SLE)? - Serum albumin: 4.5 - Hgb: 13 - Hct: 40 - WBC: 15 - ESR: 9 1. The hemoglobin and hematocrit (Hgb, Hct). 2. The erythrocyte sedimentation rate (ESR). 3. The serum albumin level. 4. The white blood cell count (WBC).

Answer: 4 1. A normal hemoglobin is 12 to 15 g/dL, and normal hematocrit is 36% to 45%. 2. A normal ESR is between 1 and 20 mm/hr for a female client. 3. A normal albumin level is between 3.5 and 5 g/dL. 4. The client diagnosed with SLE is at an increased risk for infection, and this WBC count indicates an infection requiring medical intervention.

Which assessment data indicate the treatment for the client diagnosed with bacterial meningitis is effective? 1. There is a positive Brudzinski's sign and photophobia. 2. The client tolerates meals without nausea. 3. There is a positive Kernig's sign and elevated temperature. 4. The client is able to flex the neck without pain.

Answer: 4 1. A positive Brudzinski's sign—flexion of the knees and hip when the neck is flexed—indicates the presence of meningitis. Therefore, the treatment is not effective. Sensitivity to light is a common clinical manifestation of meningitis. 2. This does not indicate whether the meningitis is resolving. 3. Kernig's sign—the leg cannot be extended when the client is lying with the thigh flexed on the abdomen—is a clinical manifestation of meningitis. An elevated temperature indicates the client still has meningitis. 4. The client does not have nuchal rigidity, which indicates the client's treatment is effective.

The client is being evaluated to rule out Parkinson's disease. Which diagnostic test confirms this diagnosis? 1. A positive magnetic resonance imaging (MRI) scan. 2. A biopsy of the substantia nigra. 3. A stereotactic pallidotomy. 4. There is no test that confirms this diagnosis.

Answer: 4 1. An MRI is not able to confirm the diagnosis of Parkinson's disease. 2. This is the portion of the brain where Parkinson's disease originates, but this area lies deep in the brain and cannot be biopsied. 3. This is a surgery that relieves some of the clinical manifestations of Parkinson's disease. To be eligible for this procedure, the client must have failed to achieve an adequate response with medical treatment. 4. Many diagnostic tests are completed to rule out other diagnoses, but Parkinson's disease is diagnosed based on the clinical presentation of the client and the presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia.

The nurse writes the goal "the client will list three food sources of cobalamin vitamin B12" for the client diagnosed with pernicious anemia. Which foods listed by the client indicate the goal has been met? 1. Brown rice, dried fruits, and oatmeal. 2. Beef, chicken, and pork. 3. Broccoli, asparagus, and kidney beans. 4. Liver, cheese, and eggs.

Answer: 4 1. Brown rice, dried fruit, and oatmeal are sources of nonheme iron. Nonheme iron comes from vegetable sources. 2. Beef, chicken, and pork are sources of heme iron or animal sources of iron. 3. Broccoli, asparagus, and kidney beans are sources of folic acid. 4. Liver, cheese, and eggs are sources of vitamin B12.

The client calls the clinic first thing in the morning and tells the nurse, "I have been vomiting and having diarrhea since last night." Which response is appropriate for the nurse to make? 1. Encourage the client to eat dairy products. 2. Have the client go to the emergency department. 3. Request the client to obtain a stool specimen. 4. Tell the client to stay on a clear liquid diet.

Answer: 4 1. Dairy products contain milk and increase flatus and peristalsis. These products should be discouraged. 2. Symptoms lasting less than 24 hours would not warrant the client going to the emergency department; if anything, an appointment at a clinic would be appropriate. 3. A stool specimen may be needed at some point, but not this early in the disease process. 4. A clear liquid diet is recommended because it maintains hydration without stimulating the gastrointestinal tract; diarrhea and vomiting lasting longer than 24 hours, along with dehydration and weakness, would warrant the client being evaluated.

The client is diagnosed with atherosclerosis and coronary artery disease. The client experiences sudden chest pain when walking to the nurse's station. Which intervention should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Apply oxygen via nasal cannula. 3. Obtain a STAT electrocardiogram. 4. Have the client sit in a chair.

Answer: 4 1. Sublingual nitroglycerin is the medication of choice for angina, but it is not the first intervention. 2. Applying oxygen is appropriate, but it is not the first intervention. 3. A STAT ECG should be ordered, but it is not the first intervention. 4. Stopping the client from whatever activity the client is doing is the first intervention because this decreases the oxygen demands of the heart muscle and may decrease or eliminate the chest pain.

The UAP notifies the RN that the client diagnosed with chronic obstructive pulmonary disease is reporting shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement? 1. Notify the respiratory therapist (RT). 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter reading. 4. Tell the UAP to leave the oxygen alone.

Answer: 4 1. The RN can take care of this situation and does not need to notify the RT. 2. The UAP cannot increase oxygen. The RN should treat oxygen as a medication. Also, increasing the oxygen level could cause the client to stop breathing as a result of carbon dioxide narcosis. 3. The pulse oximeter reading will be low because the client has COPD. 4. The oxygen level for a client diagnosed with COPD must remain between 2 and 3 L/min because the client's stimulus for breathing is low blood oxygen levels. If the client receives increased oxygen, the stimulus for breathing will be removed, and the client will stop breathing.

The client diagnosed with severe osteoarthritis is in the long-term care facility. Which nursing task should the RN delegate to the unlicensed assistive personnel (UAP)? 1. Feed the client the breakfast meal. 2. Give the client an OTC antacid. 3. Monitor the client's INR results. 4. Assist the client to the shower room.

Answer: 4 1. The RN should encourage the client to maintain independent functioning, and delegating the UAP to feed the client would be encouraging dependence. 2. Although the antacid aluminum hydroxide, magnesium hydroxide, simethicone (Maalox) is an over-the-counter (OTC) medication, a UAP cannot administer any medication to a client. 3. The UAP cannot assess or evaluate any of the client's diagnostic information. 4. The UAP could assist the client in ambulating to the shower room and assist with morning care.

The client had abdominal surgery and is receiving bag #5 of total parenteral nutrition (TPN) via a subclavian line infusing at 126 mL/hr. The nurse realizes bag #6 is not on the unit and TPN bag #5 has 50 mL left to infuse. Which intervention should the nurse implement? 1. Decrease the rate of bag #5 to a keep-open rate. 2. Prepare to hang a 1,000-mL bag of normal saline. 3. When bag #5 is empty, convert to a heparin lock. 4. Infuse D10W at 126 mL/hr via the subclavian line.

Answer: 4 1. The client could experience hypoglycemia if the rate of infusion is decreased. TPN must be tapered when discontinuing. 2. Normal saline does not have glucose, so the client would be at risk for hypoglycemia. 3. The client must be tapered off TPN to prevent hypoglycemia; therefore, the line cannot be converted to a heparin lock. 4. Dextrose 10% has enough glucose to prevent hypoglycemia and should be administered until bag #6 arrives at the unit.

The nurse identifies the problem "high risk for complications" for the client with a right total hip replacement being discharged from the hospital. Which problem would have the highest priority? 1. Self-care deficit. 2. Impaired skin integrity. 3. Abnormal bleeding. 4. Prosthetic infection.

Answer: 4 1. The client is being discharged, so a self-care deficit would not be a potential complication. 2. The client is being discharged and is ambulating; therefore, impaired skin integrity should not be a problem. 3. The client would have been taking a prophylactic anticoagulant but would not be at risk for abnormal bleeding. 4. The client must inform all HCPs, especially the dentist, of the hip prosthesis, because the client should be taking prophylactic antibiotics before any invasive procedure. Any bacteria invading the body may cause an infection in the joint, and this may result in the client having the prosthesis removed.

Which client should the RN charge nurse on the substance abuse unit assign to the licensed practical nurse (LPN)? 1. The client diagnosed with chronic alcoholism in the unit now 3 days. 2. The client reporting palpitations and has a history of cocaine abuse. 3. The client diagnosed with amphetamine abuse and has tried to commit suicide. 4. The client diagnosed with cannabinoid abuse threatening to leave AMA.

Answer: 4 1. The client should be assessed for delirium tremens and should be assigned to an RN. 2. Palpitations indicate cardiac involvement, and because the client has a history of cocaine abuse, this client should be assigned to an RN. 3. This client is at high risk for injury to self and should be assigned to an RN and be on one-to-one precautions. 4. The client has a right to leave against medical advice (AMA), and marijuana abuse is not life-threatening to him or to others. Therefore, the LPN could be assigned to this client.

The client receiving a continuous heparin drip reports sudden chest pain on inspiration and tells the nurse, "Something is really wrong with me." Which intervention should the nurse implement first? 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client's lung sounds. 4. Apply oxygen via nasal cannula.

Answer: 4 1. The heparin drip may be increased because the client has now thrown a pulmonary embolus (PE), but this needs an HCP's order. 2. The HCP will be notified because the client has a suspected embolus, but it is not the first intervention. 3. The client has probably thrown a PE, and assessing the lungs will not do anything for a client in imminent risk of death. PEs are life-threatening, and assessing the client is not a priority in a life-threatening situation. 4. The client probably has a PE, and the priority is to provide additional oxygen, so oxygenation of tissues can be maintained.

Which data indicate to the nurse the client diagnosed with end-stage liver disease is improving? 1. The client has a tympanic wave. 2. The client is able to perform asterixis. 3. The client is confused and lethargic. 4. The client's abdominal girth has decreased.

Answer: 4 1. The tympanic wave indicates ascites, which is not an indicator of improving health. 2. Asterixis is a flapping of the hands, which indicates an elevated ammonia level. 3. Confusion and lethargy indicate increased ammonia levels. 4. A decrease in the abdominal girth indicates an improvement in the ascitic fluid.

Which client should the registered nurse (RN) charge nurse of the day surgery unit, assign to a new graduate nurse in orientation? 1. The client after an arthroscopy with an AP of 110 and BP of 94/60. 2. The client with open reduction of the ankle who is confused. 3. The client with a total hip replacement being transferred to the ICU. 4. The client diagnosed with low back pain after a myelogram.

Answer: 4 1. This client is showing clinical manifestations of hypovolemic shock and should not be assigned to an inexperienced nurse. 2. Confusion could be a clinical manifestation of many complications after surgery, so this client should not be assigned to an inexperienced nurse. 3. This client is being transferred to the ICU, which indicates the client is not stable; therefore, this client should not be assigned to an inexperienced nurse. 4. A myelogram is a routine diagnostic test. With minimal instruction, an inexperienced nurse could care for this client.

The 25-year-old client diagnosed with a C6 spinal cord injury is crying and asks the nurse, "Why did I have to survive? I wish I was dead." Which statement is the nurse's best response? 1. "Don't talk like that. At least you are alive and able to talk." 2. "God must have something planned for your life. Pray about it." 3. "You survived because the people at the accident saved your life." 4. "This must be difficult to cope with. Would you like to talk?"

Answer: 4 1. This is negating the client's feelings and will abruptly end any conversation the client may want or need to have. 2. This is imposing the nurse's religious beliefs on the client, and these are clichés, which do not address the client's feelings. 3. This is explaining why the client survived, but the client isn't really asking for information. The client is expressing and showing emotions that must be addressed by the nurse. 4. This is a therapeutic response that allows the client to verbalize feelings.

The client with a history of substance abuse presents to the emergency department reporting right flank pain, and the urinalysis indicates microscopic blood. Which intervention should the nurse implement? 1. Determine the last illegal drug use. 2. Insert a #22 French indwelling catheter. 3. Give the client a back massage. 4. Medicate the client for pain.

Answer: 4 1. This is not pertinent to the client's current situation. 2. The nurse should strain all the client's urine, but a large indwelling catheter does not need to be inserted into this client; this isn't a bladder stone, it is a ureteral stone. 3. A back massage is a nice thing to do, but it will not help renal colic caused by ureteral calculi. 4. The client should be medicated for pain, which is excruciating, and the client's history of substance abuse should not be an issue.

The client diagnosed with non-Hodgkin's lymphoma tells the nurse, "I am so tired. I just wish I could die." Which stage of the grieving process does this statement represent? 1. Anger. 2. Denial. 3. Bargaining. 4. Acceptance.

Answer: 4 1. This statement does not represent the anger stage of grieving. 2. This statement does not represent the denial stage of grieving. 3. This statement does not represent the bargaining stage of grieving. 4. This statement indicates the client is ready to die and is in the acceptance stage of the grieving process.

The client is performing breast self-examination (BSE) by the American Cancer Society's recommended steps and has completed palpating the breast. Which step is next when completing the BSE? 1. Stand before the mirror and examine the breast. 2. Lean forward and look for dimpling or retractions. 3. Examine the breast using a circular motion. 4. Pinch the nipple to see if any fluid can be expressed.

Answer: 4 1. This step is the first step in BSE. 2. This is step three in the BSE process. 3. This is included in steps four and five and is described as using a systematic process of examining the breast. Using circular motions and dividing the breast into wedges or vertical strips to palpate the entire breast is encouraged. This step was described in the stem as having been completed. 4. The American Cancer Society no longer recommends breast self-exam as a screening tool for women with an average risk of breast cancer. A woman at high risk may need to be instructed on the process. The last step of BSE after palpation is to express the nipple by gently squeezing the nipple. Any discharge should be brought to the attention of an HCP. Nipple discharge can be caused by many factors such as carcinoma, papilloma, pituitary adenoma, cystic breasts, and some medications.

Which action by the UAP requires intervention by the RN? 1. The UAP used two washcloths when washing the perineal area. 2. The UAP emptied the indwelling catheter and documented the amount. 3. The UAP applied moisture barrier cream to the anal area. 4. The UAP is wiping the client's perineal area from back to front.

Answer: 4 1. Using two washcloths to clean the client's perineal area is an appropriate action to prevent a urinary tract infection. 2. This action does not require intervention. 3. Moisture barrier cream is not considered a medication and can be applied by the UAP after the perineum is cleaned. 4. The UAP should wipe the area from front to back to prevent fecal contamination of the urinary meatus, which could result in a urinary tract infection.

The nurse is preparing the client newly diagnosed with asthma for discharge. Which data indicate the teaching about the peak flowmeter has been effective? 1. "I can continue my usual activities without medication if I am in the yellow zone." 2. "It takes 1 to 2 days to establish my personal best." 3. "When I can't talk while walking, I need to take my quick-relief medicine." 4. "When I am in the red zone, I must take my quick-relief medication and not exercise."

Answer: 4 1. Yellow means caution. The client should follow some, but not all, usual activities. 2. The client's personal best takes 2 to 3 weeks to establish. 3. When a client can't talk while walking, there is shortness of breath, which indicates the client does not have tight control, but this has nothing to do with the peak flow meter. 4. When the client is in the red zone, the client should take the quick-relief medication and should not exercise or follow regular routines.

The nurse is teaching a class on sexually transmitted infections (STIs) to high school sophomores. Which information should be included in the discussion? Select all that apply. 1. Oral sex decreases the chance of transmitting a sexual disease. 2. Sexual activity during menses decreases the transmission of diseases. 3. Frequent sexual activity is necessary to transmit a sexual disease. 4. Unprotected sex puts the individual at risk for many diseases. 5. Get vaccinated to prevent the most common STI.

Answer: 4, 5 1. Oral sex still involves mucous membrane-to-mucous membrane contact, and disease transmission is possible; herpes simplex 2 is simply herpes simplex 1 transferred to the genitalia. 2. This is a myth. 3. The more often the person engages in sexual contact and the more sexual partners, the more likely the person will contract an STI; however, one time is enough to contract a deadly STI, such as AIDS. 4. According to developmental theories, adolescents think they are invincible, and nothing will happen to them. This attitude leads adolescents to participate in high-risk behaviors without regard to consequences. 5. Teenagers and preteens should get vaccinated for HPV, the most common STI prevented by a vaccine.